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Perceptual link between inadequate water, sanitation, and hygiene (WASH) stressors and common mental symptoms in Ethiopian health workers: A qualitative study

Background Despite the rising prevalence of common mental symptoms, information is scarce on how health workers make sense of symptoms of mental disorders and perceive a link with inadequate water, sanitation, and hygiene (WASH) as work stressors to understand causation and produce useful knowledge for policy and professionals. Therefore, this study aimed to explore how health workers perceive the link between inadequate WASH and common mental symptoms (CMSs) at hospitals in central and southern Ethiopian regions. Methods We used an interpretive and descriptive phenomenological design guided by theoretical frameworks. Three focus group discussions (FGDs) and 10 in-depth interviews with health workers were conducted. We explored the perceived link with inadequate WASH after assessing health workers’ conceptualization of common mental health symptoms. The interviews and FGDs were audio recorded, transcribed, and translated into English. Coding and categorizing were supported by MaxQDA software 2020. Thematic analysis was performed and themes were supported by participants’ quotes when necessary. Results Four themes emerged from the data based on the guiding theoretical models relevant to the research questions. Most health workers believed and frequently suggested that inadequate water supply, functional hand hygiene, environmental cleaning, and waste management services at the points of care increased the risk of occupational stress, job anxiety, and occupational depression symptoms. Many participants believed that inadequate WASH would cause them to experience negative professional quality of life including burnout, compassion dissatisfaction, and compassion fatigue at work despite believing that WASH problems cannot be solved at the individual level. Participants recurrently listed many individual, organizational, and system-level barriers to reducing and coping with inadequate WASH as stressors. Conclusions Healthcare workers perceived inadequate WASH components as contributing to symptoms of common mental disorders and negatively impacting their professional quality of life. They faced multiple barriers at individual, organizational, and health system levels, which hindered their ability to manage work-related stress and seek mental health support. The findings suggest the implementation of integrated WASH and mental health services for healthcare workers, ranging from establishing individual-level interventions to increasing access to WASH around care areas through collaborative efforts with healthcare administration, broader health systems, water supplies, and sewerage services.

Minimally Invasive Assessment of Peripheral Residual Disease During Maintenance or Observation in Transplant-Eligible Patients With Multiple Myeloma

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported. In multiple myeloma (MM), measurable residual disease (MRD) is assessed in bone marrow (BM). However, less invasive evaluation of peripheral residual disease (PRD) in blood could be advantageous and less cumbersome. We investigated the prognostic value of PRD monitoring after 24 cycles of maintenance in 138 transplant-eligible patients with MM enrolled in the GEM2012MENOS65/GEM2014MAIN clinical trials. PRD was assessed using next-generation flow (NGF) and mass spectrometry (MS). Positive PRD by NGF in 16/138 (11.5%) patients was associated with a 13-fold increased risk of progression and/or death; median progression-free survival (PFS) and overall survival (OS) were 2.5 and 47 months, respectively. Considering patients' MRD status in BM as the reference, PRD detection using NGF showed positive and negative predictive values of 100% and 73%, respectively. Presence of PRD helped identifying patients at risk of imminent progression among those with positive MRD in BM. Patients with undetectable PRD according to both NGF and MS showed 2-year PFS and OS rates of 97% and 100%, respectively. In multivariate analyses including the Revised International Staging System and the complete remission status, only MRD in BM and PRD by NGF showed independent prognostic value for PFS. This study supports the use of less invasive PRD monitoring during maintenance or observation in transplant-eligible patients with MM.

Patterns of belatacept use and risk of post-transplant lymphoproliferative disorder in US kidney transplant recipients: An analysis of the Organ Procurement and Transplantation Network database

Background Belatacept is approved for the prophylaxis of organ rejection in Epstein-Barr virus (EBV)-seropositive kidney transplant recipients and is associated with a risk of post-transplant lymphoproliferative disorder (PTLD). Methods Data from the Organ Procurement and Transplantation Network were used to examine patterns of belatacept use, describe patient characteristics, and estimate risk of PTLD in EBV-seropositive, kidney-only transplant recipients receiving belatacept- or calcineurin inhibitor (CNI)-based immunosuppression as part of US Food and Drug Administration-mandated safety monitoring. Results During the study period (June 15, 2011–June 14, 2016), 94.9% (1631/1719) of belatacept-treated and 89.7% (59,992/66,905) of CNI-treated patients with known EBV serostatus were EBV seropositive. Among EBV-seropositive patients, 50.2% (belatacept) and 56.8% (CNI) received a standard criteria donor kidney, 59.5% and 18.7% received basiliximab induction, and 22.9% and 50.8% received antithymocyte globulin induction. PTLD developed in nine belatacept-treated patients (two with central nervous system [CNS] involvement) and 225 CNI-treated patients (nine with CNS involvement). Four and 81 patients, respectively, died due to PTLD. Kaplan–Meier analysis did not show a significant between-group difference in PTLD estimated incidence rates within 5 years (0.70% versus 0.48%, respectively; p = 0.18). Additionally, estimated PTLD incidence was not significantly different between treatment groups in a propensity score matched cohort. Conclusions The majority of adult kidney-only transplant recipients treated with belatacept in routine clinical practice are EBV seropositive. In this study, the risk of PTLD in these patients, while higher than for CNI-based immunosuppression, remained low after adjusting for differences in patient characteristics. Trial registration These studies are registered at ClinicalTrials.gov: NCT01670058 and NCT01656343.

Denosumab Prevents Bone Loss and Microarchitectural Deterioration in Premenopausal Women With Breast Cancer Receiving Estradiol Suppression Therapy

Effect of pig breeding scale on manure resource utilization-The moderating effect based on technology cognition

The utilization of manure resources is an important measure to promote the development of agricultural green low-carbon cycle and solve the challenges associated with the current large-scale development of the livestock and poultry breeding industry. Based on the survey data of pig farmers in Qingdao, Shandong Province, China, this paper constructs a theoretical analysis framework of pig breeding scale and technical cognition on the utilization behavior of livestock and poultry manure resources of pig farmers. The binary Logit model and the moderating effect model are used to deeply explore the scale effect of breeding scale on the utilization behavior of pig farmers’ manure resources, and the moderating effect of technical cognition on the influence of breeding scale on the utilization behavior of manure resources. First, at the present stage, pig farmers show certain differences in the resource utilization of manure. Due to the differences in the personal characteristics, family characteristics, and breeding characteristics of pig farmers, the influencing factors of resource utilization of pig farmers of different scales are different; Second, the scale of pig breeding has a significant positive promoting effect on the resource utilization of manure, increasing the probability of pig farmers to treat manure, guiding retail and small-scale farmers to moderately expand the scale of breeding, gradually moving to large-scale breeding, realizing centralized management and resource utilization of manure, and reducing the unit cost of manure treatment. Third, technical ease of use has a positive regulatory effect on pig breeding scale and manure resource utilization behavior. When pig farmers perceive that the technology of manure resource utilization is easy to use, they will increase the probability of participating in the resource utilization of manure, reduce the environmental pollution caused by improper disposal of manure, and promote the low-carbon and circular development of livestock and poultry industry. Based on the above findings, this paper aims to provide practical enlightenment for policy makers and researchers to strengthen the environmental governance and sustainable development of livestock industry.

Association of Participation in Medicare's Oncology Care Model With Spending, Utilization, and Quality Outcomes Among Commercially Insured and Medicare Advantage Members

PURPOSE The Oncology Care Model (OCM), a value-based payment model for traditional Medicare beneficiaries with cancer, yielded total spending reductions that were outweighed by incentive payments, resulting in net losses to the Centers for Medicare & Medicaid Services. We studied whether the OCM yielded spillover effects in total episode spending, utilization, and quality among commercially insured and Medicare Advantage (MA) members, who were not targeted by the program. PATIENTS AND METHODS This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices. We used difference-in-differences analyses to assess the association between the OCM and total episode spending, defined as medical spending during a 6-month episode. Secondary outcomes included hospitalization and emergency department (ED) utilization and quality measures. RESULTS From the pre-OCM to the OCM period, mean total episode payments increased from $45,504 in US dollars (USD) to $46,239 USD for OCM-participating practices, and increased from $50,519 USD to $58,591 USD for non-OCM practices (adjusted difference-in-differences –$6,287 USD [95% CI, –$10,076 USD to –$2,498 USD], P = .001). The OCM was associated with adjusted spending decreases for both high-risk (–$6,756 USD [95% CI, –$10,731 USD to –$2,781 USD], P = .001) and low-risk (–$4,171 USD [95% CI, –$7,799 USD to –$543 USD], P = .025) episodes. OCM-associated spending reductions were strongest for outpatient (–$5,243 USD [95% CI, –$8,589 USD to –$1,897 USD], P = .002) and infused/injected anticancer drug (–$3,031 USD [95% CI, –$5,193 USD to –$869 USD], P = .006) spending. There were no associations between OCM participation and changes in hospital or ED utilization nor quality of care. CONCLUSION The OCM was associated with reductions in spending for nontargeted members, a spillover effect.

Automated quantitative pupillometry as a predictor for transtentorial brain herniation in patients with malignant acute ischemic stroke

Brain herniation can be a life-threatening condition, resulting in poor prognosis and higher fatality rates. We examined whether quantitative characteristics of sequential pupillary light reflex (PLR) could serve as biomarkers for identifying brain herniation in fatal acute stroke cases with anterior circulation involvement admitted to neurological intensive care unit (Neuro-ICU). Automatic pupillometer assessed PLR automatically every 4–6 hours, measuring eight specific features: NPi (Neurological pupil index) score, initial resting and constriction pupil size, constriction change, constriction velocity, constriction latency, and dilation velocity. Generalized estimating equations were used to analyze the main effects of assessment time (3-to-0 hours, just before brain herniation, and 27-to-21 hours, considerably before) and clinical groups. The study involved 59 patients (mean age 68.8 ± 1.6 years, 23 females) divided into herniation (n = 10) and non-herniation (n = 49) groups. The herniation group exhibited significantly lower ipsilateral NPi scores at 3-to-0 hours (1.80 ± 0.44, p < 0.0001) compared to 27-to-21 hours (4.26 ± 2.21). Additionally, the herniation group had a larger ipsilateral pupil size at constriction at 3-to-0 hours (4.01 ± 0.40 mm) compared to 27-to-21 hours (2.11 ± 0.17 mm). Specifically, at 3-to-0 hours, the herniation group had lower NPi scores (1.80 ± 0.44 vs. 3.97 ± 0.13, p < 0.0001) and larger pupil size at constriction (4.01 ± 0.04 mm vs. 2.90 ± 0.10 mm, p = 0.007) compared to the non-herniation group. These findings suggest that evaluating PLR characteristics can aid in the early identification of brain herniation, facilitating timely triage and appropriate surgical management.

Randomized Phase III SIERRA Trial of ¹³¹ I-Apamistamab Before Allogeneic Hematopoietic Cell Transplantation Versus Conventional Care for Relapsed/Refractory AML

PURPOSE Older patients with relapsed or refractory AML (RR AML) have dismal prognoses without allogeneic hematopoietic cell transplantation (alloHCT). SIERRA compared a targeted pretransplant regimen involving the anti-CD45 radioconjugate 131 I-apamistamab with conventional care. METHODS SIERRA (ClinicalTrials.gov identifier: NCT02665065 ) was a phase III open-label trial. Patients age ≥55 years with active RR AML were randomly assigned 1:1 to either an 131 I-apamistamab–led regimen before alloHCT or conventional care followed by alloHCT if initial complete remission (CR)/CR with incomplete platelet recovery (CRp) occurred. Initial response was assessed 28-56 days after alloHCT in the 131 I-apamistamab group and 28-42 days after salvage chemotherapy initiation; patients without CR/CRp or with AML progression could cross over to receive 131 I-apamistamab followed by alloHCT. The primary end point was durable complete remission (dCR) lasting 180 days after initial CR/CRp. Secondary end points were overall survival (OS) and event-free survival (EFS), assessed hierarchically in the intention-to-treat (ITT) population. RESULTS The ITT population included 153 patients ( 131 I-apamistamab [n = 76]; conventional care [n = 77]). In total, 44/77 conventional care arm patients crossed over and 40/77 (52%) received 131 I-apamistamab and alloHCT, with six patients (13.6%) experiencing a dCR. In the ITT population, the dCR rate was significantly higher with 131 I-apamistamab (17.1% [95% CI, 9.4 to 27.5]) than conventional care (0% [95% CI, 0 to 4.7]; P < .0001). The OS hazard ratio (HR) was 0.99 (95% CI, 0.70 to 1.41; P = .96), and the EFS HR was 0.23 (95% CI, 0.15 to 0.34), with HR <1 favoring 131 I-apamistamab. Grade ≥3 treatment-related adverse events occurred in 59.7% and 59.2% of the 131 I-apamistamab and conventional care groups, respectively. CONCLUSION The 131 I-apamistamab–led regimen was associated with a higher dCR rate than conventional care in older patients with RR AML. 131 I-apamistamab was well tolerated and could address an unmet need in this population.

A qualitative exploration of the enablers of and barriers to conformance with antibiotic withdrawal periods on smallholding, peri-urban pig farms in Kiambu County, Kenya

Non-conformance with antibiotic withdrawal period guidelines represents a food safety concern, with potential for antibiotic toxicities and allergic reactions as well as selecting for antibiotic resistance. In the Kenyan domestic pig market, conformance with antibiotic withdrawal periods is not a requirement of government legislation and evidence suggests that antibiotic residues may frequently be above recommended limits. In this study, we sought to explore enablers of and barriers to conformance with antibiotic withdrawal periods for pig farms supplying a local independent abattoir in peri-urban Nairobi. We drew upon semi-structured interviews with farmers and government animal health professionals as well as focus groups which involved private animal health professionals. We also explored farmers’ engagement with antibiotic withdrawal periods by visiting thirteen pig farms (supplying one of two local independent abattoirs) weekly for one month in order to capture instances of antibiotic use. We analysed data using reflexive thematic analysis. All farmers participating in the study demonstrated an awareness of the concept of antibiotic withdrawal periods and described intentions to conform, motivated by caring for others, wanting to prevent harm or a perception that regulation around antibiotic withdrawal periods existed for local independent abattoirs. The antibiotic use practices that we identified showed limited opportunities for non-conformance with antibiotic withdrawal periods. Farmers and veterinarians reported that instances of antibiotic use were uncommon, especially in slaughter-weight pigs, and were mainly restricted to the treatment of clinical signs under the supervision of an animal health professional. Local factors presented barriers to antibiotic withdrawal period conformance including farmers’ economic constraints, lack of formal medicine recording, an absence of consistent abattoir monitoring and resource emergency, such as water scarcity on farms. This study demonstrates the importance of these contextual factors to conformance with antibiotic withdrawal periods. We highlight the need to account for farm-level influences when planning future research and interventions aimed at reducing the presence of antibiotic residues in meat from smallholding pig farms in peri-urban Nairobi.

Oncology Care Model and Ripple Effects of Value-Based Care

Cardiac MR image reconstruction using cascaded hybrid dual domain deep learning framework

Recovering diagnostic-quality cardiac MR images from highly under-sampled data is a current research focus, particularly in addressing cardiac and respiratory motion. Techniques such as Compressed Sensing (CS) and Parallel Imaging (pMRI) have been proposed to accelerate MRI data acquisition and improve image quality. However, these methods have limitations in high spatial-resolution applications, often resulting in blurring or residual artifacts. Recently, deep learning-based techniques have gained attention for their accuracy and efficiency in image reconstruction. Deep learning-based MR image reconstruction methods are divided into two categories: (a) single domain methods (image domain learning and k-space domain learning) and (b) cross/dual domain methods. Single domain methods, which typically use U-Net in either the image or k-space domain, fail to fully exploit the correlation between these domains. This paper introduces a dual-domain deep learning approach that incorporates multi-coil data consistency (MCDC) layers for reconstructing cardiac MR images from 1-D Variable Density (VD) random under-sampled data. The proposed hybrid dual-domain deep learning models integrate data from both the domains to improve image quality, reduce artifacts, and enhance overall robustness and accuracy of the reconstruction process. Experimental results demonstrate that the proposed methods outperform than conventional deep learning and CS techniques, as evidenced by higher Structural Similarity Index (SSIM), lower Root Mean Square Error (RMSE), and higher Peak Signal-to-Noise Ratio (PSNR).

Episteme

A reliable unmanned aerial vehicle multi-ship tracking method

As the global economy expands, waterway transportation has become increasingly crucial to the logistics sector. This growth presents both significant challenges and opportunities for enhancing the accuracy of ship detection and tracking through the application of artificial intelligence. This article introduces a multi-object tracking system designed for unmanned aerial vehicles (UAVs), utilizing the YOLOv7 and Deep SORT algorithms for detection and tracking, respectively. To mitigate the impact of limited ship data on model training, transfer learning techniques are employed to enhance the YOLOv7 model’s performance. Additionally, the integration of the SimAM attention mechanism within the YOLOv7 detection model improves feature representation by emphasizing salient features and suppressing irrelevant information, thereby boosting detection capabilities. The inclusion of the partial convolution (PConv) module further enhances the detection of irregularly shaped or partially occluded targets. This module minimizes the influence of invalid regions during feature extraction, resulting in more accurate and stable features. The implementation of PConv not only improves detection accuracy and speed but also reduces the model’s parameters and computational demands, making it more suitable for deployment on computationally constrained UAV platforms. Furthermore, to address issues of false negatives during clustering in the Deep SORT algorithm, the IOU metric is replaced with the DIOU metric at the matching stage. This adjustment enhances the matching of unlinked tracks with detected objects, reducing missed detections and improving the accuracy of target tracking. Compared to the original YOLOv7+Deep SORT model, which achieved an MOTA of 58.4% and an MOTP of 78.9%, the enhanced system achieves a MOTA of 65.3% and a MOTP of 81.9%. This represents an increase of 6.9% in MOTA and 3.0% in MOTP. After extensive evaluation and analysis, the system has demonstrated robust performance in ship monitoring scenarios, offering valuable insights and serving as a critical reference for ship surveillance tasks.

Erratum: Treatment Intensification With Either Fludarabine, AraC, G-CSF and Idarubicin, or Cladribine Plus Daunorubicin and AraC on the Basis of Residual Disease Status in Older Patients With AML: Results From the NCRI AML18 Trial

Sex differences in the association between composite dietary antioxidant index and hyperlipidemia: Insights from NHANES

Background Previous studies have shown that both the composite dietary antioxidant index (CDAI) and sex are strongly associated with a variety of cardiovascular diseases, but sex differences between CDAI and hyperlipidemia are unknown. Objective This study utilized data from the National Health and Nutrition Examination Survey (NHANES) to investigate the sex differences between CDAI and hyperlipidemia. Method We calculated the CDAI of the six dietary antioxidants using data from NHANES, explored the relationship between CDAI and the prevalence of hyperlipidemia using multivariate logistic regression analysis, and analyzed for potential nonlinear associations using restricted cubic spline. Finally, the association between CDAI and hyperlipidemia was further explored using multivariate logistic regression in different genders. Results The study included a total of 34,754 participants with a mean age of 47.04 years, of whom 49.37% were man. In a fully adjusted multivariable binary logistic regression model, CDAI was negatively associated with the prevalence of hyperlipidemia (OR = 0.99, 95% CI:0.98–0.99). In addition, participants in the highest quartile had a lower risk of hyperlipidaemia compared with the lowest quartile of CDAI (OR = 0.83, 95%CI: 0.76–0.92). We also found a non-linear relationship (non-linear P = 0.003, Inflection point = -0.179). Finally, we found that the association between CDAI and the prevalence of hyperlipidemia was significantly stronger in the female population than in the male population (P for interaction <0.05). Conclusion Our study highlights the L-shaped association between CDAI and the prevalence of hyperlipidemia in the general adult population. In addition, this association was more significant in the female population than in the male population.

Efficacy and Safety of Roxadustat for Anemia in Patients Receiving Chemotherapy for Nonmyeloid Malignancies: A Randomized, Open-Label, Active-Controlled Phase III Study

PURPOSE We evaluated the efficacy and safety of roxadustat, a first-in-class hypoxia-inducible factor prolyl hydroxylase inhibitor, for chemotherapy-induced anemia (CIA) in patients with nonmyeloid malignancies receiving multicycle treatments of chemotherapy. PATIENTS AND METHODS In this open-label, noninferiority phase III study conducted at 44 sites in China, 159 participants age ≥18 years with CIA nonmyeloid malignancy and CIA were randomly assigned (1:1) to oral roxadustat or subcutaneous recombinant human erythropoietin-α (rHuEPO-α) three times a week for 12 weeks. Roxadustat starting dosages were 100, 120, and 150 mg three times a week for participants weighing 40-<50, 50-60, and >60 kg, respectively. rHuEPO-α starting dosage for all participants was 150 IU/kg three times a week. Both roxadustat and rHuEPO-α dosages could be modified. The primary end point was least-squares mean (LSM) change in hemoglobin (Hb) concentration from baseline to the concentration averaged over weeks 9-13. RESULTS Of the 159 participants randomly assigned, 140 were included in the per-protocol set (roxadustat, n = 78; rHuEPO-α, n = 62). The LSM (95% two-sided CI) change from baseline to weeks 9-13 in Hb concentration was 17.1 (13.58 to 20.71) g/L with roxadustat and 15.4 (11.34 to 19.50) g/L with rHuEPO-α (mean difference [95% CI], 1.7 [–3.39 to 6.84]). The lower bound of the one-sided 97.5% CI for the treatment difference (‒3.4 g/L) was greater than the predefined noninferiority margin of ‒6.6 g/L, establishing noninferiority. Noninferiority was supported by five of six key secondary end points. Rates of adverse events were generally comparable between treatments and consistent with previous findings. CONCLUSION Roxadustat was noninferior to rHuEPO-α in treating CIA in participants with nonmyeloid malignancies receiving multicycle treatments of myelosuppressive chemotherapy. The oral formulation of roxadustat may potentially increase compliance.

Baseline characteristics and 2-year functional outcome data of patients undergoing an arthroscopic rotator cuff repair in Switzerland, results of the ARCR_Pred study

The ARCR_Pred study was initiated to document and predict the safety and effectiveness of arthroscopic rotator cuff repair (ARCR) in a representative Swiss patient cohort. In the present manuscript, we aimed to describe the overall and baseline characteristics of the study, report on functional outcome data and explore case-mix adjustment and differences between public and private hospitals. Between June 2020 and November 2021, primary ARCR patients were prospectively enrolled in a multicenter cohort across 18 Swiss and one German orthopedic center. Baseline characteristics, including sociodemographic and diagnostic variables, were reported. Clinical scores and patient-reported outcome measures were assessed up to 24-month follow-up. After screening 2350 individuals, 973 patients with ARCR were included. Follow-up rates reached 99%, 95%, 89% and 88% at 6 weeks, 6, 12, and 24 months, respectively. While the proportion of massive tears was higher in the study population (44% vs. 20%, Std. Diff. = 0.56), there were no other major differences in key characteristics between enrolled and non-enrolled patients or in patients lost to follow-up. Functional scores improved over time, with positive changes rates ranging from 83% to 92% at 6-month, reaching 91% to 97% at 12- and 24-month follow-up. In linear mixed models, used to estimate the associations between baseline factors, hospital type and standardized 0–100 scores, marginal effects for time ranged from 20 to 30, 28 to 39 and 34 to 41 points at the 6-, 12- and 24-month follow-up, respectively. Except at the 12-month follow-up, where marginal effects for the interaction terms ranged from -5 to -4 points in the standardized scores, there were no consistent outcome differences between public and private hospitals. Increasing number of years of education was consistently associated with better scores, greater feelings of depression and anxiety, smoking and ASA group III-IV were consistently associated with worse scores. Tear severity showed a consistent negative association solely for the Constant-Score. The ARCR_Pred study shows high potential for generalizability to the population of patients undergoing an ARCR in Switzerland. Further analyses are needed to establish relevant clinimetrics for the Swiss population and to compare outcomes for surgical techniques, surgeon experiences profiles and post-operative management.

Erratum: ReNeu: A Pivotal, Phase IIb Trial of Mirdametinib in Adults and Children With Symptomatic Neurofibromatosis Type 1-Associated Plexiform Neurofibroma

Validating quality standards in Palestinian emergency departments: An e-Delphi survey approach

To validate Palestine’s previously derived emergency department quality standards (EDQS) using an e-Delphi survey. A two-round e-Delphi survey validated the EDQS, developed in an earlier study through a literature review and consensus-building among Palestinian emergency medicine and healthcare quality experts. The study purposively sampled 53 emergency department and healthcare quality experts with over 5 years of experience. A Likert scale was used to rate the standards on readability, clarity, and comprehensiveness in the initial round to reach consensus on the EDQS, with detailed feedback. An expanded expert group refined the shortlisted standards in the next phase. Lime Survey collected data anonymously. A set of 100 EDQS was validated through a two-round e-Delphi survey. In the initial round, 103 standards were presented, and consensus was achieved, resulting in a refined list of 100 standards. Among these, 39 standards fell under the clinical pathway domain, and 61 under the administrative pathway domain. In the second round, the validity of these standards was affirmed, with 96.4% consensus for clinical standards and 97.3% for administrative standards. Additionally, seven subdomains of EDQS were associated with the clinical pathway domain: triage, treatment, transportation, medication safety, patient flow, and medical diagnostic services, and nine subdomains were linked to the administration pathway domain: documentation, information management systems, access-location, design, leadership, management, workforce staffing, training, equipment, supplies, capacity-resuscitation rooms, resources for a safe working environment, performance indicators, and patient safety-infection prevention and control programs. The study validated context emergency department quality standards in Palestine, with over 97% consensus indicating a commitment to quality care. Experts suggest further research on implementation feasibility. Validated standards can aid healthcare leaders in resource allocation, staff training, and enhancing patient care, potentially leading to significant improvements in emergency healthcare in Palestine.

Long-Term Risk of Subsequent Neoplasms in 5-Year Survivors of Childhood Neuroblastoma: A Dutch Childhood Cancer Survivor Study-LATER 3 Study

PURPOSE Neuroblastoma survivors have an increased risk of developing subsequent malignant neoplasms (SMNs), but the risk of subsequent nonmalignant neoplasms (SNMNs) and risk factors are largely unknown. We analyzed the long-term risks and associated risk factors for developing SMNs and SNMNs in a well-characterized cohort of 5-year neuroblastoma survivors. METHODS We included 563 5-year neuroblastoma survivors from the Dutch Childhood Cancer Survivor Study (DCCSS)-LATER cohort, diagnosed during 1963-2014. Subsequent neoplasms were ascertained by linkages with the Netherlands Cancer Registry and the Dutch Nationwide Pathology Databank (Palga) and medical chart review. We calculated standardized incidence ratios (SIRs), absolute excess risk (AER), and cumulative incidences. Multivariable competing risk regression analysis was used to evaluate risk factors. RESULTS In total, 23 survivors developed an SMN and 60 an SNMN. After a median follow-up of 23.7 (range, 5.0-56.3) years, the risk of SMN was elevated compared with the general population (SIR, 4.0; 95% CI, 2.5 to 5.9; AER per 10,000 person-years, 15.1). The 30-year cumulative incidence was 3.4% (95% CI, 1.9 to 6.0) for SMNs and 10.4% (95% CI, 7.3 to 14.8) for SNMNs. Six survivors developed an SMN after iodine-metaiodobenzylguanidine ( 131I MIBG) treatment. Survivors treated with 131I MIBG had a higher risk of developing SMNs (subdistribution hazard ratio [SHR], 5.7; 95% CI, 1.8 to 17.8) and SNMNs (SHR, 2.6; 95% CI, 1.2 to 5.6) compared with survivors treated without 131I MIBG; results for SMNs were attenuated in high-risk patients only (SMNs SHR, 3.6; 95% CI, 0.9 to 15.3; SNMNs SHR, 1.5; 95% CI, 0.7 to 3.6). CONCLUSION Our results demonstrate that neuroblastoma survivors have an elevated risk of developing SMNs and a high risk of SNMNs. 131I MIBG may be a treatment-related risk factor for the development of SMN and SNMN, which needs further validation. Our results emphasize the need for awareness of subsequent neoplasms and the importance of follow-up care.