Set Of Facilities Research Articles

Aflibercept Monotherapy versus Bevacizumab-First for Diabetic Macular Edema: A Cost Analysis Based on Diabetic Retinopathy Clinical Research Network Protocol AC Results

To calculate the costs of treatment for diabetic macular edema with bevacizumab-first (step therapy) compared with aflibercept monotherapy. Cost analysis of the treatment arms based on a published study. None. Published results from the Diabetic Retinopathy Clinical Research Network protocol AC were used to assess costs. Data incorporated in the usage and outcome model included the frequency of injections, medication type, visits, and imaging. Costs were modeled based on the 2022 Medicare reimbursement data for both facility (hospital-based) and nonfacility settings in Miami. Outcomes were similar in protocol AC so were not differentially studied. Results were extrapolated so as to estimate lifetime (17 years for the age of the cohort). Cost of treatment options. Over the 2 years reported in the protocol AC, the cost required to treat in the facility (nonfacility setting) was $42 000 ($32 000) in the aflibercept monotherapy group and $29 000 ($22 000) in the bevacizumab-first group. Extrapolated modeled lifetime costs were $158 000 ($136 000) and $125 000 ($103 000), respectively. The total cost with bevacizumab-first was 33% lower at year 2 and 21% lower at year 17 compared with aflibercept monotherapy. Savings per year for the 2 years results were $6500 ($5000) in the facility (nonfacility) setting. For the extrapolated 17 years model, annual savings were $1900 ($1900) in the facility (nonfacility) setting. The professional fees accounted for a minority of overall costs; in contrast, medication costs accounted for 82% of the total costs for the aflibercept monotherapy and 73% in the bevacizumab-first group at 2 years. Our model predicted an additional 15% lifetime cumulative savings if patients still not meeting the threshold criteria after switching to aflibercept were placed back on bevacizumab, and a similar degree of improvement if those on not meeting threshold criteria on aflibercept monotherapy were switched to bevacizumab. Medication is the dominant driver of the total expenses associated with the treatment of diabetic macular edema. Although cost savings are realized with bevacizumab-first step therapy, the magnitude was not as much as might be intuited, probably because of the high (70%) incidence of patients switching to aflibercept within protocol AC.

CMS Issues Final Rule on 2023 Medicare Physician Payment

Back to table of contents Previous article Next article Government & LegalFull AccessCMS Issues Final Rule on 2023 Medicare Physician PaymentMark MoranMark MoranSearch for more papers by this authorPublished Online:15 Nov 2022https://doi.org/10.1176/appi.pn.2022.12.12.46AbstractThe final rule makes permanent Medicare coverage of audio-only mental health telehealth services, the only category of services that will be eligible for audio-only delivery on a permanent basis after the public health emergency ends.The federal government approved a decrease in the “conversion factor” used to calculate physician payment that will result in an overall cut to physician reimbursement under the Medicare program for 2023. The change goes into effect on January 1, 2023.As part of the 2023 Final Medicare Physician Fee Schedule issued November 1, the conversion factor will decrease by $1.53, or 4.42% of last year’s conversion factor. The conversion factor is a variable that is multiplied by the relative value unit (RVU) assigned to every physician service or procedure to derive payment for that particular service or procedure. A decrease in the conversion factor results in an overall average decrease in reimbursement for all physicians; how it will affect each physician depends on that physician’s practice patterns, geographic location, and other factors.The decrease is due largely to the fact that a 3% increase legislated by Congress last year will expire. Additionally, there is a further 1.5% decrease to the conversion factor that is the result of budget-neutrality requirements mandating a downward shift in payment to account for increases in utilization and total relative value units.In a September letter to CMS Administrator Chiquita Brooks-Lasure, APA CEO and Medical Director Saul Levin, M.D., M.P.A., said proposed payment cuts will only exacerbate the nation’s mental health crisis and added that President Joe Biden has stated that access to mental health and substance use treatment is a priority for his administration (APA Registers Concerns About Potential Cuts to Medicare Physician Payment).In positive news, CMS approved increased payment for services in facility settings and services provided in the home—a provision supported by APA—and aligned the rules for evaluation and management (E/M) code selection and documentation in these settings with the requirements currently in place for outpatient E/M services.Overall, the new fee schedule provides some clarity around the psychiatric practice and reimbursement landscape after the expiration of the COVID-19 public health emergency (PHE), which is expected to end in 2023. The COVID-19 PHE was last renewed on October 13, 2022, for 90 days, marking January 11, 2023, as either the next renewal date or the end of the PHE. Congress has already passed into law a 151-day extension beyond the end date of the PHE of many of the telehealth flexibilities authorized as part of Medicare’s pandemic response. Importantly for psychiatry, some flexibilities—like the waiver of in-person visit requirements for the prescription of controlled substances—are not eligible for the 151-day extension, and barring further rulemaking, in-person visits will again be required for prescription of controlled substances. The final rule has made permanent coverage for audio-only mental health telehealth services, the only category of services that will be eligible for audio-only delivery on a permanent basis after the PHE.Once the 151-day extension ends, psychiatrists should plan to see all established patients in person within 12 months. New patients must be seen in person before receiving telehealth services and once a year thereafter. Patients who established care via telehealth during the PHE or during the 151-day extension will be considered established patients.Some exceptions are allowed to the required subsequent 12-month in-person visits based on hardship; the hardship must be documented in the patient’s medical record with a clear reason for the exception—such as significant travel time, mobility challenges, or scheduling unavailability for either patient or provider. ■More information on CPT coding, documentation, and telepsychiatry practice.For questions, contact [email protected] ISSUES NewArchived

Influencing factors of Legionella reproduction in secondary water supply operation and management

Objective: To analyze the pollution status and influencing factors of Legionella pneumophila in a secondary water supply facility in a city. Methods: From June to August 2020, a survey on the level of Legionella pneumophila in secondary water supply unit was carried out in a city in northern China, and 304 sets of secondary water supply facilities were included in the study. A total of 760 water samples were collected from the inlet and outlet water of the secondary water supply facilities and some water samples in the water tank were collected for the detection of Legionella pneumophila, standard plate-count bacteria and related physical and chemical indicators. Through questionnaire survey, the basic information of secondary water supply facilities and daily management of water quality were collected. Multivariate logistic regression model was used to analyze the influencing factors of Legionella pneumophila contamination. Results: Among 304 sets of secondary water supply facilities, most of them were located in residential buildings [57.24% (174/304)]. High and low water tank water supply, low water tank variable frequency conversion water supply and non-negative pressure water supply accounted for 26.6% (81/304), 36.8% (112/304) and 36.5% (111/304), respectively. About 25.7% of facilities (78/304) were positive for Legionella pneumophila. Among them, the positive rates of Legionella pneumophila in high and low water tank water supply, low water tank variable frequency conversion water supply and non-negative pressure water supply facilities were 38.3% (31/81), 29.5% (33/112) and 12.6% (14/111), respectively. The results of multivariate logistic regression model analysis showed that the disinfectant residue could reduce the risk of Legionella pneumophila contamination in water samples, and the OR (95%CI) value was 0.083 (0.022-0.317). The increase of the standard plate-count bacteria and conductivity might increase the risk of Legionella pneumophila contamination in water samples. The OR (95%CI) values were 3.160 (1.667-5.99) and 1.004 (1.001-1.006), respectively. Compared with the non-negative pressure water supply, the risk of Legionella pneumophila contamination of secondary water supply facilities was increased by water supply from high and low water tanks and variable frequency conversion water supply from low water tanks, with OR (95%CI) values of 4.296 (2.096-8.803) and 2.894 (1.449-5.782), respectively. Conclusion: The positive rate of Legionella pneumophila in secondary water supply in the study city is high. Disinfectant residue, conductivity and method of water supply are associated with the positive rate of Legionella pneumophila.

The perception of outpatient care quality by healthcare users in Ukraine

ABSTRACT Background Ukraine has been improving the quality of health care by reforming the health care system. Evidence on healthcare users’ perceptions of quality is important for future system changes. This paper aims to analyze the aspects of quality that outpatient care users find most important. Methods Data from a longitudinal household survey ‘Health Index. Ukraine’ in 2016–2019 were used. The survey had a sample size of over 10,000 participants per wave. Data were analyzed using descriptive statistics as well as binary regression analysis. Results Our results showed the importance of quality attributes as ‘effectiveness of treatment’ and ‘qualification of medical personnel’ as well as changes in the perception of quality attributes connected with payment policies and general management of the facility (like working hours, setting and hygiene ensuring by medical personnel). Conclusions Our study provides new insights into the importance of healthcare quality attributes for outpatient healthcare users in Ukraine, showing the need to develop in future a national policy on quality and a national quality strategy for health care that incorporates quality aspects important to patients to make the healthcare system more responsive to the needs and expectations of healthcare users.

The delivery of essential newborn care in conflict settings: A systematic review.

Although progress has been made over the past 30 years to decrease neonatal mortality rates, reductions have been uneven. Globally, the highest neonatal mortality rates are concentrated in countries chronically affected by conflict. Essential newborn care (ENC), which comprises critical therapeutic interventions for every newborn, such as thermal care, initiation of breathing, feeding support, and infection prevention, is an important strategy to decrease neonatal mortality in humanitarian settings. We sought to understand the barriers to and facilitators of ENC delivery in conflict settings. We systematically searched Ovid/MEDLINE, Embase, CINAHL, and Cochrane databases using terms related to conflict, newborns, and health care delivery. We also reviewed grey literature from the Healthy Newborn Network and several international non-governmental organization databases. We included original research on conflict-affected populations that primarily focused on ENC delivery. Study characteristics were extracted and descriptively analyzed, and quality assessments were performed. A total of 1,533 abstracts were screened, and ten publications met the criteria for final full-text review. Several barriers emerged from the reviewed studies and were subdivided by barrier level: patient, staff, facility, and humanitarian setting. Patients faced obstacles related to transportation, cost, and access, and mothers had poor knowledge of newborn danger signs. There were difficulties related to training and retaining staff. Facilities lacked supplies, protocols, and data collection strategies. Strategies for improved ENC implementation include maternal and provider education and increasing facility readiness through upgrades in infrastructure, guidelines, and health information systems. Community-based approaches may also play a vital role in strengthening ENC.

Right to abortion & safe abortion will reduce maternal mortality

Recent report of the United Nations population fund’s state of the world population says that around 08 women die every day in India because of unsafe abortion. There are many reasons behind the deaths such as taking abortion pills without consulting doctor, abortion carried out by untrained personals, abortion in hospitals without facilities settings etc. Married women have the right to abortion but what about the unmarried pregnant women; this case is one of the major cause of unsafe abortion especially in our country India. Right to abortion simply means one can go for safe abortion i.e. the abortion will be carried out by a trained doctor in a hospital approved for pregnancy termination having facilities settings. Time to time amendments in Medical termination of Pregnancy act took place but no right provided to unmarried. Supreme Court in its judgment on 29th September 2022 gave right to abortion to unmarried pregnant women too up to 20 weeks from the date of gestation. This judgement came in a case that filed on July 2022 by 25 years old pregnant women. The judgement is a revolution and save many lives of women because it will stop or reduce the number of unsafe abortions. The article discussed about the impact of this decision on women in near future, unsafe abortion, medical abortion using medications, actions and adverse effects of medications used for abortion, medical termination of pregnancy act 1971, amendment in act and effect of Supreme Court’s judgement on women’s health and mortality.

Toward the Development of Rapid, Automated Identification Tests for Neat Organic Liquids Using Benchtop NMR Instrumentation.

The advent of benchtop nuclear magnetic resonance (NMR) instrumentation has paved the way for the use of this technology away from traditional NMR facility settings. Still, a wider adoption of benchtop NMR systems for routine identification testing has been hampered by inherent instrumental limitations (including low sensitivity and reduced signal dispersion) and workflow automation challenges. The present study summarizes the results of a cross-company collaboration aiming at the development of rapid, automated identification tests for incoming materials in liquid form intended for pharmaceutical manufacturing. Potential scenarios that analysts may encounter during the development of identification tests using benchtop NMR instrumentation are described, and suitable strategies for data collection and analysis are discussed. Challenges and opportunities for benchtop NMR implementation are illustrated using common organic solvents and laboratory reagents in a neat form, for which reference NMR data are provided.

Management of patients with allergic diseases during pregnancy: lecture

ABSTRACT. In connection with the considerable increase of prevalence of allergic diseases (AD) there all more often are situations, when it will be to decide the question of management of patients a doctor with an allergy during pregnancy. Prevalence of AD (allergic rhinitis/conjunctivitis, allergic phenotypes of bronchial asthma and hives, atopic dermatitis, food/drug/insect allergy, anaphylaxis) among pregnant women can arrive 30 %. It is possible to distinguish three types of influence of pregnancy on clinical motion of AD: 1) presence of pregnancy does not affect motion of AD; 2) on a background pregnancy comes remission of AD; 3) on a background pregnancy arise up intensifying of AD and their motion are burdened. It is difficult to predict exactly how the course of AD will occur during pregnancy, while the nature of treatment of a pregnant woman with AD and the level of their control are extremely important. At pregnancy diagnosis of AD is based on data of allergic anamnesis, food diary, physical inspection. Thus realization of skin and provocative tests with allergens contra-indicated. Application of provocative tests is also forbidden with a histamine, а methacholine and an acetylcholine. At treatment of pregnant from AD must be taken into account possible side effects of antiallergic drugs. Setting of modern medicinal facilities allows in most cases to control motion of allergic pathology for pregnant and avoid development of side effects of drugs. Treatment of AD during pregnancy the best result must provide for a mother and child. Medical workers must inform the women of reproductive age and pregnant of potential risks and present/absent proofs of unconcern/ununconcern of diagnostic and curative events.

Workplace health promotion programs for employees in long-term care facilities - a systematic review

Abstract Background Employees in long-term care facilities (LTC) are exposed to physically and mentally demanding workloads. Due to the specific working conditions and processes in LTC, recent literature recommends that care setting-specific health promotion is required. The objective was to systematically review the current evidence of workplace health promotion programs among employees in LTC. Methods A systematic review was conducted in accordance with the PRISMA 2020 Statement. The literature search was applied in the online databases PubMed, Web of Science, Cochrane Central Register of Controlled Trials, and APA PsycArticles (Jan 2000 - Feb 2022). Studies were included if (1) participants worked in any occupational setting in LTC, (2) personal health and outcomes related to occupational health were measured as primary outcome, and (3) studies were randomized controlled trials. Methodological quality was assessed using the Cochrane risk of bias assessment tool (RoB 2). Results The literature search yielded 23.007 articles, resulting in 24 included studies and 21 unique interventions with a total of 6.625 participants at baseline. Most participants were female (85.2% to 100%). Interventions were grouped into person-directed (n = 4), person/work interface-directed (n = 10), work-directed (n = 0), and combined approaches (n = 7). Of these studies, two studies (2/4) using a person-directed approach, four studies (4/10) using a person/work interface-directed approach, and four studies (4/7) using a combined approach demonstrated significant improvements in personal health-related outcomes and occupational health-related outcomes. Methodological quality can be rated as some concerns. Conclusions Interventions that incorporate a combination of intervention approaches appear promising for improving health and work-related outcomes among employees in LTC. There is a lack of evidence for only work-directed approaches to health promotion in LTC. High-level quality studies are still needed. Key messages • Combined intervention approaches to workplace health promotion in long-term care facility settings appear to be beneficial. • High-level quality studies on workplace health promotion in long-term care facilities are still needed.

An adaptive memetic algorithm for the bidirectional loop layout problem

Given a set of facilities, a set of positions arranged in a loop configuration and a flow cost matrix, the bidirectional loop layout problem (BLLP) is to find a facility-to-position assignment with the minimum sum of the products of flow costs and facility distances. The flow cost between two facilities is the unit cost of transporting items between two facilities, and the distance between two positions is shorter in the clockwise or counterclockwise direction in the loop. The BLLP is a relevant model for manufacturing systems; however, as the problem is known to be NP-hard, solving the problem is computationally challenging. This paper presents a memetic algorithm for BLLP that features an adaptive crossover selection and a dedicated 3-phase local search. Experiments of the proposed algorithm are conducted on 65 benchmarks, demonstrating a competitive performance compared with the current best algorithms. Additional experiments are conducted to study the impacts of the essential components of the algorithm.

Health worker perceptions of stigma towards Zambian adolescent girls and young women: a qualitative study

BackgroundThe high prevalence of HIV among adolescent girls and young women aged 15–24 in Eastern and Southern Africa indicates a substantial need for accessible HIV prevention and treatment services in this population. Amidst this need, Zambia has yet to meet global testing and treatment targets among adolescent girls and young women living with HIV. Increasing access to timely, high-quality HIV services in this population requires addressing the intensified anticipated and experienced stigma that adolescent girls and young women often face when seeking HIV care, particularly stigma in the health facility setting. To better understand the multi-level drivers and manifestations of health facility stigma, we explored health workers’ perceptions of clinic- and community-level stigma against adolescent girls and young women seeking sexual and reproductive health, including HIV, services in Lusaka, Zambia.MethodsWe conducted 18 in-depth interviews in August 2020 with clinical and non-clinical health workers across six health facilities in urban and peri-urban Lusaka. Data were coded in Dedoose and thematically analyzed.ResultsHealth workers reported observing manifestations of stigma driven by attitudes, awareness, and institutional environment. Clinic-level stigma often mirrored community-level stigma. Health workers clearly described the negative impacts of stigma for adolescent girls and young women and seemed to generally express a desire to avoid stigmatization. Despite this lack of intent to stigmatize, results suggest that community influence perpetuates a lingering presence of stigma, although often unrecognized and unintended, in health workers and clinics.ConclusionsThese findings demonstrate the overlap in health workers’ clinic and community roles and suggest the need for multi-level stigma-reduction approaches that address the influence of community norms on health facility stigma. Stigma-reduction interventions should aim to move beyond fostering basic knowledge about stigma to encouraging critical thinking about internal beliefs and community influence and how these may manifest, often unconsciously, in service delivery to adolescent girls and young women.

Health workers’ experiences of implementation of Helping Mothers Survive Bleeding after Birth training in Tanzania: a process evaluation using the i-PARIHS framework

BackgroundIn-service training, including the competency-based Helping Mothers Survive Bleeding After Birth (HMS BAB) is widely implemented to improve the quality of maternal health services. To better understand how this specific training responds to the needs of providers and fits into the existing health systems, we explored health workers’ experiences of the HMS BAB training.MethodsOur qualitative process evaluation was done as part of an effectiveness trial and included eight focus group discussions with 51 healthcare workers in the four districts which were part of the HMS BAB trial. We employed deductive content analysis informed by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) construct of context, recipients, innovation and facilitation.ResultsOverall, health workers reported positive experiences with the training content and how it was delivered. They are perceived to have improved competencies leading to improved health outcomes. Interviews proposed that peer practice coordinators require more support to sustain the weekly practices. Competing tasks within the facility in the context of limited time and human resources hindered the sustainability of weekly practices. Most health facilities had outlined the procedure for routine learning environments; however, these were not well operational.ConclusionThe HMS BAB training has great potential to improve health workers’ competencies around the time of childbirth and maternal outcomes. Challenges to successful implementation include balancing the intervention within the routine facility setting, staff motivation and workplace cultures.

Exploring preferences of market traders of the type and delivery methods of HIV services in Lilongwe, Malawi

Background: Reaching all people with HIV services, including traders in the informal economy, is critical to meeting UNAIDS’ 95-95-95 goals. However, traders prioritise their business over attendance at health facilities. This limits their access to health services. This study explores market traders’ preferences for the potential type and delivery methods of HIV services at Lilongwe Central market. Method: The study used an exploratory qualitative study design in Lilongwe, Malawi. Sixteen in-depth interviews were conducted among traders at Lilongwe Central market between June and September 2022. In the same period, we also conducted four key informant interviews involving three officers responsible for HIV services at the district and council levels, and the market chairman. Results: HIV services preferred by market traders include HIV testing, antiretroviral therapy, condom dispensation, voluntary medical male circumcision and HIV awareness campaigns. These services should be offered daily or when the market is less crowded, and they could be delivered either in the market or a health facility setting. These services can be provided by both lay and health workers, depending on traders’ preferences, and must be integrated with other health services to mitigate unintended HIV status disclosure concerns. Conclusion: The achievement of UNAIDS’ 95-95-95 goals by 2030 requires that HIV services should be available to all those who require them at times and locations that are convenient for them, through providers they have chosen, and provided as either integrated or standalone services depending on the target group's perception of the role of these two models in mitigating stigma. This will necessitate the development of new approaches targeting underserved groups, such as traders in markets.

Optimal allocation of dynamic wireless charging facility for electric vehicles

It is widely recognized that electric vehicle (EV) users get frustrated by the limited range of EVs, slow charging, and limited charging facilities available in the vicinity of their journey route. These factors contribute to slowing down the uptake of EVs. Dynamic wireless charging (DWC) system has the potential to offer a cost-effective solution to these issues. This paper investigates the DWC allocation problem from the decision makers’ perspective to minimize individual users’ costs as well as the investment cost for DWC facilities. We propose a mixed-integer optimization model to achieve a cost-effective solution for the optimal placement of DWC facilities on the large road network while maintaining an acceptable state-of-charge level. Sensitivity analysis is conducted on the optimization model parameters to check the feasibility and significance of model solutions for DWC placements. The results provide useful insights into the optimal settings of DWC facilities under multiple route environments.

Disaster Prevention and Mitigation Index Assessment of Green Buildings Based on the Fuzzy Analytic Hierarchy Process

Assessment systems for green buildings around the world have been developed over many years, but there is a lack of assessment elements for the disaster prevention and mitigation (DPM) capabilities of green buildings in many indicators. DPM indexes based on the four main aspects of structural safety, DPM design, facility settings, and resource utilization are proposed here with consideration to the complex natural disasters that occur in China (fires, earthquakes, floods, etc.) and relevant codes. Then, an assessment system for the DPM indexes of green buildings is established by the fuzzy analytic hierarchy process (FAHP) in order to evaluate the DPM ability of green buildings and to quantify the impact of different indexes on the DPM ability of green buildings; this system is also used to evaluate and compare DPM capability suggestions, taking two green buildings in South and North China as examples. The results show that the DPM capacities of the two green buildings were evaluated as good, but that the scores for the site planning and water-saving systems of the green building in South China were significantly lower—meaning that measures such as optimizing drainage systems, managing stormwater runoff, permeable paving, rainwater gardens, and installing rainwater harvesting equipment should be implemented. Then, the theory of the utilization rate of DPM conversion is put forward, providing a reference for the future development of green building DPM index systems.

Advanced testing and debugging support for reactive executable DSLs

Executable Domain-Specific Languages (xDSLs) allow the definition and the execution of behavioral models. Some behavioral models are reactive, meaning that during their execution, they accept external events and react by exposing events to the external environment. Since complex interaction may occur between the reactive model and the external environment, they should be tested as early as possible to ensure the correctness of their behavior. In this paper, we propose a set of generic testing facilities for reactive xDSLs using the standardized Test Description Language (TDL). Given a reactive xDSL, we generate a TDL library enabling the domain experts to write and run event-driven TDL test cases for conforming reactive models. To further support the domain expert, the approach integrates interactive debugging to help in localizing defects, and mutation analysis to measure the quality of test cases. We evaluate the level of genericity of the approach by successfully writing, executing, and analyzing 247 event-driven TDL test cases for 70 models conforming to two different reactive xDSLs.

'This disease is not meant for the hospital, it is Asram': Implications of a traditionally-defined illness on healthcare seeking for children under-5 in rural Ashanti, Ghana.

Every child has the right to survive, grow and develop. However, in spite of the considerable global gains that have been made in child survival, Sub-Saharan Africa still has the highest child mortality rates and accounts for the greatest burden of mortality globally. The majority of these children die without ever reaching a health facility. The practice of appropriate healthcare-seeking behaviour has a great potential to reduce the occurrence of severe and life-threatening childhood illnesses. Several factors, however, influence healthcare-seeking behaviour, including perceptions of the cause of illness and socio-cultural perspectives. This study seeks to understand local concepts of a traditionally-defined illness complex, Asram, and its influence on healthcare seeking behavior of mothers/caregivers. This qualitative study was conducted from October 2019 to February 2020. Four Focus Group Discussions were conducted with mothers/caregivers of children under-5 and 22 Key Informant Interviews with mothers/caregivers of children who had Asram, health workers at district, facility, and community levels, and Asram healers. Participants were selected from two rural communities, Akutuase and Wioso of the Asante Akim North district in the Ashanti region of Ghana. Data analysis was carried out iteratively throughout data collection, using a thematic analysis approach. The study shows that Asram is a childhood illness complex that is perceived to have been acquired spiritually and/or inherited. Nine types of Asram were described. This childhood illness was said to be treatable by Asram healers who had sub-specialties in treatment approaches that were determined by the Asram type reported. Mothers/caregivers trusted Asram healers and preferred to call on them first. This was found to be the main reason for delays in seeking healthcare for children under-5 who showed symptoms of Asram. Asram is a childhood illness complex that is believed to be better managed outside the health facility setting. This study complements existing knowledge and creates opportunities for further research and the introduction of more effective interventions in the effort to improve child survival in rural communities.

On a Pickup to Delivery Drone Routing Problem: Models and algorithms

A new variant of the Pickup and Delivery Routing problem is presented. Given a set of customers, facilities, a depot, and a homogeneous fleet of drones, the Pickup to Delivery Drone Routing Problem (PDDRP) aims to find a drone scheduling such that a drone serves the customer’s order from a set of available facilities. Each drone starts in the depot, flies to pickup the customer’s order in a facility, and continues its flight to deliver the parcel to a customer. Then, the drone begins another service, and once its last service is completed, it returns to the depot. The objective is to minimize the makespan associated with the drone fleet. The layer of facilities forcing drones to visit one of them to pickup the parcel makes the problem different from traditional pickup and delivery routing problems. Three mixed-linear programming models are presented to obtain optimal solutions for the problem. The first model is related to the multiple Traveling Salesman Problem (m-TSP), the second is associated with the Parallel Machine Scheduling Problem (PMS), and the third was developed specifically for the new problem.Given the high computational complexity of the PDDRP, a Greedy Randomized Adaptive Search Procedure (GRASP) was designed to find near-optimal solutions when exact approaches cannot achieve (near) optimal solutions. Computational experiments show that a commercial solver could solve only small problem instances. GRASP can find reasonable solutions in a short time when medium and large instance sizes need to be solved. Finally, is shown that some routing problems for delivery, allowing truck-drone collaboration, could be formulated as an extension of PMS.

Declining commercial market share in facial reconstructive surgery: Implications for academic plastic surgery and training future generations

As a surgical discipline without anatomic boundaries, plastic surgery overlaps with several other specialties. This study aims to measure longitudinal trends in the proportion of commercially reimbursed procedures performed by plastic surgeons compared to other specialists. We hypothesize that there is encroachment in commercial market share by anatomically defined subspecialists within otolaryngology, ophthalmology, and dermatology. The IBM® MarketScan® Research Databases were queried to extract patients who underwent rhinoplasty, eyelid procedures, and skin cancer reconstruction covered by commercial insurance from 2007 to 2016 in the USA. Surgeon specialty was identified. Poisson regression modeled predictors of provider specialty for each procedure over time, adjusting for patient gender, region, facility setting, and diagnosis. A total of 430,472 rhinoplasty, eyelid, and skin cancer procedures were performed during the study period. For each year, the proportion of cases performed by plastic surgeons decreased by 2.1% for rhinoplasty compared to otolaryngologists, 2.0% for eyelid procedures compared to ophthalmologists, and 3.0% for skin cancer reconstruction compared to dermatologists (p<0.001). Plastic surgeons were less likely to perform the procedure if the underlying diagnosis or preceding procedure drew from referral bases of "anatomic" specialists, such as sinonasal disease for otolaryngologists (incidence rate ratio [IRR] 0.829), disorders of the eyelid or orbit for ophthalmologists (IRR 0.646), and Mohs excision for dermatologists (IRR 0.381) (p<0.001). Plastic surgeons are losing ground on commercially reimbursed facial reconstructive procedures historically performed by the specialty. Plastic surgeons must develop strategies to preserve the commercial market share of these procedures and avoid compromise to academic centers and resident education.

Clinical Features and Burden of Postacute Sequelae of SARS-CoV-2 Infection in Children and Adolescents

The postacute sequelae of SARS-CoV-2 infection (PASC) has emerged as a long-term complication in adults, but current understanding of the clinical presentation of PASC in children is limited. To identify diagnosed symptoms, diagnosed health conditions, and medications associated with PASC in children. This retrospective cohort study used electronic health records from 9 US children's hospitals for individuals younger than 21 years who underwent antigen or reverse transcriptase-polymerase chain reaction (RT-PCR) testing for SARS-CoV-2 between March 1, 2020, and October 31, 2021, and had at least 1 encounter in the 3 years before testing. SARS-CoV-2 positivity by viral test (antigen or RT-PCR). Syndromic (symptoms), systemic (conditions), and medication PASC features were identified in the 28 to 179 days following the initial test date. Adjusted hazard ratios (aHRs) were obtained for 151 clinically predicted PASC features by contrasting viral test-positive groups with viral test-negative groups using proportional hazards models, adjusting for site, age, sex, testing location, race and ethnicity, and time period of cohort entrance. The incidence proportion for any syndromic, systemic, or medication PASC feature was estimated in the 2 groups to obtain a burden of PASC estimate. Among 659 286 children in the study sample, 348 091 (52.8%) were male, and the mean (SD) age was 8.1 (5.7) years. A total of 59 893 (9.1%) tested positive by viral test for SARS-CoV-2, and 599 393 (90.9%) tested negative. Most were tested in outpatient testing facility settings (322 813 [50.3%]) or office settings (162 138 [24.6%]). The most common syndromic, systemic, and medication features were loss of taste or smell (aHR, 1.96; 95% CI, 1.16-3.32), myocarditis (aHR, 3.10; 95% CI, 1.94-4.96), and cough and cold preparations (aHR, 1.52; 95% CI, 1.18-1.96), respectively. The incidence of at least 1 systemic, syndromic, or medication feature of PASC was 41.9% (95% CI, 41.4-42.4) among viral test-positive children vs 38.2% (95% CI, 38.1-38.4) among viral test-negative children, with an incidence proportion difference of 3.7% (95% CI, 3.2-4.2). A higher strength of association for PASC was identified in those cared for in the intensive care unit during the acute illness phase, children younger than 5 years, and individuals with complex chronic conditions. In this large-scale, exploratory study, the burden of pediatric PASC that presented to health systems was low. Myocarditis was the most commonly diagnosed PASC-associated condition. Acute illness severity, young age, and comorbid complex chronic disease increased the risk of PASC.