Initial Request Research Articles

Direct vs. redirected admission of critically ill children to PICU after interfacility transfer: a retrospective cohort study.

Critically ill children must often be transported long distances for access to critical care resources in Canada. This study aims to describe and compare characteristics and outcomes in patients presenting in the community and requiring inter-facility transport and admission to a Pediatric Intensive Care Unit (PICU). This is a retrospective cohort study of children admitted to the ICU at the Hospital for Sick Children from 2016 to 2019 after inter-facility transport. Characteristics and outcomes were compared between children admitted to the PICU within 24 h from their initial critical care transport request, and children admitted after initial redirection to a non-ICU care setting, 24-72 h from request. The primary outcome was severity of illness at PICU admission. Secondary outcomes included duration of mechanical ventilation, organ dysfunction, PICU length of stay and mortality. A total of 2,730 patients were admitted after inter-facility transport to either the medical/surgical or cardiac ICU within 72 h of initial critical care transport request. Of these children, 2,559 (94%) were admitted within 24 h and 171 (6%) were admitted between 24 and 72 h. Children admitted after initial redirection were younger and residing in more rural centers. Children who were initially redirected had lower severity of illness (PRISM-IV median score 3 vs. 5, p = 0.047) and lower risk of mortality. Initial redirection to a non-ICU care setting rather than directly admitting to the PICU did not result in increased severity of illness or mortality. This study highlights the need to better understand which factors influence disposition decision-making at the time of initial transport request. Further research should focus on the impact of transport factors on clinical outcomes after PICU admission.

Analysis of association between new-onset type 2 diabetes mellitus and pancreatic cancer: retrospective research

Introduction. Pancreatic cancer is characterized by an extremely unsatisfactory prognosis, despite the development of technologies for the treatment of this pathology. In more than 80 % of patients at the time of the initial request for medical care, the disease is represented by a locally advanced or metastatic stage. Currently used methods of treatment of this nosology are most effective at the early stages of the disease. The absence of characteristic clinical, instrumental and laboratory symptoms, as well as organizational measures for the early detection of this neoplasia creates certain difficulties for effective treatment. Type 2 diabetes is probably one of the risk factors for the development of pancreatic cancer. Epidemiological studies have shown that newly diagnosed type 2 diabetes is associated with a 1.5–2.0-fold increased risk of developing pancreatic cancer in patients over 50 years of age. Insulin resistance and its associated hyperglycemia, hyperinsulinemia, and inflammation are thought to be the main mechanisms contributing to the development of diabetes-related pancreatic cancer. New-onset type 2 diabetes mellitus may be a preclinical sign of pancreatic cancer, and patients with newly diagnosed diabetes may constitute a population in which pancreatic cancer can be detected at an early stage, that will significantly improve the results of treatment.
 Objective. To analyze the relationship between new-onset type 2 diabetes mellitus and the development of pancreatic cancer.
 Material and methods. A retrospective analysis of the medical records of patients with a confirmed diagnosis of pancreatic cancer, who were treated at the Academician A.M. Granov Russian Scientific Center of Radiology and Surgical Technologies from 2019 to 2022, was carried out. As a source of information, data from medical records of inpatient and outpatient treatment cards were used. In total, the data of 203 persons were studied: morphologically confirmed pancreatic ductal adenocarcinoma was diagnosed in 172 patients (group I), in 31 patients pancreatic tumors had a different histological structure: acinar carcinoma, neuroendocrine tumors (group II). Group I excluded 8 patients without diabetes mellitus who were taking medications, which affect the blood glucose levels. The frequency of occurrence of type 2 diabetes mellitus in the groups was analyzed and then the statistical significance was assessed using the calculation of Fisher's exact test. Group I was analyzed by sex and age, then patients from group I aged 50–75 years were divided into 3 subgroups depending on the glycemic profile: 1) patients with long-term type 2 diabetes mellitus (anamnesis more than 3 years); 2) patients with new-onset type 2 diabetes mellitus (anamnesis less than 3 years); 3) patients without disorders of glucose metabolism. In the subgroup of patients with a long history of type 2 diabetes mellitus, the fact of disease decompensation was additionally assessed.
 Results. Type 2 diabetes mellitus was more common in patients with pancreatic ductal adenocarcinoma (p 0.01, Fisher's exact test p = 0.0012) than in other pancreatic neoplasms. The age of patients in group I ranged from 36 to 81 years. The average age of men was 61 ± 8.5 years. The average age of women was 58.9 ± 8.2 years. Among patients of group I aged 50–75 years, new-onset type 2 diabetes mellitus occurred in 78 (68.4 %) persons, type 2 diabetes mellitus with an anamnesis of more than 3 years was detected in 19 (16.6 %) patients, normal metabolism of glucose was observed in 17 (14 %) patients. Of 19 patients with a long anamnesis of type 2 diabetes mellitus (more than 3 years), decompensation in the form of impaired glycemic control was observed in 12 (63.2 %) patients before the diagnosis of pancreatic cancer, in 7 (36.8 %) patients no signs of decompensation of the course of type 2 diabetes mellitus were registered.
 Conclusions. New-onset type 2 diabetes mellitus occurred in 78 (64.4 %) patients over 50 years of age with pancreatic ductal adenocarcinoma. The data obtained indicate the feasibility of conducting studies to identify patients aged 50–70 years with newly diagnosed type 2 diabetes in the risk group for the development of pancreatic cancer and examine this contingent at the stage of primary health care. Further retrospective as well as prospective multicenter studies on the association between newly diagnosed type 2 diabetes mellitus and the risk of developing pancreatic cancer are required.

The burden of recurrence acute pancreatitis and annual event rates are underestimated because of high rates of home self-management

Background/objectivesThe event-rate of recurrent acute pancreatitis (RAP) in patient populations is critical for powering research studies. We hypothesize that some patients manage RAP attacks at home, reducing event rate estimations based on counting emergency department (ED) visits and hospitalizations only. The aim of this study was to determine the rates of home self-management of recurrent acute pancreatitis compared to ED visits and hospitalizations. MethodsAn anonymous 8-question survey was sent to 1825 individuals on an email list of individuals with a history of acute pancreatitis (AP) or chronic pancreatitis or interest in pancreatic diseases. Question were designed to identify subjects with RAP within the past 2 years and to subdivide patients based on having a chronic pain syndrome or not. ResultsAfter an initial email request and one reminder a total of 194 subjects responded with 98 RAP subjects suitable for analysis. Annual AP events included an average of 1.44 hospitalizations, 1.37 ED visits, 2.46 disrupted work/school/social engagements, and 3.95 pancreatitis-like pain attacks per year. Patients with RAP average 6.8 RAP events per year with 58.4 % managed at home. ConclusionsThe burden of disease in patients with RAP is significantly underestimated, especially for patients with chronic pain. Future studies should include measures to capture RAP events managed at home and utilize methods of documenting RAP events.

Characteristics and patient impact of boarding in the pediatric emergency department, 2018–2022

ObjectivesBoarding admitted patients in the emergency department is an important cause of throughput delays and safety risks in adults, though has been less studied in children. We assessed changes in boarding in a pediatric ED (PED) from 2018 to 2022 and modeled associations between boarding and select quality metrics. MethodsWe performed a retrospective analysis of PED patients admitted to non-psychiatric services, broken into four periods: pre-COVID-19 (Period I, 01/2018–02/2020), early pandemic (II, 03/2020–06/2021), COVID-19 variants (III, 07/2021–06/2022), and non-COVID respiratory viruses (IV, 07/2022–12/2022). Patients were classified as critical (intensive care units (ICU)) or acute care (non-ICU inpatient services) based on their initial bed request. We compared median boarding times with Kruskal-Wallis tests. We assessed the relationship between boarding time and hospital length-of-stay (LOS) through hazard regression models, and the association between boarding time and PED return visit, readmission, and patient safety events through adjusted logistic regressions. ResultsMedian PED boarding time significantly increased from Period I (acute: 2.4 h; critical: 3.0 h) to Period II (acute: 3.0 h, critical: 4.0 h) to Period III (acute: 4.4 h, critical: 6.6 h) to Period IV (acute: 6.2 h; critical: 9.5 h). On survival analysis, as boarding time increased, hospital LOS increased for acute admissions and decreased for critical admissions. Increased acute care boarding time was associated with higher odds of a filed safety report. ConclusionsSince July 2021, PED boarding time increased for admitted children across acute and critical admissions. The relationship between acute care boarding and longer hospital LOS suggests a resource-inefficient, self-perpetuating cycle that demands multi-disciplinary solutions.

Comparison of erector spinae plane block and serratus anterior plane block for postoperative analgesia in uniportal thoracoscopic lobectomy: a randomized controlled trial

BackgroundPostoperative pain remains a significant concern following uniportal thoracoscopic surgery. The analgesic efficacy of erector spinae plane block (ESPB) and serratus anterior plane block (SAPB) in terms of postoperative opioid consumption in uniportal thoracoscopic surgery still needs further studies.MethodsA randomized controlled trial was conducted, enrolling 150 patients who underwent uniportal thoracoscopic lobectomy. The patients were randomly allocated to three groups in a 1:1:1 ratio: the ESPB group (administered 20 ml of 0.5% ropivacaine), the SAPB group (administered 20 ml of 0.5% ropivacaine), and the standard care (control) group. The primary endpoint was the consumption of sufentanil during the first 24 h following surgery. Secondary endpoints assessed the area under the curve (AUC) of pain numerical rating scale (NRS) scores, occurrence of moderate to severe pain, time to initial sufentanil request, and postoperative adverse events.ResultsNo significant difference was observed in the consumption of sufentanil during the first 24 h following surgery between the ESPB and SAPB groups (adjusted difference, 1.53 [95% CI, -5.15 to 2.08]). However, in comparison to the control group, both intervention groups demonstrated a significant decrease in sufentanil consumption, with adjusted differences of -9.97 [95% CI, -13.10 to -6.84] for the ESPB group and -12.55 [95% CI, -15.63 to -9.47] for the SAPB group. There were no significant differences in AUC of NRS scores during rest and movement between the ESPB and SAPB groups, with adjusted differences of -7.10 [95% CI, 1.33 to -15.55] for the rest condition and 5.61 [95% CI, -13.23 to 2.01] for the movement condition. At 6 h postoperatively, there were fewer patients with moderate to severe pain in the ESPB group compared with those in the SAPB group (adjusted difference, -1.37% [95% CI, -2.29% to -0.45%]. The time to first sufentanil request significantly differed among the three groups (ESPB vs Control P < 0.01, SAPB vs Control P < 0.01, ESPB vs SAPB P = 0.015).ConclusionsIn patients undergoing uniportal thoracoscopic lobectomy, although the differences between the two groups are not statistically significant, both the ESPB and SAPB demonstrate effective reduction in postoperative opioid consumption and the need for rescue analgesics compared to the control group. Moreover, the ESPB group experienced a significantly lower incidence of moderate to severe pain at 6 h postoperatively compared to the SAPB group.Trial registrationThe study was registered in the Chinese Clinical Trial Registry (registration No: ChiCTR1900021695, Date of registration: March 5th, 2019).

The impact of prior authorization review on orthopaedic subspecialty care: a prospective multicenter analysis

BackgroundPrior authorization review (PAR), in the United States, is a process that was initially intended to focus on hospital admissions and costly high-acuity care. Over time, payors have broadened the scope of PAR to include imaging studies, prescriptions, and routine treatment. The potential detrimental effect of PAR on healthcare has recently been brought into the limelight, but its impact on orthopedic subspecialty care remains unclear. This study investigated the denial rate, the duration of care delay, and the administrative burden of PAR on orthopedic subspecialty care. MethodsA prospective, multicenter study was performed analyzing the PAR process. Orthopedic shoulder and/or sports subspecialty practices from six states monitored payor-mandated PAR during the course of providing routine patient care. The insurance carrier (traditional Medicare, managed Medicare, Medicaid, commercial, worker’s compensation or government payor (i.e. Tricare, VA), location of service, rate of approval/ denial, time to approval/ denial, and administrative time required to complete process were all recorded and evaluated. ResultsOf 1,065 total PAR requests, we found a 1.5% (16/1065) overall denial rate for advanced imaging or surgery when recommended by an orthopedic subspecialist. Commercial and Medicaid insurance resulted in a small but statistically significantly higher rate of denial compared to traditional Medicare, managed Medicare, worker’s compensation, or governmental insurance (p < 0.001). The average administrative time spent on a single PAR was 19.5 minutes, and patients waited an average of 2.2 days to receive initial approval. Managed Medicare, commercial insurance, worker’s compensation, and Medicaid required approximately 3 to 4 times more administrative time to process a PAR than to traditional Medicare or other governmental insurance (p<0.001). After controlling for the payor, we identified a significant difference in approval/denial based on geographic location (p<0.001). An appeal resulted in a relatively low rate of subsequent denial (20%). However, approximately a third of all appeals remained in limbo for 30 days or more after the initial request. ConclusionThis is the largest prospective analysis to date of the impact of PAR on orthopedic subspecialty care in the United States. Nearly all PAR requests are eventually approved when recommended by orthopedic subspecialists, despite requiring significant resource utilization and delaying care. Current PAR practices constitute an unnecessary process that increases administrative burden and negatively impacts access to orthopedic subspecialty care. As healthcare shifts to value-based care, PAR should be called into question, as it does not seem to add value but potentially negatively impacts cost and timeliness of care.

Robust Symbol Timing Synchronization for Initial Access under LEO Satellite Channel.

This paper proposes a robust symbol timing synchronization scheme for return link initial access based on the Digital Video Broadcasting-Return Channel via Satellite 2nd generation (DVB-RCS2) system for the Low Earth Orbit (LEO) satellite channel. In most cases, the feedforward estimator structure is considered for implementing Time Division Multiple Access (TDMA) packet demodulators such as the DVB-RCS2 system. More specifically, the Non-Data-Aided (NDA) approach, without using any kind of preamble, pilot, and postamble symbols, is applicable for fine symbol timing synchronization. However, it hinders the improvement in estimation accuracy, especially when dealing with short packet lengths during the initial access from the User Terminal (UT) to the Gateway (GW). Moreover, when a UT sends a short random access packet for initial access or resource request to the LEO satellite channel, the conventional schemes suffer from a large Doppler error depending on UT's location in a beam and satellite velocity. To ameliorate these problems, we propose a novel symbol timing synchronization algorithm for GW, and its advantage is confirmed through computer simulation.

Insurance Request and Approval Process for Proton Beam Therapy in Patients with Esophageal Cancer

Randomized data suggests proton beam therapy (PBT) reduces the risk and severity of toxicities when compared to IMRT in the neoadjuvant or definitive setting for esophageal cancer. As a critical barrier to access to PBT, we investigate our institutional experience with the prior authorization (PA) process for patients (pts) with esophageal cancer. One hundred and four (104) consecutive pts with esophageal cancer from 2016-2020 at one institution for whom PBT was recommended were analyzed. Data was collected from the customer relations management (CRM) database and electronic health record. Patient characteristics, tumor characteristics, treatment parameters, types of insurance, and clinical outcomes (OS, LF, DF) were recorded. Timepoints of the steps of the PA process included the PA team's initial inquiry, the initial decision, first through third appeals, and outcomes of each appeal (the third of which was regarded as the final decision). Rates of approval and successful appeal were calculated. Logistic and Cox regression models were used to evaluate whether insurance decisions were associated with clinical factors or clinical outcomes. Approval rates by Medicare (n = 68) and private insurance (n = 36) were 100 and 42% on initial request, at a median (range) 0 and 3 (0-15) days from inquiry to determination, respectively. All 21 pts initially denied coverage appealed the decision. Overall, denial was overturned in 48% of pts (median [range] time, 14 [7-36] days from initial inquiry [FIQ]), i.e., PBT was eventually approved for them. The remaining pts proceeded with self-pay or photon therapy. Upon first appeal, 14 pts were denied (median [range] time, 7 [1-26] days FIQ). Upon second appeal, 6 pts were denied (median [range] time, 18 [7-34] days FIQ). Finally, upon third appeal, 2 pts were denied and 1 patient was approved (median [range] time, 2 [20-39] days). Medicare insurance (P < .01) and possessing secondary insurance (P = .02) were found to be associated with increased likelihood of initial approval. Notably, a trend was found between clinical trial enrollment and decreased likelihood of initial approval. Neither initial nor final insurance decisions were found to be associated with OS, LF, or DF. Despite randomized data and policy efforts supporting the use of PBT in esophageal cancer, pts with private payers experience treatment delays and often eventual denial after appeal.

Insurance Approval Delay of Biologic Therapy Dose Escalation Associated with Disease Activity in Patients with Inflammatory Bowel Disease.

Dose escalation of self-injectable biologic therapy for inflammatory bowel diseases may be required to counteract loss of response and/or low drug levels. Payors often require completion of a prior authorization (PA), which is a complex approval pathway before providing coverage. If the initial PA request is denied, clinic staff must complete a time and resource-intensive process to obtain medication approval. This study measured time from decision to dose escalate to insurance approval and evaluated impact of approval time on disease activity. This was a single-center retrospective analysis of adult patients with IBD prescribed an escalated dose of biologic therapy at an academic center with an integrated specialty pharmacy team from January to December 2018. Outcomes included time to insurance approval and the association between approval time and follow-up C-reactive protein (CRP) and Short Inflammatory Bowel Disease Questionnaire (SIBDQ) scores. Associations were tested using linear regression analyses. 220 patients were included, median age 39, 53% female, and 96% white. Overall median time from decision to dose escalate to insurance approval was 7days [interquartile range (IQR) 1, 14]. Approval time was delayed when an appeal was required [median of 29days (IQR 17, 43)]. Patients with a longer time to insurance approval were less likely to have CRP improvement (p = 0.019). Time to insurance approval did not significantly impact follow-up SIBDQ scores. Patients who had a longer time to insurance approval were less likely to have improvement in CRP, highlighting the negative clinical impact of a complex dose escalation process.

IPACK block with spinal anesthesia compared to fentanyl-based spinal anesthesia for postoperative analgesia following arthroscopic meniscectomy: a randomized, prospective study

BackgroundLocal anesthesia and intrathecal narcotics are utilized to provide postoperative analgesia. IPACK (infiltration between the knee capsule and popliteal artery) is a new localized analgesic approach for knee surgery. This randomized study aimed to compare fentanyl-based spinal anesthesia and IPACK block-based spinal anesthesia for postoperative analgesia in patients undergoing arthroscopic meniscectomy.ResultsIn group F, the VAS (visual analog scale) was higher than in group I, whereas the total amount of morphine was lower in group I (P < .05). In group F (3.92 ± 1.54), the initial painkiller request occurred earlier than in group I (8.82 ± 0.44). In addition, total morphine administrated in group F (20.81 ± 0.69) was significantly higher than in group I (9.54 ± 0.73) (P < .05). Group I had a higher level of patient satisfaction 24 h after surgery than group F (P < .05). In the current study, there were no significant adverse effects linked to the use of fentanyl. Moreover, no complications associated with the IPACK block were detected.ConclusionsThe combination of IPACK block and hyperbaric bupivacaine spinal anesthesia is an effective treatment for initial postoperative pain following arthroscopic meniscectomy, according to the findings of this study. IPACK block prolongs postoperative analgesia more than intrathecal fentanyl.Trial registrationThis study was registered with Clinical Trials Registry (NCT05833776).

0470 Factors Associated with Discordant Initial Home Sleep Apnea Testing and Polysomnography

Abstract Introduction Nocturnal polysomnography (PSG) is the gold standard for diagnosing obstructive sleep apnea (OSA). Home sleep apnea tests (HSAT) have been incorporated in the diagnostic algorithm in patients with a high pre-test suspicion of OSA. While many studies have compared HSATs with PSGs, it is not well understood what factors may be responsible for inconclusive HSAT results. Methods We performed a retrospective chart review of adult patients who underwent a non-diagnostic HSAT evaluation, who subsequently tested positive for OSA (on PSG) between 1/1/2022 and 11/1/2022. We collected demographic and sleep study data. Patients who did not have a follow up PSG were excluded. Results A total of 20 patients were reviewed. 80% had a negative HSAT with a positive subsequent PSG. The average age was 33.9 years (SD +/- 11.3 years). 43% were male and 50% were Caucasian. The average BMI was 29 kg/m2 (SD +/- 5.3 kg/m2). The average Epworth Sleepiness Scale score (ESS) was 8 (median 6.5) with only 31% reporting an ESS &amp;gt;10. The average HSAT recording time was 449.1 minutes. The average respiratory disturbance index (RDI) on the follow up PSG was 17.7 events/hour of sleep (SD +/- 12). Only 1 patient was diagnosed with severe OSA. 38% were diagnosed with anxiety in this cohort. Other co-morbidities were insignificant. Of all the HSATs performed, 40% were denied for an initial PSG evaluation and converted to an HSAT evaluation. Conclusion HSATs are validated in patients with a high pretest probability of OSA. Anxiety was found in one third of patients included (possibly contributing to a negative initial HSAT). Patient demographics however were also not remarkable for a high risk of OSA in this group (e.g. non-obese, &amp;lt; 55 years, female). The subsequent diagnosis for OSA was also only mild or moderate (93.8%) in this lower risk cohort. Hence, another explanation for the initial negative HSAT evaluation may have been the insurance denial of the initial PSG request (40%). Denials of low risk patients for PSG may contribute to a misuse of resources. We also need to educate referring physicians to follow appropriate HSAT ordering criteria (based on high OSA risk factors). Support (if any)

Comparison of Tele-stroke transfer between intervention and non-intervention cases and 30-day outcome events (P8-5.018)

<h3>Objective:</h3> We sought to study patient characteristics and 90-day clinical outcomes among telestroke transfers and compared characteristics between the patients who received stroke interventions of tPA +/− thrombectomy versus who did not. <h3>Background:</h3> Telestroke programs are crucial in providing access to regional medical centers that may not have direct in-person neurology. Patients who get emergently transferred to an affiliated tertiary medical center after an acute telestroke evaluation may not end up requiring advanced tertiary care, which raises a question of potentially futile transfer. <h3>Design/Methods:</h3> We retrospectively analyzed 204 consecutive emergent telestroke transfers from affiliated 19 regional medical centers between October 3rd, 2021, to May 3rd, 2022. The primary outcome of interest was 90-day clinical outcome and 30-day readmission. Baseline patient characteristics were compared. <h3>Results:</h3> Among total 204 patients (mean age 64, female [51.0%]), 181 (88.7%) cases had initial transfer request to our ER and 126 (61.8%) cases were eventually admitted to the ICU. A total of 72 (35.3%) patients underwent an intervention. There was a significant difference in patients age (68 vs 62, <i>P</i>&lt;0.05), acuity of care (<i>i.e.</i>, ICU admission, 78% vs. 53%, <i>P</i>&lt;0.001), stroke diagnosis (ischemic stroke, 93% vs. 25%; hemorrhagic stroke 4% vs 43%; <i>P</i>&lt;0.001), neurosurgery consult (8.3% vs. 43.2%, <i>P</i>&lt;0.001), presenting NIHSS (13 vs 7, <i>P</i>&lt;0.001) in patients with or without intervention, respectively. The 90-day death outcome or 30-day readmission were similar between the two groups of intervention versus without intervention (<i>P</i>&gt;0.05). There were no differences in length of stay or death during index admission in these 2 groups (P&gt;0.05). Goals of care discussions prior to transfer were unclear for both groups, and majority of these two groups were labeled as full code (P&gt;0.05). <h3>Conclusions:</h3> There are patients that do not require interventions, yet require transfer after tele-stroke evaluations, requiring additional resources. Future studies are warranted to understand preventable and unnecessary transfers. <b>Disclosure:</b> Dr. Sivakumar has nothing to disclose. Dr. Ghasemi has nothing to disclose. Dr. Trivedi has nothing to disclose. Dr. Silver has received personal compensation in the range of $5,000-$9,999 for serving as an Expert Witness for Various legal firms. Dr. Silver has received intellectual property interests from a discovery or technology relating to health care. Dr. Silver has received publishing royalties from a publication relating to health care. Dr. Silver has received publishing royalties from a publication relating to health care. Dr. Silver has received publishing royalties from a publication relating to health care. Dr. Silver has received personal compensation in the range of $500-$4,999 for serving as a Consultant with Women’s Health Initiative. Dr. Silver has received personal compensation in the range of $500-$4,999 for serving as a Consultant with Best Doctors, Inc./Teladoc, Inc.. Dr. Silver has a non-compensated relationship as a Consultant with ABPN that is relevant to AAN interests or activities. Dr. Silver has a non-compensated relationship as a Member, Regional Board of Directors with American Heart Association that is relevant to AAN interests or activities. Dr. Henninger has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Astrocyte Pharmaceuticals, Inc.. The institution of Dr. Henninger has received research support from DoD. The institution of Dr. Henninger has received research support from NIH. Dr. Kobayashi has nothing to disclose. Dr. Jun-O’Connell has nothing to disclose.

Pre-hospital blood products for hazardous area response team paramedics: A service evaluation to inform decisions on future practice

Aim To identify the number of incidents, over a 1-year period in a single UK Ambulance Service Trust, where patients attended by Hazardous Area Response Team (HART) paramedics where eligible to receive Pre-hospital Blood Products (PHBP) but did not due to the unavailability of a suitably trained clinician. Methods This was a Service Evaluation using a three-stage method of filtering data to reduce bias and improve accuracy when identifying eligible cases. These stages consisted of an initial data request, a peer review filtering stage and then finally an Expert Consensus Panel review of cases to determine whether PHBP should have been administered. Results The consensus group considered 14 cases that would have ‘Likely’ or ‘Certainly’ have received PHBP if a suitably trained clinician was available on scene. Twelve cases involved a traumatic cause whilst the remaining two were medical. Similarly, 12 cases involved patients with spontaneous circulation whilst two patients had no pulse. South Western Ambulance Service Foundation Trust (SWASFT) Bristol HART attended eight and Exeter HART six of these cases. Conclusion This study reveals that across the South West of England, there were a number of patients, being attended by HART, who may potentially benefit from PHBP but are not receiving this intervention due to the unavailability of a suitably trained clinician. This could be far more in the event of a multi or mass-casualty event. HART paramedic access to PHBPs would enable more patients to access a potentially lifesaving treatment and contribute to narrowing the care gap identified in the Manchester Arena Inquiry. The authors recommend that a local pilot trial is undertaken to explore whether a HART PHBP service is feasible, sustainable, cost-effective, appropriate, and safe.

Detection and Prevention of SIP REGISTER Injection Attack on a VoLTE Network

Recent technological advances have indicated widespread use of Voice Over Long-Term Evolution (VoLTE) networks based on developing 5G networks. Despite its ease of design and deployment, VoLTE is vulnerable to many sorts of attacks at the control plane's Session Initiation Protocol (SIP), which exchanges signaling messages for calls via starting call setups, management, and termination. These SIP attacks may take the form of modified SIP messages that force the SIP devices to restart, or they may take the form of flooding the SIP devices with invite messages, register requests that cause the device to run out of memory, and denying genuine users access to the device. These attacks are commonly known as Distributed Denial of Service (DDoS) attacks. The SIP register injection attack, which might be injected during the commencement step by SIP equipped devices (SIP smartphones), prior to setting up the Secured Internet Protocol (IPsec) tunnel for the remaining SIP sessions, is of particular relevance, due to its characteristics of exhausting the available bandwidth, memory, and CPU resources, resulting in SIP device failure. Consequently, there is a need to address this difficulty by building an SIP register injection attack detection and mitigation technique. Prior to being processed by the Proxy Call Session Control Function. The proposed scheme verifies each initial register request from User Equipment (UE) at the home network of Internet Protocol Multimedia Subsystems (IMS) and compares it to the incoming SIP register request pattern with those stored on the scheme's table (P-CSCF). The proposed technique detects and drops every SIP register request with an abnormal pattern that is associated with an attack. The method proved promising with detection accuracy of over 96.67 percent, which is a solid potential as a preliminary setup towards the creation of a robust Real-time SIP detection and mitigation scheme for 5G networks.

Polyphonie et confinement

Between January 2019 and December 2022, a student (named L.A.) doing a BTS (a senior technologist's certificate) in Management was treated using a trimodal system of care by the BAPU of the Claude Bernard Center. How was this original system organized, and how did changes related to the lockdown of March–May 2020 allow for progress in the proposed treatment? The consulting psychologist, Ms. Beaudré, received the initial request: L.A. had multiple difficulties (learning, language, social, psychic, somatic, etc.). Rapid guidance was recommended in an individual space dedicated to educational psychology, while continuing with consultations. In the educational psychology space, L.A. met with Mr. Sanchez and first explained to him her concerns about her difficulties with the French language, her rejection of her mother tongue and her accent. Her learning difficulties made her fear she would fail the BTS. L.A. had low self-esteem. At the start of the lockdown of March–May 2020, the educational psychological support was done at a distance (by telephone), and this did not help to reduce L.A.’s anxiety. Shortly before the start of the lockdown, L.A. had met with Ms. Dziwulski, psychologist-psychotherapist, as part of a therapeutic relaxation session. The question of the physical isolation was an overwhelming concern. The isolation imposed by COVID-19 posed a serious problem for the continued use of this trimodal system of care: how to continue working with L.A.? Within the parameters of this trimodal care, an attempt was made to adapt the follow-up for L.A. around the question of the verbal contact via telephone and the physical presence (distant or real), in a way which would allow this young woman to question/examine the orders given by her inner voice that she called her “policeman”. The temporary suspension of in person contact, as well as work on her self-image and imagination, the exclusivity of her inner voice and then the application of the telephone voice/real physical presence at the BAPU leading to the questioning of the role of the body in her difficulties, allowed L.A to exist differently. The establishment of and the modifications made to this system of care ultimately functioned as a mediation, which provided L.A. the possibility of acquiring another voice, another space in which to think.

From Rosa Mistika, Chapter 7

from Rosa Mistika, Chapter 7 Euphrase Kezilahabi (bio) and Jay Boss Rubin (bio) Strict as he was when it came to raising his daughters, Zakaria still wanted to see them married off as quickly as possible. When he heard Rosa had gotten herself a fiancé, he was delighted. Zakaria could already feel the load being lifted from his shoulders. Around this time, Zakaria was accustomed to saying, "Having so many daughters is a real hassle! You wouldn't believe the number of visitors we get. People stopping by to ask for directions," he'd complain. "People asking for a glass of water, then getting up to leave after a single sip." Five daughters in one location did attract a lot of attention. Boys in the area referred to Zakaria's compound as "the zoo." Zakaria and Regina awaited the arrival of Rosa's fiancé with great anticipation. They also wondered, Where is he going to sleep? It would be a shame for a guest—especially an important one—to have to cram into an already-crowded house. They'd ask him to sleep in the living room, they decided. That was the best they could do. Their other daughters all heard the whispers that a visitor would soon be in their midst—the man who'd proposed to Rosa, they gathered. When Deogratias finally arrived, he was given the royal treatment. Each day, a chicken was slaughtered in his honor. No one rushed into the official business they had to discuss, and Deogratias was given ample time to spend with his fiancé. There was only one thing that bothered Zakaria and Regina: while he was eating, and even when he paused to utter greetings of respect to passing elders, Deogratias failed to take off his hat. Somehow, he failed to understand this most basic custom, even though he was an African like them. Zakaria and Deogratias were seated at the fire one evening when Deogratias first braved the matter of the mahari, the dowry he had come to pay. Zakaria was well prepared. "Aaa, yes, my child, the mahari," he began. "My wife and I have started discussing it, but I can't yet give you our final answer. I'll just tell you our initial requests, so you can get your affairs in order. For starters"—Zakaria paused and motioned with his mouth over to their dilapidated dwelling—"you won't be shocked to hear we need a house." Zakaria went into great detail about how he envisioned the new structure. "If you can help me out with the roof," he said, "I can manage the rest. The mahari should also include," he continued, "four cows, two goats, a pestle [End Page 129] and mortar set, three chairs, and a thousand shillings. Last but not least, for now, one jug of moonshine. Not as part of the official dowry, but for me personally." "None of that is a problem," Deogratias responded after Zakaria was done. "Back home," he said with pride, "we pay up to 30 cows for the mahari, sometimes more." "Don't speak too soon!" Zakaria said right away. "That was only my partial list. And I still have to send you to my relatives. And the relatives from my wife's side of the family must have their needs met, too. After all," he explained, "the child is not mine alone to give away." "Sawa," Deogratias agreed. "None of what you say is unfair." The following day, Zakaria intended to show his guest around the island. Deogratias wasn't opposed to it; it was his first time visiting Ukerewe. For Zakaria, there was only one place such a tour could take them: to a location he was already quite familiar with. Zakaria led Deogratias to the edge of a clump of trees. From somewhere inside, plumes of smoke were issuing and a soft murmur could be heard. Deogratias knew right away where they were headed. He was a boozer, after all, just like Zakaria. Deogratias could booze it up like a full-grown man. Inside the thicket, Zakaria and Deogratias joined the small crowd gathered around the fire. They stayed at the village distillery the entire...

Tell me more, tell me more: repeated personal data requests increase disclosure

Abstract Personal data is of great commercial benefit and potential sensitivity. However, for the consumers who provide their personal data, doing so comes with potential costs, benefits and security risks. Typically, consumers have the option to consent to the use of personal/sensitive data but existing research suggests consumer choices may only be weakly related to their concerns (the privacy paradox). Here, we examine if the repetitive nature of data requests alters behaviour but not concern, therefore, explaining the divergence. This work is theoretically grounded in ‘Foot in the door’ research in which small initial requests facilitate subsequent larger requests. An initial laboratory study asking for real, personal data demonstrated increased information disclosure at a subsequent request. A second online study replicated the increased information disclosure effect and found no change in associated privacy concern. We find this supports foot-in-the-door as one explanation of the privacy paradox. We suggest ways for businesses and consumers to encourage an acceptable level of disclosure to match personal beliefs for mutual trust and benefit.

Examining Racial and Ethnic Disparity in Prosecutor's Bail Requests and Downstream Decision-making.

Although research into prosecutorial and judicial decision-making has been conducted for the past three decades, a great deal still remains unknown. Most research focuses on the 'back end' of the adjudication process, leaving decision points prior to the final phases unanalyzed. Drawing on unique data from the New York County District Attorney's Office that tracks 43,971 felony complaints, this research explores racial and ethnic disparity at multiple decision points during case processing, with a focus on the prosecutor's initial bail request. A combination of regression modeling and path analysis were applied, revealing that the effects of race and ethnicity vary by decision point. Black defendants demonstrated increased bail requests and likelihood of indictment. However, together with Latino defendants, they were less likely to be detained prior to trial compared with White defendants. Despite identifying a mix of positive and negative cumulative effects, we found significant indirect effects of black defendants via bail request that contribute to the unwarranted racial disparities in both pre-trial detention and indictment outcomes. Insights gleaned from this research help prosecutors understand how their initial actions influence final outcomes, as well as contributing to the national conversation on the use of cash bail.

The Golden Hour of Casualty Care: Rapid Handoff to Surgical Team is Associated With Improved Survival in War-injured US Service Members.

To examine time from injury to initiation of surgical care and association with survival in US military casualties. Although the advantage of trauma care within the "golden hour" after an injury is generally accepted, evidence is scarce. This retrospective, population-based cohort study included US military casualties injured in Afghanistan and Iraq, January 2007 to December 2015, alive at initial request for evacuation with maximum abbreviated injury scale scores ≥2 and documented 30-day survival status after injury. Interventions: (1) handoff alive to the surgical team, and (2) initiation of first surgery were analyzed as time-dependent covariates (elapsed time from injury) using sequential Cox proportional hazards regression to assess how intervention timing might affect mortality. Covariates included age, injury year, and injury severity. Among 5269 patients (median age, 24 years; 97% males; and 68% battle-injured), 728 died within 30 days of injury, 68% within 1 hour, and 90% within 4 hours. Only handoffs within 1 hour of injury and the resultant timely initiation of emergency surgery (adjusted also for prior advanced resuscitative interventions) were significantly associated with reduced 24-hour mortality compared with more delayed surgical care (adjusted hazard ratios: 0.34; 95% CI: 0.14-0.82; P = 0.02; and 0.40; 95% CI: 0.20-0.81; P = 0.01, respectively). In-hospital waits for surgery (mean: 1.1 hours; 95% CI; 1.0-1.2) scarcely contributed ( P = 0.67). Rapid handoff to the surgical team within 1 hour of injury may reduce mortality by 66% in US military casualties. In the subgroup of casualties with indications for emergency surgery, rapid handoff with timely surgical intervention may reduce mortality by 60%. To inform future research and trauma system planning, findings are pivotal.

Integrating long-acting reversible contraceptives into primary care internal medicine practices: A clinical innovation to reduce wait time.

Long-acting reversible contraception (LARC) has long been regarded as highly effective and safe. However, access is limited and lengthy when specialty referrals are required. To integrate LARC services into an urban internal medicine primary care practice to decrease wait time for LARC procedures. This pre-post with control group study took place at two large urban academic primary care practices (Practices A and B) and included patients ages 18 to 45 years assigned female sex at birth. Pre-implementation baseline data were collected retrospectively from 2019 to 2020 by identifying subjects who requested LARC insertion or removal via their primary care practice and were referred to Obstetrics and Gynecology (Ob/Gyn) for the procedure. Wait time was noted from time of initial request in the medical record to time of procedure. Practice A developed an integrated primary care LARC program in which one of their LARC-trained providers began offering these procedures within their own practice. All other providers within the practice were educated on how to counsel patients about the devices and procedures. Practice B did not have an in-house LARC provider and continued referring patients to Ob/Gyn. Post-implementation data were collected prospectively 2021-2022. Ninety-one patients in Practice A experienced a significant decrease in wait time (87 vs 21 days, p < 0.001) over the observation period, with a majority undergoing procedures on their first visit with the in-house LARC provider. Wait time for the 54 patients in Practice B remained unchanged (57 vs 47 days, p = .59), often requiring multiple specialty visits. Integrating LARC services into a primary care internal medicine practice can significantly reduce wait times for these procedures with the potential to contribute to increased reproductive and menstrual autonomy.