Scarce Medical Resources Research Articles

Ventilator Allocations: The Effect of Mere Identifiability

The COVID-19 crisis has raised a dire dilemma among medical professionals. Faced with a shortage of critical equipment and supplies, how do hospital administrators and physicians determine whether to divert resources from one patient to another? Most decision-makers will prioritize saving younger patients over older ones, because older patients generally have a much shorter life expectancy. But emotions, such as those elicited when a patient's name is known and the patient is thereby humanized, can interfere with rational decision-making. At the height of the pandemic, we conducted three studies in which participants were asked to imagine being hospital officials tasked with allocating ventilators under two conditions: when the affected patients were and were not identified by name. Participants were less likely to reassign a ventilator from an older patient to a younger one when the patients had been named than when they had not. These results suggest that decisionmakers are more likely to make the efficient choice—the one that should save more years of life—when the individuals affected by the choice remain anonymous. When patients are humanized by being named, less rational and more emotional considerations appear to govern how people choose to distribute lifesaving equipment. Our findings imply that keeping patients anonymous may help facilitate the efficient allocation of scarce medical resources.

The accuracy of nurse-led triage of adult patients in the emergency centre of urban private hospitals.

Background: Triage is applied in emergency centres (ECs) to assign degrees of urgency to illnesses or injuries to decide in which order to treat patients, especially when there are many patients or casualties, facilitating the allocation of scarce medical resources. A triage nurse determines triage priority by assessing patients using an established triage tool with specific criteria. The South African Triage Scale is widely used in South African ECs. Although the South African Triage Scale has been adopted and implemented in both private and public healthcare ECs in South Africa, few studies have assessed the accuracy of nurse-led triage in private ECs.Aim: To determine the accuracy of nurse-led triage in ECs in urban, private hospitals.Methods: A quantitative, descriptive, retrospective study was done. Three private hospitals with similar average patient volumes were purposively selected. We sampled the nursing notes as follows: 1) we stratified nursing notes by nurse qualification and then 2) for each category of nurse we stratified nursing notes according to triage priority level and 3) then systematically randomly selected the recommended number of notes from each triage priority level for each nurse category. We retrospectively audited 389 EC nursing notes to determine the accuracy of nurse-led triage. For each note, we independently applied the South African Triage Scale, and then determined agreement between our score and the score determined by the triage nurse.Results: We recorded 342 triage errors, consisting of triage early warning scores (TEWS) errors (n = 168), discriminator errors (n = 97) and additional investigation errors (n = 77). Overall agreement between the triage nurses and our scores was 71.7% (n = 279). Triage errors (n = 110) consisted of 3.9% (n = 15) over-triage errors and 24.4% (n = 95) under-triage errors. The highest level of agreement was between our scores and the scores of the emergency trained registered nurses (85%) and enrolled nursing assistants (78%).Conclusion: In South African ECs, the South African Triage Scale is not always correctly applied, which can lead to almost a quarter (24.4%) of cases being under-triaged and not receiving timeous care. Our results suggest that emergency trained registered nurses are well equipped to be triage nurses, and that this skill should be developed in South African nursing curricula.

Providing laypeople with results from dynamic infectious disease modelling studies affects their allocation preference for scarce medical resources\u2014a factorial experiment

BackgroundAllocation of scarce medical resources can be based on different principles. It has not yet been investigated which allocation schemes are preferred by medical laypeople in a particular situation of medical scarcity like an emerging infectious disease and how the choices are affected by providing information about expected population-level effects of the allocation scheme based on modelling studies. We investigated the potential benefit of strategic communication of infectious disease modelling results.MethodsIn a two-way factorial experiment (n = 878 participants), we investigated if prognosis of the disease or information about expected effects on mortality at population-level (based on dynamic infectious disease modelling studies) influenced the choice of preferred allocation schemes for prevention and treatment of an unspecified sexually transmitted infection. A qualitative analysis of the reasons for choosing specific allocation schemes supplements our results.ResultsPresence of the factor “information about the population-level effects of the allocation scheme” substantially increased the probability of choosing a resource allocation system that minimized overall harm among the population, while prognosis did not affect allocation choices. The main reasons for choosing an allocation scheme differed among schemes, but did not differ among those who received additional model-based information on expected population-level effects and those who did not.ConclusionsProviding information on the expected population-level effects from dynamic infectious disease modelling studies resulted in a substantially different choice of allocation schemes. This finding supports the importance of incorporating model-based information in decision-making processes and communication strategies.

Experience and Appreciation of Health Care Teams Regarding a New Model of Pharmaceutical Care in Long-Term Care Settings.

In long-term care (LTC) homes, the management of frail older residents' pharmacotherapy may be challenging for health care teams. A new pharmaceutical care model highlighting the recently expanded scope of pharmacists' practice in Quebec, Canada, was implemented in two LTC homes. This study aimed to evaluate health care providers' experience and satisfaction with this new practice model. Twenty-three semi-structured interviews were performed and analyzed thematically. Positive results of the model have been identified, such as increased timeliness of interventions. Barriers were encountered, such as lack of clarity regarding roles, and suboptimal communication. The increased involvement of pharmacists was perceived as useful in the context of scarce medical resources. Although requiring time and adjustments from health care teams, the new model seems to contribute to the health care providers' work satisfaction and to positively influence the timeliness and quality of care offered to LTC residents.

A multi-zone spatial flow impact factor model for evaluating and layout optimization of infection risk in a Fangcang shelter hospital

Respiratory infectious diseases have caused several pandemics and scarcity of medical resources. As a temporary hospital for infectious disease patients, the Fangcang shelter hospital requires effective air distribution. We developed the multi-zone SFIF (SFIFM) model by combing a natural ventilation multi-zone model (MIX: Multi-zone Infiltration and eXfiltration) and spatial flow impact factor (SFIF) model, which can calculate the contribution of other zones to the risk of infection in the target zone. Compared with the experimental data in the reference, the model can be used to characterize the influence between zones. A three-zone large building was used for the analysis of the relationship between ventilation rate and SFIFM. An existed Fangcang shelter hospital was evaluated and the layout was optimized with this model. The results showed that both mechanical and natural ventilation would influence SFIFM. By optimizing the layout, the weighted SFIFM on health care worker zone could be reduced by 0.022, and the infection risk could be reduced by 14.42%. This model could more clearly show the relationship between zones, ventilation rate, concentration, and infection risk. It could be applied to evaluate and optimize the location of infectious sources, susceptibles, mechanical ventilation, and purifiers under variable conditions. This model may be helpful in reducing the risk of infection in large space buildings and providing guidance for ensuring public health safety.

Facilitating remote access to specialist medical expertise through the scaled up adoption of a smartphone application: A South African case

Background. In the context of a shortage of medical specialists, a medical referral app, designed for use on smartphones, was launched in 2014 for use by doctors in the public health service in South Africa. Objectives. As this is a novel intervention, with potential to have an impact on the use of scarce resources, and because not much was known about the use of the app, a descriptive study was undertaken to assess its adoption in Western Cape Government Health (WCGH) facilities. Methods. Usage data of the app in WCGH facilities, in terms of referral and user numbers, were obtained from the date of its introduction in 2014. In addition, all the referrals to WCGH facilities for July 2019, stripped of any identifying data of patients or doctors, were analysed for origin, destination, outcome and response times. Descriptive statistics were used to analyse the data. Results. Use of the app grew rapidly from 40 referrals per quarter to 16 437 per quarter after 5 years in use, with a cumulative total of 95 381 referrals. In July 2019, active users of the system included 913 sending doctors and 298 receiving doctors, representing 20 medical specialties. The senders and receivers were representative of every level in the healthcare system, from clinic to tertiary hospital. In July 2019, a total of 5 941 referrals were sent by means of the app to public facilities in Western Cape Province. Of the referrals, 80% were classified as acute and 20% as non-urgent. The referral outcomes included 51% accepted for transfer, 19% accepted for a specialist appointment, and 13% concluded with advice alone without the need for a specialist appointment or patient transfer – this category accounted for 28% of non-urgent referrals and 9% of acute referrals. In 50% of referrals, advice was given to the referring doctor, either as an additional or the only outcome. The median response times were 9 minutes for acute referrals and 19 minutes for non-urgent referrals. Conclusions. This study documents the scale-up of a mobile phone consultation and referral app from pilot phase to significant growth in use across a resource-constrained healthcare system. In a large proportion of cases, advice was given to the referring doctor by means of the app, frequently obviating the need for a specialist appointment or patient transfer. This finding demonstrates that a mobile app has the potential to reduce the need for face-to-face specialist visits, thereby improving the use of scarce medical resources

COVID-19 and the Ethics of Whom to Treat First: A Utilitarian Approach

The scarcity of resources in healthcare is always a problem. The problem is worsened by rising cases of coronavirus, mounting pressure on the available limited resources. The ethical issue emanating from this situation is the problem of whom to treat first. In the midst of scarce medical resources, who shall receive medical attention first? Between an ordinary patient and victim of coronavirus, between the critical and mild victim, and between the aged and the young, who shall be treated first? The paper adopted a utilitarian approach in solving the problem. The finding is that the number of persons to benefit from treating a particular patient, duration of treatment, age and health condition of the patient, chances of recovery, and quality of life after recovery are factors to be considered in taking the ethical decision. The work is qualitative research using library materials such as journal articles, books and unpublished materials as sources of data, while hermeneutics and philosophical analysis are applied in studying them.

Development of decision-making considerations to support equitable patient selection in paediatric haemophilia trials

Abstract Background Clinical trials for investigational haemophilia treatments such as gene therapy offer a potentially life-changing opportunity to those who are selected for enrolment. However, the number of enrolment slots available for these trials is often greatly exceeded by the number of eligible patients. Many of the strategies that are commonly used to select candidates for participation can be highly unsystematic, inequitable, and subjective. A more rigorous set of criteria is therefore needed to evaluate each candidate's suitability for trial participation in order to eliminate bias in selection and fulfill the ethical principle of justice. Aims To review current knowledge and issues in patient selection for paediatric haemophilia clinical trials with competitive availability, and to develop a more objective standard for decision-making that takes into account the needs of all involved parties. Methods A literature search on the ethics of trial participant selection and the practice of fairly distributing limited medical resources was conducted to identify previous literature and best practices in the area. A list of essential decision-making considerations was then designed to guide the selection of paediatric participants for haemophilia therapy trials through iterative group discussions between a diverse team of health professionals at McMaster Children's Hospital, Hamilton, ON, Canada. Results Current practices in resolving this ethical issue are highly heterogenous, although there are some common themes and recommendations. The three main criteria supported by the team and the literature search for inclusion in the considerations were: medical need, need for support, and potential safety considerations for the patient. Three measures for evaluating each criterion were developed and added for consideration during the decision-making process. The role of patient selection in meeting the scientific aims of the trial was also considered. Conclusion Attempting to create an equitable, systematic decision-making procedure for clinical trial participant selection involves a wide variety of competing values and ethical considerations, and discrepancies between recommendations are commonplace. The criteria presented here are intended to be used as a guideline to assist the equitable selection of paediatric patients for participation in haemophilia clinical trials with highly limited enrolment, although it may have some applicability to other areas of clinical research or therapeutic areas concerned with the allocation of scarce medical resources. Next steps should involve speaking with patients, community members and other stakeholders in order to include their perspectives. Assessment of medical need, potential support needs, and safety considerations form the basis of criteria for discussions around how to make enrolment in paediatric haemophilia clinical trials more equitable © Shutterstock

Ethical Principles in Personal Protective Equipment Inventory Management Decisions and Partnerships Across State Lines During the COVID-19 Pandemic

The COVID-19 pandemic created unprecedented strain on the personal protective equipment (PPE) supply chain. Given the dearth of PPE and consequences for transmission, GetMePPE Chicago (GMPC) developed a PPE allocation framework and system, distributing 886 900 units to 274 institutions from March 2020 to July 2021 to address PPE needs. As the pandemic evolved, GMPC made difficult decisions about (1) building reserve inventory (to balance present and future, potentially higher clinical acuity, needs), (2) donating to other states/out-of-state organizations, and (3) receiving donations from other states. In this case study, we detail both GMPC's experience in making these decisions and the ethical frameworks that guided these decisions. We also reflect on lessons learned and suggest which values may have been in conflict (eg, maximizing benefits vs duty to mission, defined in the context of PPE allocation) in each circumstance, which values were prioritized, and when that prioritization would change. Such guidance can promote a values-based approach to key issues concerning distribution of PPE and other scarce medical resources in response to the COVID-19 pandemic and related future pandemics.

Medical students positions regarding resource allocation in times of crisis

Objective To compare the perspectives of medical students in the preclinical and clinical phases of medical training on the issue of rationing scarce medical resources in times of crisis. Methods Questionnaire-based cross-sectional study. Results A total of 201 participants took part in the study, with 100 participants in the preclinical phase group, and 101 in the clinical phase group. A multivariable analysis found that just 14.9% (n = 34) of the clinical phase students were willing to give a short-supplied blood unit to the first-arrived patient to the emergency department when more patients are expected compared to 63.9% in the preclinical group (n = 62) ( p < 0.001, OR = 0.75 95% CI: 0.029−0.192). Seventy-four percent (n = 74) of the clinical phase students were found to be willing to remove a patient from a respirator to allocate it to an ill child compared to 35.7% (n = 35) in the preclinical phase group ( p < 0.001, OR = 4.168 95% CI: 1.931−8.998). Of the clinical phase group, 46.6% (n = 41) were willing to allocate a short supplied flu medicine to a patient with poor prognosis compared to 57.7% (n = 56) in the preclinical phase group ( p = 0.04, OR = 0.457 95% CI: 0.216−0.966). Conclusion Clinical exposure during training may affect the way medical students make ethical decisions, independent of age, sex, as well as marital and parental status.

Looking Back and Looking Forward: (Re)Interpreting Consumer Insights in a Time of Transition

Looking Back and Looking Forward: (Re)Interpreting Consumer Insights in a Time of Transition

64Cu-ATSM Predicts Efficacy of Carbon Ion Radiotherapy Associated with Cellular Antioxidant Capacity

Simple SummaryCarbon ion radiotherapy is an emerging cancer treatment modality that has a greater therapeutic window than conventional photon radiotherapy. To maximize the efficacy of this extremely scarce medical resource, it is important to identify predictive biomarkers of higher carbon ion relative biological effectiveness (RBE) over photons. Here we show that the carbon ion RBE in human cancer cells correlates with the cellular uptake of 64Cu(II)-diacetyl-bis(N4-methylthiosemicarbazone) (64Cu-ATSM), a potential radioligand that reflects an over-reduced intracellular environment. High RBE/64Cu-ATSM cells show greater steady-state levels of antioxidant proteins and increased capacity to scavenge reactive oxygen species in response to X-rays than low RBE/64Cu-ATSM counterparts. These data suggest that the cellular antioxidant activity is a possible determinant of carbon ion RBE predictable by 64Cu-ATSM uptake.Carbon ion radiotherapy is an emerging cancer treatment modality that has a greater therapeutic window than conventional photon radiotherapy. To maximize the efficacy of this extremely scarce medical resource, it is important to identify predictive biomarkers of higher carbon ion relative biological effectiveness (RBE) over photons. We addressed this issue by focusing on cellular antioxidant capacity and investigated 64Cu(II)-diacetyl-bis(N4-methylthiosemicarbazone) (64Cu-ATSM), a potential radioligand that reflects an over-reduced intracellular environment. We found that the carbon ion RBE correlated with 64Cu-ATSM uptake both in vitro and in vivo. High RBE/64Cu-ATSM cells showed greater steady-state levels of antioxidant proteins and increased capacity to scavenge reactive oxygen species in response to X-rays than low RBE/64Cu-ATSM counterparts; this upregulation of antioxidant systems was associated with downregulation of TCA cycle intermediates. Furthermore, inhibition of nuclear factor erythroid 2-related factor 2 (Nrf2) sensitized high RBE/64Cu-ATSM cells to X-rays, thereby reducing RBE values to levels comparable to those in low RBE/64Cu-ATSM cells. These data suggest that the cellular activity of Nrf2-driven antioxidant systems is a possible determinant of carbon ion RBE predictable by 64Cu-ATSM uptake. These new findings highlight the potential clinical utility of 64Cu-ATSM imaging to identify high RBE tumors that will benefit from carbon ion radiotherapy.

Commentary on "The Father-Daughter Dinner Dance: A Waltz With Ethics and COVID-19".

This story—“The Father-Daughter Dinner Dance: A Waltz With Ethics and COVID-19”—is based on conversations I have had with friends, family, and colleagues about the allocation of medical resources during the COVID-19 pandemic. The characters and conversation in this story are all fictional. Although there is a strong public health effort to flatten the curve of infected individuals with COVID-19 over a longer period of time so that the health care system does not become overwhelmed, it is very likely that this pandemic will cause medical shortages. We are already hearing about a lack of personal protective equipment, ICU beds, and lifesaving technologies such as ventilators.1 During medical shortages, decision makers turn to bioethicists for advice on how to prioritize difficult decisions in an ethical and systematic manner. It is well noted that utilitarian approaches to decision making during times of scarce resources in health care are deemed acceptable.2 The basic criterion of utilitarianism as formulated by Jeremy Bentham in 1789 is the greatest happiness for the greatest number.3 In health care, it is desirable to save the greatest number of lives or the most life-years by giving priority to individuals likely to survive the longest after a given treatment.4 One of the most influential medical journals recently published an article that offered 6 recommendations for the fair allocation of scarce medical resources using a utilitarian perspective.1 Utilitarian approaches do not take into account that some health care professionals discriminate against certain groups of people. Although most health professionals are not likely to intentionally discriminate against their patients, they may hold negative attitudes that could cause their patients to feel disrespected and misunderstood.5 Research has demonstrated how some negative attitudes toward certain stigmatized groups are more acceptable than others. For example, negative attitudes toward people with mental illness or obesity are more acceptable than explicit racist or sexist beliefs.6,7 Negative attitudes become harmful stereotypes that create systemic barriers to health equity and result in biased clinical decision making in diagnosis and treatment of marginalized groups. In light of the knowledge we have about the negative health effects of discrimination on marginalized groups, it is frightening to think how a utilitarian approach could create life-threatening disadvantages during discussions of the fair allocation of scarce resources. This story highlights how social positions and identities intersect to create an environment of bias and discrimination against certain members of society.8 The daughter is a young, educated woman. She does not seem to have a chronic illness. She has completed a philosophy degree, but there is some pressure on universities to eliminate the humanities in favor of degrees deemed more productive. We do not have information on the father’s educational attainment, but we know that he has a blue-collar job and that he has a mental illness. The father and daughter’s social identities interact with the concept of ageism, which usually occurs against older adults; in this case, though, ageism is shown to affect younger adults depending on their health status. The mother, who comes into the story briefly, brings issues of gender and body image as intersections that combine with mental health to highlight further injustice and inequity. The purpose of creating a story on such a timely and complicated topic is to encourage the reader to think about how injustice toward one group can end up perpetuating systems of inequities toward other groups of people, especially when utilitarian approaches to lifesaving resource allocation are left unquestioned.

CORRELATION OF PAP SMEAR AND COLPOSCOPIC FINDING WITH DIRECTED BIOPSY TO ASSESS THE ADVANTAGE OF CONCURRENT TESTING BY CYTOLOGY AND COLPOSCOPY IN THE DETECTION OF CERVICAL NEOPLASM

Background: Cervical cancer was the second most common cancer among women 15-44 years of age and in 2018 it was the fourth most frequent cancer and cause of cancer death among all women in the world
 Methods:Women (18-65 yrs) attending Department of Obstetrics and Gynaecology, SMS Medical College, Jaipur were recruited for study. After applying inclusion and exclusion criteria written and informed consent were taken from all study participants
 Results: On histopathology report we found that 10% had normal inflammation followed by 9.33% had carcinoma in situ, 8% had CIN-2, 6.67% had CIN-1, 5.67% had CIN-3 and Squamous cell carcinoma each.
 Conclusion: Pap smear and colposcopy both the tests can be used to complement each other in a hospital based screening programme, where facilities for both modalities are available. Hence use of single visit approach in which cytology, colposcopy and guided biopsy all are done in single sitting, and treated accordingly in resource poor countries like ours will enable maximal utilization of scarce medical resources.
 Keywords: Pap smear, CIN, Cervical cancer

Asian Pacific Society of Cardiology Consensus Recommendations for Pre-participation Screening in Young Competitive Athletes.

Sports-related sudden cardiac death is a rare but devastating consequence of sports participation. Certain pathologies underlying sports-related sudden cardiac death could have been picked up pre-participation and the affected athletes advised on appropriate preventive measures and/or suitability for training or competition. However, mass screening efforts – especially in healthy young populations – are fraught with challenges, most notably the need to balance scarce medical resources and sustainability of such screening programmes, in healthcare systems that are already stretched. Given the rising trend of young sports participants across the Asia-Pacific region, the working group of the Asian Pacific Society of Cardiology (APSC) developed a sports classification system that incorporates dynamic and static components of various sports, with deliberate integration of sports events unique to the Asia-Pacific region. The APSC expert panel reviewed and appraised using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed, which were then put to an online vote. Consensus was reached when 80% of votes for a recommendation were agree or neutral. The resulting statements described here provide guidance on the need for cardiovascular pre-participation screening for young competitive athletes based on the intensity of sports they engage in.

Optimal allocation of resources to healthcare workers or the general populace: a modelling study.

We consider a model that distinguishes susceptible; infected, but not yet infectious; pre-symptomatic, symptomatic, asymptomatic, and hospitalized infectious; recovered and dead members of two groups: healthcare workers (HCW) and members of the community that they serve. Because of the frequency or duration of their exposures to SARS-CoV-2, a greater fraction of HCW would experience severe COVID-19 symptoms that require medical care, which reduces mortality rates, absent personal protective equipment (PPE). While N95 masks (and, possibly, other scarce medical resources) are available to members of both groups, they do not use them equally well (i.e. efficacy and compliance differ). We investigated the optimal allocation of potentially scarce medical resources between these groups to control the pandemic and reduce overall infections and mortality via derivation and analysis of expressions for the reproduction numbers and final size. We also simulated prevalence and cumulative incidence, quantities relevant to surge capacity and population immunity, respectively. We found that, under realistic conditions, the optimal allocation is virtually or entirely to HCW, but that allocation of surplus masks and other medical resources to members of the general community also reduces infections and deaths.

Ethical Guidance for Hard Decisions: A Critical Review of Early International COVID-19 ICU Triage Guidelines

This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources.

Drastic changes in the practice of end-of-life care during the COVID-19 pandemic.

This article discusses drastic changes in the practice of end-of-life care during the COVID-19 pandemic. It reviews the ethical dilemmas of individual autonomy versus societal justice, human beneficence versus public health non-maleficence that arose during the pandemic due to prolonged, high acutity,= critical illness in the setting of a highly contageous respiratory virus, protective personal equipment shortages,m crisis standards of care to distribute scarce medical resources, and changes in interactions between treating clinicians, patients, and visitors. The lessons learned during the pandemic response will directly inform and impact the appraoch to future pandemic events.

Evaluation of a tele-expertise experiment for skin cancer detection: the perspective of GPs

Abstract Background The incidence of skin cancer has shown an increasing trend in the world and in France over the last four decades. In this context, the delay to access a specialist opinion strongly impacts the patient outcomes. However, the medical demographics of dermatologists in France have been decreasing over the past years. Hence, a tele-expertise (TLE) experiment for skin tumors detection, which allows general practitioners to obtain feedback from a dermatologist within 7 days using a smartphone application, has been set up in the Hauts-de-France region since 2015. Thus, this study aims at understanding the advantages and drawbacks of TLE in the detection of skin tumors perceived by general practitioners. Methods Exploratory study carried out with 15 general practitioners participating in the experiment in the Hauts-de-France region. Semi-structured interviews were conducted between february and april 2021 and analyzed after transcription. Results The main advantages perceived by general practitioners are: (i) fast access to a specialized feedback; (ii) formalization of the request and commitment of the dermatologist; (iii) ease of regulating patients to a specialist; (iv) lower travel frequency and stress for patients; (v) ability to send medical information securely. The drawbacks are most related to the lack of functionalities and the graphical user interface of the application. Conclusions Tele-expertise is a well accepted technological innovation in dermatology among general practitioners, which enables the best use of the scarce medical resources available in the region and to address the needs of patients. The sustainability of TLE in dermatology and its extension to other territories is possible and desirable. Key messages Tele-expertise in dermatology has its place in enabling the early management of malignant skin tumors. The qualitative approach makes it possible to understand general practitioners visions after the introduction of a technological innovation into their practices.

Flu vaccination during COVID-19 pandemic: a lesson from an Italian teaching hospital

Influenza is an acute viral respiratory infection that causes significant morbidity and mortality worldwide, with indirect costs considerably exceeding direct costs on patients and society. Flu vaccination is one of the major strategies for preventing it, especially among healthcare workers (HCWs), to avoid onward transmission to patients and colleagues. The aim of this research is to analyze the flu vaccination coverage rate among HCWs and to study which factors conditioned their adherence. The observational study was conducted in an Italian teaching hospital located in Rome (Italy) and data were collected from October to December 2020. A total of 6,568 HCWs was included considering physicians, nurses and other HCWs as job categories. Age class, gender and job category variables were analyzed. Statistically significant differences among groups were tested through χ2 test. Univariate analyses and a multivariate logistic regression (p < 0.05) were performed to assess differences in flu vaccination adherence. The flu vaccination coverage rate was 60.94%. Considering the job categories, physicians reached the highest coverage (76.09%) followed by others HCWs (64.25%) and nurses (49.09%). According to the logistic regression, belonging to 20-40 age class was significantly associated with higher flu vaccination adherence, as well as being nurses (OR 0.26, 95% CI 0.22-0.31) or other HCWs (OR 0.48, 95% CI 0.40-0.58). Findings showed an encouraging vaccination coverage rate among HCWs. Deeper knowledge of the value of vaccination among younger HCWs could be probably a reason for higher adherence as well as the wrong perception of being at low risk of illness or transmitting infections may explains job categories differences. Especially when considering the disrupting impact of the SARS-CoV-2 pandemic, an improved attitude towards flu vaccination would reduce stress on hospitals and preserve scarce medical resources.Key messages Reaching high coverage rates for flu vaccination could save healthcare resources.It is crucial to preserve this positive trend for the future years by spreading the message to all the involved stakeholders.