Optimization Program Research Articles

Subthalamic Deep Brain Stimulation under General Anaesthesia for Parkinson's Disease: Institutional Experience and Outcomes.

Direct targeting in deep brain stimulation (DBS) has remarkably impacted the patient's experience throughout the surgery and the overall logistics of the procedure. When the individualised plan is co-registered with a 3D image acquired intraoperatively, the electrodes can be safely placed under general anaesthesia. How this applies to a general practice scenery (outside clinical trials and in a moderate caseload centre) has been scarcely reported. Prospective single-centre study of patients treated with asleep subthalamic DBS for Parkinson's disease between January 2021 and December 2022. Clinical, motor, medication-dependence and quality-of-life outcomes were evaluated after optimal programming (6 months). Wilcoxon test was used to compare pre- versus post-repeated measures. Surgical-related parameters were also analysed. 89 patients primarily operated for DBS were included in the study. Intraoperative electrode replacement was not necessary. Mean surgical duration was 217 (SD 44) minutes, including the implantation of the generator; and mean length of stay was 3 (SD 1) days. There was one surgical-related complication (delayed infection). Significant and clinically relevant improvement was seen in UPRS III (mean decrease 62%) (p<0.001) and PDQ-8 (50% increase) (p<0.001) after 6 months. Daily doses of medication were decreased by a mean of 68%, p<0.001). DBS can be safely performed under general anaesthesia in a pragmatic clinical environment, provided a multidisciplinary committee for patient selection and a dedicated surgical and anaesthetic team are available. The effectiveness in ameliorating motor symptoms, the ability to reduce the drug load, and the improvement in quality of life demonstrated in clinical trials could be reproduced under more generalised conditions as in our centre. The need for a team learning curve and the progressive evolution in, and adaptation to, trajectory planning software, anaesthetic management, intraoperative imaging, DBS device upgrades and programming schemes should be contemplated in the transition process to direct targeting.

Deciphering the Therapeutic Potential of Novel Pentyloxyamide-Based Class I, IIb HDAC Inhibitors against Therapy-Resistant Leukemia.

Histone deacetylase inhibitors (HDACi) are established anticancer drugs, especially in hematological cancers. This study aimed to design, synthesize, and evaluate a set of HDACi featuring a pentyloxyamide connecting unit linker region and substituted phenylthiazole cap groups. A structural optimization program yielded HDACi with nanomolar inhibitory activity against histone deacetylase class I/IIb enzymes. The novel inhibitors (4d and 4m) showed superior antileukemic activity compared to several approved HDACi. Furthermore, 4d and 4m displayed synergistic activity when combined with chemotherapeutics, decitabine, and clofarabine. In vitro pharmacokinetic studies showed the most promising profile for 4d with intermediate microsomal stability, excellent plasma stability, and concentration-independent plasma protein binding. Additionally, 4d demonstrated comparable in vivo pharmacokinetics to vorinostat. When administered in vivo, 4d effectively inhibited the proliferation of leukemia cells without causing toxicity. Furthermore, the binding modes of 4d and 4m to the catalytic domain 2 of HDAC6 from Danio rerio were determined by X-ray crystallography.

Discovery of UCB9386: A Potent, Selective, and Brain-Penetrant Nuak1 Inhibitor Suitable for In Vivo Pharmacological Studies.

Nuak1 (NUAK family SnF1-like kinase-1) is a serine-threonine kinase and a member of the AMPK family. Interest in Nuak1 has increased over the years due to the role it plays in several biological processes, from tumor cell invasion and proliferation to Tau stabilization. Nuak1 is expressed in many cancer cell lines and many reports describe this target as an oncogene, the inhibition of which is hypothesized to be valuable for treating various cancer types including glioma. We report here the discovery of Nuak1 inhibitors originating from HTS hit 9 with excellent selectivity and the subsequent medicinal chemistry optimization program, supported by structural information from the first crystal structures of a Nuak1 chimeric protein which provided insights into the binding modes of our compounds. These efforts yielded a nanomolar cell potent, highly selective and brain penetrant Nuak1 inhibitor UCB9386 (56) suitable for in vivo pharmacological studies for central nervous system (CNS) disorders.

Replotting and Revitalization of Sentrum Agraris Lotta as Sustainable Agriculutre and Eco-Education Site

Sentrum Agraris Lotta (SAL) is a centre for agricultural training developed by the Catholic Diocese of Manado, under the Social and Economic Development Commission of the Diocese, aimed at educating farmers and agriculture practitioners of North Sulawesi. 6 Ha of agricultural site is currently underutilized and requiring a remapping of land utilization for long term revitalization program for site optimization. In accordance with the Diocese’s strategic planning for SAL, the agricultural facility is expected to be productively income generating and self-sustainable. Therefore, this community development activity was conducted to remap and replot the SAL site area to a multifunction agriculture complex that is income generating and self-sustaining, becoming a productive reflection for eco-education, agrotourism and sustainable agriculture educational. Replotting resulted a masterplan with 6 plantation demplots, apothecary demplot and permaculture demplot, along with lodging facilities.

Blood pressure monitoring using telemedicine technologies in patients with chronic heart failure

Continuous monitoring of cardiovascular patients is one of the most important tasks in modern cardiology. Monitoring chronic heart failure (CHF) patients is critical because of instability, high prevalence and life-threatening nature of this disease. Currently, active search and development of optimal devices and programs for medical telemonitoring continues. This review presents the results of Russian and foreign studies on the use of invasive and non-invasive technologies for monitoring blood pressure (BP) levels and demonstrates their clinical significance. Innovative cuffed and cuffless BP monitoring devices are evaluated. The effectiveness of hypertension and CHF management using remote monitoring is compared with standard practice. The relationship between the risk of hospitalization for CHF and the monitoring is demonstrated. The paper presents data on the cost-effectiveness of using telemedicine technologies such as BP monitoring for CHF management.

The implementation of preoperative optimization in British Columbia: a quality improvement initiative.

Surgical patient optimization is a proactive approach to improve postoperative outcomes. This article reviews the development of the Surgical Patient Optimization Collaborative, an initiative supporting preoperative optimization in British Columbia, Canada. The Collaborative facilitated optimization programs over two cohorts between 2019 and 2024. A "Change Package" offered screening, intervention, and measurement tools for the following 13 surgical risk factors: anemia, anxiety, body mass index (cohort 2 only), cardiac status, frailty, glycemic control, nutrition, sleep apnea, pain management, physical activity, smoking, social support, substance use, and venous thromboembolism (cohort 1 only). Monthly data submissions from participating sites included the number of patients undergoing optimization, National Surgical Quality Improvement Program-defined 30-day outcomes, length of stay, and patient-reported measures. Run charts were used to analyze the progress of optimization implementation across both cohorts. Fourteen sites participated in each cohort. In total, 9,686 patients were screened for optimization, with 7,100/7,505 (95%) patients receiving at least one optimization intervention. Improvement shifts in the number of patients screened were identified in the run charts across both cohorts. Most patients felt that their optimization improved their surgical experience and outcomes. Data for clinical outcomes were inconsistently reported from sites and precluded analyses. Barriers to implementation included project complexity and structural characteristics, and facilitators were knowledge and beliefs about the intervention, reflection, and evaluation. Preoperative optimization programs were successfully implemented across multiple sites in British Columbia. High-quality clinical outcome analyses are still needed to determine the impact of preoperative optimization on postoperative outcomes. The insight gained from the Collaborative's implementation process may help inform future multicentre preoperative optimization efforts.

A strategy for achieving optimisation of radiological protection in digital radiology proposed by ICRP

Radiology is now predominantly a digital medium and this has extended the flexibility, efficiency and application of medical imaging. Achieving the full benefit of digital radiology requires images to be of sufficient quality to make a reliable diagnosis for each patient, while minimising risks from radiation exposure, and so involves a careful balance between competing objectives. When an optimisation programme is undertaken, a knowledge of patient doses from surveys can be valuable in identifying areas needing attention. However, any dose reduction measures must not degrade image quality to the extent that it is inadequate for the clinical purpose. The move to digital imaging has enabled versatile image acquisition and presentation, including multi-modality display and quantitative assessment, with post-processing options that adjust for optimal viewing. This means that the appearance of an image is unlikely to give any indication when the dose is higher than necessary. Moreover, options to improve performance of imaging equipment add to its complexity, so operators require extensive training to be able to achieve this. Optimisation is a continuous rather than single stage process that requires regular monitoring, review, and analysis of performance feeding into improvement and development of imaging protocols. The ICRP is in the process of publishing two reports about optimisation in digital radiology. The first report sets out components needed to ensure that a radiology service can carry optimisation through. It describes how imaging professionals should work together as a team and explains the benefits of having appropriate methodologies to monitor performance, together with the knowledge and expertise required to use them effectively. It emphasises the need for development of organisational processes that ensure tasks are carried out. The second ICRP report deals with practical requirements for optimisation of different digital radiology modalities, and builds on information provided in earlier modality specific ICRP publications.

A Pharmacist Medication Titration Program for Patients with Cardiac Sarcoidosis and Systolic Heart Failure: A Retrospective Cohort Study

Background A multidisciplinary approach improves guideline‐directed medical therapy (GDMT) in systolic heart failure (HF), but its efficacy in patients with HF due to cardiac sarcoidosis (CS) is unreported. Methods and Results In a retrospective cohort study, we reviewed 848 patients from our institutional CS clinics, identifying those with a CS diagnosis, HF (LVEF &lt; 50%) at index evaluation, and echocardiograms within 90 days and 11‐36 months. Patients were stratified by participation in a pharmacist‐led medication therapy management (MTM) program for GDMT optimization (MTM vs non‐MTM [NMTM]) without randomization. Demographics, LVEF, GDMT (quantified by Kansas City Medical Optimization [KCMO] score), and immunosuppressive therapy were assessed. Primary outcomes included changes in KCMO score, LVEF, and cardiovascular event‐free survival (unplanned HF hospitalization, LVAD/heart transplant, or death). The final cohort included 111 patients (median age 57 years, 34% female, 64% NYHA Class I‐II); 43 (39%) were MTM and 68 (61%) were NMTM. Mean KCMO score was similar at index evaluation (MTM: 23.2; NMTM: 29.6, p=0.83). At follow‐up (median 16 months), the KCMO score increased significantly in both groups (MTM: 23.2 to 74.8, p&lt;0.001; NMTM: 29.6 to 58.7, p&lt;0.001), but was higher in MTM (p=0.001). Mean LVEF trended towards higher values in MTM (44.4% vs 40.0%, p=0.05). The primary clinical outcome occurred in 1 MTM (2.3%) and 16 NMTM (23.5%) patients, with higher risk in NMTM (HR 11.97 [95%CI 1.58 ‐ 90.54], p=0.002). Conclusions In this retrospective cohort study, a pharmacist‐led MTM program was associated with favorable GDMT optimization and lower risk of adverse cardiovascular outcomes in CS patients with HF.

Abstract 4135127: Traveling more than a 20-mile radius to a Heart Failure Center can affect the quality of Heart Failure Care.

Introduction: We recognized the profound importance of access to care among patients with heart failure (HF). The geographical location of HF centers may significantly impact health outcomes, especially for those with limited transportation. This social determinant of health (SDOH) aspect is critical in bridging the gap in achieving HF care. Hypothesis/Methods: This was a single-center observational study conducted at a tertiary heart failure center in central Pennsylvania. We assessed the impact of travel distance by comparing patients who travel within a 20-mile radius to those who travel beyond a 20-mile radius. A total of 322 patients were referred to the HF clinic and enrolled in a guideline-directed medical therapy (GDMT) optimization program. Data collected included distance to Hershey Medical Center (HMC), health insurance coverage, HF etiology, onset, and echocardiogram. The distance was calculated based on the patient’s zip code. Results: Among patients enrolled in the HF-GDMT program, 194 travel within 20 miles, and 128 travel beyond a 20-mile radius to HMC. The mean travel distance to HMC was 9.1 miles (within) and 40.9 miles beyond 20 miles. The majority of patients were 81.3% white, 67% male, and the average age was 64. Most patients had heart failure with reduced ejection fraction (HFrEF) at 92.9%, 63% nonischemic, and 57.5% new onset. The comorbidities in both groups were similar, including hypertension, hyperlipidemia, and coronary artery disease (CAD). When comparing both groups, those who traveled beyond the 20-mile radius to HMC had more chronic HF at 55.5% vs. 34% in patients who traveled within the 20-mile radius. Upon enrollment, most patients were on suboptimal doses of either 1 or 2 of the four pillars of GDMT for HFrEF. Conclusions: The findings of this study revealed that patients with HF who travel beyond a 20-mile radius to HMC are more likely to have chronic HF, suggesting a delay in seeking care. A delay in referral may affect the timely initiation of appropriate GDMT and will likely lead to worse health outcomes. This underscores the urgent need for interventions to address barriers like transportation to improve HF care, offering a potential avenue for better patient outcomes.

Abstract 4135525: Bridging the Gap: How a Specialized Heart Failure Program Improves Guideline-Directed Medical Therapy Optimization for Rural Patients

Background: Previous research has shown that patients with heart failure with reduced ejection fraction (HFrEF) living in rural areas have suboptimal utilization of guideline-directed medical therapy (GDMT). Considering the associated increased mortality risk, this highlights the need for novel approaches to improve GDMT optimization for rural patients. The aim of this study was to evaluate how rural residence influences outcomes in a multidisciplinary, telehealth-based HF-GDMT optimization program implemented at our institution. Methods: We studied 322 patients who participated in a HF-GDMT optimization program led by a HF nurse practitioner and clinical pharmacist at Penn State Hershey Medical Center. We categorized residence at the time of enrollment using the Rural-Urban Commuting Area (RUCA) classification system. Differences in patient characteristics and program outcomes between the two groups were analyzed. P &lt; 0.05 indicated statistical significance. Results: Among the 322 patients enrolled, 56 (17.4%) resided in rural areas and 266 (82.6%) in urban areas. Rural patients were younger (mean age 61.1 vs. 65.1; p=0.04) and the two groups differed significantly in racial demographics (p=0.006). The rural group had a higher proportion of patients with chronic HF (55.4% vs. 39.8%; p=0.038) and fewer patients with a recent HF hospitalization (30.4% vs. 49.2%; p=0.012). As far as outcomes, program completion rates were similar between rural and urban patients (83.9% vs. 83.1%; p=1). Those who received target doses of the four GDMT drug classes versus the maximum tolerated dose were also similar between the rural and urban groups (21.4% vs. 15.8%; p=0.32). Conclusions: Patients from rural areas were more likely to present with chronic HF and less likely to have recent HF hospitalizations compared to their urban counterparts, suggesting potential disparities in access to HF care. Despite these differences, program outcomes, measured by completion rates and GDMT medication titration, were comparable between the two groups. Our findings emphasize the crucial role of specialized HF programs in advancing GDMT use for rural patients, which may ultimately improve HF outcomes and bridge the healthcare gap.

Abstract 4122650: 1-year comparison of quadruple therapy sequencing strategies for heart failure with reduced ejection fraction using an individual-based state-transition microsimulation model

Introduction: Guidelines recommend quadruple therapy (angiotensin receptor blocker-neprilysin inhibitor [ARNI]), beta-blocker, mineralocorticoid receptor antagonist (MRA), and sodium-glucose co-transporter 2 inhibitor [SGLT2I]) as the cornerstone of heart failure (HF) with reduced ejection fraction (HFrEF) management. Yet, guidelines do not propose a specific order of initiation and titration (or “sequencing strategy”) of these agents, due to the absence of trial evidence. Aims: To model the 1-year efficacy and harms of proposed HFrEF quadruple therapy sequencing strategies using a microsimulation model. Methods: We conducted an individual-based state-transition microsimulation modeling study to compare the 1-year cumulative incidence of death, total HF hospitalization, and adverse events with 6 different HFrEF medication sequencing strategies (emulating 2 different traditional strategies, 2 two-drug combinations, a "cluster" strategy, and four-drug "simultaneous" strategy), each with two versions (weekly or biweekly medication adjustments), applied to treatment-naïve outpatients with HFrEF. We modeled death as an incidence at 1 year, and total HF hospitalization (first and recurrent events) and adverse events (bradycardia, hyperkalemia, hypotension, and renal impairment) as incidence rates per 100 patient-years. Results: At 1 year, an estimated 15.5% died without treatment compared to 6.9% with the traditional sequence adjusted biweekly, and 5.2-6.3% with other sequencing strategies. Similarly, the HF hospitalization rate decreased from 32.8 per 100 patient-years with no treatment to 11.1 per 100 patient-years traditional sequencing adjusted biweekly, and 6.9-9 per 100 patient-years with other strategies. The incidence rates of medication-related adverse events per 100 patient-years were: hypotension (5.8-6.9), renal impairment (4.6-6.0), bradycardia (2.9-3.2), and hyperkalemia (approximately 0.5). Conclusions: For treatment-naïve outpatients with HFrEF, pharmacotherapy sequencing strategies that started 2 to 4 medications on the first visit reduced the risk of death and hospitalization at 1 year compared to a traditional sequencing strategy. Weekly medication adjustments did not outperform biweekly adjustments when &gt;=2 medications were started on the initial visit. These findings can inform clinicians and policymakers in developing HFrEF medication optimization programs with sequencing strategy protocols that fit the local practical context.

Optimizing focused very-high-energy electron beams for radiation therapy based on Monte Carlo simulation

A TOPAS-based optimization program has been developed to precisely concentrate the dose of focused very-high-energy electron (VHEE) beams on deep-seated targets. This is accomplished by optimizing the magnetic gradients, positions, and number of quadrupole magnets within TOPAS. Using only three quadrupole magnets, the program focuses 250 MeV VHEE beams to achieve a maximum dose position deeper than 17 cm, while maintaining entrance and exit doses within 25% and limiting the lateral dimensions to ≤ 1 cm at the maximum dose location. The linear relationship between the magnetic gradient of the last quadrupole magnet and the maximum dose position enables dose location adjustments through gradient variation. Multiple positions were validated in TOPAS with errors within 1%. The spread-out electron peak (SOEP) is achieved by combining two VHEE beams with different maximum dose positions using the differential evolution method, covering a target depth of 12–17 cm and attaining a dose flatness better than 99%. This pioneering program imposes constraints on entrance dose, exit dose, maximum dose position, and the lateral dimensions of dose deposition at the maximum dose position within phantom. This program may be a promising tool in the applications of focused VHEE in highly conformal treatment plans based on TOPAS.

Design of optimum spacecraft reorientation control with a combined criteria of quality based on the quaternions

Specifical original problem of attitude controlling for spacecraft was proposed in this paper. Problem of optimal rotation from a known initial state in a prescribed spatial orientation was studied in detail (turnaround time is not fixed). Design of optimal program of reorientation is based on new indicator of quality that combines energy costs including the contribution of controlling torques and integral of rotary energy (in a known proportion) and reorientation time; presence of duration factor bounds time of rotation finish. To construct an optimal control of angular momentum changing, quaternionic method and the maximum principle were applied. Differential equation that relates spacecraft angular momentum and quaternion of spacecraft orientation is a base to obtain analytic solution to a problem. We reveal the properties of optimum control program analytically, and study key features of optimum motion in details. Also, we write the formalized equations, mathematical formulas to design optimal law for change of spacecraft’s angular momentum. Analytic relations and equations are given for finding the optimal solution. Control law (in as explicit dependence between phase variables and con-trolling variables has been formulated. Main relations determining optimum values of parameters for rotation control algorithm were given. The closed-form law for rotation was obtained for dynamically symmetric solids. Numerical example as well as results of mathematical modeling of spacecraft motion that formed using optimum control are presented. This data as addition to the made theoretic descriptions shows reorientation process (in virtual form) and demonstrates practical feasibility of the developed control method. A designed algorithm for optimal control of rotation improves an efficiency of attitude system, and originates more economical performing of space vehicle during its flight along orbit.

Design of optimum spacecraft reorientation control with a combined criteria of quality based on the quaternions

Specifical original problem of attitude controlling for spacecraft was proposed in this paper. Problem of optimal rotation from a known initial state in a prescribed spatial orientation was studied in detail (turnaround time is not fixed). Design of optimal program of reorientation is based on new indicator of quality that combines energy costs including the contribution of controlling torques and integral of rotary energy (in a known proportion) and reorientation time; presence of duration factor bounds time of rotation finish. To construct an optimal control of angular momentum changing, quaternionic method and the maximum principle were applied. Differential equation that relates spacecraft angular momentum and quaternion of spacecraft orientation is a base to obtain analytic solution to a problem. We reveal the properties of optimum control program analytically, and study key features of optimum motion in details. Also, we write the formalized equations, mathematical formulas to design optimal law for change of spacecraft’s angular momentum. Analytic relations and equations are given for finding the optimal solution. Control law (in as explicit dependence between phase variables and con-trolling variables has been formulated. Main relations determining optimum values of parameters for rotation control algorithm were given. The closed-form law for rotation was obtained for dynamically symmetric solids. Numerical example as well as results of mathematical modeling of spacecraft motion that formed using optimum control are presented. This data as addition to the made theoretic descriptions shows reorientation process (in virtual form) and demonstrates practical feasibility of the developed control method. A designed algorithm for optimal control of rotation improves an efficiency of attitude system, and originates more economical performing of space vehicle during its flight along orbit.

Coordinating a bi‐level blood supply chain with interactions between supply‐side and demand‐side operational decisions

AbstractIn most blood supply chains, blood centers and hospitals make individual decisions, resulting in an inefficient structure of the blood supply chain, which in turn renders supply and demand matching a challenging exercise. In this work, we make the very first attempt to optimize the interaction between blood centers and hospitals. To that end, this paper investigates collection, production, replenishment, issuing, inventory, and wastage decisions under three different blood supply chain channel structures, that is, the decentralized, centralized, and coordinated structures. We propose a bi‐level optimization program to model the decentralized system and use the Karush–Kuhn–Tucker optimality conditions to solve that. In such a system, hospitals tend to order more than their actual need, resulting in overcollection, overproduction, and high wastage rates. On the other hand, in a centralized system decisions are made by a central decision‐maker, which results in higher performance. Recognizing the challenges of implementing a centralized system, we design a novel coordination mechanism to motivate hospitals to operate in a centralized system. Analysis of a case study in Canada indicates that integration can significantly improve the performance of system; allowing substitution between blood products can decrease the total cost of the blood supply chain by 14.41%; an increase in supply or decrease in demand can be detrimental under inappropriate structure, facilitating coordination mechanism; offering subsidy beyond a threshold is not beneficial to the blood centers.

Optimal operating strategy of hybrid heat pump − boiler systems with photovoltaics and battery storage

The growing need to reduce energy consumption and greenhouse gas emissions is driving the search for more efficient heating solutions in buildings. Hybrid heating systems, which combine air-to-water heat pumps (AWHP) with traditional gas boilers, are a common solution after refurbishment investments. However, managing these systems effectively, particularly when integrated with photovoltaic (PV) panels and battery energy storage systems (BESS), remains a complex task. For instance, heat pumps perform poorly in very cold conditions, making boilers a more efficient option; however, it might be advantageous to use it to increase electricity self-consumption. Optimal management depends on multiple factors, including future forecast data. In this paper, a daily optimization program is developed by means of a brute-force approach using forecast data. The core innovation of this paper is the use of an artificial neural network (ANN) that, trained on predictive optimization results, can determine the optimal solution in real-time without the need for future forecasts. The ANN achieved a 99.16% accuracy in new scenarios, successfully optimizing costs, CO2 emissions, and primary energy use. Results indicate up to 19% cost savings in colder cities, a 12% reduction in CO2 emissions, and a 3% decrease in primary energy consumption. This approach holds significant potential for enhancing the integration of renewable energy sources, contributing to long-term sustainability goals.

Efficacy and tolerability of extracorporeal shock wave therapy in patients with plantar fasciopathy: a systematic review with meta-analysis and meta-regression.

Plantar fasciopathy (PF) is a common musculoskeletal condition characterized by heel pain and functional impairment. Extracorporeal shock wave therapy (ESWT) has gained increasing interest in the treatment of PF, but the optimal ESWT program is still debated. Therefore, this systematic review with meta-analysis and meta-regression aimed at providing a comprehensive assessment of the efficacy and tolerability of ESWT in PF management. Randomized controlled trials (RCTs) published until February 2023 were systematically searched on PubMed/MEDLINE, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and PEDro. Studies assessing adult patients with PF treated with ESWT were considered. The primary outcome was the tolerability of ESWT, measured by treatment adherence, dropouts, and safety. Secondary outcomes were pain intensity and functional outcomes. Meta-analysis and meta-regression were performed to examine the relationship between ESWT program characteristics and treatment outcomes. The quality of included studies was assessed using the Jadad scale and the Cochrane risk-of-bias tool. Eleven studies met the inclusion criteria and were included in the analysis. Our findings showed that ESWT is effective in reducing pain intensity assessed by Visual Analogue Scale [focal-ESWT: -2.818 (SE 0.803, -4.393, -1.244; P< 0.0001; radial-ESWT: -3.038 (SE 0.428, -3.878, -2.199; P<0.001)]. Meta-regression analysis indicated a positive relationship between specific ESWT parameters (frequency, number of pulses, energy flux density and frequency, and number of pulses, pressure) and pain intensity (all P<0.05) and dropout (all P<0.05). ESWT seems to be an effective and tolerable treatment for PF, albeit the peculiarity of parameters might affect both the efficacy in pain relief and the adherence to the treatment. Physicians should consider individual patient characteristics when selecting the ESWT parameters for PF treatment. Further high-quality studies are warranted to establish the optimal ESWT protocol to treat PF.

Perceived barriers and facilitators to implementation of injury prevention programs in the military: Feedback from inside the trenches

BackgroundMusculoskeletal injuries enact a substantial burden in military settings, incurring high costs, long-term disability, and impacting military readiness. This has led to a prioritization of injury prevention programs. Understanding the challenges faced by those trying to implement these programs could help standardize and better inform future efforts. The purpose was to capture perceptions of barriers and facilitators to implementation of injury prevention programs in the US Armed Forces. MethodsA cross-sectional survey with open-ended questions was circulated to relevant stakeholders; key themes were derived using conceptual content analysis. Four questions were asked concerning injury prevention programs: 1) barriers, 2) facilitators, 3) how can leadership best support, and 4) how can subject matter experts best collaborate to make these programs successful? ResultsThe survey reached at least 300 individuals working with the armed services worldwide; 91 completed the survey. The mean (SD) time working with military service members was 11.5 (8.2) years; 93 % worked with active-duty service members, 71.4 % were licensed healthcare providers, and 55 % worked in settings with established injury prevention programs. Only 45.2 % of participants believed an appropriate, clear way to measure program success currently exists. Nearly 85 % believed that lacking standardization of definitions and metrics hinders program assessment. Wide variability existed in opinions regarding who should be primarily responsible for promoting/supporting injury prevention efforts. Key themes included resources as both a facilitator (when present) and barrier (when absent), organizational culture, and leadership support. Leadership can best help by prioritizing the programs and valuing the programming through modeling the desired behavior. Program staff can collaborate by focusing on enabling change, integrating into organizational/unit culture and collaborating with leaders to change policy. ConclusionsFactors leading to incidence and recovery of musculoskeletal injuries are multifactorial, requiring collaborative multidisciplinary approaches for optimal injury prevention program development and implementation. Leadership support/prioritization, unit-level cultural acceptance and sufficient resources are essential facilitators to implementing prevention programs. Developing standardized, relevant metrics for assessing program effectiveness and establishing organizational best practices are necessary for long term program viability and lasting change.

The Association of Comorbidities With Total Knee Arthroplasty Healthcare Utilization

Patients undergoing total knee arthroplasty (TKA) tend to have various comorbidities such as obesity, hypertension, and cancer, which are partially associated with their advanced age. This study aimed to elucidate the associations of these comorbidities with hospital charge (HC), hospital costs (HCo), and length of stay (LOS). A national database was queried for patients who underwent primary TKA from 2012 to 2020. There were 30 comorbidities classified using the Elixhauser Comorbidity Index. For each comorbidity of interest, patients were matched to another patient by age, sex, and all other comorbidities except the comorbidity of interest. Matched cohorts were analyzed via multivariable regression analyses controlled for age, sex, procedure year, hospital location, and comorbidities to predict increases in HC, HCo, and LOS. A total of 1,014,831 patients were included. Mean HC, HCo, and LOS were $64,097, $17,299, and 2.5 days, respectively. Weight loss, blood loss anemia, coagulopathies, and fluid and electrolyte disorders were associated with the largest increases in HC, with 6, 5, 5, and 5% increases, respectively (P < 0.05). Pulmonary hypertension, non-metastatic tumors, paralysis, and obesity were associated with increased HCo, with 6, 4, 4, and 4% increases, respectively (P < 0.05). All comorbidities except hypothyroidism were associated with increased LOS. Pulmonary hypertension, weight loss, paralysis, fluid and electrolyte disorders, and human immunodeficiency virus/acquired immunodeficiency syndrome were associated with were associated with 53, 21, 15, 14, and 12%, respectively, increased odds of having LOS greater than or equal to four days' increase (P < 0.05). This study offers targets for the reduction of HC, HCo, and LOS for patients with these modifiable and non-modifiable ailments through protocol change. Optimization programs targeting malnourished patients, patients with pulmonary hypertension, and other comorbidities are encouraged. These results also provide clinicians with a quantifiable way to communicate financial burden and recovery time after TKA to patients' unique problem lists.

Identifying and optimizing psychosocial frailty in surgical practice

Psychosocial frailty is under-screened for and under-treated in patients undergoing surgery, even though patients with psychosocial frailty are at increased risk for postoperative complications. Numerous approaches exist to identifying psychosocial frailty in the preoperative period, ranging from neighborhood-level indices to patient-level, patient-reported data. Presurgical optimization of psychosocial frailty has returned mixed results, focusing primarily on psychological well-being with limited attention paid to addressing a patient's social risk profile. Mediators and moderators of psychosocial frailty in surgical outcomes must be further elucidated before investigators can appropriately trial psychosocial optimization programs that benefit patients. In recent years, new policies and system-level changes have incentivized screening for psychosocial frailty, and additional reimbursement strategies should be formulated to address frailty in the preoperative period in a feasible, sustainable, and cost-effective manner.