Medical Practice Research Articles

Analysis of Barriers to Medical Opioid Pain Medication Using the Japanese Version of the Barriers Questionnaire II (JBQ-II): Pharmacists and Nurses Perspective in Japan

Background Some Japanese patients with cancer pain have negative beliefs regarding opioid therapy. The Japanese version of the Barriers Questionnaire II (JBQ-II) determines barriers to cancer pain management. Few studies reported JBQ-II scores in Japan, and none focused on pharmacists. Accordingly, we aimed to explore the relationship between health care professionals’ knowledge of and willingness to use opioids, and their JBQ-II scores. Additionally, the variances in JBQ-II scores among nurses, hospital pharmacists, and pharmacy pharmacists were assessed. Methods This cross-sectional survey employed the JBQ-II for nurses and pharmacists in hospitals and pharmacies across Japan. Participants were requested to respond to the JBQ-II concerning their affiliation, knowledge of opioid analgesics, and willingness to utilize these drugs for medical practice. Results A total of 55 hospital pharmacists, 25 pharmacy pharmacists, and 24 nurses responded to the survey. The group-knowledgeable about medical use of narcotics had significantly lower total JBQ-II scores (25.43, standard deviation [SD]: 15.11) than those had by the group with insufficient knowledge (34.50, SD: 18.41). There was no statistically significant difference in total JBQ-II scores among those willing to use opioids medically. The total JBQ-II scores of hospital pharmacists, pharmacy pharmacists, and nurses were 31.00 (SD: 15.11), 33.96 (SD: 19.25), and 27.21 (SD: 15.56), respectively. However, the differences were not statistically significant. Conclusions Health care professionals in Japan with knowledge about opioids for medical purposes had a significantly lower total JBQ-II score than those with insufficient knowledge. Thus, health care professionals’ knowledge plays a crucial role in reducing barriers to using narcotic drugs.

In-depth exploration of the radiation exposure to staff performing endoscopic retrograde cholangiopancreatography procedures (ERCP) through RANDO phantom and TLDs.

This study provides a comprehensive evaluation of the occupational radiation exposure faced by healthcare professionals during Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures. Utilizing an anthropomorphic RANDO phantom equipped with Thermoluminescent Dosimeters (TLDs), we replicated ERCP scenarios to measure radiation doses received by medical staff. The study meticulously assessed radiation exposure in various corresponding body regions typically occupied by medical staff during ERCP, with a focus on eyes, thyroid, hands, and reproductive corresponding organ regions. The findings revealed significant variations in radiation doses across different body parts, highlighting areas of higher exposure and underscoring the need for improved protective measures and procedural adjustments. The effective radiation doses were calculated using standard protocols, considering the varying levels of protection offered by lead aprons and thyroid shields. The results demonstrate the substantial radiation exposure experienced by healthcare staff, particularly in regions not adequately shielded. This study emphasizes the necessity for enhanced radiation safety protocols in clinical settings, advocating for advanced protective equipment, training in radiation safety, and the exploration of alternative imaging modalities. The findings have crucial implications for both patient and staff safety, ensuring the continued efficacy and safety of ERCP and similar interventional procedures. This research contributes significantly to the field of occupational health and safety in interventional radiology, providing vital data for the development of safer medical practices.

Can the spirit of motivational interviewing be taught online? A comparative study in general practitioners.

ObjectiveMotivational Interviewing (MI) is an evidence-based approach to enhance patients' motivation and is increasingly in demand in medical practice. Online teaching methods offer advantages to train health care professionals, but only very few studies examined whether MI-specific interviewing skills (""MI-skills""), and especially MIspecific attitudes (the "MI-spirit"), can be taught online and whether learning gains differ from those in face-to-face courses. This study compared the effects of 7 h of basic training for experienced general practitioners (GP) in either an online or a traditional face-to-face format with a non-trained control group. Methods"MI-skills" and "MI-spirit" were measured in a prospective analysis in 49 experienced GPs before and one week after training ResultsAn ANOVA on gain-scores demonstrated significant differences between groups in both MI-specific skills (VASE-R, p = 0.006) and "MIspirit" (MIKAT, p = 0.029; HRQ, p < 0.001) from pre- to posttest. Post-hoc comparisons revealed significant improvement only in the training groups (VASE-R, p < 0.001; MIKAT, p = 0.014 for online, p = 0.003 for face-to-face; HRQ, p < 0.001). ConclusionThe results suggest similar effects of both online and face-to-face training of "MI-skills" and "MI-spirit" to GPs. Practice Implication: Online learning opportunities should be integrated in MIT programs for general practitioners where appropriate.

Exploring the potential of fennel (&lt;i&gt;Foeniculum vulgare&lt;/i&gt; Mill.) as a valuable medicinal plant: a comprehensive (review)

Introduction. Foeniculum vulgare Mill., commonly known as fennel or drugstore dill, is very common as one of the world's oldest spice plants, which has significant economic importance and wide application in the pharmaceutical industry. In medical practice, the fruits of this plant are mainly used, which are included in the State Pharmacopoeia of the XIV edition and are a source of essential oil. They are used as an antispasmodic and carminative agent in the form of an infusion. Fennel grass harvested before flowering is used for food, as well as fruits, stems and inflorescences of the plant as a seasoning.Text. The purpose of this study is to summarize scientific papers on the morphological characteristics, phytochemical compounds, therapeutic properties and basic mechanisms of pharmacological activity of F. vulgare. A systematic literature search was conducted using relevant keywords such as "fennel", "Foeniculum vulgare Mill.", "therapeutic" and "pharmacology" in well-known databases, including ScienceDirect, Scopus, EBSCO and Medline. The search covered articles published before April 25, 2023 in available journals. The results of the study showed that fennel has a wide range of pharmacological properties, including antioxidant, anti-cancer, anti-inflammatory, antifungal, antibacterial and estrogenic effects. These effects can be explained by the presence of aromatic compounds, in particular anethole, estragole and fenchone, which are abundantly present in fennel.Conclusion. The diverse pharmacological properties and rich chemical composition of fennel make it a promising raw material for the development of new medicines. Further study of the therapeutic potential of fennel through in vivo and in vitro studies will contribute to the establishment of mechanisms of pharmacological action of biologically active substances (BAS) of fennel.

Tramadol/Diclofenac Fixed-Dose Combination for Acute Pain Management: Bioavailability Assessment of a Generic Product.

The multimodal analgesia strategy for acute pain involves using 2 or more analgesic medications with distinct mechanisms of action. This study assessed the bioavailability and tolerability of 2 tramadol hydrochloride (50mg)/diclofenac sodium (50mg) fixed-dose combination formulations under fed conditions to attend the Brazilian regulatory requirements for generic product registration. An open-label, randomized, single-dose, 2-period, 2-way crossover trial was conducted, including healthy subjects of both sexes. Subjects received a single dose of either the test or reference formulation of tramadol/diclofenac fixed-dose combination tablets with a 7-day washout period. Blood samples were collected up to 36hours after dosing for tramadol and 12hours for diclofenac and quantified using a validated liquid chromatography-tandem mass spectrometry method. Of 56 subjects enrolled, 53 completed the study. The 90% confidence intervals for maximum plasma concentration and area under the concentration-time curve from time 0 to the last quantifiable concentration were within acceptable bioequivalence limits of 80%-125%. Considering the results presented in this study, the test formulation is bioequivalent to the reference formulation and could be interchangeable in medical practice.

The use of photodynamic therapy in medical practice

Cancer therapy, especially for tumors near sensitive areas, demands precise treatment. This review explores photodynamic therapy (PDT), a method leveraging photosensitizers (PS), specific wavelength light, and oxygen to target cancer effectively. Recent advancements affirm PDT’s efficacy, utilizing ROS generation to induce cancer cell death. With a history spanning over decades, PDT’s dynamic evolution has expanded its application across dermatology, oncology, and dentistry. This review aims to dissect PDT’s principles, from its inception to contemporary medical applications, highlighting its role in modern cancer treatment strategies.

ANALYSIS OF THE FORM AND SURFACE OF DENTAL IMPLANTS

The aim of the work – to study the peculiarities of the shape and surface relief of the main types of dental implants. Materials and methods. 12 dental implants used in the medical practice of Ukrainian dental clinics were studied. The study of the shape and surface relief of the implants was carried out using a scanning electron microscope GSM-649 (Japan). Results. All implants in the apical part have the shape of a cone with threads and cutting grooves. The thread with a large profile is located in the apical part of the implant, has an average pitch of turns of 1.1±0.05 mm and a profile height of 0.3±0.02 mm. The thread with a small profile is located in the part of the implant near the neck, has a pitch of 0.4±0.02 mm and a profile height of 0.1±0.02 mm. The thread pitch of implants with a single profile is 0.8±0.05 mm, and the height of the profile is 0.2±0.01 mm. Threads with a triangular profile have a profile angle of 50.0±2.9 degrees. The highest roughness is the surface of the top of the fine profile thread with the height of micro-uniformities from 7.0±2.2 to 36.0±8.3 μm, the smallest roughness with the height of micro-uniformities from 3.0±1.1 to 14.0±6.1 μm have surface areas in the area of the implant neck. Conclusions. 50% of the examined implants were made with two thread profiles: a large one in the apical side and a small one closer to the neck, 50% – with the same thread profile from the apical end to the neck. In most implants, the thread with a small profile is made in the form of annular grooves. The large thread of the implants had a rectangular, rounded and triangular profile with one or two steps. In some implants, as they approach the neck, the shape changes and the height of the thread profile decreases. The shape of the profile of small threads in all implants was close to rounded. The implants had different surface roughness. The highest roughness was recorded on the surface of the top of the small profile thread, and the lowest – in the area without a thread in the area of the implant neck.

INTESTINAL PARASITISM IN WORKING HORSES AND ASSOCIATED ZOONOTIC RISKS IN LOWLANDS OF NEPAL

The presence of intestinal parasites influences equines' well-being and working performance. However, the scenario of parasitism in working horses in the lowlands of Nepal is yet to be explored. The present study aimed to reveal the prevalence and diversity of intestinal parasites (protozoa and helminths) and to list the zoonotic species in working horses in the lowlands of Nepal. Fresh fecal samples (N=102) from horses were collected at two locations (Chitwan and Birgunj) in the lowlands of Terai and were transferred to the research laboratory. Coproscopy was carried out via direct wet mount, formalin ethyl acetate (FEA) sedimentation, saturated salt flotation, and acid-fast staining techniques. Coproscopy revealed an overall prevalence rate of 90.2% (92/102) with 15 known diverse species of parasites (Protozoa: 5 and Helminths: 10) and an unknown coccidian, out of which eight possess zoonotic potential. The prevalence and diversity of intestinal parasites were higher in adult than in young animals (90.7%; 15 spp. vs. 88.9%; 11 spp.) The overall prevalence of helminths was double that of protozoa (89.2% vs. 43.1%). Furthermore, polyparasitism was much more prevalent than monoparasitism (85.3% vs 4.9%). Co-infection with two parasite species (37%) was higher in young horses. In comparison, triplet infection (34%) was higher in adults, and a maximum concurrency of up to six species of parasites at a time was recorded. Following it, the differences in the prevalence rate of parasites based on the predictor of risks, like sex, grazing, domestication type, nature of the floor, and medication practices, were statistically significant. Working horses in the lowlands of Terai harbored a significant variety of intestinal parasites with important prevalence. Since eight of the reported parasitic species were zoonotic, infected horses pose a zoonotic risk to the owners. Therefore, timely deworming, pasture management, and reduction in working pressure are highly recommended.

The Role of Sports Medicine in Preventing and Managing Common Injuries in Athletes

Many international athletic organizations have proposed injury-reduction strategies. These practices include injury screening, emergency medical care, along with injury management measures prior to return-to-play. The extent to which these methods are being adopted in a developing nation like Iraq is uncertain. This paper was contributed to study the role of sports medicine in preventing and managing common injuries in athletes. Our paper focused on the role of sports medicine in treating injured athletes in Iraq. To build up, our methodology’s study was enrolled rate of acute injuries for 80 cases based on organized the demographic characteristics of sports players with three basics which are football, athletics, and handball. The data were analysed using the SPSS program. This study was presented a cumulative analysed and covered all 80 cases during period from 17th January 2022 to 19th March 2023.mThe findings demonstrated a lack of pre-season screening and return-to-play preparedness for all injured athletes. Furthermore, for the majority of injury categories, best practice standards were not followed. This study identified constraints, including sports resource providers' inadequate knowledge, insufficient and insufficiently specialized facilities for treating injured athletes, and policies mandating treatment for injured athletes. These obstacles hinder the implementation of best medical practices.

Modern Approaches to the Treatment of Acute Facial Pain.

Acute facial pain presents a complex challenge in medical practice, requiring a comprehensive and interdisciplinary approach to its management. This narrative review explores the contemporary landscape of treating acute facial pain, delving into pharmacological, non-pharmacological, and advanced interventions. The significance of tailored treatment strategies, rooted in the diverse etiologies of facial pain, such as dental infections, trigeminal neuralgia, temporomandibular joint disorders, sinusitis, or neurological conditions like migraines or cluster headaches, is underscored. We particularly emphasize recent advances in treating trigeminal neuralgia, elucidating current treatment concepts in managing this particular acute facial pain. Recent research sheds light on various treatment modalities for acute facial pain. Pharmacotherapy ranges from traditional NSAIDs and analgesics to anticonvulsants and antidepressants. Non-pharmacological interventions, including physical therapy and psychological approaches, play pivotal roles. Advanced interventions, such as nerve blocks and surgical procedures, are considered in cases of treatment resistance. Moreover, we explore innovative technologies like neuromodulation techniques and personalized medicine, offering promising avenues for optimizing treatment outcomes in acute facial pain management. Modern management of acute facial pain requires a nuanced and patient-centric approach. Tailoring treatment strategies to the individual's underlying condition is paramount. While pharmacotherapy remains a cornerstone, the integration of non-pharmacological interventions is essential for comprehensive care. Advanced interventions should be reserved for cases where conservative measures prove inadequate. Furthermore, leveraging innovative technologies and personalized medicine holds promise for enhancing treatment efficacy. Ultimately, a holistic approach that considers the diverse needs of patients is crucial for effectively addressing acute facial pain.

Categorization of the amyotrophic lateral sclerosis population via the clinical determinant of post-onset ΔFS for study design and medical practice.

The amyotrophic lateral sclerosis (ALS) functional rating scale-revised (ALSFRS-R) has become the most widely utilized measure of disease severity in patients with ALS, with change in ALSFRS-R from baseline being a trusted primary outcome measure in ALS clinical trials. This is despite the scale having several established limitations, and although alternative scales have been proposed, it is unlikely that these will displace ALSFRS-R in the foreseeable future. Here, we discuss the merits of delta FS (ΔFS), the slope or rate of ALSFRS-R decline over time, as a relevant tool for innovative ALS study design, with an as yet untapped potential for optimization of drug effectiveness and patient management. In our view, categorization of the ALS population via the clinical determinant of post-onset ΔFS is an important study design consideration. It serves not only as a critical stratification factor and basis for patient enrichment but also as a tool to explore differences in treatment response across the overall population; thereby, facilitating identification of responder subgroups. Moreover, because post-onset ΔFS is derived from information routinely collected as part of standard patient care and monitoring, it provides a suitable patient selection tool for treating physicians. Overall, post-onset ΔFS is a very attractive enrichment tool that is, can and should be regularly incorporated into ALS trial design.

EPortfolios: Enhancing confidence in student radiographers' communication of radiographic anatomy and pathology. Across-sectional study.

In 2020, the Medical Radiation Practice Board of Australia made several revisions to its professional capabilities. To address this, medical radiation practitioners, including diagnostic radiographers, are required to escalate urgent findings in all radiographic settings. However, the confidence of radiographers in articulating descriptions of radiographic findings varies despite this requirement. This cross-sectional study explores how the implementation of eportfolio affects student self-perceived confidence in identifying and describing radiographic findings in both an academic and a clinical setting. A Qualtrics survey was distributed to second-year radiography students who had used eportfolios. The survey comprised of four questions using a Likert-scale and one open-ended question. Quantitative data were analysed using the Wilcoxon signed-rank test and qualitative data was thematically assessed. Overall, 55 of 65 radiographic students (85%) completed the survey. Confidence (strongly agree and agree) decreased from 89% to 74% between academic and clinical environments when identifying abnormalities, and 89% to 73% when describing findings. This finding highlights the challenges students face when in the clinical environment. Wilcoxon signed rank test analysed a statistically significant relation between the two environments (P < 0.05). However, the relationship between identifying and describing skills was not statistically significant (P > 0.05). Following a review of the qualitative data, three recurring themes were identified among responses. ePortfolios assist in improving confidence in identification and description of radiographic abnormalities, particularly in an academic setting. The clinical environment presents unique challenges which may limit student clinical performance; however, this requires further investigation.

[Brain death: from the transformation of medical concept to the change of medical practice].

The implementation of death determination by clinicians usually involves three steps: learning the concept of death, mastering the skills of death determination, and recording the results of death determination. Each process needs to be changed with the progress of medical science. The transformation of brain death concept is the establishment and formation of the latest cognition of "irreversible brain function", which needs to be completed based on the theoretical learning of recognized standards. The transformation of brain death determination is the learning and mastering of the latest skills of brain death determination, which requires relearning and retraining based on special technologies. The transformation of brain death determination is the habit formation of standardized records of brain death judgement results, which needs to be completed based on the continuous improvement of case quality control. The gradual advancement of the three steps will accelerate the process of determining brain death in China.

Brain Tumor and Lung Disease Detection using Deep Learning

Brain Tumor and Lung Disease Detection using Deep Learning stands at the forefront of medical innovation, revolutionizing diagnostics with cutting-edge technology. Leveraging intricate algorithms and convolutional neural networks (CNNs), it automates the analysis of MRI scans for brain tumors and chest CT-Scans for lung diseases. Through meticulous feature extraction, this system precisely identifies diverse tumor types like glioma, meningioma, and pituitary tumors, along with lung pathologies such as bacterial pneumonia, viral pneumonia, and tuberculosis. By harnessing the power of deep learning, this ambitious project aims to significantly enhance diagnostic efficiency and accuracy, ushering in a new era in medical practice. Beyond expediting diagnoses, it holds promise in tailoring treatment strategies for improved patient care and treatment outcomes across neurology and pulmonology. Keywords: Brain Tumor Detection, Lung Disease Identification, Advanced Medical Diagnostics, Convolutional neural networks, Neural Network-based Diagnosis, Medical Diagnostics.

Informed Consent in Clinical Studies in the Republic of Srpska

As human medicine is developing at a galloping pace, continuously offering new medical products, diagnostic methods and preventive programmes, there is almost no time gap between their creation and application in medical practice. All these biomedical achievements are primarily intended to improve public health and the patient’s quality of life and health. Hence, it is important to define potential risks, side effects, and unwanted outcomes when applying a medical product/treatment before integrating it into healthcare. Unlike any other product/treatment intended for human use, medical products/treatments require prior clinical testing on human subjects (sick or sound). The authors of this paper have restricted their scientific interest to the participant (human subject) of a clinical study as one of the core elements of a clinical investigation, representing at the same time its means and its aim. By analyzing relevant international as well as national legal rules and ethical principles of the Republic of Srpska related to the participation of humans in clinical studies, it will be concluded that the participants’ safety and right to self-determination, integrity, and autonomy manifested through their independent right to either consent or refuse to participate in a clinical study supersedes the interests of science or society. However, clinical trial-related statistical data obtained from randomly chosen healthcare institutions in the Republic of Srpska will show certain derogations from prescribed ethical policies. Considering this fact, the authors have paid special attention to thematising the ethicality of recruiting participants for a clinical study based on partial or no information related to the purpose, methods, potential risks and side effects of the investigation in the name of the greater good for humanity. Such practice has accentuated the discretionary powers of ethical review committees on the one side and the uncertainty of the right to informed consent on the other.

Seeking help for atrial fibrillation: the role of the body in distributed decision making

We adopt Rapley's (2008) concept of distributed decision making to explore the role of the body in people's decisions to seek medical care. We conducted in-depth interviews with patients diagnosed with atrial fibrillation (AF) who were taking long-term anticoagulants to prevent stroke. We interviewed seventeen patients recruited from English anticoagulant clinics using the biographic-narrative-interpretive method, and conducted thematic, structural and metaphorical analyses. This pluralistic analysis focused on how distributed decision-making was enacted through a range of socio-material, relational and embodied practices. Participants told how they experienced AF-related sensations that fluctuated in intensity and form. Some had no symptoms at all; others experienced sudden incapacitation – these experiences shaped different journeys towards seeking medical help. We draw on work by Mol (2002) to show how the body was differently observed, experienced and done across contexts as the narratives unfolded. We show that as part of a relational assemblage, involving social, material and technological actors over time, a new body-in-need-of-help was enacted and medical help sought. This body-in-need-of-help was collectively discussed, interpreted and experienced through distribution of body parts, fluids and technological representations to shape decisions.RAPLEY T., 2008. Distributed decision making: the anatomy of decisions-in-action. Sociology of Health & Illness, 30, 429–444.MOL A., 2002. The body multiple: ontology in medical practice. Duke University Press: Durham.

Development and validation of machine learning models to predict unplanned hospitalizations of patients with diabetes within the next 12 months

BACKGROUND: The incidence of diabetes mellitus (DM) both in the Russian Federation and in the world has been steadily increasing for several decades. Stable population growth and current epidemiological characteristics of DM lead to enormous economic costs and significant social losses throughout the world. The disease often progresses with the development of specific complications, while significantly increasing the likelihood of hospitalization. The creation and inference of a machine learning model for predicting hospitalizations of patients with DM to an inpatient medical facility will make it possible to personalize the provision of medical care and optimize the load on the entire healthcare system.AIM: Development and validation of models for predicting unplanned hospitalizations of patients with diabetes due to the disease itself and its complications using machine learning algorithms and data from real clinical practice.MATERIALS AND METHODS: 170,141 depersonalized electronic health records of 23,742 diabetic patients were included in the study. Anamnestic, constitutional, clinical, instrumental and laboratory data, widely used in routine medical practice, were considered as potential predictors, a total of 33 signs. Logistic regression (LR), gradient boosting methods (LightGBM, XGBoost, CatBoost), decision tree-based methods (RandomForest and ExtraTrees), and a neural network-based algorithm (Multi-layer Perceptron) were compared. External validation was performed on the data of the separate region of Russian Federation.RESULTS: The best results and stability to external validation data were shown by the LightGBM model with an AUC of 0.818 (95% CI 0.802–0.834) in internal testing and 0.802 (95% CI 0.773–0.832) in external validation.CONCLUSION: The metrics of the best model were superior to previously published studies. The results of external validation showed the relative stability of the model to new data from another region, that reflects the possibility of the model’s application in real clinical practice.

Palliative care at the present stage in Krasnoyarsk

Palliative medicine, aimed at ensuring the quality of life of patients with severe and incurable diseases, is becoming increasingly important in medical practice. In this article, we consider the current state and prospects for the development of palliative medicine in the city of Krasnoyarsk. The study showed that the number of patients in need of palliative care is increasing, mainly people older than working age with diseases of the cardiovascular system and oncological diseases. Approaches to anesthesia, prevention and treatment of pressure sores in hospice patients are described. The problems include a lack of qualified personnel and violations of the socio-psychological status of medical personnel, limited access to palliative medicine for remote areas of the region.

Key aspects of developing standard operating procedures

In modern medical practice, standard operating procedures play a crucial role in ensuring quality medical care. The development and implementation of effective SOPs require a systematic approach and active participation of medical personnel. This article discusses the stages of developing standard operating procedures and outlines the fundamental principles of developing SOPs in healthcare institutions. Drawing on the successful experience of a State Budgetary Healthcare Institution «City Clinical Hospital №52 of the Moscow City Health Department», the authors highlight key aspects and provide recommendations based on practical experience for the implementation of standard procedures to enhance the efficiency and safety of medical care. The authors analyze the importance of standardizing processes in healthcare and discuss the key stages of creating and implementing SOPs, including forming professional teams, engaging experts, and justifying the legislative framework. The research findings can be valuable for methodologists, senior nurses, and healthcare institution leaders seeking to improve the quality of medical care through the systematization and standardization of operating procedures.

Practice recommendations for physiotherapists in Canada managing adverse events associated with acupuncture.

In Canada, acupuncture is a regulated medical practice that involves inserting thin needles at specific points on the body to alleviate pain and other health conditions. Acupuncture is a controlled act in physiotherapy practice. Therefore, physiotherapists who incorporate acupuncture into their practice should have the necessary education and roster this controlled act with the regulatory college in their province. Although acupuncture can be helpful, potential complications can arise, ranging from minor bruising to life-threatening conditions such as pneumothorax and cardiac tamponade. This article provides information on the potential adverse effects of acupuncture and provides recommendations for physiotherapists regarding prevention and management of any incidents that may arise during treatment.