Local System Research Articles

Key issues in Japan's public health centers to prepare for future pandemics: a text mining study using a topic model.

In Japan, over 450 public health centers played a central role in the operation of the local public health system in response to the COVID-19 pandemic. This study aimed to identify key issues for improving the system for public health centers for future pandemics. We conducted a cross-sectional study using an online questionnaire. The respondents were first line workers in public health centers or local governments during the pandemic. We solicited open-ended responses concerning improvements needed for future pandemics. Issues were identified from these descriptions using morphological analysis and a topic model with KHcoder3.0. The number of topics was estimated using Perplexity as a measure, and Latent Dirichlet Allocation for meaning identification. We received open-ended responses from 784 (48.6%) of the 1,612 survey respondents, which included 111 physicians, 330 nurses, and 172 administrative staff. Morphological analysis processed these descriptions into 36,632 words. The topic model summarized them into eight issues: 1) establishment of a crisis management system, 2) division of functions among public health centers, prefectures, and medical institutions, 3) clear role distribution in public health center staff, 4) training of specialists, 5) information sharing system (information about infectious diseases and government policies), 6) response to excessive workload (support from other local governments, cooperation within public health centers, and outsourcing), 7) streamlining operations, and 8) balance with regular duties. This study identified key issues that need to be addressed to prepare Japan's public health centers for future pandemics. These findings are vital for discussions aimed at strengthening the public health system based on experiences from the COVID-19 pandemic.

Profiling the acceleration and deceleration components in elite futsal players

ABSTRACT This retrospective observational study explores the acceleration and deceleration demands of elite male futsal players (age: 28.8 ± 2.4 years, weight: 73.7 ± 6.2 kg, height: 175.9 ± 5.9 cm) in official matches. Utilising a local positioning system, tracking data from twelve matches involving two elite teams with nineteen players was analysed. Physical demands were assessed at various thresholds, considering standing and rolling efforts based on initial and final velocities. The most prevalent efforts were rolling accelerations (32.4%) and decelerations (31.3%), along with standing accelerations (18.7%) and decelerations (17.6%). A majority of efforts occurred within small distances (less than 10 metres), representing 27.9% to 71.1% of cases. Intensity comparisons revealed that larger distances consistently had significantly higher velocities (d = 0.67 to d = 5.91). High-intensity efforts over large distances were notably shorter than their low-intensity counterparts, both in standing (d = 1.75 to d = 1.98) and rolling (d = 0.64 to d = 0.82) effort types. In essence, elite futsal players predominantly engage in rolling accelerations and decelerations within short distances, exhibiting average speeds below 3 m·s−2. This insight into the nuanced dynamics of player movements provides valuable information for optimising training regimens and enhancing performance in elite futsal competitions.

Clinical Practice Guidelines to Support Capacity Building in Orthopaedic Surgical Outreach: An International Consensus Building Approach.

Surgical outreach to low- and middle-income countries (LMICs) by organizations from high- income countries is on the rise to help address the growing burden of conditions warranting surgery. However, concerns remain about the impact and sustainability of such outreach. Leading organizations (e.g., the World Health Organization) advocate for a capacity-building approach to ensure the safety, quality, and sustainability of the local health-care system. Despite this, to our knowledge, no guidelines exist to inform such efforts. We aimed to develop clinical practice guidelines (CPGs) to support capacity-building in orthopaedic surgical outreach utilizing a multistakeholder and international voting panel. We followed a modified American Academy of Orthopaedic Surgeons (AAOS) CPG development process. We systematically reviewed the existing literature across 7 predefined capacity-building domains (partnership, professional development, governance, community impact, finance, coordination, and culture). A writing panel composed of 6 orthopaedic surgeons with extensive experience in surgical outreach reviewed the existing literature and developed a consensus-based CPG for each domain. We created an international voting panel of orthopaedic surgeons and administrators who have leadership roles in outreach organizations or hospitals with which outreach organizations partner. Members individually reviewed the CPGs and voted to approve or disapprove each guideline. A CPG was considered approved if >80% of panel members voted to approve it. An international voting panel of 14 surgeons and administrators from 6 countries approved all 7 of the CPGs. Each CPG provides recommendations for capacity-building in a specific domain. For example, in the domain of partnership, the CPG recommends the development of a documented plan for ongoing, bidirectional partnership between the outreach organization and the local team. In the domain of professional development, the CPG recommends the development of a needs-based curriculum focused on both surgical and nonsurgical patient care utilizing didactic and hands-on techniques. As orthopaedic surgical outreach grows, best-practice CPGs to inform capacity-building initiatives can help to ensure that resources and efforts are optimized to support the sustainability of care delivery at local sites. These guidelines can be reviewed and updated in the future as evidence that supports capacity-building in LMICs evolves.The global burden of disease warranting surgery is substantial, and morbidity and mortality from otherwise treatable conditions remain disproportionately high in low- and middle-income countries (LMICs)1,2. It is estimated that up to 2 million (about 40%) of injury-related deaths in LMICs could be avoided annually if mortality rates were reduced to the level of those in high-income countries (HICs)3. Despite this, progress toward improved access to safe, timely surgery in resource-poor areas has been slow. Historically, nongovernmental organizations (NGOs) have tried to address unmet surgical needs through short-term outreach trips; however, growing criticism has highlighted the limitations of short-term trips, including limited follow-up, an increased burden on the local workforce, and further depletion of local resources4-6. In light of ongoing concerns, public health priorities have shifted toward models that emphasize long-term capacity-building rather than short-term care delivery. Capacity-building is an approach to health-care development that builds independence through infrastructure development, sustainability, and enhanced problem-solving while taking context into account7,8.

Calcipotriol Nanosuspension-Loaded Trilayer Dissolving Microneedle Patches for the Treatment of Psoriasis: In Vitro Delivery and In Vivo Antipsoriatic Activity Studies.

Psoriasis, affecting 2-3% of the global population, is a chronic inflammatory skin condition without a definitive cure. Current treatments focus on managing symptoms. Recognizing the need for innovative drug delivery methods to enhance patient adherence, this study explores a new approach using calcipotriol monohydrate (CPM), a primary topical treatment for psoriasis. Despite its effectiveness, CPM's therapeutic potential is often limited by factors like the greasiness of topical applications, poor skin permeability, low skin retention, and lack of controlled delivery. To overcome these challenges, the study introduces CPM in the form of nanosuspensions (NSs), characterized by an average particle size of 211 ± 2 nm. These CPM NSs are then incorporated into a trilayer dissolving microneedle patch (MAP) made from poly(vinylpyrrolidone) and w poly(vinyl alcohol) as needle arrays and prefrom 3D printed polylactic acid backing layer. This MAP features rapidly dissolving tips and exhibits good mechanical properties and insertion capability with delivery efficiency compared to the conventional Daivonex ointment. The effectiveness of this novel MAP was tested on Sprague-Dawley rats with imiquimod-induced psoriasis, demonstrating efficacy comparable to the marketed ointment. This innovative trilayer dissolving MAP represents a promising new local delivery system for calcipotriol, potentially revolutionizing psoriasis treatment by enhancing drug delivery and patient compliance.

Pediatric anesthesia outreach in low and middle-income countries: Models, motives, and moral misalignments.

A lack of anesthesia and surgical capacity leaves approximately 1.7 billion children per annum without access to surgical and anesthetic care. Over the past 50 years, the predominant strategy to address this lack of access has been to provide surgical capacity primarily from high-income countries (HICs) to low and middle-income countries (LMICs) in the form of short-term surgical missions. More recently, the international medical community has recognized the need to build sustainable surgical capacity in resource-constrained settings. This article reviews three models of surgical aid: the vertical model (short-term surgical missions); the horizontal model (system-wide capacity building); and the diagonal model, which is a hybrid of the first two. At their core, medical aid interventions exist on a spectrum ranging from providing surgical capacity to building surgical capacity. The skills, attitudes, and behaviors that drive success in providing medical capacity are fundamentally different from those that drive success in building medical capacity. The root cause of this difference is a shift in the moral duty of the visiting physician from a duty solely to the patient in front of them (based on the primacy of the doctor-patient relationship) to include a duty to the local physicians and the local medical system, and by extension to the next 10 000 patients in need of care. Failure to address the conflicts engendered by this fundamental moral shift risks undermining capacity-building efforts in all models of medical aid.

Calibration and pose measurement of a combined vision sensor system for industrial robot grasping of brackets

Recently, visual sensing measurement and its application in industrial robot operations have been widely researched, promoting the development of instrumentation and automation. This study proposes a combined vision sensor system for robot grasping, focusing on combined sensor system calibration and bracket pose measurements. The system configuration and working strategy of the combined vision system are introduced. Thereafter, the calibration of the combined vision coordinate systems is presented, wherein a global vision system acts as the external measuring equipment for accurately calibrating the local vision. Furthermore, a pose estimation method using a local vision system (LVS) is proposed, including morphology-based image enhancement and principal component analysis based corner recognition methods. Verification experiments, including combined calibration and bracket pose measurements, were performed to validate the effectiveness and accuracy of the proposed combined vision measurement strategy. The results demonstrated that the proposed system applies to industrial robot grasping of brackets. In addition, the proposed robot-sensor calibration method improves calibration accuracy. Finally, the proposed corner detection method is effective and accurate for different bracket detection applications. This study provides a system that improves robot grasping results by considering key factors, such as vision measurement accuracy, and calibration methods.

Towards a shared understanding of the learning health system in a large academic-based health system: A qualitative analysis.

Healthcare delivery is currently undergoing major structural reform, and the Learning Health System (LHS) has been proposed as an aspirational model to guide healthcare transformation. As efforts to build LHS take considerable investment from health systems, it is critical to understand their leaders' perspectives on the rationale for pursuing an LHS and the potential benefits for doing so. This paper describes the qualitative analysis of semi-structured interviews (n = 17) with health system leaders about their general perceptions of the LHS, description of key attributes and potential benefits, and perception of barriers to and facilitators for advancing the model. Participants universally endorsed the goal of the local health system aspiring to become an LHS. Participants identified many recognized attributes of LHS, though they emphasized unique attributes and potential benefits. There was also heterogeneity in participants' views on what to prioritize, how to structure the local LHS within existing initiatives, and how new initiatives should be implemented. Improving conceptual clarity of attributes of the LHS would improve its potential in guiding future reform.

Experimental study on the punching failure model of soft red rock subgrade by BPT-BVM methods and it’s assessment of the load bearing capacity

The recommended bearing capacity of medium weathering mudstone foundation is less than the capacity of the rock structure to withstand loads in Southwest China. A comprehensive failure characterization of medium weathering mudstone in Chengdu has been performed including bearing plate test (BPT), binocular vision measurement (BVM) test, uniaxial compressive strength test, trial trench test of shallow rock surface and 3D imaging in this paper. Failure behavior of rock has been modeled with 3D imaging algorithm that utilizes Zhang’s calibration method in BVM system combination with trial trench test of shallow rock surface. The bearing capacity of medium weathering mudstone foundation were extracted from uniaxial experiments and BPT-BVM test by fitting relevant material properties to the data. The results revealed that: Bearing capacity of medium weathering mudstone of layered isotropic in Chengdu is undervalued. Specifically, the characteristic load carrying value is in the range 1500–2500 kP, that is 50% higher than in the local standard system. Failure process is different from Hoek–Brown Failure Criterion, presenting a wave peak transfer phenomenon of the increment displacement into the distance. Thus, it can be reduced to that of punching failures for thin bedded structures of Moudstone foundations. Compressive strength of soft rock proves to be main factor limiting the bearing capacity, a clear correlation between the uniaxial compressive strength reduction coefficient and the bearing capacity has been used to establish, leading to the proposal of a load bearing capacity prediction model.

Co-existence of potentially sustainable indigenous food systems and poor nutritional status in Ho indigenous community, India: an exploratory study

Co-existence of potentially sustainable indigenous food systems and poor nutritional status in Ho indigenous community, India: an exploratory study

Building an inclusive ecosystem for minority and women entrepreneurs: A case study of Columbus

We all agree that it is essential to build an inclusive entrepreneurship ecosystem for all kinds of people, particularly minority and women entrepreneurs, as the past studies are clear to demonstrate underperformance of those demographic groups. At the same time, we are only beginning to understand what kind of systemic barriers exist for women or minority entrepreneurs at the regional system level. Furthermore, it requires a different set of knowledge about how we can practically create an inclusive ecosystem. This paper applies the concept of equity planning for the context of economic development. This paper examines a case study of the City of Columbus, Ohio, in 2018–2019 in which the City Government actively promoted to build an inclusive ecosystem for women and minority entrepreneurs. We induce five essential steps that we could learn from this inclusionary practice which provide tangible implications for other city governments, nonprofit organizations, foundations, and other stakeholders of local entrepreneurship systems.

SLM-SLAM: A Visual SLAM System Based on Segmented Large-Scale Model in Dynamic Scenes and Zero-shot Conditions

Abstract In the real world, the presence of various dynamic objects can impact the localization accuracy of the majority of typical Visual Simultaneous Localization and Mapping (VSLAM) systems. Simultaneously, many dynamic VSLAM systems based on neural networks require pre-training for specific application scenarios. We present SLM-SLAM, the first VSLAM system that implements zero-shot processing of dynamic scenes. It achieves the capability to handle various dynamic objects without the necessity for pre-training, enabling straightforward adaptation to different application scenarios. Firstly, we designed an open-world semantic segmentation module based on a segmented large-scale model to acquire semantic information in the scene. Subsequently, we devised a label-based strategy for selecting feature points, jointly optimizing poses with the weighted labels provided by both semantic and geometric information. Finally, we refined the keyframe selection strategy of ORB-SLAM3 to prevent matching errors caused by an insufficient number of remaining static feature points in the scene. We conducted experiments on the TUM dataset, the KITTI dataset, and real world scenarios. The results indicate that in dynamic scenes, our SLM-SLAM significantly improves localization accuracy compared to ORB-SLAM3, and its performance is comparable to state-of-the-art dynamic VSLAM systems.

Information propagation of focus wave mode localized waves in anisotropic turbulent seawater

The evolution of the information transfer capability of an optical system for underwater focused wave mode localized wave (FWMLW) in anisotropic weakly turbulent absorbing seawater is studied. By developing the probability distribution function as well as the detection probability of the vortex modes carried by the FWMLW and the average bit error rate of the FWMLW underwater system, the information capacity of the FWMLW system with a pointing error is modeled. Through a numerical analysis of the effects of turbulent seawater and optical system parameters on the built light intensity, the detection probability, and the information capacity models, we find that the FWMLW system has an optimal delay time determined by the spectrum bandwidth when the spectrum bandwidth is greater than 1. The information capacity of the FWMLW system is higher than that of the X localized wave system under the same turbulent seawater channel condition, and FWMLW is a better optical signal source for vortex mode division multiplexing underwater systems than a Bessel–Gaussian beam.

A Vision/Inertial Navigation/Global Navigation Satellite Integrated System for Relative and Absolute Localization in Land Vehicles

This paper presents an enhanced ground vehicle localization method designed to address the challenges associated with state estimation for autonomous vehicles operating in diverse environments. The focus is specifically on the precise localization of position and orientation in both local and global coordinate systems. The proposed approach integrates local estimates generated by existing visual–inertial odometry (VIO) methods into global position information obtained from the Global Navigation Satellite System (GNSS). This integration is achieved through optimizing fusion in a pose graph, ensuring precise local estimation and drift-free global position estimation. Considering the inherent complexities in autonomous driving scenarios, such as the potential failures of a visual–inertial navigation system (VINS) and restrictions on GNSS signals in urban canyons, leading to disruptions in localization outcomes, we introduce an adaptive fusion mechanism. This mechanism allows seamless switching between three modes: utilizing only VINS, using only GNSS, and normal fusion. The effectiveness of the proposed algorithm is demonstrated through rigorous testing in the Carla simulation environment and challenging UrbanNav scenarios. The evaluation includes both qualitative and quantitative analyses, revealing that the method exhibits robustness and accuracy.

Long-Time Assessment of the Organic Farmer’s Market in Granada (Spain)

In recent years the world has seen an increase in the popularity of farmer’s markets, short food supply chains and local food systems. This growth can be attributed to the public’s growing consciousness of the impracticality of the global food system, globalization’s waste of fossil fuels, the fear of food chemicals, and small farmers’ desire to directly sell their products, among other things. Although there are a wealth of farmer’s market surveys and research on this topic that has been conducted over the past decades around the world, scant data have been collected about farmer’s markets in the south of Spain. This study focuses on the organic farmer’s market in Granada (Spain) and consists of five surveys developed in 8 years which are analyzed to help better understand this market that was first established in the Spring of 2013. It will also consider research on farmer’s markets in Europe and beyond in order to compare the situation of the Granada market as well as bringing in some new ideas of how it can be improved.

Driving innovation in energy and telecommunications: next-generation energy storage and 5G technology for enhanced connectivity and energy solutions

Driving innovation in energy and telecommunications involves leveraging next-generation energy storage and 5G technology to enhance connectivity and energy solutions. This review explores the intersection of these two domains, highlighting the importance of advancements in energy storage and 5G technology for a sustainable and connected future. Energy storage is crucial for balancing the supply and demand of electricity in modern power systems. Traditional energy storage methods, such as batteries and pumped hydro, have limitations in terms of scalability, efficiency, and cost-effectiveness. Next-generation energy storage technologies, including advanced batteries, hydrogen storage, and thermal storage, offer promising solutions to overcome these limitations. These technologies enable efficient energy storage at scale, facilitating the integration of renewable energy sources like solar and wind into the grid. By storing excess energy generated during periods of low demand, next-generation energy storage systems ensure a reliable and stable power supply, reducing the reliance on fossil fuels and lowering greenhouse gas emissions. In parallel, the evolution of telecommunications technology, particularly the advent of 5G networks, is revolutionizing connectivity and communication. 5G technology offers significantly higher data transfer speeds, lower latency, and increased network capacity compared to its predecessors. These capabilities are essential for supporting emerging technologies such as the Internet of Things (IoT), autonomous vehicles, and smart grids. With 5G-enabled IoT devices, utilities can monitor energy consumption in real-time, optimize grid operations, and detect and respond to faults more efficiently. Moreover, 5G connectivity enhances the efficiency and reliability of energy storage systems by enabling seamless communication between distributed energy resources and grid operators. The convergence of next-generation energy storage and 5G technology presents numerous opportunities for driving innovation in both energy and telecommunications sectors. One of the key areas of innovation is the development of smart energy storage systems equipped with 5G connectivity. These systems can autonomously adjust their operation based on grid conditions, weather forecasts, and energy demand patterns, optimizing energy storage and distribution in real-time. Furthermore, advanced energy management algorithms leveraging artificial intelligence (AI) and machine learning (ML) algorithms can optimize energy usage and storage, further improving the efficiency and reliability of the grid. Another area of innovation lies in the integration of renewable energy resources with 5G-enabled microgrids. Microgrids are localized energy systems that can operate independently or in conjunction with the main grid. By combining renewable energy sources with energy storage and 5G-enabled communication, microgrids can provide reliable, clean, and resilient power to remote or urban areas. These microgrids can also facilitate peer-to-peer energy trading, allowing consumers to buy and sell excess energy within their communities, fostering energy independence and sustainability. Furthermore, advancements in battery technology, such as solid-state batteries and flow batteries, are enhancing the performance and reliability of energy storage systems. Solid-state batteries offer higher energy density, faster charging rates, and improved safety compared to conventional lithium-ion batteries. Flow batteries, on the other hand, provide scalability and long-duration storage capabilities, making them suitable for grid-scale applications. Integrating these advanced battery technologies with 5G-enabled monitoring and control systems enhances the overall resilience and flexibility of the energy infrastructure. In addition to technological advancements, driving innovation in energy and telecommunications requires collaboration among various stakeholders, including policymakers, regulators, industry players, and research institutions. Policies and regulations should incentivize the deployment of next-generation energy storage and 5G infrastructure, promote interoperability standards, and ensure data privacy and security. Public-private partnerships can facilitate the investment and deployment of innovative solutions, while research and development initiatives can spur further technological advancements. Driving innovation in energy and telecommunications through next-generation energy storage and 5G technology is essential for building a sustainable, connected, and resilient future. By leveraging advanced energy storage systems, smart grids, and 5G-enabled communication networks, we can optimize energy usage, reduce carbon emissions, and enhance the reliability and efficiency of our energy infrastructure. Collaboration and investment across various sectors are key to unlocking the full potential of these transformative technologies and achieving a brighter, more sustainable future for generations to come. Keywords: Innovation, Energy, Telecommunications, Next-Generation, 5G technology, Enhanced connectivity.

Unlocking carbon finance: Empowering energy communities for mutual benefit

This study investigates the potential of utilizing carbon credits to finance innovative local energy communities in Europe, addressing a significant gap in academic literature. Despite the growing interest in voluntary carbon credits as a mechanism for offsetting carbon emissions, there is limited evidence connecting local energy systems to voluntary carbon markets. The study explores whether carbon credits could serve as a practical tool for funding the development of energy communities, contributing to sustainable energy transitions and climate mitigation strategies. The research employs a comprehensive methodology to assess the quality of carbon credit projects and examines ten innovative energy community projects in Europe. Key findings reveal there is potential for using carbon credits to finance energy community initiatives. However, challenges persist, particularly regarding financing barriers and the volatile nature of carbon markets. The study underscores the importance of policy support in establishing clear standards for voluntary markets and promoting the accessibility of carbon offsets. Furthermore, it suggests potential solutions such as pre-financing agreements and the utilization of carbon market derivatives to enhance project viability. Overall, the study offers insights into the intersection between voluntary carbon markets and local energy initiatives, providing a foundation for further research and policy development in the field of local sustainable development and climate change mitigation.

Dose Optimization of Intravenous Indocyanine Green for Malignant Lung Tumor Localization

Background: Intravenously administered indocyanine green (ICG) accumulates in lung tumors, facilitating their detection via a fluorescence spectrum measurement. This method aids in identifying tumor locations that are invisible to the naked eye. We aim to determine the optimal ICG dose and administration method for accurate tumor identification during lung resection surgeries, utilizing a novel ICG fluorescence spectroscopy system for precise tumor localization. Materials and Methods: ICG should be dissolved in the provided solution or distilled water and administered intravenously approximately 24 h before surgery, beginning with an initial dose of 0.5 mg/kg. If the tumor detection rate is insufficient, the dose may be gradually increased to a maximum of 5.0 mg/kg to determine the optimal dosage for effective tumor detection. This fluorescence spectroscopy during surgery may reveal additional lesions that remain undetected in preoperative assessments. The primary endpoint includes the correct diagnostic rate of tumor localization. The secondary endpoints include the measurement of the intraoperative ICG fluorescence spectral intensity in lung tumors, the assessment of the operability and safety of intraperitoneal ICG administrations, the measurement of the ICG fluorescence spectral intensity in surgical specimens, the comparison of the spectral intensity in lung tissues during collapse and expansion, the correlation between ICG camera images and fluorescence spectral intensity, and the comparison of fluorescence analysis results with histopathological findings. The trial has been registered in the jRCT Clinical Trials Registry under the code jRCTs011230037. Results and Conclusions: This trial aims to establish an effective methodology for localizing and diagnosing malignant lung tumors, thereby potentially improving surgical outcomes and refining treatment protocols.

The Impact of COVID-19 on Consumer Perceptions of Local Food Market Channels

The COVID-19 pandemic had a profound impact on food systems. Despite disrupting conventional markets—such as grocery stores—farmers that focused on short supply chains found new market opportunities. As consumers increasingly became concerned with the safety of in-person shopping, some turned to purchasing directly from farmers and markets that carried products marketed as local, organic, and/or sustainable. With these changes in mind, I ask how consumer perceptions of local food systems (LFSs) changed in the two years after COVID-19. If consumers are more aware of local markets, farmers might reorient production to focus on local supply chains and sustainable production methods. To evaluate consumer perceptions, I use survey responses from residents in five communities in the US South in 2019 and 2022. Using a treatment effects model with propensity score matching, I show that residents became more aware of most local market channels, such as specialty retail stores and Community Supported Agriculture (CSA). Some residents were also more likely to have a positive perception of markets that provide fresh vegetables to low-income residents. Finally, residents wanted more investment into markets that make fresh, local products more available, such as community-owned groceries and CSA.

Translating government policy into practice: How new UK medical schools enact widening participation.

Increasing the diversity of medical students, or widening participation (WP), is critical for social justice and healthcare delivery, and many governments are setting policies to encourage WP. However, establishing policy is only the first step in an educational change process: we also need to know "how" policy is enacted or how medical schools interpret and put into practice WP policy. Addressing this gap, the aim of this study was to examine policy enactment in six new UK medical schools with an explicit WP mandate. This qualitative study, underpinned by social constructivism, used semi-structured interviews to explore the experiences of key actors (6 Deans and 14 Admissions staff) of putting policy into practice when setting up a new medical school. Data coding and analysis were initially inductive, using thematic analysis. We then applied Ball's theory of policy enactment to organise the data into four contextual dimensions of 'situation', 'professional', 'material' and 'external'. On the surface, there were many similarities across the six schools in terms of the four dimensions. However, how these dimensions interacted illuminated tensions and differences. For example, some schools found themselves increasingly subjected to local and extra-local rule systems, including pressure to follow host university norms and hosts struggling to accept that medical schools are heavily regulated. There were also tensions between the new medical schools and the medical education "establishment", including lack of power and being judged by overly narrow outcomes. Different contexts seem to influence the enactment of WP to medicine in different places, even in the same country, even in medical schools established at the same time. That policy enactment is a complex, non-linear process of enactment is important to acknowledge: context is critical. Our findings will inform future policies and practices that aim to increase WP in medicine.

OPT-In; Optimized Patient Treatment Outcomes in Plaque Psoriasis: A 3-Year State-Transition Treatment-Sequencing Model in the Italian Setting.

There are several treatment options for plaque psoriasis (PsO), but uncertainty remains around the optimal sequencing of treatments. The aims of this study were to investigate how adopting a best-treatment-first treatment sequence impacts patient outcomes and healthcare systems and to quantify the cost of treatment failure to the healthcare system. A 3-year state-transition treatment-sequencing model which identifies all possible treatment sequences in PsO was adapted to the Italian healthcare setting. Treatments considered in the model are those with European Medicines Agency marketing authorization and reimbursement in Italy as of December 2022. Italian market share data (2019-2021) and list prices (2022) informed the current prescribed sequences; these sequences were compared against all possible sequences to determine opportunities for improvement. Both the national perspective in Italy as well as the local perspective from seven regions were considered. The cost of treatment failure was informed through a questionnaire circulated to Italian dermatologists. Overall, 1284 possible treatment sequences are possible when four lines of treatment are considered for patients with moderate-to-severe PsO in Italy. Within the estimated range of treatment failures across those sequences (0.97-2.56 per patient over 3 years), current prescribing behavior from the national perspective suggests patients will face 1.44 failures on average; this highlights the potential for improvement. For every treatment failure, the cost borne by the Italian National Healthcare Service (NHS) is €676.80. Overall, prescribing more optimized treatment sequences results in a 22.95% reduction in failures with a 2.27% increase in costs. The regional analyses found similar trends. Results suggest that selecting the most effective treatment sequences for incident patients provides the greatest opportunity to reduce treatment failures and maximize patient outcomes with a modest impact on costs. While regional variations exist, there is room for improvement across the board, which could translate to more efficient local healthcare systems.