Search results for: patient waiting time

Authors: Rosa Tsegaye Aga, Xuan Jiang, Pavel Vazquez Faci, Siqing Liu, Simon Rayner, Endalkachew Alemu, Markos Abebe

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Tuberculosis (TB) is a major cause of disease globally. In most cases, TB is treatable and curable, but only with the proper treatment. There is a time when drug-resistant TB occurs when bacteria become resistant to the drugs that are used to treat TB. Current strategies to identify drug-resistant TB bacteria are laboratory-based, and it takes a longer time to identify the drug-resistant bacteria and treat the patient accordingly. But machine learning (ML) and data science approaches can offer new approaches to the problem. In this study, we propose to develop an ML-based model to predict the antibiotic resistance phenotypes of TB isolates in minutes and give the right treatment to the patient immediately. The study has been using the whole genome sequence (WGS) of TB isolates as training data that have been extracted from the NCBI repository and contain different countries’ samples to build the ML models. The reason that different countries’ samples have been included is to generalize the large group of TB isolates from different regions in the world. This supports the model to train different behaviors of the TB bacteria and makes the model robust. The model training has been considering three pieces of information that have been extracted from the WGS data to train the model. These are all variants that have been found within the candidate genes (F1), predetermined resistance-associated variants (F2), and only resistance-associated gene information for the particular drug. Two major datasets have been constructed using these three information. F1 and F2 information have been considered as two independent datasets, and the third information is used as a class to label the two datasets. Five machine learning algorithms have been considered to train the model. These are Support Vector Machine (SVM), Random forest (RF), Logistic regression (LR), Gradient Boosting, and Ada boost algorithms. The models have been trained on the datasets F1, F2, and F1F2 that is the F1 and the F2 dataset merged. Additionally, an ensemble approach has been used to train the model. The ensemble approach has been considered to run F1 and F2 datasets on gradient boosting algorithm and use the output as one dataset that is called F1F2 ensemble dataset and train a model using this dataset on the five algorithms. As the experiment shows, the ensemble approach model that has been trained on the Gradient Boosting algorithm outperformed the rest of the models. In conclusion, this study suggests the ensemble approach, that is, the RF + Gradient boosting model, to predict the antibiotic resistance phenotypes of TB isolates by outperforming the rest of the models.

Keywords: machine learning, MTB, WGS, drug resistant TB

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Authors: Sara Mahmood, Omar Ahmed, Youssef Aladham, Moustafa Abdelnaby

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The varied complications of COVID-19 present an ongoing challenge to healthcare professionals. A rare presentation of complicated sinusitis with pre-septal cellulitis and hard palatal necrosis in a COVID-19 patient, was reported. A 52-year-old male was admitted to the hospital with typical COVID manifestations where he had two successive COVID-19 positive swabs. During his admission, he developed symptoms of right orbital complications of sinusitis along with both clinical and radiological evidence of ipsilateral hard palatal necrosis. Imaging confirmed a diagnosis of right pan-sinusitis complicated with right pre-septal infection and hard palatal bony defect on the same side. Intra-operatively, the sphenopalatine artery was found to be thrombosed. This case focuses on the possible association between these manifestations and the known thromboembolic complications of COVID-19. Ongoing management of such complicated rare cases should be through a multidisciplinary team.

Keywords: COVID-19, sinusitis, sphenopalatine artery, thrombosis

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Authors: Ali Kassem, Yaser Kamal, Mohamed Abdel Wahab, Mohamed Hussen

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Introduction: Atherosclerosis is one of the leading causes of death all over the world. Recently, there is an increasing interest in Carotid Intima-Medial Thickness (CIMT) and Ankle Brachial Index (ABI) as non-invasive tools for identifying subclinical atherosclerosis. We aim to examine the role of CIMT and ABI as predictors of the severity of angiographically documented coronary artery disease (CAD). Methods: A cross-sectional study conducted on 60 patients who were investigated by coronary angiography at Sohag University Hospital, Egypt. CIMT: After the carotid arteries were located by transverse scans, the probe was rotated 90 ° to obtain and record longitudinal images of bilateral carotid arteries ABI: Each patient was evaluated in the supine position after resting for 5 min. ABI was measured in each leg using a Doppler Ultrasound while the patient remained in the same position. The lowest ABI obtained for either leg was taken as the ABI measurement for the patient. Results: Patients with carotid mean IMT ≥ 0.9 mm had significantly more severe coronary artery disease than patients without thickening (mean IMT > 0.9 mm). Similarly, patients with low ABI (< 0.9) had significantly more severe coronary artery disease than patients with ABI ≥ 0.9. When the patients were divided into 4 groups (group A, n = 15, mean IMT < 0.9 mm, ABI ≥ 0.9; group B, n = 25, mean IMT < 0.9 mm, low ABI; group C, n = 5, mean IMT ≥ 0.9 mm, ABI ≥ 0.9; group D, n = 19, mean IMT ≤ 0.9 mm, low ABI), the presence of significant coronary stenosis (> 50%) of the groups were significantly different (group A, n = 5: (33.3%); group B, n = 11: (52.4%); group C, n = 4: (60%); group D, n=15, (78.9%), P = 0.001). Conclusion: CIMT and ABI provide useful information on the severity of CAD. Early and aggressive intervention should be considered in patients with CAD and abnormalities in one or both of these non-invasive modalities.

Keywords: ankle brachial index, carotid intima media thickness, coronary artery disease, predictors of severity

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Authors: Andrew Read, Alice Parry, Kate Woods

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Since the advent of the SARS-CoV-2 pandemic, the search for medications that can reduce mortality and morbidity has been a global research priority. Several multi-center trials have recently demonstrated improved mortality associated with the use of Tocilizumab, an interleukin-6 receptor antagonist, in patients with severe SARS-CoV-2 pneumonia. Initial data supported the administration in patients requiring respiratory support (non-invasive or invasive ventilation), but more recent data has shown benefit in all hypoxic patients. At the height of the second wave of COVID-19 infections in London, our hospital introduced the use of Tocilizumab for patients with severe COVID-19. Tocilizumab is licensed for use in chronic inflammatory conditions and has been associated with an increased risk of severe bacterial and fungal infections, as well as reactivation of chronic viral infections (e.g., hepatitis B). It is a specialist drug that suppresses the formation of C-reactive protein (CRP) for 6 – 12 weeks. It is not widely used by the general medical community. We aimed to assess Tocilizumab use in our hospital and to implement changes to the protocol as required to ensure administration was safe and appropriate. A retrospective study design was used to assess prescriptions over an initial 3-week period in both intensive care and on the medical wards. This amounted to a total of 13 patients. The initial data collection identified four key areas of concern: adherence to national and local inclusion & exclusion criteria; a collection of appropriate screening blood prior to administration; documentation of informed consent or best interest decision and documentation of Tocilizumab administration on patient discharge information, to alert future healthcare providers that typical measures of inflammation and infection, such as CRP, are unreliable for up to 3-months. Data were collected from electronic notes, blood results and observation charts, and cross referenced with pharmacy data. Initial results showed that all four key areas were completed in approximately 50% of cases. Of particular concern was adherence to exclusion criteria, such as current evidence of bacterial infection, and ensuring the correct screening blood was sent to exclude infections such as hepatitis. To remedy this and improve patient safety, the initial data was presented to relevant healthcare professionals. Subsequently, three interventions were introduced and education on each provided to hospital staff. An electronic ‘order set’ collating the appropriate screening blood was created simplifying the screening process. Pre-formed electronic documentation which can be inserted into the notes was created to provide a framework for consent discussions and reduce the time needed for junior doctors to complete this task. Additionally, a ‘Tocilizumab’ administration card was created and administered via pharmacy. This was distributed to each patient on discharge to ensure future healthcare professionals were aware of the potential effects of Tocilizumab administration, including suppression of CRP. Following these changes, repeat data collection over two months illustrated that each of the 4 safety aspects was met with a 100% success rate in every patient. Although this demonstrates good progress and effective interventions the challenge will be to maintain this progress. The audit data collection is ongoing

Keywords: education, patient safety , SARS-CoV-2, Tocilizumab

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Authors: Omkar More, Isha Saini, Gracy Mathai

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To study whether there is any clinical correlation between pterygium and dry eye and to evaluate the status of the tear film in patients with pterygium. Methods: 100 eyes with pterygium were compared with 100 control eyes without pterygium. Patients between 20 – 70 years were included in the study. A detailed history was taken and Schirmer’s test and TBUT were performed on all to evaluate the status of dry eye. Schirmer’s test ˂ 10 mm and TBUT ˂10 seconds was considered abnormal. Results: Maximum number (52) of patients affected by dry eye in both the groups were in the age group 31-40 years which statistically showed age as a significant factor of association for both pterygium and dry eye (P < 0.01).Schirmer’s test was slightly reduced in patients with pterygium(18.73±5.69 mm). TBUT was significantly reduced in the case group (12.26±2.24sec).TBUT decreased maximally in 51-60 yrs age group (13.00±2.77sec) with pterygium showing a tear film instability. On comparison of pterygia and controls with normal and abnormal tear film, Odd’s Ratio was 1.14 showing a risk of dry eye in pterygia patients to be 1.14 times higher than controls. Conclusion: Whether tear dysfunction is a precursor to pterygium growth or pterygium causes tear dysfunction is still not clear. Research and clinical evidence, however, suggest that there is a relationship between the two. This study is, therefore, undertaken to investigate the correlation between pterygium and dry eye. The patients with pterygia were compared with normals to evaluate their status regarding dryness. A close relationship exists between ocular irritation symptoms and functional evidence of tear instability. Schirmer’s test and TBUT should routinely be used in the outpatient department to diagnose dry eye in patients with pterygium and these patients should be promptly treated to prevent any sight-threatening complications.

Keywords: footfall, nursing assessment, quality improvement, six sigma

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Authors: Siddharth Rana

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As we know so far, there are 3 dimensions that we are capable of interpreting and perceiving, and there is a 4th dimension, called time, about which we don’t know much yet. We, as humans, live in the 4th dimension, not the 3rd. We travel 3 dimensionally but cannot yet travel 4 dimensionally; perhaps if we could, then visiting the past and the future would be like climbing a mountain or going down a road. So far, we humans are not even capable of imagining any higher dimensions than the three dimensions in which we can travel. We are the beings of the 4th dimension; we are the beings of time; that is why we can travel 3 dimensionally; however, if, say, there were beings of the 5th dimension, then they would easily be able to travel 4 dimensionally, i.e., they could travel in the 4th dimension as well. Beings of the 5th dimension can easily time travel. However, beings of the 4th dimension, like us, cannot time travel because we live in a 4-D world, traveling 3 dimensionally. That means to ever do time travel, we just need to go to a higher dimension and not only perceive it but also be able to travel in it. However, traveling to the past is not very possible, unlike traveling to the future. Even if traveling to the past were possible, it would be very unlikely that an event in the past would be changed. In this paper, some approaches are provided to define time, our movement in time to the future, some aspects of time travel using dimensions, and how we can perceive a higher dimension.

Keywords: time, dimensions, String theory, relativity

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Authors: Ani Thomas

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Every narrative is a temporal construct. Every narrative creates a qualitative experience of time for the viewer. The paper argues for the concept of a qualified time that emerges from the interaction between the narrative and the audience. The paper also challenges the conventional understanding of narrative time as either story time, real time or discourse time. Looking at narratives through the medium of Cinema, the study examines how narratives create and manipulate duration or durée, the qualitative experience of time as theorized by Henri Bergson. The paper further analyzes how Cinema and, by extension, narratives are nothing but Durée and the filmmaker, the artist of durée, who shape and manipulate the perception and emotions of the viewer through the manipulation and construction of durée. The paper draws on cinematic works to look at the techniques to demonstrate how filmmakers use, for example, editing, sound, compositional and production narratives etc., to create various modes of durée that challenge, amplify or unsettle the viewer’s sense of time. Bringing together the Viewer’s durée and exploring its interaction with the narrative construct, the paper explores the emergence of the new qualitative time, the narrative durée, that defines the audience experience.

Keywords: cinema, time, bergson, duree

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Authors: Ashvamedh, Chandra Bhushan Singh, Anil Kumar Sarda

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Introduction: Ileal perforation is a common cause for peritonitis in developing countries. Surgery is the ideal treatment as it eliminates soilage of peritoneal cavity in an effort to lessen the toxaemia and enhance the recovery of the patient. However, there is no uniformity of standardized operative procedure that is most effective for management. Material and method: The study was conducted on 66 patients of perforation peritonitis from November 2013 to February 2015 in Lok Nayak Hospital. Data of each patient were recorded on a pre-determined proforma. The methods used for repair were Primary repair, Resection anastomosis (RA) and Ileostomy. Result: Male preponderance was noticed among the patients with majority in their third decade. Of all perforations 40.9% were tubercular and 34.8% were typhoid. Amongst operated cases 27.3% underwent primary repair, RA was performed in 45.5%, Ileostomy in 27.3%patients. The average time taken for RA and ileostomy was more than primary repair. The type of repair bear no significance to size or no of perforation but was significant statistically for distance from I/C valve(P=.005) and edema of bowel wall(p=.002) when analysed for post op complications. Wound infection, dehiscence, intra-abdominal collections were complications observed bearing no significance to type of repair. Ileostomy per se has its own complications peristomal skin excoriation seen in 83.3%, electrolyte imbalance in 33.3%, duration for closure averaged 188 days (median 150 days, range 85-400 days). Conclusion: Primary closure is preferable in patients with single, small perforations. RA is advocated in patients with multiple or large perforation, perforation proximal to stricture. Ileostomy should not be considered as primary definitive procedure and reserved only for moribund patients as a lifesaving procedure. It has more morbidity and requires a second surgery for closure increasing the cost of treatment as well.

Keywords: ileal perforation, ileostomy, perforation peritonitis, typhoid perforation management

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Authors: Humraaz Kaja, Kofi Mensah, Frasia Oosthuizen

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Background and Aim: Vilazodone was approved in 2011 as an antidepressant to treat the major depressive disorder. As a relatively new drug, it is not clear if all adverse effects have been identified. The aim of this study was to review the adverse effects reported to the WHO Programme for International Drug Monitoring (PIDM) in order to add to the knowledge about the safety profile and adverse effects caused by vilazodone. Method: Data on adverse effects reported for vilazodone was obtained from the database VigiAccess managed by PIDM. Data was extracted from VigiAccess using Excel® and analyzed using descriptive statistics. The data collected was compared to the patient information leaflet (PIL) of Viibryd® and the FDA documents to determine adverse drug reactions reported post-marketing. Results: A total of 9708 adverse events had been recorded on VigiAccess, of which 6054 were not recorded on the PIL and the FDA approval document. Most of the reports were received from the Americas and were for adult women aged 45-64 years (24%, n=1059). The highest number of adverse events reported were for psychiatric events (19%; n=1889), followed by gastro-intestinal effects (18%; n=1839). Specific psychiatric disorders recorded included anxiety (316), depression (208), hallucination (168) and agitation (142). The systematic review confirmed several psychiatric adverse effects associated with the use of vilazodone. The findings of this study suggested that these common psychiatric adverse effects associated with the use of vilazodone were not known during the time of FDA approval of the drug and is not currently recorded in the patient information leaflet (PIL). Conclusions: In summary, this study found several adverse drug reactions not recorded in documents emanating from clinical trials pre-marketing. This highlights the importance of continued post-marketing surveillance of a drug, as well as the need for further studies on the psychiatric adverse events associated with vilazodone in order to improve the safety profile.

Keywords: adverse drug reactions, pharmacovigilance, post-marketing surveillance, vilazodone

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Authors: Atmaja Patel

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Since the development of lasers in 1951, the first medical application was reported by Goldman in 1962. In 1960, T.H. Maiman produced the first Ruby laser and was used in cardiovascular surgery by McGuff in 1963. After a long time of investigations and new developments in laser technology first clinical applications were performed by Choy and Ginsburg in 1983. Introduction of the first true dental laser was in 1989. This paper is to highlight the various treatments and prevention of periodontal diseases. Lasers have become more predictable and effective form of treatment for periodontal diseases. The advantages of lasers include reduced use of anaesthesia, coagulation that yields a dry surgical field and hence better visibility, reduced need of sutures, minimal swelling and scarring, less pain and medication, faster healing and increased patient acceptance.

Keywords: lasers, periodontal surgery, diode laser, healing

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Authors: Kulwinder Singh Mann

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The innovative features of information system, known as Radiology Information System (RIS), for electronic medical records has shown a good impact in the hospital. The objective is to help and make their work easier; such as for a physician to access the patient’s data and for a patient to check their bill transparently. The interoperability of RIS with the other intra-hospital information systems it interacts with, dealing with the compatibility and open architecture issues, are accomplished by two novel mechanisms. The first one is the particular message handling system that is applied for the exchange of information, according to the Health Level Seven (HL7) protocol’s specifications and serves the transfer of medical and administrative data among the RIS applications and data store unit. The second one implements the translation of information between the formats that HL7 and Digital Imaging and Communication in Medicine (DICOM) protocols specify, providing the communication between RIS and Picture and Archive Communication System (PACS) which is used for the increasing incorporation of modern medical imaging equipment.

Keywords: RIS, PACS, HIS, HL7, DICOM, messaging service, interoperability, digital images

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Authors: Salam Saudagar, Ankit Kamboj, Niraj Mohan, Satgounda Patil, Nilesh Powar

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Task Assignment and Scheduling is a challenging Operations Research problem when there is a limited number of resources and comparatively higher number of tasks. The Cost Management team at Cummins needs to assign tasks based on a deadline and must prioritize some of the tasks as per business requirements. Moreover, there is a constraint on the resources that assignment of tasks should be done based on an individual skill level, that may vary for different tasks. Another constraint is for scheduling the tasks that should be evenly distributed in terms of number of working hours, which adds further complexity to this problem. The proposed greedy approach to solve assignment and scheduling problem first assigns the task based on management priority and then by the closest deadline. This is followed by an iterative selection of an available resource with the least allocated total working hours for a task, i.e. finding the local optimal choice for each task with the goal of determining the global optimum. The greedy approach task allocation is compared with a variant of Hungarian Algorithm, and it is observed that the proposed approach gives an equal allocation of working hours among the resources. The comparative study of the proposed approach is also done with manual task allocation and it is noted that the visibility of the task timeline has increased from 2 months to 6 months. An interactive dashboard app is created for the greedy assignment and scheduling approach and the tasks with more than 2 months horizon that were waiting in a queue without a delivery date initially are now analyzed effectively by the business with expected timelines for completion.

Keywords: assignment, deadline, greedy approach, Hungarian algorithm, operations research, scheduling

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Authors: P. Moskal, T. Bednarski, P. Bialas, E. Czerwinski, A. Gajos, A. Gruntowski, D. Kaminska, L. Kaplon, G. Korcyl, P. Kowalski, T. Kozik, W. Krzemien, E. Kubicz, Sz. Niedzwiecki, M. Palka, L. Raczynski, Z. Rudy, P. Salabura, N. G. Sharma, M. Silarski, A. Slomski, J. Smyrski, A. Strzelecki, A. Wieczorek, W. Wislicki, M. Zielinski, N. Zon

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A new concept and results of the performance tests of the TOF-PET detection system developed at the Jagiellonian University will be presented. The novelty of the concept lies in employing long strips of polymer scintillators instead of crystals as detectors of annihilation quanta, and in using predominantly the timing of signals instead of their amplitudes for the reconstruction of Lines-of-Response. The diagnostic chamber consists of plastic scintillator strips readout by pairs of photo multipliers arranged axially around a cylindrical surface. To take advantage of the superior timing properties of plastic scintillators the signals are probed in the voltage domain with the accuracy of 20 ps by a newly developed electronics, and the data are collected by the novel trigger-less and reconfigurable data acquisition system. The hit-position and hit-time are reconstructed by the dedicated reconstruction methods based on the compressing sensing theory and the library of synchronized model signals. The solutions are subject to twelve patent applications. So far a time-of-flight resolution of ~120 ps (sigma) was achieved for a double-strip prototype with 30 cm field-of-view (FOV). It is by more than a factor of two better than TOF resolution achievable in current TOF-PET modalities and at the same time the FOV of 30 cm long prototype is significantly larger with respect to typical commercial PET devices. The Jagiellonian PET (J-PET) detector with plastic scintillators arranged axially possesses also another advantage. Its diagnostic chamber is free of any electronic devices and magnetic materials thus giving unique possibilities of combining J-PET with CT and J-PET with MRI for scanning the same part of a patient at the same time with both methods.

Keywords: PET-CT, PET-MRI, TOF-PET, scintillator

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Authors: Sarah Gounden, Mukesh Dheda, Boikhutso Tlou, Elizabeth Ojewole, Frasia Oosthuizen

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Background: Antiretroviral therapy (ART) has been effective in the reduction of mortality and resulted in an improvement in the prognosis of HIV-infected patients. However, treatment with antiretrovirals (ARVs) has led to the development of many adverse drug reactions (ADRs). It is, therefore, necessary to determine the safety profile of these medicines in a South African population in order to ensure safe and optimal medicine use. Objectives: The aim of this study was to quantify ADRs experienced with the different ARVs currently used in South Africa, to determine the safety profile of ARV medicine in South Africa based on reported ADRs, and to determine the ARVs with the lowest risk profile based on specific patient populations. Methodology: This was a quantitative study. Individual case safety reports for the period January 2010 – December 2013 were obtained from the National Pharmacovigilance Center; these reports contained information on ADRs, ARV medicine, and patient demographics. Data was analysed to find associations that may exist between ADRs experienced, ARV medicines used and patient demographics. Results: A total of 1916 patient reports were received of which 1534 met the inclusion criteria for the study. The ARV with the lowest risk of ADRs were found to be lamivudine (0.51%, n=12), followed by lopinavir/ritonavir combination (0.8%, n=19) and abacavir (0.64%, n=15). A higher incidence of ADRs was observed in females compared to males. The age group 31–50 years and the weight group 61–80 kg had the highest incidence of ADRs reported. Conclusion: This study found that the safest ARVs to be used in a South African population are lamivudine, abacavir, and the lopinavir/ritonavir combination. Gender differences play a significant role in the occurrence of ADRs and both anatomical and physiological differences account for this. An increased BMI (body mass index) in both men and women showed an increase in the incidence of ADRs associated with ARV therapy.

Keywords: adverse drug reaction, antiretrovirals, HIV/AIDS, pharmacovigilance, South Africa

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Authors: Pinar Dogan, Merve Tarhan, Ahu Kurklu

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Syrian refugees who sheltering due to war has protected by the Government of Turkey since 2011. Since Syria was a medium-low income country prior to the war, it is known that chronic health problems weren’t common among citizens. However, it is also known that they frequently use health services in our country because of the spread of infectious and acute diseases due to insufficient sanitation and crowding after the war. This study was planned to compare the social distances of the community against the Syrian refugees and the perceptions of accessing health care services. The descriptive-cross sectional study was carried out on 1262 individuals living in Istanbul. A questionnaire form consisted of Personal Information Form, The Bogardus Social Distance Scale (BSDS) and The Survey of Access to Healthcare Services (AHS) was used as data collection tool. Descriptive tests and chi-square test were used for statistical analysis. It was found that the majorities of participants was satisfied with the health services and were waiting for more than 40 minutes to be examined. It was determined that participants have high scores from BSDS. At the same time, the majority of participants stated that their level of access to health care is diminishing due to refugees. Participants who experienced disruption in access to health services due to refugees were found to have higher scores from BSDS. The data collection process in the study will continue until 2400 individuals are reached. With these conclusions, it is considered necessary that the effect of the presence of the refugees in reaching the health services and nursing care of the society should be revealed through extensive researches to be conducted in Turkey.

Keywords: health care services, nursing care, social distances, Syrian refugees

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Authors: Athina Thanou, Eirini Eleni Tsiropoulou, Symeon Papavassiliou

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The problem of museum visitor experience and congestion management – in various forms - has come increasingly under the spotlight over the last few years, since overcrowding can significantly decrease the quality of visitors’ experience. Evidence suggests that on busy days the amount of time a visitor spends inside a crowded house museum can fall by up to 60% compared to a quiet mid-week day. In this paper we consider the aforementioned problem, by treating museums as evolving social systems that induce constraints. However, in a cultural heritage space, as opposed to the majority of social environments, the momentum of the experience is primarily controlled by the visitor himself. Visitors typically behave selfishly regarding the maximization of their own Quality of Experience (QoE) - commonly expressed through a utility function that takes several parameters into consideration, with crowd density and waiting/visiting time being among the key ones. In such a setting, congestion occurs when either the utility of one visitor decreases due to the behavior of other persons, or when costs of undertaking an activity rise due to the presence of other persons. We initially investigate how visitors’ behavioral risk attitudes, as captured and represented by prospect theory, affect their decisions in resource sharing settings, where visitors’ decisions and experiences are strongly interdependent. Different from the majority of existing studies and literature, we highlight that visitors are not risk neutral utility maximizers, but they demonstrate risk-aware behavior according to their personal risk characteristics. In our work, exhibits are organized into two groups: a) “safe exhibits” that correspond to less congested ones, where the visitors receive guaranteed satisfaction in accordance with the visiting time invested, and b) common pool of resources (CPR) exhibits, which are the most popular exhibits with possibly increased congestion and uncertain outcome in terms of visitor satisfaction. A key difference is that the visitor satisfaction due to CPR strongly depends not only on the invested time decision of a specific visitor, but also on that of the rest of the visitors. In the latter case, the over-investment in time, or equivalently the increased congestion potentially leads to “exhibit failure”, interpreted as the visitors gain no satisfaction from their observation of this exhibit due to high congestion. We present a framework where each visitor in a distributed manner determines his time investment in safe or CPR exhibits to optimize his QoE. Based on this framework, we analyze and evaluate how visitors, acting as prospect-theoretic decision-makers, respond and react to the various pricing policies imposed by the museum curators. Based on detailed evaluation results and experiments, we present interesting observations, regarding the impact of several parameters and characteristics such as visitor heterogeneity and use of alternative pricing policies, on scalability, user satisfaction, museum capacity, resource fragility, and operation point stability. Furthermore, we study and present the effectiveness of alternative pricing mechanisms, when used as implicit tools, to deal with the congestion management problem in the museums, and potentially decrease the exhibit failure probability (fragility), while considering the visitor risk preferences.

Keywords: museum resource and visitor management, congestion management, propsect theory, cyber physical social systems

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Authors: Shailendra Kumar Singh

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In the 21st century, we are living through extraordinary times as we are linguistically blessed to live through an era in which the each sociolinguistic example of living appears to be refreshingly new without any precedence of the past. The word `New Linguistic World Order’ is no longer just the intangible fascination but an indication of the emerging reality that we are living through a time in which the word ‘linguistic purism’ no longer invokes the sense of self categorization and self identification. The contemporary world of today is linguistically rewarding. This is a time in which the very existence of global, powerful and local needs to be revisited in the context of power shift, demographic shift, social psychological shift and technological shift. Hence, the old linguistic world view has to be challenged in the midst of 21st century. The first years of the 21st century have thus far been marked by the rise global economy, technological revolution and demographic shift, now we are witnessing linguistic shift which is leading towards forming a new linguistic world order. On the other hand, with rising powers of China and India in Asia in tandem the notion of alternative west is set to become a lot more interesting linguistically. It comes at a point when the world is moving towards inclusive globalization due to vanishing power corridor of the west and ascending geopolitical impact of emerging superpower and superpower in waiting. Now it is a reality that the western world no longer continues to rise – in fact, it will have more pressure to act in situation when the alternative west is looking for balanced globalization. It is more than likely that demographically strong languages of alternative west will be in advantageous position. The paper challenges our preconceptions about the nature of sociolinguistic nature of world in the 21st century. It investigates what a linguistic world is likely to be in the future in contrast to what was a linguistic world before 21st century. In particular, the paper tries to answer the following questions: (a) What will be the common linguistic thread across world? (b) How unprecedented transformations can be mapped linguistically? (c) Do we need alternative linguistics to define inclusive globalization as the linguistic reality of the contemporary world has already been reshaped by increasingly integrated world economy, linguistic revolution and alternative west? (d) In which ways these issues can be addressed holistically? (e) Why linguistic world order is changing dramatically? (f) Is it true that the linguistic world around is changing faster than we can even really cope? (g) Is it true that what is coming next is linguistically greater than ever? (h) Do we need to prepare ourselves with new theoretical strategies to address emerging sociolinguistic reality?

Keywords: alternative linguistics, new linguistic world order, power shift, demographic shift, social psychological shift, technological shift

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Authors: Peregrine James Dalziel, Philip Vu Tran

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Objective / Introduction: Demand for radiology services from Emergency Departments (ED) continues to increase with greater demands placed on radiology staff providing reports for the management of complex cases. Queuing theory indicates that wide variability of process time with the random nature of request arrival increases the probability of significant queues. This can lead to delays in the time-to-availability of radiology reports (TTA-RR) and potentially impaired ED patient flow. In addition, greater “cognitive workload” of greater volume may lead to reduced productivity and increased errors. We sought to quantify the potential ED flow improvements obtainable from increased radiology providers serving 3 public hospitals in Melbourne Australia. We sought to assess the potential productivity gains, quality improvement and the cost-effectiveness of increased labor inputs. Methods & Materials: The Western Health Medical Imaging Department moved from single resident coverage on weekend days 8:30 am-10:30 pm to a limited period of 2 resident coverage 1 pm-6 pm on both weekend days. The TTA-RR for weekend CT scans was calculated from the PACs database for the 8 month period symmetrically around the date of staffing change. A multivariate linear regression model was developed to isolate the improvement in TTA-RR, between the two 4-months periods. Daily and hourly scan volume at the time of each CT scan was calculated to assess the impact of varying department workload. To assess any improvement in report quality/errors a random sample of 200 studies was assessed to compare the average number of clinically significant over-read addendums to reports between the 2 periods. Cost-effectiveness was assessed by comparing the marginal cost of additional staffing against a conservative estimate of the economic benefit of improved ED patient throughput using the Australian national insurance rebate for private ED attendance as a revenue proxy. Results: The primary resident on call and the type of scan accounted for most of the explained variability in time to report availability (R2=0.29). Increasing daily volume and hourly volume was associated with increased TTA-RR (1.5m (p<0.01) and 4.8m (p<0.01) respectively per additional scan ordered within each time frame. Reports were available 25.9 minutes sooner on average in the 4 months post-implementation of double coverage (p<0.01) with additional 23.6 minutes improvement when 2 residents were on-site concomitantly (p<0.01). The aggregate average improvement in TTA-RR was 24.8 hours per weekend day This represents the increased decision-making time available to ED physicians and potential improvement in ED bed utilisation. 5% of reports from the intervention period contained clinically significant addendums vs 7% in the single resident period but this was not statistically significant (p=0.7). The marginal cost was less than the anticipated economic benefit based assuming a 50% capture of improved TTA-RR inpatient disposition and using the lowest available national insurance rebate as a proxy for economic benefit. Conclusion: TTA-RR improved significantly during the period of increased staff availability, both during the specific period of increased staffing and throughout the day. Increased labor utilisation is cost-effective compared with the potential improved productivity for ED cases requiring CT imaging.

Keywords: workflow, quality, administration, CT, staffing

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Authors: Mamoun S. Ideis, Zein Salah

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Virtual Rehabilitation (VR) refers to using Virtual Reality’s hardware and simulations as means of exercising tools to rehabilitate patients in need. These patients will undergo their treatment exercises while playing different computer games, which helps achieve greater motivation for patients undergoing their therapeutic exercises. Virtual Rehabilitation systems adopt computer games as part of the treatment therapy. In this paper, we present a preliminary proposal to using adaptive computer games in Virtual Rehabilitation therapy. We also present some tips in designing those adaptive computer games by using different machine learning algorithms in order to create a personalized experience for each patient, which in turn, increases the potential benefits of the treatment that each patient receives. Furthermore, we propose a method of comparing the results of treatment using the adaptive computer games with the results of using static and classical computer games.

Keywords: virtual rehabilitation, physiotherapy, adaptive computer games, post-stroke, game design

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Authors: Oyvind Nordvik, Peder O. L. Heggdal, Jonas Brannstrom, Flemming Vassbotn, Anne Kari Aarstad, Hans Jorgen Aarstad

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Background: Hearing Loss (HL) is a condition that may affect people in all stages of life, but the prevalence increases with age, mostly because of age-related HL, generally referred to as presbyacusis. As human speech is related to relatively high frequencies, even a limited hearing loss at high frequencies may cause impaired speech intelligibility. Being diagnosed with, treated for and living with a chronic condition such as HL, must for many be a disabling and stressful condition that put ones coping resources to test. Stress is a natural part of life and most people will experience stressful events or periods. Chronic diseases, such as HL, are risk factor for distress in individuals, causing anxiety and lowered mood. How an individual cope with HL may be closely connected to the level of distress he or she is experiencing and to personality, which can be defined as those characteristics of a person that account for consistent patterns of feelings, thinking, and behavior. Thus, as to distress in life, such as illness or disease, available coping strategies may be more important than the challenge itself. The same line of arguments applies to level of experienced health-related quality of life (HRQoL). Aim: The aim of this study was to investigate the relationship between distress, HRQoL, reported hearing loss, personality and coping in patients with HL. Method: 158 adult (aged 18-78 years) patients with HL, referred for hearing aid (HA) fitting at Haukeland University Hospital in western Norway, participated in the study. Both first-time users, as well as patients referred for HA renewals were included. First-time users had been pre-examined by an ENT-specialist. The questionnaires were answered before the actual HA fitting procedure. The pure-tone average (PTA; frequencies 0.5, 1, 2, and 4 kHz) was determined for each ear. The Eysenck personality inventory, neuroticism and lie scales, the Theoretically Originated Measure of the Cognitive Activation Theory of Stress (TOMCATS) measuring active coping, hopelessness and helplessness, as well as distress (General Health Questionnaire (GHQ) - 12 items) and the EORTC Quality of Life Questionnaire general part were answered. In addition, we used a revised and shortened version of the Abbreviated Profile of Hearing Aid Benefit (APHAB) as a measure of patient-reported hearing loss. Results: Significant correlations were determined between APHAB (weak), HRQoL scores (strong), distress scores (strong) on the one side and personality and choice of coping scores on the other side. As measured by stepwise regression analyses, the distress and HRQoL scores were scored secondary to the obtained personality and coping scores. The APHAB scores were as determined by regression analyses scored secondary to PTA (best ear), level of neuroticism and lie score. Conclusion: We found that reported employed coping style, distress/HRQoL and personality are closely connected to each other in this patient group. Patient-reported HL was associated to hearing level and personality. There is need for further investigations on these questions, and how these associations may influence the clinical context.

Keywords: coping, distress, hearing loss, personality

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Authors: Ayda Youssef, Mohammed Ali Khalaf, Tarek Rafaat

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Background: Langerhans cell histiocytosis (LCH) is a rare multi-systemic disease that shows an abnormal proliferation of these kinds of cells associated with a granular infiltration that affects different structures of the human body, including the lung, liver, spleen, lymph nodes, brain, mucocutaneous, soft tissue (head and neck), and salivary glands. Evaluation of the extent of disease is one of the major predictors of patient outcome. Objectives: To recognize the pathogenesis of Langerhans cell histiocytosis (LCH), describe the radiologic criteria that are suggestive of LCH in different organs rather than the bones and to illustrate the appropriate differential diagnoses for LCH in each of the common extra-osseous sites. Material and methods: A retrospective study was done on 150 biopsy-proven LCH patients from 2007 to 2012. All patients underwent imaging studies, mostly US, CT, and MRI. These patients were reviewed to assess the extra-skeletal manifestations of LCH. Results: In 150 patients with biopsy-proven LCH, There were 33 patients with liver affection, 5 patients with splenic lesions, 55 patients with enlarged lymph nodes, 9 patient with CNS disease and 11 patients with lung involvement. Conclusions: Because of the frequent LCH children and evaluation of the extent of disease is one of the major predictors of patient outcome. Radiologist need to be familiar with its presentation in different organs and regions of body outside the commonest site of affection (bones). A high-index suspicion should be raised a biopsy is recommended in the presence of radiological suspicion. Chemotherapy is the preferred therapeutic modality.

Keywords: langerhans cell histiocytosis, extra-skeletal, pediatrics, radiology

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Authors: Zoe Goldberger, Priscilla S. Briquez, Jeffrey A. Hubbell

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Tumor cells have mutations resulting from genetic instability that the immune system can actively recognize. Immune checkpoint immunotherapy (ICI) is commonly used in the clinic to re-activate immune reactions against mutated proteins, called neoantigens, resulting in tumor remission in cancer patients. However, only around 20% of patients show durable response to ICI. While tumor mutational burden (TMB) has been approved by the Food and Drug Administration (FDA) as a criterion for ICI therapy, the relevance of the subcellular localizations of the mutated proteins within the tumor cell has not been investigated. Here, we hypothesized that localization of mutations impacts the effect of immune responsiveness to ICI. We analyzed publicly available tumor mutation sequencing data of ICI treated patients from 3 independent datasets. We extracted the subcellular localization from the UniProtKB/Swiss-Prot database and quantified the proportion of membrane, cytoplasmic, nuclear, or secreted mutations per patient. We analyzed this information in relation to response to ICI treatment and overall survival of patients showing with 1722 ICI-treated patients that high mutational burden localized at the membrane (mTMB), correlate with ICI responsiveness, and improved overall survival in multiple cancer types. We anticipate that our results will ameliorate predictability of cancer patient response to ICI with potential implications in clinical guidelines to tailor ICI treatment. This would not only increase patient survival for those receiving ICI, but also patients’ quality of life by reducing the number of patients enduring non-effective ICI treatments.

Keywords: cancer, immunotherapy, membrane neoantigens, efficacy prediction, biomarkers

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Authors: Alaoui Hamza, Moutacalli Mohamed Tarik, Chebak Ahmed

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The number of people suffering from hemiplegia is growing each year. This lower limb disability affects all the aspects of their lives by taking away their autonomy. This implicates their close relatives, as well as the health system to provide the necessary care they need. The integration of exoskeletons in the medical field became a promising solution to resolve this issue. This paper presents an exoskeleton designed to help hemiplegic people get back the sensation and ability of normal walking. For this purpose, three step models have been created. The first step allows a simple forward movement of the leg. The second method is designed to overcome some obstacles in the patient path, and finally the third step model gives the patient total control over the device. Each of the control methods was designed to offer a solution to the challenges that the patients may face during the walking process.

Keywords: ability of normal walking, exoskeleton, hemiplegic patients, lower limb motion- mechatronics

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Authors: Salam N. Abdo, Orien L. Tulp, George P. Einstein

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The purpose of this exploratory study was to gather the insights into psoriasis etiology, treatment, and patient experience, for developing psoriasis and psoriatic arthritis diagnostic test. Data collection methods consisted of a comprehensive meta-analysis of relevant studies and psoriasis patient survey. Established meta-analysis guidelines were used for the selection and qualitative comparative analysis of psoriasis and psoriatic arthritis research studies. Only studies that clearly discussed psoriasis etiology, treatment, and patient experience were reviewed and analyzed, to establish a qualitative data base for the study. Using the insights gained from meta-analysis, an existing psoriasis patient survey was modified and administered to collect additional data as well as triangulate the results. The hypothesis is that specific types of psoriatic disease have specific etiology and pathophysiologic pattern. The following etiology categories were identified: bacterial, environmental/microbial, genetic, immune, infectious, trauma/stress, and viral. Additional results, obtained from meta-analysis and confirmed by patient survey, were the common age of onset (early to mid-20s) and type of psoriasis (plaque; mild; symmetrical; scalp, chest, and extremities, specifically elbows and knees). Almost 70% of patients reported no prescription drug use due to severe side effects and prohibitive cost. These results will guide the development of psoriasis and psoriatic arthritis diagnostic test. The significant number of medical publications classified psoriatic arthritis disease as inflammatory of an unknown etiology. Thus numerous meta-analyses struggle to report any meaningful conclusions since no definitive results have been reported to date. Therefore, return to the basics is an essential step to any future meaningful results. To date, medical literature supports the fact that psoriatic disease in its current classification could be misidentifying subcategories, which in turn hinders the success of studies conducted to date. Moreover, there has been an enormous commercial support to pursue various immune-modulation therapies, thus following a narrow hypothesis/mechanism of action that is yet to yield resolution of disease state. Recurrence and complications may be considered unacceptable in a significant number of these studies. The aim of the ongoing study is to focus on a narrow subgroup of patient population, as identified by this exploratory study via meta-analysis and patient survey, and conduct an exhaustive work up, aiming at mechanism of action and causality before proposing a cure or therapeutic modality. Remission in psoriasis has been achieved and documented in medical literature, such as immune-modulation, phototherapy, various over-the-counter agents, including salts and tar. However, there is no psoriasis and psoriatic arthritis diagnostic test to date, to guide the diagnosis and treatment of this debilitating and, thus far, incurable disease. Because psoriasis affects approximately 2% of population, the results of this study may affect the treatment and improve the quality of life of a significant number of psoriasis patients, potentially millions of patients in the United States alone and many more millions worldwide.

Keywords: biologics, early diagnosis, etiology, immune disease, immune modulation therapy, inflammation skin disorder, phototherapy, plaque psoriasis, psoriasis, psoriasis classification, psoriasis disease marker, psoriasis diagnostic test, psoriasis marker, psoriasis mechanism of action, psoriasis treatment, psoriatic arthritis, psoriatic disease, psoriatic disease marker, psoriatic patient experience, psoriatic patient quality of life, remission, salt therapy, targeted immune therapy

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Authors: Meghana Pandit, Abhishek Chakraborty

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There are a multitude of factors that influence the clinical success of bariatric surgery. This study seeks to determine the efficacy of preoperative weight management education. The Food and Fitness Program at Mount Sinai serves to educate patients on topics such as stress management, sleep habits, body image, nutrition, and exercise 5-6 months before their surgeries to slowly decrease their weight. Each month, patients are weighed, and a different topic is presented. To evaluate the longitudinal effects of these lectures, patient’s weights are evaluated at the first appointment, before an informative lecture is presented. Weights are then reevaluated at the last appointment before the surgery. The weights were statistically analyzed using a paired t-test and the results demonstrated a statistically significant difference (p < .0001, n=55). Thus, it is reasonable to conclude that the education paradigm employed successfully empowered patients to maintain and reduce their gross BMI before clinical intervention.

Keywords: bariatric, surgery, weight, education

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Authors: Shraddha Acharya, Sharad Kumar Sharma, Ratna Bhattarai, Bhagwan Maharjan, Deepak Dahal, Serpahine Kaminsa

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Background: Drug-resistant (DR) tuberculosis (TB) continues to be a threat in Nepal, with an estimated 2800 new cases every year. The treatment of DR-TB with second line TB drugs is complex and takes longer time with comparatively lower treatment success rate than drug-susceptible TB. Delay in treatment initiation for DR-TB patients might further result in unfavorable treatment outcomes and increased transmission. This study thus aims to determine median time taken to initiate second-line treatment among Rifampicin Resistant (RR) diagnosed TB patients and to assess the proportion of treatment delays among various type of DR-TB cases. Method: A retrospective cohort study was done using national routine electronic data (DRTB and TB Laboratory Patient Tracking System-DHIS2) on drug resistant tuberculosis patients between January 2020 and December 2022. The time taken for treatment initiation was computed as– days from first diagnosis as RR TB through Xpert MTB/Rif test to enrollment on second-line treatment. The treatment delay (>7 days after diagnosis) was calculated. Results: Among total RR TB cases (N=954) diagnosed via Xpert nationwide, 61.4% were enrolled under shorter-treatment regimen (STR), 33.0% under longer treatment regimen (LTR), 5.1% for Pre-extensively drug resistant TB (Pre-XDR) and 0.4% for Extensively drug resistant TB (XDR) treatment. Among these cases, it was found that the median time from diagnosis to treatment initiation was 6 days (IQR:2-15.8). The median time was 5 days (IQR:2.0-13.3) among STR, 6 days (IQR:3.0-15.0) among LTR, 30 days (IQR:5.5-66.8) among Pre-XDR and 4 days (IQR:2.5-9.0) among XDR TB cases. The overall treatment delay (>7 days after diagnosis) was observed in 42.4% of the patients, among which, cases enrolled under Pre-XDR contributed substantially to treatment delay (72.0%), followed by LTR (43.6%), STR (39.1%) and XDR (33.3%). Conclusion: Timely diagnosis and prompt treatment initiation remain fundamental focus of the National TB program. The findings of the study, however suggest gaps in timeliness of treatment initiation for the drug-resistant TB patients, which could bring adverse treatment outcomes. Moreover, there is an alarming delay in second line treatment initiation for the Pre-XDR TB patients. Therefore, this study generates evidence to identify existing gaps in treatment initiation and highlights need for formulating specific policies and intervention in creating effective linkage between the RR TB diagnosis and enrollment on second line TB treatment with intensified efforts from health providers for follow-ups and expansion of more decentralized, adequate, and accessible diagnostic and treatment services for DR-TB, especially Pre-XDR TB cases, due to the observed long treatment delays.

Keywords: drug-resistant, tuberculosis, treatment initiation, Nepal, treatment delay

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Authors: Stephanie Nihan, Jayson M. Fadrigalan, Pyay P. San, Steven M. Santos, Weihui Li

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People of all ages who use wheelchairs are left with the inconvenience of not having an easy way to take their vital signs. Typically, patients are required to visit the hospital in order to take the vital signs. VitalGO is a wheel chair system that equipped with medical devices to take vital signs and then transmit data to a mobile application for convenient, long term health monitoring. The vital signs include oxygen saturation, heart rate, and blood pressure, breathing rate and body temperature. Oxygen saturation and heart rate are monitored through pulse oximeter. Blood pressure is taken through a radar sensor. Breathing rate is derived through thoracic impedance while body temperature is measured through an infrared thermometer. The application receives data through bluetooth and stores in a database for review in a simple graphical interface. The application will have the ability to display this data over various time intervals such as a day, week, month, 3 months, 6 months and a year. The final system for the mobile app can also provide an interface for both the user and their physician(s) to record notes or keep record of daily symptoms that a patient might be having. The user’s doctor will be granted access by the user to view the patient information for assistance with a more accurate diagnosis. Also, this wheelchair accessory conveniently includes a foldable table/desk as somewhere to place an electronic device that may be used to access the app. The foldable table will overall contribute to the wheelchair user’s increased comfort and will give them somewhere to place food, a book, or any other form of entertainment that would normally be hard to juggle on their lap.

Keywords: wheel chair, vital sign, mobile application, telemedicine

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Authors: Siti Rahayu, Khairulniza Mohd Puat, Kesavan R., Mohammad Harris A., Jalila, Kunalan G., Fazir Mohamad

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The greatest challenge has been in establishing and maintaining the dedicated nursing team. Continuity is served when nurses are assigned exclusively for managing wound, where they can continue to build expertise and skills. In addition, there is a growing incidence of chronic wounds and recognition of the complexity involved in caring for these patients. We would like to share 4 cases with different techniques of wound management. 1st case, 39 years old gentleman with underlying rheumatoid arthritis with chronic periprosthetic joint infection of right total knee replacement presented with persistent drainage over right knee. Patient was consulted for two stage revision total knee replacement. However, patient only agreed for debridement and retention of implant. After debridement, large medial and lateral wound was treated with Instillation Negative Pressure Wound Therapy Dressings. After several cycle, the wound size reduced, and conventional dressing was applied. 2nd case, 58 years old gentleman with underlying diabetes presented with right foot necrotizing fasciitis with gangrene of 5th toe. He underwent extensive debridement of foot with rays’ amputation of 5th toe. Post debridement patient was started on Instillation Negative Pressure Wound Therapy Dressings. After several cycle of VAC, the wound bed was prepared, and he underwent split skin graft over right foot. 3 rd case, 60 years old gentleman with underlying diabetes mellitus presented with right foot necrotizing soft tissue infection. He underwent rays’ amputation and extensive wound debridement. Upon stabilization of general condition, patient was discharge with regular wound dressing by same nurse and doctor during each visit to clinic follow up. After 6 months of follow up, the wound healed well. 4th case, 38-year-old gentleman had alleged motor vehicle accident and sustained closed fracture right tibial plateau. Open reduction and proximal tibial locking plate were done. At 2 weeks post-surgery, the patient presented with warm, erythematous leg and pus discharge from the surgical site. Empirical antibiotic was started, and wound debridement was done. Intraoperatively, 50cc pus was evacuated, unhealthy muscle and tissue debrided. No loosening of the implant. Patient underwent multiple wound debridement. At 2 weeks post debridement wound healed well, but the proximal aspect was unable to close immediately. This left the proximal part of the implant to be exposed. Patient was then put on VAC dressing for 3 weeks until healthy granulation tissue closes the implant. Meanwhile, antibiotic was change according to culture and sensitivity. At 6 weeks post the first debridement, the wound was completely close, and patient was discharge home well. At 3 months post operatively, patient wound and fracture healed uneventfully and able to ambulate independently. Complex wounds are too serious to be dealt with. Team managing complex wound need continuous support through the provision of educational tools to support their professional development, engagement with local and international expert, as well as highquality products that increase efficiencies in services

Keywords: VAC (Vacuum Assisted Closure), empirical- initial antibiotics, NPWT- negative pressure wound therapy, NF- necrotizing fasciitis, gangrene- blackish discoloration due to poor blood supply

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Authors: Ariane Plaisance, Holly O. Witteman, Patrick Michel Archambault

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Upon admission to an intensive care unit (ICU), all patients should discuss their wishes concerning life-sustaining interventions (e.g., cardiopulmonary resuscitation (CPR)). Without such discussions, interventions that prolong life at the cost of decreasing its quality may be used without appropriate guidance from patients. We employed user-centered design to adapt an existing decision aid (DA) about CPR to create a novel wiki-based DA adapted to the context of a single ICU and tailored to individual patient’s risk factors. During Phase 1, we conducted three weeks of ethnography of the decision-making context in our ICU to identify clinician and patient needs for a decision aid. During this time, we observed five dyads of intensivists and patients discussing their wishes concerning life-sustaining interventions. We also conducted semi-structured interviews with the attending intensivists in this ICU. During Phase 2, we conducted three rounds of rapid prototyping involving 15 patients and 11 other allied health professionals. We recorded discussions between intensivists and patients and used a standardized observation grid to collect patients’ comments and sociodemographic data. We applied content analysis to field notes, verbatim transcripts and the completed observation grids. Each round of observations and rapid prototyping iteratively informed the design of the next prototype. We also used the programming architecture of a wiki platform to embed the GO-FAR prediction rule programming code that we linked to a risk graphics software to better illustrate outcome risks calculated. During Phase I, we identified the need to add a section in our DA concerning invasive mechanical ventilation in addition to CPR because both life-sustaining interventions were often discussed together by physicians. During Phase II, we produced a context-adapted decision aid about CPR and mechanical ventilation that includes a values clarification section, questions about the patient’s functional autonomy prior to admission to the ICU and the functional decline that they would judge acceptable upon hospital discharge, risks and benefits of CPR and invasive mechanical ventilation, population-level statistics about CPR, a synthesis section to help patients come to a final decision and an online calculator based on the GO-FAR prediction rule. Even though the three rounds of rapid prototyping led to simplifying the information in our DA, 60% (n= 3/5) of the patients involved in the last cycle still did not understand the purpose of the DA. We also identified gaps in the discussion and documentation of patients’ preferences concerning life-sustaining interventions (e.g.,. CPR, invasive mechanical ventilation). The final version of our DA and our online wiki-based GO-FAR risk calculator using the IconArray.com risk graphics software are available online at www.wikidecision.org and are ready to be adapted to other contexts. Our results inform producers of decision aids on the use of wikis and user-centered design to develop DAs that are better adapted to users’ needs. Further work is needed on the creation of a video version of our DA. Physicians will also need the training to use our DA and to develop shared decision-making skills about goals of care.

Keywords: ethnography, intensive care units, life-sustaining therapies, user-centered design

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Authors: Mohanad Rezeq, Tarik Aouam, Frederik Gailly

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In times of armed conflicts, various security checkpoints are placed by authorities to control the flow of merchandise into and within areas of conflict. The flow of humanitarian trucks that is added to the regular flow of commercial trucks, together with the complex security procedures, creates congestion and long waiting times at the security checkpoints. This causes distribution costs to increase and shortages of relief aid to the affected people to occur. Our research proposes a decision-support tool to assist planners and policymakers in building efficient plans for the distribution of relief aid, taking into account congestion at security checkpoints. The proposed tool is built around a multi-item humanitarian distribution planning model based on multi-phase design science methodology that has as its objective to minimize distribution and back ordering costs subject to capacity constraints that reflect congestion effects using nonlinear clearing functions. Using the 2014 Gaza War as a case study, we illustrate the application of the proposed tool, model the underlying relief-aid humanitarian supply chain, estimate clearing functions at different security checkpoints, and conduct computational experiments. The decision support tool generated a shipment plan that was compared to two benchmarks in terms of total distribution cost, average lead time and work in progress (WIP) at security checkpoints, and average inventory and backorders at distribution centers. The first benchmark is the shipment plan generated by the fixed capacity model, and the second is the actual shipment plan implemented by the planners during the armed conflict. According to our findings, modeling and optimizing supply chain flows reduce total distribution costs, average truck wait times at security checkpoints, and average backorders when compared to the executed plan and the fixed-capacity model. Finally, scenario analysis concludes that increasing capacity at security checkpoints can lower total operations costs by reducing the average lead time.

Keywords: humanitarian distribution planning, relief-aid distribution, congestion, clearing functions

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