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Chronic pancreatitis is associated with impaired quality of life, high incidence of comorbidities, serious complications and mortality. Healthcare costs are exorbitant. Some medical societies have developed guidelines for treatment based on scientific evidence, but the gathered level of evidence for any individual topic is usually low and, therefore, recommendations tend to be vague or weak. In the present position papers on chronic pancreatitis from the Societat Catalana de Digestologia and the Societat Catalana de Pàncrees we aimed at providing defined position statements for the clinician based on updated review of published literature and on multidisciplinary expert agreement. The final goal is to propose the use of common terminology and rational diagnostic/therapeutic circuits based on current knowledge. To this end 51 sections related to chronic pancreatitis were reviewed by 21 specialists from 6 different fields to generate 88 statements altogether. Statements were designed to harmonize concepts or delineate recommendations. Part 2 of these paper series discuss topics on treatment and follow-up. The therapeutic approach should include assessment of etiological factors, clinical manifestations and complications. The complexity of these patients advocates for detailed evaluation in multidisciplinary committees where conservative, endoscopic, interventional radiology or surgical options are weighed. Specialized multidisciplinary units of Pancreatology should be constituted. Indications for surgery are refractory pain, local complications, and suspicion of malignancy. Enzyme replacement therapy is indicated if evidence of exocrine insufficiency or after pancreatic surgery. Response should be evaluated by nutritional parameters and assessment of symptoms. A follow-up program should be planned for every patient with chronic pancreatitis. © 2021 Elsevier España, S.L.U.

Palliative radiation therapy (pRT) is an effective tool for people with incurable cancer, in the treatment of many cancer-related symptoms such as pain, bleeding and dyspnea. As utilization rates for palliative radiation therapy increase, the demands on the healthcare system continue to grow. Radiation Therapists with advanced knowledge, skills and judgements began demonstrating their ability to practice autonomously in 2004, with the development of the Clinical Specialist Radiation Therapist (CSRT) role. Since this time, CSRTs with a specific focus in pRT (pCSRT) have been increasing in both numbers as well as their positive effects on the cancer care system. Integrating a pCSRT into the existing pRT system has resulted in increased access to and quality of pRT being delivered to palliative cancer patients. The benefits of the addition of pCSRTs to the cancer care system include increasing system capacity and increasing quality of care. This white paper provides information related to the improvements that can be realized in a RT program related to the care and treatment of its palliative patients by adding a pCSRT to the interprofessional healthcare team and suggest it as one of many strategies that can be undertaken to make improvements to access and quality of care.

Human trafficking is a pandemic human rights violation with an emerging paradigm shift that reframes an issue traditionally seen through a criminal justice lens to that of a public health crisis, particularly for children. Children and adolescents who are trafficked or are at risk for trafficking should receive evidence-based, trauma-informed, and culturally responsive care from trained health care providers (HCPs). The purpose of this article was to engage and equip pediatric HCPs to respond effectively to human trafficking in the clinical setting, improving health outcomes for affected and at-risk children. Pediatric HCPs are ideally positioned to intervene and advocate for children with health disparities and vulnerability to trafficking in a broad spectrum of care settings and to optimize equitable health outcomes.

Antimicrobial resistance (AMR) continues to threaten global health. Although global and national AMR action plans are in place, infection prevention and control is primarily discussed in the context of healthcare facilities with home and everyday life settings barely addressed.\ud \ud As seen with the recent global SARS-CoV-2 pandemic, everyday hygiene measures can play an important role in containing the threat from infectious microorganisms.\ud \ud This position paper has been developed following a meeting of global experts in London, 2019. It presents evidence that home and community settings are important for infection transmission and also the acquisition and spread of AMR. It also demonstrates that the targeted hygiene approach offers a framework for maximizing protection against colonization and infections, thereby reducing antibiotic prescribing and minimizing selection pressure for the development of antibiotic resistance. If combined with the provision of clean water and sanitation, targeted hygiene can reduce the circulation of resistant bacteria in homes and communities, regardless of a country's Human Development Index (overall social and economic development). Achieving a reduction of AMR strains in healthcare settings requires a mirrored reduction in the community.\ud \ud The authors call upon national and international policy makers, health agencies and healthcare professionals to further recognize the importance of targeted hygiene in the home and everyday life settings for preventing and controlling infection, in a unified quest to tackle AMR.

Objective Communication in healthcare has influenced and been influenced by the COVID-19 pandemic. In this position paper, we share observations based on the latest available evidence and experiential knowledge that have emerged during the pandemic, with a specific focus on policy and practice. Methods This is a position paper that presents observations relating to policy and practice in communication in healthcare related to COVID-19. Results Through our critical observations as experts in the field of healthcare communication, we share our stance how healthcare communication has occured during the pandemic and suggest possible ways of improving policy and professional practice. We make recommendations for policy makers, healthcare providers, and communication experts while also highlighting areas that merit further investigation regarding healthcare communication in times of healthcare crises. Conclusion We have witnessed an upheaval of healthcare practice and the development of policy on-the-run. To ensure that policy and practice are evidence-based, person-centred, more inclusive and equitable, we advocate for critical reflection on this symbiotic relationship between COVID-19 and the central role of communication in healthcare. Practice implications This paper provides a summary of the key areas for development in communication in healthcare during COVID-19. It offers recommendations for improvement and a call to review policies and practice to build resilience and inclusive and equitable responsiveness in communication in healthcare.

Hematopoietic stem cell transplantation (HSCT) patients can suffer from various musculoskeletal problems resulting in long-term functional incapacity. Physical therapy (PT), as a part of the healthcare team, has been historically advocated for regaining functional capacity and improving quality of life post-HSCT. Because of the nature of this condition and the burden of post-transplant complications, this patient group requires a unique approach toward their rehabilitation that takes into account their complex musculoskeletal presentation ranging from fascia, muscle, tendons, bones, and ligaments. However, to our knowledge there is no universal standardized PT protocol or pathway to help guide rehab specialists to achieve optimal gains for this patient group, and anecdotal evidence suggests that these patients do not always receive the PT care they require. Hence, in collaboration with the Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation, the Survivorship Special Interest Group of the American Society of Blood and Marrow Transplantation, and the Quality of Life Committee of the Eastern Mediterranean Blood and Marrow Transplantation, herein the Physical Therapy Association for Graft Versus Host Disease provides a brief review on role of PT in mitigating musculoskeletal complications in HSCT patients and makes evidence-based recommendations for incorporation of PT into routine HSCT care. ispartof: Biol Blood Marrow Transplant vol:25 issue:6 pages:e191-e198 ispartof: location:United States status: published

Background In Victoria, Australia, public hospitals are administered through a system of devolved governance. Overall, Victoria's public health system has a record of good performance when comparing measurable safety outcomes to the rest of Australia. However, in 2015 a cluster of preventable perinatal deaths were identified at a health service in Melbourne's outer fringes. Questions What were the factors that contributed to these preventable deaths, and what were the outcomes of the four key inquiries commissioned by the Victorian government after the identification of the cluster? What can be learnt by comparing this crisis in one Victorian health service to similar events at other health services in Australia and the United Kingdom? Methods This paper discusses the crisis at the Victorian health service and expands on the factors that contributed to the crisis, the inquiries, subsequent recommendations, and the response from the Victorian state government. Similarities between this case and others in Australia and the United Kingdom are discussed. Findings A common theme in the four inquiries into the crisis at the health service in Victoria was that inadequate clinical governance was a key factor that led to these events. As a result, a number of significant changes were implemented across the state to improve patient safety across all areas of health care. When comparing this Victorian crisis to similar events at other health services across the world, inadequate clinical governance consistently appears as a key contributing factor to poor clinical outcomes. Discussion All cases discussed had a delay in the identification of clusters of poor clinical outcomes. This was found to be a direct result of inadequate clinical governance structures at both a local and government level. Conclusion A robust clinical governance framework that is enacted at both the government and the health organisation level is essential to deliver high quality and safe patient care.

Background Over the last number of years, the healthcare system has become more complex in managing increasing costs and outcomes within a defined budget. To be effective through reform, especially moving forward from the COVID-19 pandemic, healthcare leaders, specifically in nursing, have an increased need for business acumen beyond traditional leadership and management principles. Aim This paper examines the concept of business acumen in the profession of nursing, specifically for managers and higher nurse leaders, establishing whether these skills are optional or essential. Discussion Nurses learn and develop broad skills in leadership and management, but less specifically about business or the broader system. With a contemporary Australian health system aiming to be more effective, nurses may require a greater level of business acumen to adequately understand the mechanics of business decision making in the system when designing care models, as well as representing the business potential of nursing in balance with clinical outcomes through reform. Conclusion The modern nurse, in addition to clinical skills, may need a foundational understanding of business evolving throughout their career, to maximise innovative growth across the system, in meeting the healthcare needs of our community now and into the future. Without a foundation level of business acumen and an understanding of the system across the profession, nurses may not be empowered with their full potential of being a strong voice influencing health system reform.

Aim To describe the state of the professionalisation of midwifery in Belgium, and to formulate recommendations for advancing the midwifery profession. Methods A descriptive overview of maternity care in Belgium and the professionalisation of midwifery through an analysis of relevant policy and academic texts, underpinned by Greenwood’s sociological criteria for a profession: (1) own body of knowledge, (2) recognised authority, (3) broader community sanctions, (4) own code of ethics and (5) professional culture sustained by formal professional associations. From these insights, recommendations for advancing the midwifery profession in Belgium are formulated. Findings Current strengths of the professionalisation of midwifery in Belgium included unified midwifery education programmes, progress in midwifery research and overarching national documents for guiding midwifery education, practice and regulation. In contrast however challenges, such as the limited recognition of midwives’ roles by its clientele, limitations of midwives’ competencies and autonomy, lacking development of advanced roles in maternity care practice and a lack of unity of the organisation and its members, were also identified. Based on these, recommendations are made to strengthen Belgian midwifery. Conclusions Recommendations for advancing the midwifery profession in Belgium includes in particular increasing public awareness of midwives’ roles and competencies, implementing the full scope of midwifery practice and monitoring and advancing this practice. Thus, professional autonomy over both midwifery practice and working conditions should be enhanced. United midwifery organisations, together with women’s groups, other maternity care professionals and policy-makers as equal partners are key to bring about changes in the Belgian maternity care landscape.

Highlights • In this position paper, we provide a collection of views on the role of AI in the COVID-19 pandemic, from the clinical needs to the design of AI-based systems, to the translation of the developed tools to the clinic. We highlight key factors in designing system solutions - per specific task; as well as design issues in managing the disease on the national level. We focus on three specific use-cases for which AI systems can be built: from the early disease detection, the management of the disease in a hospital setting, and building patient-specific predictive models that require the combination of imaging with additional clinical features. Infrastructure considerations and population modeling in two European countries will be described. This pandemic has made the practical and scientific challenges of making AI solutions very explicit. A discussion concludes this paper, with a list of challenges facing the community in the AI road ahead., In this position paper, we provide a collection of views on the role of AI in the COVID-19 pandemic, from clinical requirements to the design of AI-based systems, to the translation of the developed tools to the clinic. We highlight key factors in designing system solutions - per specific task; as well as design issues in managing the disease at the national level. We focus on three specific use-cases for which AI systems can be built: early disease detection, management in a hospital setting, and building patient-specific predictive models that require the combination of imaging with additional clinical data. Infrastructure considerations and population modeling in two European countries will be described. This pandemic has made the practical and scientific challenges of making AI solutions very explicit. A discussion concludes this paper, with a list of challenges facing the community in the AI road ahead.

Breastfeeding offers one of the most fundamental global health benefits for babies. Breastmilk is lifesaving, providing not only nutrition but immunologic benefits and as such is strongly supported by the World Health Organization and leading healthcare associations worldwide. When the COVID-19 pandemic started in 2020, the impact of the restrictions to prevent the spread of the disease created challenges and questions about provision of safe, quality care, including breastfeeding practices, in a new 'normal' environment. Mothers were temporarily separated from their babies where infection was present or suspected, parents were prevented from being present on neonatal units and vital breastfeeding support was prevented. This discussion paper provides an overview of essential areas of knowledge related to practice for neonatal nurses and midwives who care for breastfeeding mothers and babies, in the context of the COVID-19 pandemic and the latest global guidance. Three areas will be discussed; the protective benefits of breastfeeding, keeping breastfeeding mothers and babies together and supporting mothers to breastfeed their babies. Finally, care recommendations are presented to serve as a summary of key points for application to practice for neonatal nurses and midwives.

The coronavirus disease 2019 (COVID-19) pandemic poses an enormous challenge to healthcare systems in affected communities. Older patients and those with pre-existing medical conditions have been identified as populations at risk of a severe disease course. It remains unclear at this point to what extent chronic liver diseases should be considered as risk factors, due to a shortage of appropriate studies. However, patients with advanced liver disease and those after liver transplantation represent vulnerable patient cohorts with an increased risk of infection and/or a severe course of COVID-19. In addition, the current pandemic requires unusual allocation of healthcare resources which may negatively impact the care of patients with chronic liver disease that continue to require medical attention. Thus, the challenge hepatologists are facing is to promote telemedicine in the outpatient setting, prioritise outpatient contacts, avoid nosocomial dissemination of the virus to patients and healthcare providers, and at the same time maintain standard care for patients who require immediate medical attention.

Pragmatic trials can improve our understanding of how treatments will perform in routine practice. In a series of eight papers, the GetReal Consortium has evaluated the challenges in designing and conducting pragmatic trials and their specific methodological, operational, regulatory, and ethical implications. The present final paper of the series discusses the operational and methodological challenges of data collection in pragmatic trials. A more pragmatic data collection needs to balance the delivery of highly accurate and complete data with minimizing the level of interference that data entry and verification induce with clinical practice. Furthermore, it should allow for the involvement of a representative sample of practices, physicians, and patients who prescribe/receive treatment in routine care. This paper discusses challenges that are related to the different methods of data collection and presents potential solutions where possible. No one-size-fits-all recommendation can be given for the collection of data in pragmatic trials, although in general the application of existing routinely used data-collection systems and processes seems to best suit the pragmatic approach. However, data access and privacy, the time points of data collection, the level of detail in the data, and the lack of a clear understanding of the data-collection process were identified as main challenges for the usage of routinely collected data in pragmatic trials. A first step should be to determine to what extent existing health care databases provide the necessary study data and can accommodate data collection and management. When more elaborate or detailed data collection or more structured follow-up is required, data collection in a pragmatic trial will have to be tailor-made, often using a hybrid approach using a dedicated electronic case report form (eCRF). In this case, the eCRF should be kept as simple as possible to reduce the burden for practitioners and minimize influence on routine clinical practice.

Introduction Increasingly, over the past decade, there has been a global shift in healthcare away from fixed "fee for service" payment mechanisms towards value-based reimbursement models rewarding safety and quality patient outcomes. Curbing the burgeoning costs of healthcare while incentivising higher quality and safer patient care are key drivers of this approach. At face value, this is clearly a worthwhile endeavour. However, there is a lack of conclusive evidence to support the effectiveness of such schemes where they have been introduced internationally. For this reason, Australia has largely been an observer of the shift in payment modalities that are occurring in other countries such as the United States and the United Kingdom. Method This paper presents an overview of current Australian practice in pricing for safety and quality in Healthcare. Recommendations are provided to help infection control professionals prepare for the upcoming introduction of funding reforms aimed at reducing complications acquired in Australian public hospitals. Conclusion The implications for infection control professionals are wide-ranging. This will be a period of significant adjustment for the public health system in Australia.

Background: Patients’ perspectives provide valuable information on quality of care. This study evaluates the feasibility and validity of Internet administration of Service Satisfaction Scale for Cancer Care (SCA) to assess patient satisfaction with outcome, practitioner manner/skill, information, and waiting/access. Patients and methods: Primary data collected from November 2007 to April 2008. Patients receiving cancer care within 1 year were recruited from oncology, surgery, and radiation clinics at a tertiary care hospital. An Internet-based version of the 16-item SCA was developed. Participants were randomised to Internet SCA followed by paper SCA 2 weeks later or vice versa. Seven-point Likert scale responses were converted to a 0–100 scale (minimum–maximum satisfaction). Response distribution, Cronbach’s alpha, and test–retest correlations were calculated. Results: Among 122 consenting participants, 78 responded to initial SCA. Mean satisfaction scores for paper/Internet were 91/90 (outcome), 95/94 (practitioner manner/skill), 89/90 (information), and 86/86 (waiting/access). Response rate and item missingness were similar for Internet and paper. Except for practitioner manner/skill, test–retest correlations were robust r = 0.77 (outcome), 0.74 (information), and 0.75 (waiting/access) (all P < 0.001). Conclusions: Internet SCA administration is a feasible and a valid measurement of cancer care satisfaction for a wide range of cancer diagnoses, treatment modalities, and clinic settings.

Objective Healthcare organizations are increasingly implementing electronic health records (EHRs) and other related health information technology (IT). Even in institutions which have long adopted these computerized systems, employees continue to rely on paper to complete their work. The objective of this study was to explore and understand human-technology integration factors that may be causing employees to rely on paper alternatives to the EHR. Methods We conducted semi-structured interviews with 20 key-informants in a large Veterans Affairs Medical Center (VAMC), with a fully implemented EHR, to understand the use of paper-based alternatives. Participants included clinicians, administrators, and IT specialists across several service areas in the medical center. Results We found 11 distinct categories of paper-based workarounds to the use of the EHR. Paper use related to the following: (1) efficiency; (2) knowledge/skill/ease of use; (3) memory; (4) sensorimotor preferences; (5) awareness; (6) task specificity; (7) task complexity; (8) data organization; (9) longitudinal data processes; (10) trust; and (11) security. We define each of these and provide examples that demonstrate how these categories promoted paper use in spite of a fully implemented EHR. Conclusions In several cases, paper served as an important tool and assisted healthcare employees in their work. In other cases, paper use circumvented the intended EHR design, introduced potential gaps in documentation, and generated possible paths to medical error. We discuss implications of these findings for EHR design and implementation.

As to the alignment of "Horizon 2020", ir is a more integrated approach to European science policy than expressed in the proposals previously drafted, and specifically considers: (i) promoting excellence in Science, (ii) establishing a sound industrial leadership and (iii) expressing an ambition to address current and future societal challenges. In this respect, the quest for a knowledge-based economy in Europe should result in proposals for industrial and employment policies that will consolidate the major European advantages in the biomedical, healthcare and pharmaceutical sectors. Horizon 2020 also provides the possibility of adopting a more flexible and simplified management route to drive European research through innovation, research and development. What should be additionally considered? Unmet medical needs, under pressure from demographic changes, await the generation of new medicines and health technologies which will evolve into a driver for a unified European policy. We believe that this should be focused on harnessing pharmaceutical knowledge for clinical use, as part of a response to accommodate patient needs and economic growth based on a robust, scientific approach. The bolder ambition for European research is to unlock key bottlenecks currently undermining European competitiveness. The historical lack of an appropriate business/innovation environment with reduced access to adequate risk finance instruments has severed the path for economic growth and industrial development. These issues are of critical importance and a solution is urgently needed to foster translation from the university to the healthcare sector through the generation and support of start-ups, spin-offs, university-industry consortia, and other platforms, which support translational research. The ultimate goal is implementation of holistic programmes: the 'bench to bedside' paradigm of medicines and other healthcare products. The European Research Council supports the basic biomedical research programmes of long term importance for development of medicines; however, fundamental research initiatives on medicines development will not be competitive in such an environment. In order to strengthen the long term outlook, we must foster innovative research within the university sector, EUFEPS proposes that a fund for such research be set up within Horizon 2020, which would be open for individual research groups and which would include Public-Public Partnerships (complementing already existing Public-Private Partnerships). How do we look for implementation? There is an established research agenda for medicines research that is globally focused, and which incorporates a cooperative model between universities and industry, facilitating integration of complex technologies. Regulatory Science will play an important role in this integration. This agenda uses tools arising from systems approaches (including discovery with systems biology and also systems pharmacology) and has the potential for providing better knowledge management, as well as technological innovation (including manufacturing). It also addresses the drive towards personalised medicines and can, with support from both public and private sectors, foster translation of knowledge to new technologies and from that, to new medicinal products and complex integrated systems. This is a part of a strategy capable of solving unmet medical needs, which would increase the quality of life of patients suffering from chronic and debilitating diseases. The instruments to allow the development of a research agenda should strengthen existing partnerships such as the IMI-JU model; allow for the creation of European-network infrastructures that can bring together existing competences with adequate European coordination, thus promoting advanced training and continuous professional development for the pharmaceutical sciences. This will be the cornerstone of a knowledge management strategy, providing education and training for healthcare professionals and scientists. A key role for EUFEPS is to help the research community to embrace these new holistic policies applied to the spectrum of pharmaceutical, medical and cognate sciences.

Background: Due to the aging of the population, cancer has become a health priority worldwide. While the number of elderly cancer patients is rapidly increasing, many barriers still exist to their effective management. Compared with their younger counterparts, the elderly are less likely to receive optimal medical, psychological and spiritual treatment provided in a culturally competent manner. Design: The scanty literature on cultural competence in elderly cancer patients has been reviewed. Additional material has been selected based on the authors' clinical research in medical oncology and psycho-oncology, and on their scholarly work in anthropology and bioethics. Results: The aging process is a synergistic product of biological, behavioral and social issues within a cultural context. Knowledge about how older people understand, perceive and experience their illness trajectory and make choices is essential to the planning and delivering of effective cancer care. Conclusion: This position paper of the SIOG Task Force on Cultural Competence in the Elderly creates awareness of the influence of culture in geriatric oncology. Negotiating cross-cultural issues in geriatric oncology helps managing possible conflicts between patients, families and physicians over differing health care values, beliefs, or practices. Possible areas of future scholarly investigation and clinical research are identified.

Background Patient-centered health care, where we design and deliver care to address the needs and preferences of patients, represents an important paradigm shift. Patient-reported outcomes (PROs) are critical to capture the patient voice, understand how illness and treatments affect people, and establish how well services and treatments address what matters most to patients. Objective Originally developed for use in research, PROs are now used to monitor individuals and populations, manage care, evaluate services and providers, and inform policy. However, moving PROs beyond research settings incurs considerable methodological, organizational, technological, and ethical considerations. National collaborative networks of researchers, clinicians, patients, and other stakeholders can address these challenges by coordinating development, creating standards for use, sharing costs and delivery platforms, and improving widespread uptake of core sets of measures to better inform health care decisions and improve outcomes. Discussion We introduce eight papers from researchers, clinicians, patients, and decision makers who participated in deliberations around creating a national network to accelerate the application and harmonized use of PROs in Canada. They offer a snap shot of the strategies that pioneers and innovative thinkers are using to integrate the patient voice into comprehensive care, research, and health policy planning of chronic diseases.

Objectives The aim of the study was to extend a previously published checklist of study design features to include study designs often used by health systems researchers and economists. Our intention is to help review authors in any field to set eligibility criteria for studies to include in a systematic review that relate directly to the intrinsic strength of the studies in inferring causality. We also seek to clarify key equivalences and differences in terminology used by different research communities. Study Design and Setting Expert consensus meeting. Results The checklist comprises seven questions, each with a list of response items, addressing: clustering of an intervention as an aspect of allocation or due to the intrinsic nature of the delivery of the intervention; for whom, and when, outcome data are available; how the intervention effect was estimated; the principle underlying control for confounding; how groups were formed; the features of a study carried out after it was designed; and the variables measured before intervention. Conclusion The checklist clarifies the basis of credible quasi-experimental studies, reconciling different terminology used in different fields of investigation and facilitating communications across research communities. By applying the checklist, review authors' attention is also directed to the assumptions underpinning the methods for inferring causality.

Objective This article reviews the available evidence and guidance on methods to identify reports of quasi-experimental (QE) studies to inform systematic reviews of health care, public health, international development, education, crime and justice, and social welfare. Study Design and Setting Research, guidance, and examples of search strategies were identified by searching a range of databases, key guidance documents, selected reviews, conference proceedings, and personal communication. Current practice and research evidence were summarized. Results Four thousand nine hundred twenty-four records were retrieved by database searches, and additional documents were obtained by other searches. QE studies are challenging to identify efficiently because they have no standardized nomenclature and may be indexed in various ways. Reliable search filters are not available. There is a lack of specific resources devoted to collecting QE studies and little evidence on where best to search. Conclusion Searches to identify QE studies should search a range of resources and, until indexing improves, use strategies that focus on the topic rather than the study design. Better definitions, better indexing in databases, prospective registers, and reporting guidance are required to improve the retrieval of QE studies and promote systematic reviews of what works based on the evidence from such studies.

Objective To investigate whether the use of the think-aloud method with propositional analysis could be helpful in the design of a Clinical Decision Support System (CDSS) providing guideline recommendations about long-term follow-up of childhood cancer survivors. Materials and methods The think-aloud method was used to gain insight into healthcare professionals’ information processing while reviewing a paper-based guideline. A total of 13 healthcare professionals (6 physicians and 7 physician assistants) prepared 2 fictitious patient consults using the paper-based guideline. Propositional analysis was used to analyze verbal protocols of the think-aloud sessions. A prototype CDSS was developed and a usability study was performed, again with the think-aloud method. Results The analysis revealed that the paper-based guideline did not support healthcare practitioners in finding patient-specific recommendations. An information processing model for retrieving recommendations was developed and used as input for the design of a CDSS prototype user interface. Usability analysis of the prototype CDSS showed that the navigational structure of the system fitted well with healthcare practitioners’ daily practices. Conclusions The think-aloud method combined with propositional analysis of healthcare practitioners’ verbal utterances while they processed a paper-based guideline was useful in the design of a usable CDSS providing patient-specific guideline recommendations.

What will be the future of internal medicine in Europe? Because of rapidly growing concerns regarding the position of internal medicine in many European countries, the European Federation of Internal Medicine (EFIM) has established a working group to analyze the situation. Being well aware of the variation in working practices in the different countries, the members of the group used an “all-European” approach to answer the following questions: • Are there problems for internal medicine? If so, what are these problems and why? • Why do the health care systems in the European countries need internal medicine? • Why do patients need internal medicine? • What needs to be done? Internal medicine is the modern, clinical, and scientific medical discipline that is responsible for the care of adult patients with one or more complex, acute, or chronic illnesses. Internal medicine is the cornerstone of an integrated health care delivery service that is needed today. Decision-makers in politics and hospitals, insurers, journalists, and the general public need a better understanding of what internal medicine can offer to the health care system and to the individual patient.

Antimicrobial resistance is an important global issue that impacts the efficacy of established antimicrobial therapy. This is true globally and within the Arab countries of the Middle East, where a range of key Gram-negative pathogens pose challenges to effective therapy. There is a need to establish effective treatment recommendations for this region given specific challenges to antimicrobial therapy, including variations in the availability of antimicrobials, infrastructure and specialist expertise. This consensus provides regional recommendations for the first-line treatment of hospitalized patients with serious infections caused by World Health Organization critical priority Gram-negative pathogens Acinetobacter baumannii and Pseudomonas aeruginosa resistant to carbapenems, and Enterobacteriaceae resistant to carbapenems and third-generation cephalosporins. A working group comprising experts in infectious disease across the region was assembled to review contemporary literature and provide additional consensus on the treatment of key pathogens. Detailed therapeutic recommendations are formulated for these pathogens with a focus on bacteraemia, nosocomial pneumonia, urinary tract infections, skin and soft tissue infections, and intra-abdominal infections. First-line treatment options are provided, along with alternative agents that may be used where variations in antimicrobial availability exist or where local preferences and resistance patterns should be considered. These recommendations take into consideration the diverse social and healthcare structures of the Arab countries of the Middle East, meeting a need that is not filled by international guidelines. There is a need for these recommendations to be updated continually to reflect changes in antimicrobial resistance in the region, as well as drug availability and emerging data from clinical trials.

Scientific communication and writing forms an integral element of constantly developing and evolving health sciences. Scientific research and writing forms a foundation on which stands the future of mankind and the environment. Being a health care professional, it is our collective responsibility to ensure constant updating of the existing knowledge and imparting any new concept/idea with rest of the medical fraternity. On a day to day basis, many of us tend to become quite satisfied after having delivered the right quality of health care to our dependant clientele. Yes, rightly so. But, how many of us have wondered as to what we have really done for the continuance and enhancement of the existing knowledge which we have acquired as a result of a lot of hard work by our predecessors? It is, indeed, time to introspect on this pertinent and important issue. Many of us, at some point of time, must have felt the need and wish to share our unique experiences with our colleagues in the medical fraternity. It is also true that possibly many such felt needs were never translated into effective scientific communications for various reasons. Of late, there has been a constant palpable pressure on the health care professionals to write and publish scientific papers as a part of mandatory requirement of various universities and medical councils. It may appear like a big challenge to those who are not familiar with scientific publications. On the contrary, we are quite certain that, all of us have the potential to write and publish our research work in various scientific journals. This editorial is aimed at addressing certain important issues concerning scientific writing and publications. We shall also endeavor to unfold and eliminate some of the unfounded myths and fears which may have deterred us from successfully writing and publishing our scientific work.

Intersex/disorders of sex development advocacy groups and associated health care professionals question the legitimacy of the Council of Europe issue paper, express their worries about its potentially harmful consequences, and urge the Council of Europe to consult more widely with relevant stakeholders.

Background\ud \ud The diversification of nursing and allied health profession (AHP) roles has seen unprecedented growth as organizations have sought to optimize limited health care resources. Within the UK health care system, the nonmedical consultant is viewed as the pinnacle of the clinical career ladder. Yet, nearly 15 years after their introduction, recruitment to these positions remains slow. Criticisms of nonmedical consultant practice include a lack of role clarity, a failure to work across the four domains of consultant practice, a lack of suitable applicants, and poor preparedness of new appointments. Although there is evidence exploring the nature and effectiveness of established consultant roles, little research addresses the development phase of aspiring consultants.\ud \ud \ud Objectives\ud \ud To explore the transitional journey experienced by trainee consultant radiographers as they move from advanced to consultant practitioner within a locally devised consultant development programme.\ud \ud \ud Design\ud \ud Longitudinal qualitative enquiry.\ud \ud \ud Methods and Settings\ud \ud Five trainee consultant radiographers were recruited to a locally devised consultant practice development program within a single UK hospital trust. Semistructured interviews were undertaken at 1, 6, and 12 months with the trainees.\ud \ud \ud Results\ud \ud A challenging journey was recounted involving five key emotional stages that occurred in a consistent and predictable order (ie, elation, denial, doubt, crisis, and recovery). The identified stages had close parallels with Hopson's Life Events model, suggesting that transition to consultant practice is a significant life event rather than a straightforward job promotion.\ud \ud \ud Conclusions\ud \ud Current emphasis on the four domains of practice, although providing a clear framework for expected external role outcomes, overlooks the importance of the internal or subjective career development on the perceived success or failure of the role. Employers, educators, and professional bodies have a responsibility to facilitate aspirational consultants to explore and enhance their internal career development, offering more time to define themselves and their role with support to guide them through the transition journey.

Objectives: To analyze whether there is an association between neighbourhood deprivation and morbidity and mortality of lung cancer, beyond individual level characteristics. Design: The entire Swedish population aged over 50, a total of 3.2 million individuals, was followed from January 1, 2000, until admission due to morbidity or mortality of lung cancer during the study period, or the end of the study on December 31, 2010. Multilevel logistic regression was used in the analysis with individual level characteristics (age, marital status, family income, education, immigration status, urban/rural status, mobility, and comorbidities) at the first level and level of neighbourhood deprivation at the second level. Neighbourhood deprivation was measured at small area market statistics level the use of Care Need Index, combining low educational status, low income, unemployment, and social welfare assistance. Results: There was a strong association between level of neighbourhood deprivation and morbidity and mortality of lung cancer. In the full model, which took account of individual level characteristics, the risk of morbidity of lung cancer was 1.31 and 1.36 for mortality in the most deprived neighbourhood than in the most affluent neighbourhoods. The variance at neighbourhood level was over twice the standard error, indicating significant difference in morbidity and mortality of lung cancer risk between neighbourhoods. Conclusions: This study is the largest to date of the influences of neighbourhood deprivation on morbidity and mortality of lung cancer. Results suggest that characteristics of neighbourhood affect risk of morbidity and mortality of lung cancer independently of individual level sociodemographic characteristics. Both individual and neighborhood level approaches are important in health care policies.

Summary Objectives In Austria, the general practitioner (GP) is the first point of contact for persons with health problems. Depending on the severity of the person's medical condition, a GP may refer her or him to a secondary care hospital consultant, who reports findings back to the GP in form of a paper-based discharge letter. Researchers report that paper-based communication of medical documents between different health care providers is insufficient in quality, error prone and too slow in many cases. Our aim was to develop and to realise a strategy for a stepwise replacement of the paper-based transmission of medical documents with a distributed, shared medical record. Methods In the first step of a three-steps strategy for development of a consistent, comprehensive and secure regional health care network, an electronic communication of discharge letters and diagnostic results between existing information systems of different health care providers in Tyrol, Austria, has been established: in the form of cryptographically signed S/MIME e-mail messages and, additionally, via a secure web portal system. In two further steps, an extension of the system by a bi-directional communication and by improvements of the web portal system is planned, leading to a comprehensive electronic patient record for shared care. Results After realisation of step 1, in October 2004, about 3500 electronic discharge letters were sent out from the Innsbruck University Hospital (IUH), which represents about 8% of the total number of discharge letters of the IUH. In addition, a lot of feedback was received and legal, organisational, financial and methodical difficulties were overcome. Discussion The stepwise approach to replace paper-based with electronic communication in the first step was helpful, since knowledge has been gained and cooperations were formed. For the realisation of a distributed, shared medical record (steps 2 and 3), it will not be sufficient only to replace paper-based transmission of medical documents with electronic communication technologies, but in the further steps, organisational changes will become necessary. As well, legal ambiguities must be resolved before a distributed medical record for cooperative care, used by several institutions as well as by patients, could be established.

The recognition that restructuring care processes is central to effective and efficient health care will result in the emergence of process-oriented electronic patient records (EPRs). How will these technologies come into being? Within informatics, it is often stated that to informate something, we should first model it. This paper queries whether a detailed modeling of work processes and data flows is the primary step that needs to be completed before such EPRs can be developed or tailored. Building upon a sociotechnical understanding of ICT development, we argue for a reinterpretation of 'models' in such development processes. We do so through a reverse engineering of parts of the paper-based medical record, which has received little attention in medical informatics. In process-oriented EPR design, we argue, modeling should not be conceived as the crucial first step in this design, but rather as an intervention in the organizational change-processes that constitute proper ICT development.

Getting the right information to providers can improve quality of care. We set out to provide patient-specific Electronic Medical Record (EMR)-based clinical summaries for providers taking care of HIV-positive adult patients in the resource-limited setting of Mbarara, Uganda.We evaluated the impact of implementing these clinical summaries using time-motion techniques and provider surveys.After implementation of EMR-based clinical summaries, providers spent more time in direct care of patients (2.9 min vs. 2.3 min, p0.001), and the length of patient visits was reduced by 11.5 min. Survey respondents indicated that clinical summaries improved care, reduced mistakes, and were generally accurate. Current antiretroviral medication, patient identifying information, adherence information, current medication, and current medical problems were among the highest-rated elements of the summary.By taking advantage of data stored in EMRs, efficiency and quality of care can be improved through clinical summaries, even in settings with limited resources.

The American Gastroenterological Association acknowledges the need for gastroenterologists to participate in and provide value-based care for both cognitive and procedural conditions. Episodes of care are designed to engage specialists in the movement toward fee for value, while facilitating improved outcomes and patient experience and a reduction in unnecessary services and overall costs. The episode of care model puts the patient at the center of all activity related to their particular diagnosis, procedure, or health care event, rather than on a physician's specific services. It encourages and incents communication, collaboration, and coordination across the full continuum of care and creates accountability for the patient's entire experience and outcome. This paper outlines a collaborative approach involving multiple stakeholders for gastrointestinal practices to assess their ability to participate in and implement an episode of care for obesity and understand the essentials of coding and billing for these services.

In this article, we define the electronic healthcare record and present its purpose as a tool for continuity of care. We briefly describe the current situation of usage and focus on the major challenges to wide implementation in Europe and beyond. Finally, we point out trends that show stronger involvement of the patients-citizens in the health care prevention and promotion processes, and discuss the impact on the future development of the electronic healthcare record into personal health records.

Background Clinical guidelines on infection control strategies in healthcare workers (HCWs) play an important role in protecting them during the severe acute respiratory syndrome coronavirus 2 pandemic. Poorly constructed guidelines that are incomprehensive and/or ambiguous may compromise HCWs’ safety. Objective The objective of this study was to develop and validate a tool to appraise guidelines on infection control strategies in HCWs based on the guidelines published early in the coronavirus disease 2019 pandemic. Design, setting, and outcomes A three-stage, web-based, Delphi consensus-building process among a panel of diverse HCWs and healthcare managers was performed. The tool was validated by appraising 40 international, specialty-specific, and procedure-specific guidelines along with national guidelines from countries with a wide range of gross national income. Results Overall consensus (≥75%) was reached at the end of three rounds for all six domains included in the tool. The Delphi panel recommended an ideal infection control guideline should encompass six domains: general characteristics (domain 1), engineering recommendations (domain 2), personal protective equipment (PPE) use (domain 3), and administrative aspects (domain 4-6) of infection control. The appraisal tool performed well across the six domains, and the inter-rater agreement was excellent for the 40 guidelines. All included guidelines performed relatively better in domains 1–3 than in domains 4–6, and this was more evident in guidelines originating from lower income countries. Conclusion The guideline appraisal tool was robust and easy to use. Engineering recommendations aspects of infection control, administrative measures that promote optimal PPE use, and HCW wellbeing were generally lacking in assessed guidelines. This tool may enable health systems to adopt high-quality HCW infection control guidelines during the severe acute respiratory syndrome coronavirus 2 pandemic and may also provide a framework for future guideline development.

Background Large-scale quarantine facilities staffed with non-healthcare workers (NHCW) were instrumental in preventing community spread of COVID-19 (coronavirus disease of 2019). The objective of this study was to determine the effectiveness of a newly developed procedural skills training framework in ensuring personal protective equipment (PPE) compliance of PPE-naïve NHCWs. Materials and methods We developed a PPE procedural skills training framework for NHCWs using the Learn, See, Practice, Prove, Do, and Maintain (LSPPDM) framework and international guidelines on PPE for healthcare workers. The NHCWs underwent PPE training using this framework, conducted by a team of Infection Prevention nurses, prior to being stationed within the CCF. Effectiveness of the LSPPDM PPE training framework was assessed using: 1) competency assessment scores for NHCWs, 2) PPE compliance rates from daily audit findings, and, 3) healthcare-associated COVID-19 infection rates of NHCWs. Results A total of 883 NHCWs had completed the PPE training and demonstrated competency in PPE compliance, fulfilling 100% of the checklist requirements. Mean PPE compliance of all NHCWs during the 11-week study period was noted to be >96%. The post-implementation improvement was statistically significant when the compliance was expressed in 3-days blocks) and in bed management staff (P = < 0.05). None of the 883 NHCWs who underwent PPE training via the LSPPDM framework were diagnosed with healthcare-associated COVID-19 infection. Conclusions An evidence-based skills training framework is effective in PPE training of large numbers of NHCWs, resulting in high compliance of appropriate PPE use and prevention of healthcare-associated COVID-19 infection.

Background COVID-19 is a global health crisis. Close contact with the mucous membranes and respiratory secretions of patients and aerosol-generating procedures renders dentists and other oral health professionals at high risk of exposure to SARS-CoV-2. We examined dentists’ knowledge, preparedness, and experiences of managing COVID-19 in Australia. Methods A cross-sectional online survey of dentists with a current membership with The Australian Dental Association (ADA) was conducted between March and April 2021. Results Of the 368 survey responses, most dentists (72.3%) reported having a good level of knowledge about COVID-19, with most visiting the ADA Federal COVID-19 (74.7%) and state/territory department of health websites (62.8%), respectively to source up-to-date information. Most dentists (87.6%) felt prepared to manage COVID-19 into the future, although 66% reported not receiving training or certification in the use of PPE. Over half (58.7%) reported not being concerned about contracting SARS-CoV-2 at work, with some (28.9%, n=98/339) feeling more stressed than usual and having heavier workloads. Conclusions COVID-19 had significant impact in oral healthcare in Australia. Dentistry has adapted to the varied challenges raised by the pandemic. Comprehensive training and detailed guidelines were fundamental for successful patient management during the COVID-19 outbreak.

Objectives Evidence-based healthcare contributes to the improvement of healthcare quality and informs healthcare decision-making. The provision of timely high-quality evidence is always required to fulfil the ever-changing needs and expectations of healthcare personnel. This study aimed to assess the needs and expectations of healthcare personnel regarding evidence-based healthcare in China. Methods We conducted a cross-sectional online survey from December 8, 2020 to January 15, 2021 involving 901 participants across China. Healthcare providers, policy makers, researchers and educators, and full-time postgraduate medical and nursing students working/living in China were eligible to participate. A self-developed questionnaire was used. Results Participants generally agreed that health-related research evidence was beneficial. Evidence-based resources, such as Cochrane resources, were only known or used by about half of the respondents due to difficulties related to availability and accessibility. Various types of resources, topics of evidence, and themes of workshops were of particular interest to most of the participants. Conclusions The dissemination and translation of evidence, provision of more support in evidence availability, offering evidence-based training, and determining the most in-demand research areas have been identified as priority areas of work which could fulfil the needs and expectations of healthcare personnel in China.

SummaryIn February, 2020, the European Commission published a white paper on artificial intelligence (AI) as well as an accompanying communication and report. The paper sets out policy options to facilitate a secure and trustworthy development of AI and considers health to be one of its most important areas of application. We illustrate that the European Commission's approach, as applied to medical AI, presents some challenges that can be detrimental if not addressed. In particular, we discuss the issues of European values and European data, the update problem of AI systems, and the challenges of new trade-offs such as privacy, cybersecurity, accuracy, and intellectual property rights. We also outline what we view as the most important next steps in the Commission's iterative process. Although the European Commission has done good work in setting out a European approach for AI, we conclude that this approach will be more difficult to implement in health care. It will require careful balancing of core values, detailed consideration of nuances of health and AI technologies, and a keen eye on the political winds and global competition.

Background During previous pandemics people who use drugs (PWUD) were categorized among the most vulnerable. In the current study, firstly, we wanted to evaluate the impact of the COVID-19 crisis on the prevalence of anxiety and depressive disorders among PWUD. Furthermore, we wanted to compare the prevalence of these disorders with that of members from the general population who did not use drugs. Methods We used a matched cohort design based on two separate repeated cross-sectional online surveys (April and November 2020) among PWUD and the general population. Results of GAD-7 and PHQ-9 were used as outcome variables. We calculated absolute and relative risks for matched pairs for both affective disorders, and logistic regression to compare affective disorders over both waves for PWUD. Results In April, the prevalence of affective disorders was similar for PWUD and the general population. In November, the risks for anxiety disorders increased with 64% for PWUD compared to non-PWUD (RR = 1.64, 95%CI 1.42–1.88), whereas the risks for depressive disorders more than doubled (RR = 2.29, 95%CI 1.97–2.67). Having a job and being male were protective factors for PWUD for both anxiety and depressive disorders. Limitations As this study used self-reported data, GAD-7 and PHQ-9 give an indication of the presence of anxiety and depression which might differ from a clinician's judgement. Conclusions PWUD might be disproportionally affected by COVID-19. Health care providers should be attentive to substance use as an indicator for increased risk of mental health problems.

ObjectivesTo investigate the COVID-19 infections among staff at our institution and determine the interventions required to prevent subsequent staff infections.DesignRetrospective cohort studyParticipants and settingStaff working at a single tertiary referral hospital who returned a positive test result for SARS-CoV-2 between 25 January 2020 and 25 November 2020.Main outcome measuresSource of COVID-19 infection.ResultsOf 45 staff who returned a positive test result for SARS-CoV-2, 19 were determined to be acquired at Austin Health. Fifteen (15/19; 79% [95% CI: 54–94%]) of these were identified through contact tracing and testing following exposures to other infected staff and were presumed to be staff-staff transmission, including 10 healthcare workers (HCWs) linked to a single ward that cared for COVID-19 patients. Investigation of the outbreak identified the staff tearoom as the likely location for transmission, with subsequent reduction in HCW infections and resolution of the outbreak following implementation of enhanced control measures in tearoom facilities. No HCW contacts (0/204; 0% [95% CI: 0–2%]) developed COVID-19 infection following exposure to unrecognised patients with COVID-19.ConclusionsUnrecognised infections among staff may be a significant driver of HCW infections in healthcare settings. Control measures should be implemented to prevent acquisition from other staff as well as patient-staff transmission.

Background Healthcare workers (HCW) are exposed to an increased risk of COVID-19 through direct contact with patients and patient environments. We calculated the; seroprevalence of SARS-CoV-2 in HCW at Eastern Health, a tertiary healthcare network in Victoria, and assessed associations with demographics, work location and role. Methods A cross-sectional cohort study of HCW at Eastern Health was conducted. Serum was analysed for the presence of antibodies to SARS-CoV-2, and all participants completed; an online survey collecting information on demographics, place of work, role, and exposures; to COVID-19. Seroprevalence was calculated as the proportion participants with SARS-CoV-2; antibodies out of all tested individuals. Results The crude seroprevalence of SARS-CoV-2 antibodies in this study was 2.17% (16/736). Thirteen of the 16 (81.2%) positive cases had previously been diagnosed with COVID-19 by PCR: the seroprevalence in the group not previously diagnosed with COVID by PCR was 0.42% (3/720). Having direct contact with COVID-19 patients did not increase the likelihood of having positive serology. A prior history of symptoms consistent with COVID-19 was associated with a higher likelihood of having positive serology (OR 17.2, p = 0.006, 95%CI: 2.25–131.55). Conclusion Our calculated seroprevalence of 2.17% is higher than estimated in the general Australian population, but lower than that reported in HCW internationally. The; majority of those with positive serology in our study had previously been diagnosed with COVID-19 by PCR based testing. Seropositivity was not associated with interaction with COVID-19 positive patients, highlighting effective infection prevention and control practices within the workplace.

Recent definitions of malnutrition include low muscle mass within its diagnostic criteria. In fact, malnutrition is one of the main risk factors of skeletal muscle loss contributing to the onset of sarcopenia. However, differences in the screening and diagnosis of skeletal muscle loss, especially as a result of malnutrition in clinical and community settings, still occur mainly as techniques and thresholds used vary in clinical practice. The objectives of this position paper are firstly to emphasize the link between skeletal muscle loss and malnutrition-related conditions and secondly to raise awareness for the timely identification of loss of skeletal muscle mass and function in high risk populations. Thirdly to recognize the need to implement appropriate nutritional strategies for prevention and treatment of skeletal muscle loss and malnutrition across the healthcare continuum. Malnutrition needs to be addressed clinically as a muscle-related disorder and clinicians should integrate nutritional assessment with muscle mass measurements for optimal evaluation of these two interrelated entities to tailor interventions appropriately. The design of monitoring/evaluation and discharge plans need to include multimodal interventions with nutrition and physical exercise that are key to preserve patient's muscle mass and function in clinical and community settings.

Although the study of the association between interventions in primary care and health outcomes continues to produce mixed findings, programs designed to promote the greater compliance of General Practitioners and their diabetic patients with treatment guidelines have been increasingly introduced worldwide, in an attempt to achieve better quality diabetes care through the enhanced standardisation of patient supervision. In this study we use clinical data taken from the Diabetes Register of one Local Health Authority (LHAs) in Italy’s Emilia-Romagna Region for the period 2014-2015. Firstly, we test to see whether the monitoring activities prescribed for diabetics by regional diabetes guidelines, actually have a positive impact on patients’ health outcomes and increase appropriateness in health care utilization. Secondly, we investigate whether GPs’ participation in the local Diabetes Management Program (DMP) leads to improved patient compliance with regional guidelines. Our results show that such a program, which aims to increase GPs’ involvement and cooperation in following regional guidelines for best practices, achieves its goal of improved patient compliance with the prescribed actions. In turn, through the implementation of the DMP and the greater involvement of physicians, regional policies have succeeded in promoting better health outcomes and the improved appropriateness of health care utilization.

The road to the delivery of high-quality cleft surgery into communities in the LMIC is beset with numerous hurdles. These include the availability of trained health care personnel, the availability of infrastructure in health care, parent awareness of the need for timely interventions in these children, presence of affordable treatment centres with adequate means of transport to and from these facilities for patients coming from the interior rural locations, but most importantly, the financial considerations that are the underlying limitations in most of these above mentioned considerations. We would like to approach this problem by describing the evolution of our own centre over several decades. Our centre, The Charles Pinto Centre for Cleft lip and palate at the Jubilee Mission Hospital is located in Thrissur, in the beautiful state of Kerala. In the late 1950s, Dr HS Adenwalla who had trained under experts in the art of Cleft Lip and Palate Surgery in Mumbai joined the hospital and transformed it through sheer dedication and meticulous clinical expertise into a major hub for treatment and also training in this speciality. In this endeavour he was greatly helped by non governmental organizations of which Smile Train deserves special mention in view of its model of functioning, empowering local partners by adequate funding for treatment, training and establishment of infrastructure, while ensuring strict adherence to safety standards. We believe that it is essential that there should be trained and dedicated health care personnel who are willing to treat such patients without an eye on the monetary benefits accrued, and also enough funding either from the government or from the NGOs to provide equipment and infrastructure for safe, high quality and accessible treatment and the establishment of multidisciplinary management. Lastly, the patients should also be made aware of the need for timely treatment and long-term follow- up.

AI has the potential to disrupt and transform the way we deliver care globally. It is reputed to be able to improve the accuracy of diagnoses and treatments, and make the provision of services more efficient and effective. In surgery, AI systems could lead to more accurate diagnoses of health problems and help surgeons better care for their patients. In the context of lower-and-middle-income-countries (LMICs), where access to healthcare still remains a global problem, AI could facilitate access to healthcare professionals and services, even specialist services, for millions of people. The ability of AI to deliver on its promises, however, depends on successfully resolving the ethical and practical issues identified, including that of explainability and algorithmic bias. Even though such issues might appear as being merely practical or technical ones, their closer examination uncovers questions of value, fairness and trust. It should not be left to AI developers, being research institutions or global tech companies, to decide how to resolve these ethical questions. Particularly, relying only on the trustworthiness of companies and institutions to address ethical issues relating to justice, fairness and health equality would be unsuitable and unwise. The pathway to a fair, appropriate and relevant AI necessitates the development, and critically, successful implementation of national and international rules and regulations that define the parameters and set the boundaries of operation and engagement.