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Objective Despite evidence-based guidelines stating that lipase alone should be used in the diagnosis of suspected acute pancreatitis, health care providers continue to order amylase or amylase and lipase together. The purpose of this study was to assess the utilization of appropriate laboratory testing related to the diagnosis of acute pancreatitis. Methods The study used a retrospective cross-sectional design. The timeframe was from January 1, 2020, to December 31, 2020. A retrospective chart review was used to collect data for the following: patient-provider encounter notes, patient demographics, provider demographics, differential and final diagnosis, and laboratory test results. Data analysis include stratification of categorical variables and calculation of cost savings. Results For the 12-month period, this study found 2567 (9.3%) of all amylase and lipase tests to be unnecessary. Amylase tests (1881; 73.2%) made up the most unnecessary tests followed by lipase tests (686; 26.7%). An analysis of test-ordering behavior by providers revealed that 81.5% of all unnecessary tests were ordered by MDs. Finally, this study estimated a total cost savings of $128,350 if all unnecessary tests were eliminated. Conclusion Our study demonstrated that amylase and lipase tests have been overutilized in the diagnosis of acute pancreatitis. [ABSTRACT FROM AUTHOR]

BackgroundOral anticoagulants (OACs) mitigate stroke risk in patients with atrial fibrillation (AF). The study aim was to analyze prevalence and predictors of OAC underutilization.MethodsNewly diagnosed AF patients with a CHA2DS2-VASc score ≥ 2 were identified from the US CMS Database (January 1, 2013-December 31, 2017). Patients were stratified based on having an OAC prescription versus not and the OAC prescription group was stratified by direct OAC (DOACs) versus warfarin. Multivariable logistic regression models were used to examine predictors of OAC underutilization.ResultsAmong 1,204,507 identified AF patients, 617,611 patients (51.3%) were not prescribed an OAC during follow-up (mean: 2.4 years), and 586,896 patients (48.7%) were prescribed an OAC during this period (DOAC: 388,629 [66.2%]; warfarin: 198,267 [33.8%]). Age ≥ 85 years (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.55-0.56), female sex (OR 0.96, 95% CI 0.95-0.96), Black race (OR 0.78, 95% CI 0.77-0.79) and comorbidities such as gastrointestinal (GI; OR 0.43, 95% CI 0.41-0.44) and intracranial bleeding (OR 0.29, 95% CI 0.28-0.31) were associated with lower utilization of OACs. Furthermore, age ≥ 85 years (OR 0.92, 95% CI 0.91-0.94), Black race (OR 0.78, 95% CI 0.76-0.80), ischemic stroke (OR 0.77, 95% CI 0.75-0.80), GI bleeding (OR 0.73, 95% CI 0.68-0.77), and intracranial bleeding (OR 0.72, 95% CI 0.65-0.80) predicted lower use of DOACs versus warfarin.ConclusionsAlthough OAC therapy prescription is the standard of care for stroke prevention in AF patients, its overall utilization is still low among Medicare patients ≥ 65 years old, with specific patient characteristics that predict underutilization.

Background: The underutilization of primary care services is a possible factor influencing inappropriate emergency service presentations. The objective of this study was to evaluate the proportion and characteristics of patients inappropriately accessing emergency room services from the perspective of primary care underutilization. Methods: This cross-sectional study included patients who visited the emergency room of a County Hospital, initially triaged with green, blue, or white codes, during a 2-week period in May 2017. Two primary care physicians performed a structured analysis to correlate the initial diagnosis in the emergency room with the final diagnosis to establish whether the patient's medical complaints could have been resolved in primary care. Results: A total of 1269 adult patients were included in this study. In total, the medical problems of 71.7% of patients could have been resolved by a primary care physician using clinical skills, extended resources, or other ambulatory care and out-of-hours services. Conclusions: Low awareness of out-of-hours centers and a lack of resources for delivering more complex services in primary care can lead to inappropriate presentations to the emergency services. Future research on this topic needs to be conducted at the national level. [ABSTRACT FROM AUTHOR]

Copyright of Tijdschrift voor Arbeidsvraagstukken is the property of Amsterdam University Press and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

The study investigates the impact of human capital underutilization on India's economic growth and labor productivity. For this purpose, we have employed the Autoregressive Distributed Lag (ARDL) model, which was applied using the annual time series data from 2005 to 2019. The ARDL estimation results revealed that human capital underutilization has a negative but statistically insignificant relationship with economic growth in the long run. We also found that a short-run decrease in time-related underemployment increased labor productivity. Therefore, we recommend that the policymakers consider human capital utilization measures from the perspective of both individuals and the economy, which should also be addressed in their policy framework. Furthermore, the empirical insights of the study could be helpful for future labor policy recommendations in India and emerging economies across the globe. [ABSTRACT FROM AUTHOR]

In 2023, Journal of Primary Care and Community Health published the results of 4 outstanding studies in which investigators aimed to explore and improve clinician and eligible individuals' knowledge of the rationale for lung cancer screening (LCS). Their results highlighted the underutilization of LCS, particularly for certain high risk populations, and the continued disparities in screening seen between groups of eligible individuals. Here, key findings from those 2023 Journal of Primary Care and Community Health reports, along with salient findings of other recent LCS reports, are discussed. The bases for the United States Preventive Task Force (USPSTF) LCS recommendations, barriers primary care providers face, the perspective of eligible individuals, importance of shared decision-making (SDM) and disparities between groups in LCS are reviewed along with potential strategies to ensure that more eligible individuals are offered LCS. [ABSTRACT FROM AUTHOR]

Background: Despite efforts to improve healthcare infrastructure and service delivery, significant disparities in healthcare utilization persist, leading to suboptimal health outcomes and hindering progress toward achieving universal health coverage. This research article aims to conduct a qualitative exploration of the under-foot fall in utilization of health services, shedding light on the barriers and challenges faced by individuals in accessing and utilizing health care to inform targeted interventions and improve health service utilization. Methods: This qualitative study employed free listing, pile sorting, and focus group discussions (FGDs) as data collection methods. Representatives from various stakeholders involved in the primary healthcare delivery system were selected based on their vocalness, knowledge, willingness to participate, and heterogeneity of responses. Subsequently, FGDs and key informant interviews (KIIs) were conducted to further explore the identified barriers. The collected transcripts underwent manual thematic analysis using coding rules and theme generation procedures. Results: A total of 30 participants, including healthcare providers, community leaders, and individuals from the local community, took part in the qualitative exploration. The themes encompassed limited awareness and knowledge, geographical and infrastructural barriers, socioeconomic constraints, trust and perceptions of the healthcare system, and cultural and social factors. These findings provide valuable insights into the multifaceted barriers hindering healthcare utilization and can guide the development of targeted interventions and policies to improve healthcare access and delivery in the study area. Conclusion: The identified barriers, including limited awareness and knowledge, geographical and infrastructural challenges, socioeconomic constraints, trust and perceptions of the healthcare system, cultural and social factors, and gender disparities, are consistent with the existing literature. [ABSTRACT FROM AUTHOR]

The opioid crisis in Ontario has led to a surge in preventable overdose deaths. Challenges in the mental health and addiction system, along with various contributing factors, have amplified this crisis. Underutilization of data exacerbates service gaps and hinders innovative solutions. Through stakeholder engagement, interrelated problems emerged, emphasizing the pervasive data underutilization. This research explores data usage in mental health and addictions, focusing on the opioid epidemic in Ontario and comparative jurisdictions. To improve service quality, Ontario should implement a comprehensive data management strategy. Two key recommendations include increased investment in exploring additional data use cases and evaluating policy initiatives using dynamic models throughout a patient's journey. [ABSTRACT FROM AUTHOR]

Flor Verghote,1,2 Charles Van Praet,2,3 Daan De Maeseneer,4 Camille Berquin,2,3 Ben Vanneste,1,2 Pieter De Visschere,5 Sofie LJ Verbeke,6 Valérie Fonteyne1,2 1Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium; 2Department of Human Structure and Repair, Ghent University, Ghent, Belgium; 3Department of Urology, Ghent University Hospital, Ghent, Belgium; 4Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium; 5Department of Radiology and Nuclear Medicine, Ghent University Hospital, Ghent, Belgium; 6Department of Pathology, Ghent University Hospital, Ghent, BelgiumCorrespondence: Flor Verghote, Department of Radiation Oncology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, 9000, Belgium, Tel +329332.30.15, Fax +323323015, Email flor.verghote@uzgent.bePurpose: Pronounced underuse of radiotherapy (RT) in muscle-invasive bladder cancer (MIBC) is reported. This study aims to assess the awareness about the role of RT in different MIBC settings and see whether this has increased since 2017.Materials and Methods: We reviewed the bladder cancer guidelines of the EAU, ESMO, NCCN, NICE, and AUA/ASCO/ASTRO/SUO, focusing on the role of RT in MIBC. In 2017, we evaluated the use of RT in MIBC in Belgium. This raised awareness about the indications of RT in different MIBC settings. Here, we present a retrospective pattern of care analysis of the RT use for MIBC patients at our center from January 2012 until December 2021. Frequency of RT use, patient, disease and treatment characteristics were compared between two 5-year periods (2012– 2016 and 2017– 2021).Results: Review of the guidelines suggested that RT can be used as a treatment option in most MIBC settings. However, differences between guideline recommendations existed and high-level evidence was often lacking. Overall, 221 unique MIBC patients received RT at our center. RT use for MIBC was 39% higher in the second 5-year period (Between the same periods, the number of new MIBC registrations increased with 26%). The most pronounced increase, ie, 529%, was observed in the primary setting and was in parallel with patient preference becoming the main indication for RT. Participation in clinical trials seems to have had an important impact on the frequency of RT use in the adjuvant and metastatic setting.Conclusion: We provide a critical overview of the RT indications in MIBC as recommended by the international guidelines. Increased awareness about RT as a treatment option in MIBC seems to have an impact on the treatment choice in clinical practice, as was observed in our tertiary center.Keywords: urothelial carcinoma, patterns of care, patient preference, radiation, underutilization

Rice millers access paddy through private traders, cooperatives, individual farmers, and village agents. These methods determine the capacity utilization of the mills, costs incurred, and profitability of the rice milling business. This article aimed at determining the effect of paddy sourcing methods on the volume of rice milled by small and medium-scale rice millers in Kenya. Specifically, the study sought to determine the sourcing methods used, combinations of sourcing methods, and effects of these combinations on the volume of rice milled. A multistage sampling technique resulted to a total of 160 millers comprised of 90 and 70 small and medium-scale rice millers respectively. A multinomial endogenous switching regression (MESR) was used to determine the resultant effects of paddy sourcing methods on volume of rice milled. Results: The results show that sourcing paddy directly from individual farmers, individual farmers bringing paddy to the miller, buying from traders and sourcing through agents are the four paddy-sourcing methods used by rice millers. Factors that influence utilization of a combination of sourcing methods are age of the miller, ownership of the miller, unit price of paddy, distance from the mills, ownership of the mills, degree of competition, contract agreements, access to information and finance. The highest volume of paddy sourced was achieved using a combination of three paddy sourcing methods: buying from traders, direct sourcing from individual farmers and individual farmers bringing paddy to the miller (B1D1I1A0). This combination increases volumes sourced by 114.1 %. This underscores the sole vitality of a myriad of factors in determining the choice of utilization of a combination of paddy sourcing methods. This study can influence decisions and rice milling related policy formulation towards a sustainable paddy sourcing mechanisms and consistent rice milling business.

PurposeStandard of care for definitive treatment of locally advanced cervical cancer (LACC) is concurrent chemoradiation followed by a brachytherapy boost. Only 55.8% of women in the United States receive brachytherapy, with even lower proportions in San Diego and Imperial Counties. The purpose of this study was to investigate brachytherapy practice and referral patterns in Western United States border region.Material and methodsA short survey was sent to 28 radiation oncologists in San Diego and Imperial Counties, who treat patients with gynecologic malignancies. Descriptive statistics were used for analysis.ResultsSeventeen (61%) physicians responded to the survey. All physicians reported some training in cervical cancer brachytherapy during residency, with median 6 months. Only two physicians reported personally treating all cervical cancer patients with brachytherapy; however, 92% of remaining physicians would recommend brachytherapy for patients if given time and access. The most common reason for referral (78%) was patients deemed to require hybrid or interstitial brachytherapy implants. Barriers to referral included patients' preference, insurance status, their resources, or logistics. No changes were reported for brachytherapy practices during the COVID-19 pandemic, except the addition of pre-procedural testing for SARS-CoV-2. Ninety-two percent of physicians identified inadequate maintenance of skills as a barrier to performing brachytherapy, but 77% were not interested in additional training. External beam radiation therapy boosts were rarely recommended in case scenarios describing potentially curable patients.ConclusionsThe importance of brachytherapy is widely recognized for conferring a survival benefit, but barriers to implementation include inadequate training or maintenance of skills, and larger systematic issues related to reimbursement policy, social support, and financial hardship. As most established providers were uninterested in additional brachytherapy training, future approaches to improve patients' access should be multidimensional and reflect the value of brachytherapy in definitive treatment of patients with LACC.

BACKGROUND: Many patients with atherosclerotic cardiovascular disease (ASCVD) are not on guideline-recommended statin therapy. We evaluated utilization of statins and other lipid-lowering therapy (LLT), and changes in low-density lipoprotein cholesterol (LDL-C), among patients with ASCVD over a 1-year period. METHODS: LLT and LDL-C levels at the first outpatient visit (January 1, 2017-December 31, 2018) and 1-year follow-up were evaluated using data from Cerner Real-World Data, an electronic health record-derived data set from 92 US health systems. Logistic regression was used to evaluate factors associated with high-intensity statin use. RESULTS: We identified 322 153 patients with ASCVD (median age 69 years, 58.8% men, 81.8% White). Overall, 76.1% of patients were on statins, with only 39.4% on high-intensity statins. Men were more likely to receive high-intensity statins than women (multivariable-adjusted odds ratio, 1.34 [95% CI, 1.30-1.38]). Increasing age was associated with lower odds of statin use (odds ratio, 0.79 per 5-year increase at 60 years [95% CI, 0.78-0.81]). Patients with peripheral artery disease (odds ratio, 0.40 [95% CI, 0.37-0.42]) and cerebrovascular disease (odds ratio, 0.75 [95% CI, 0.70-0.80]) had lower odds of using high-intensity statins than those with coronary artery disease. At baseline, most patients (61.3%) had elevated LDL-C (≥70 mg/dL), including 59.8% of those on low/moderate-intensity statins and 76.1% on no statin; only 45.3% achieved an LDL-C <70 mg/dL at 1 year. Nonstatin LLT use was low (ezetimibe, 4.4%; proprotein convertase subtilisin/kexin type 9 inhibitors, 0.7%). Among patients on no statin or low/moderate-intensity statin at baseline, 14.8% and 13.4%, respectively, were on high-intensity statins at 1 year. CONCLUSIONS: Among patients with ASCVD in routine care, high-intensity statins are underutilized, and uptitration and use of nonstatin therapy are uncommon. Women, older adults, and individuals with noncardiac ASCVD are particularly undertreated. Concerted efforts are needed to address therapeutic inertia for lipid management in patients with ASCVD. [ABSTRACT FROM AUTHOR]

The tropical cashew tree, Anacardium occidentale L., has remarkable potential. The tree produces the pseudo-fruit known as the cashew apple and nuts. The apple is sweet, juicy, and loaded with dietary fiber, phytonutrients, minerals, and vitamin C. Despite having high nutritional content, the cashew apple is neglected in low-technological nations like Tanzania, primarily because of negligence over the wellknown nut, its perishability, and its astringent taste. Contrarily, cashew apples are processed into various goods in high-income nations where food processing and technology improvements have been realized. Cashew apple products include juice, syrup, wine, alcohol, dietary fiber extracts, and animal feed. However, inadequate technologies and skills for postharvest handling and value addition have led to a considerable loss of cashew apples, contributing to pronounced food and nutrition insecurity. This review documents the production of cashew apples in Tanzania and reveals the fruit's critical underutilization and potential nutrition and economic opportunities. This documentation may call for interventions to create awareness of the importance of cashew apples in social-economic, food, nutrition and health, empower locals, and invite new processing technologies to diversify and extend shelf-life. The ultimate goal is to promote the utilization of this abandoned nutritious fruit. Such approaches may reduce postharvest losses and impact food and nutrition security and the social-economic empowerment of smallholder farmers. [ABSTRACT FROM AUTHOR]

BackgroundDiabetes threatens population health, especially in rural areas. Diabetes and periodontal diseases have a bidirectional relationship. A persistence of rural–urban disparities in diabetes may indicate a rural–urban difference in periodontal disease among patients with diabetes; however, the evidence is lacking. This retrospective study aimed to investigate rural–urban discrepancies in the incidence and treatment intensity of periodontal disease among patients who were newly diagnosed with type 2 diabetes in the year 2010.MethodsThe present study was a retrospective cohort design, with two study samples: patients with type 2 diabetes and those who were further diagnosed with periodontal disease. The data sources included the 2010 Diabetes Mellitus Health Database at the patient level, the National Geographic Information Standardization Platform and the Department of Statistics, Ministry of Health and Welfare in Taiwan at the township level. Two dependent variables were a time-to-event outcome for periodontal disease among patients with type 2 diabetes and the treatment intensity measured for patients who were further diagnosed with periodontal disease. The key independent variables are two dummy variables, representing rural and suburban areas, with urban areas as the reference group. The Cox and Poisson regression models were applied for analyses.ResultsOf 68,365 qualified patients, 49% of them had periodontal disease within 10 years after patients were diagnosed with diabetes. Compared to urban patients with diabetes, rural (HR = 0.83, 95% CI: 0.75–0.91) and suburban patients (HR = 0.86, 95% CI: 0.83–0.89) had a lower incidence of periodontal disease. Among 33,612 patients with periodontal disease, rural patients received less treatment intensity of dental care (Rural: RR = 0.87, 95% CI: 0.83, 0.92; suburban: RR = 0.93, 95% CI: 0.92, 0.95) than urban patients.ConclusionGiven the underutilization of dental care among rural patients with diabetes, a low incidence of periodontal disease indicates potentially undiagnosed periodontal disease, and low treatment intensity signals potentially unmet dental needs. Our findings provide a potential explanation for the persistence of rural–urban disparities in poor diabetes outcomes. Policy interventions to enhance the likelihood of identifying periodontal disease at the early stage for proper treatment would ease the burden of diabetes care and narrow rural–urban discrepancies in diabetes outcomes.

Abstract Background Non-vitamin K antagonist oral anticoagulants (NOACs) are preferred over vitamin K antagonists (VKAs) as oral anticoagulant (OAC) therapy in patients with nonvalvular atrial fibrillation (NVAF). This study aimed to estimate the current status and risk factors of OAC underutilization in the NOAC era. Method A cross-sectional study using nationwide claims data was conducted. Elderly patients with NVAF at an increased risk of stroke were selected as candidates for OAC therapy before the index date (July 1, 2018). The status of anticoagulant utilization on the index date and factors influencing the use of anticoagulants was investigated in these patients. Results Of the 11,056 patients with NVAF who were eligible for OAC therapy, 7238 (65.5%) were receiving OAC on the index date, and 6302 (87.1%) were receiving NOACs. Patients aged ≥ 75 years had higher anticoagulant utilization than those aged 65–69 years. Among comorbid diseases, while hypertension was the most influential positive factor (odds ratio [OR] = 1.644; confidence interval [CI] = 1.445–1.869) in OAC utilization, severe renal disease was the most influential negative factor (OR = 0.289; CI = 0.200–0.416). Aspirin use had a significantly low OR (OR = 0.097; CI = 0.085–0.110) of anticoagulant use. OAC use was approximately 1.5 times higher in patients with persistent or permanent AF than in those with paroxysmal AF. Conclusion Approximately one-third of patients who are recommended anticoagulation therapy do not take OACs, even though the use of NOACs has become more common. It should be widely recognized that aspirin cannot be an alternative to OACs, and anticoagulant therapy should be actively implemented.

While the crisis in India's legal aid system is well documented, the extent of utilization of legal aid lawyers for representation in court has received little attention. In this article, based on existing public data, we seek to demonstrate the extent of underutilization of legal aid services among prisoners nationally. The data reveals that over a period of 4 years, between 2016 and 2019, only 7.91% of the undertrials admitted into prisons utilized the legal aid services they were entitled to. This phenomenon of underutilization raises uncomfortable questions about the performance of India's legal aid system, particularly in the context of socio-economic vulnerability of prisoners. However, the limitations of the data mean that it is not possible to determine the reasons for such underutilization – whether underutilization is being driven by lack of awareness of legal aid or by socio-economically vulnerable undertrial prisoners choosing other options despite being aware of free legal aid. [ABSTRACT FROM AUTHOR]

Abstract Background Underutilization of health services among chronic non-communicable disease sufferers, especially for hypertension (HBP) and diabetes mellitus (DM), was considered as a significant contributing factor to substantial cases in terms of both avoidable morbidity and mortality. However, evidence on health services underutilization and its associated factors in poverty-stricken areas remain scarce based on previous literature. This study aims to describe health services underutilization for people diagnosed with chronic diseases in impoverished regions and to identify its associated factors, which are expected to provide practical implications for the implementations of interventions tailored to the specific needs of disadvantaged residents in rural China to achieve effective utilization of health services in a timely manner. Methods Data were collected from a cross-sectional survey conducted through face-to-face interviews among 2413 patients from six counties in rural central China in 2019. The Anderson behavioral model was adopted to explore the associated factors. A two-level logistic model was employed to investigate the association strengths reflected by adjusted odds ratios (AOR) and 95% confidence intervals in forest plots. Results On average, 17.58% of the respondents with HBP and 14.87% with DM had experienced health services underutilization during 1 month before the survey. Multilevel logistic regression indicated that predisposing factors (age), enabling factors (income and a regular source of care), and need factors (self-reported health score) were the common predictors of health service underutilization both for hypertensive and diabetic patients in impoverished areas, among which obtaining a regular source of care was found to be relatively determinant as a protective factor for health services underutilization after controlling for other covariates. Conclusions Our results suggested that the implementation of a series of comprehensive strategies should be addressed throughout policy-making procedures to improve the provision of regular source of care as a significant determinant for reducing health services underutilization, thus ultimately achieving equal utilization of health services in impoverished regions, especially among chronic disease patients. Our findings are expected to provide practical implications for other developing countries confronted with similar challenges resulting from underdeveloped healthcare systems and aging population structures.

Dovyalis caffra is an indigenous African tree originating from South Africa. It is resilient, with capability to remain green and productive in adverse conditions such as drought, frost and saline environments. Its ripe fruit is edible and very nutritious. It has a characteristic deep yellow colour, astringent/sour taste and strong odour. The fruit can be used in making jams, jellies, juices and wine amongst other products. Despite having great nutritional and health potential, the fruit remains considerably unexploited in Africa and beyond. In Kenya, Dovyalis caffra is considered a wild fruit tree, with its cultivation only limited to establishing hedges. Utilization for food purposes in the country is non-existent. This review aims at (1) an in-depth scrutiny of available literature and depiction of the nature, composition, utilization and potential of Dovyalis caffra fruit; and (2) to critically analyse challenges in the Kenyan perspective as well as potential interventions. The extreme underutilization of Dovyalis caffra in Kenya may be attributed to various challenges such as; the lack of awareness of the fruits food potential, limited research and scientific information, absence of standardised agronomic and agro-processing procedures, sourness of fruit and weak value chain amongst others. In addressing such challenges, several recommendations have been proposed. Such recommendations when implemented would allow for progressive adoption of Dovyalis caffra by the Kenyan population and hence the fruit’s unexploited benefits in food and health.

Copyright of Paradigma is the property of Universidad Pedagogica Experimental Libertador and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

(1) Background: The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recommend that every person aged six months and over receive the influenza vaccine every year. Previous studies indicate that rural-area residents have less access to preventative health care services. This study aims to examine the variation in influenza vaccine use among rural and urban counties in Florida. (2) Methods: The study studied 24,116 participants from the Behavioral Risk Factor Surveillance System database. The study included only patients who live in Florida. We performed logistic regression analysis using survey procedures available in SAS®. Our regression model assessed the association between receiving the influenza vaccine and county status, age, income level, education level, and health coverage. We used ArcGIS software to create prevalence and vaccination maps. (3) Results: Of the total number of the study participants, 45.31% were residents of rural counties, and 54.69% were residents of urban counties. The logistic regression model showed no significant association between residing in rural counties and not receiving influenza vaccine in the past year (−0.05560, p-value = 0.0549). However, we found significant associations between not receiving influenza vaccine and age, high education level, and not having health care coverage (−0.0412, p-value < 0.0001; −0.04462, p-value = 0.0139; and 0.4956, p-value < 0.0001, respectively). (4)Conclusions: Our study did not find an association between influenza vaccine use among rural and urban residence. Increasing age, higher education, and having health care insurance had positive associations with influenza vaccine use. [ABSTRACT FROM AUTHOR]

Background: Asymptomatic bacteriuria affects 2% to 15% of pregnant women, with 20% to 40% developing symptoms later. Symptomatic urinary tract infections are more common in pregnancy, with a prevalence of 33%, posing risks, such as preterm delivery, low birthweight, and maternal pyelonephritis. The gold standard for urinary tract infection detection is a urine culture, but point-of-care urinalysis dipsticks are frequently performed as screens during regular obstetrical visits. Leukocyte esterase has been used to justify the treatment of asymptomatic bacteriuria, even with low sensitivity and specificity. Confirmatory tests are crucial for avoiding false positives and ensuring optimal outcomes. Current guidelines for urinalysis dipstick interpretation and the decision to treat asymptomatic bacteriuria in pregnancy are limited. It remains unclear whether an evidence-based algorithm can improve test utilization, diagnosis, and treatment decisions for asymptomatic bacteriuria in pregnancy., Objective: The primary objective of our study was to develop, implement, and evaluate an evidence-based algorithm to guide urinalysis interpretation, culture, diagnosis, and antibiotic stewardship of asymptomatic bacteriuria in pregnant patients during routine obstetric visits., Study Design: The project involves both retrospective and quasi-experimental prospective medical record reviews of pregnant patients aged ≥18 years, beyond 20 weeks of gestation, from routine obstetrical visits with urinalysis dipstick tests. A doctorate in clinical laboratory sciences student developed an educational algorithm to guide urinalysis dipstick interpretation, culturing necessity, and treatment decisions based on evidence-based practice. Our study considered patient records from February 1, 2022, to February 28, 2022, as retrospective (prealgorithm implementation) data and January 24, 2023, to February 22, 2023, as prospective (postalgorithm implementation) data. Data collected from the electronic medical record included deidentified patient information, urinalysis results, culture dates and outcomes, antibiotic prescriptions, urinary tract infection or asymptomatic bacteriuria diagnoses, provider details, adverse pregnancy outcomes, and demographics. Data analysis using SPSS (version 29; SPSS IBM, Armonk, NY) involved chi-square tests, likelihood ratios, and effect size calculations, with P values of <.05 considered statistically significant., Results: This study examined a total of 1176 patient records. Preimplementation data included 440 records, of which 224 were abnormal urinalyses and 216 were normal urinalyses. Postimplementation data included 736 records, of which 255 were abnormal urinalyses and 481 were normal urinalysis. The patient demographics predominantly featured White individuals (87%), with a median maternal age of 27 years and a gestational age of 32 weeks. Our preimplementation analyses revealed significant associations of algorithm deviations with both culture utilization (P<.001) and antibiotic stewardship (P<.001). However, no significant association was observed between algorithm deviations and adverse patient outcomes. Culture underutilization decreased significantly from 43.0% (189/440) before implementation to 29.5% (217/736) after implementation (P<.001). The overall reduction in asymptomatic bacteriuria prevalence from 16.3% (8/49) to 6.7% (10/67) suggests a decrease of nearly 60.0%. In addition, antibiotic overprescription decreased significantly from 1.6% (4/258) before implementation to 0.8% (4/522) after implementation (P=.003), with a reduction from 7.1% (3/42) to 2.4% (1/41) among abnormal urinalyses., Conclusion: Our findings show a strong alignment between the use of the algorithm and subsequent clinical decisions, underscoring its potential to enhance patient care and management in obstetrical settings. Adherence to the algorithm was higher among providers displaying prudent antibiotic use., (Copyright © 2024 Elsevier Inc. All rights reserved.)

A rich body of literature is stressing the crucial importance of migration and market evolution on the underutilization of housing in cities. Rural housing is unique given its less mature market structure. Drawing on an empirical case of Sunan, the work reported in this paper addresses underlying mechanisms of housing land underutilization in rural China. Employing a multi-level modeling approach, results suggest that the likelihood of underutilization relates to household and village features, such as family attributes, housing/parcel characteristics, type of villages, and geographical locations. Additionally, underutilization was also closely associated with regional contexts including local economic development levels and migration patterns. Theoretically, we conceptualized rural housing land underutilization as a land use transition with villagers' awareness of policy change possibilities in the context of both rapid urbanization and rural transformation with nested hybrid results. We argue that urban-rural differences do not induce underutilization. Rather, policy-induced overbuilding of new houses and insistence on retaining uninhabited older houses combined with the tendency for villagers' to view investments as a mechanism to retain ties to their rural hometowns drove underutilizaiton. • We propose a multi-scalar analytical framework on the underutilization of rural housing land. • We identify the nested impacts of factors at different levels on the utility of rural housing land. • The dualistically organized regime is argued as the primary driver of housing land underutilization in rural China. • The transition of rural space from productivism to post-productivism matters as well. [ABSTRACT FROM AUTHOR]

Background: Underutilization of health services among chronic non-communicable disease sufferers, especially for hypertension (HBP) and diabetes mellitus (DM), was considered as a significant contributing factor to substantial cases in terms of both avoidable morbidity and mortality. However, evidence on health services underutilization and its associated factors in poverty-stricken areas remain scarce based on previous literature. This study aims to describe health services underutilization for people diagnosed with chronic diseases in impoverished regions and to identify its associated factors, which are expected to provide practical implications for the implementations of interventions tailored to the specific needs of disadvantaged residents in rural China to achieve effective utilization of health services in a timely manner.Methods: Data were collected from a cross-sectional survey conducted through face-to-face interviews among 2413 patients from six counties in rural central China in 2019. The Anderson behavioral model was adopted to explore the associated factors. A two-level logistic model was employed to investigate the association strengths reflected by adjusted odds ratios (AOR) and 95% confidence intervals in forest plots.Results: On average, 17.58% of the respondents with HBP and 14.87% with DM had experienced health services underutilization during 1 month before the survey. Multilevel logistic regression indicated that predisposing factors (age), enabling factors (income and a regular source of care), and need factors (self-reported health score) were the common predictors of health service underutilization both for hypertensive and diabetic patients in impoverished areas, among which obtaining a regular source of care was found to be relatively determinant as a protective factor for health services underutilization after controlling for other covariates.Conclusions: Our results suggested that the implementation of a series of comprehensive strategies should be addressed throughout policy-making procedures to improve the provision of regular source of care as a significant determinant for reducing health services underutilization, thus ultimately achieving equal utilization of health services in impoverished regions, especially among chronic disease patients. Our findings are expected to provide practical implications for other developing countries confronted with similar challenges resulting from underdeveloped healthcare systems and aging population structures. [ABSTRACT FROM AUTHOR]

Diagnostic Management Teams (DMTs) are one strategy for reducing diagnostic errors. This study examined errors in serology test selection after a positive antinuclear antibody (ANA) test in patients with suspected systemic autoimmune rheumatic disorder (SARD). This retrospective study included 246 patient cases reviewed by our ANA DMT from March to August 2019. The DMT evaluated the appropriateness of tests beyond ANA screening tests (overutilization, underutilization, or both) based on American College of Rheumatology recommendations and classified cases into diagnostic error or no error groups. Errors were quantified, and patient and provider characteristics associated with diagnostic errors were assessed. Among 246 cases, 60.6% had at least one diagnostic error in test selection. The number of sub-serology tests ordered was 2.4 times higher in the diagnostic error group than in the no error group. The likelihood of at least one diagnostic error was higher in males and African American/Black patients, although the differences were not statistically significant. Providers from general internal medicine, primary care, and non-rheumatology specialties were approximately two times more likely to make diagnostic errors than rheumatology specialists. Diagnostic errors in test selection after a positive ANA for patients with suspected SARD were common, although there were fewer errors when ordered by rheumatology specialists. These findings support the need to develop strategies to reduce diagnostic errors in test selection for autoimmunity evaluation and suggest that implementation of a DMT can be useful for providing guidance to clinicians to reduce overutilization and underutilization of laboratory tests. [ABSTRACT FROM AUTHOR]

As globalization advances, the world's international student population has continuously risen. Among this enlarged population, numerous students face adjustment problems after realizing unfamiliarity with the host culture at certain points in their sojourns, which often trigger severe psychological distress. Previous studies conducted in the U.S. university settings have pointed to the underutilization of mental health resources by international students as one of the primary risk factors for the betterment of psychological health. Up to the present, however, there is very limited research carried out in places other than leading countries of North America and the British Commonwealth on the topics of international students' mental health. Different from the predominant research settings of existing research, this article attempts to clarify the distinction in professional help-seeking willingness between Japanese domestic students and international students from other Asian regions who were enrolled in a Japanese university, performing an independent Two-sample Z-test analysis. The result of the findings showed that both Japanese domestic students and Asian international students scored below average in willingness to seek professional help from mental health providers. It also demonstrated that the degrees of local students' help-seeking willingness did not significantly differ from those of international students. Implications, limitations, and recommendations for future research are also discussed. [ABSTRACT FROM AUTHOR]

Abstract Background Evidence is emerging that older women may tolerate breast cancer therapies equally well as the young ones, providing that they receive good supportive care. It has also been reported that these patients remain outside the current therapeutic standards. The aim of this observational study was to assess the access of breast cancer patients to medical procedures. Methods We retrospectively reviewed a database of breast cancer patients registered in the National Cancer Registry in Poland, searching for the numbers of new cases and deaths in the years 2010–2015. We obtained the numbers and costs of key medical procedures provided for these patients from the National Health Fund in Poland. Breast cancer survival in the years 2010–2015 was estimated based on the mortality/incidence ratio. The t-Student test and Spearman correlation coefficient were used for the analysis of data obtained from both databases. Results There was no increase in survival throughout the years 2010–2015 in both analysed subpopulations of all breast cancer patients below and over 65 years of age, despite an unprecedented rise in healthcare funding in Poland. We noted 37% lower probability of 5-year survival in patients older than 65 years. The average number of outpatient visits and surgical procedures per person per year were slightly, yet significantly (p

Abstract Background A variety of antenatal care models have been implemented in low and middle-income countries over the past decades, as proposed by the World Health Organisation (WHO). One such model is the 2001 Focused Antenatal Care (FANC) programme. FANC recommended a minimum of four visits for women with uncomplicated pregnancies and emphasised quality of care to improve both maternal and neonatal outcomes. Malawi adopted FANC in 2003, however, up to now no study has been done to analyse the model’s performance with regards to antenatal care service quality and utilisation patterns. Methods The paper is based on data pooled from three comparable nationally representative Malawi Demographic and Health Survey (MDHS) datasets (2000, 2004 and 2010). The DHS collects data on demographics, socio-economic indicators, antenatal care, and the fertility history of reproductive women aged between 15 and 49. We pooled a sample of 8545 women who had a live birth in the last 5 years prior to each survey. We measure the impact of FANC on early access to care, underutilisation of care and quality of care with interrupted time series analysis. This method enables us to track changes in both levels and the trends of our outcome variables. Results We find that FANC is associated with earlier access to care. However, it has also been associated with unintended increases in underutilisation. We see no change in the quality of ANC services. Conclusion In light of the WHO 2016 ANC guidelines, which recommend an increase of visits to eight, these results are important. Given that we find underutilisation when the benchmark is set at four visits, eight visits are unlikely to be feasible in low-resource settings.

Background: World Health organizations (2001) introduced an antenatal care model called Focused Antenatal Care (FANC) and recommended to have a minimum of four visits. This model is still feasible for low resource setting countries like Ethiopia. Underutilization of the recommended frequency of FANC results to hurt maternal and child health outcomes. Methods: Institutional based cross-sectional study was conducted from August 1 to October 30, 2019, at Debre Markos Referral Hospital, and a total of 358 post-partum mothers were participated in this study. A multivariable binary logistic regression was employed to identify factors associated with underutilization of the recommended frequency of FANC visits. A p-value < 0.05 was a cut-off point to declare statistical significance. Results: The magnitude of the recommended frequency of FANC visits was 55.6%. The high odds of underutilization were observed among mothers who did not watch television [AOR = 3.5; 95% CI (1.25–5.99)], not listing radio [AOR = 4.29; 95% CI (1.67–10.97)], reside far from health facility [AOR = 11.3; 95% CI (4.15–30.90)], and lack companionship/s when visited health facility [AOR = 3.5; 95% CI (1.91–6.50)]. Whereas, mothers age between 20 and 34 years [ AOR = 0.21; 95% CI (0.07–0.67)] and had follow up at private clinic/s [AOR = 0.013; 95% CI (0.001–0.143)] were inversely associated with underutilization. Conclusion: More than half of the total study participants were underutilized the recommended frequency of FANC which was high. Community mobilization through mass media, improve geographical access to the health facility, and improve client-provider relationships could improve FANC utilization.

Background: The failure to order the correct diagnostic test at the right time is one of the major contributing factors of diagnostic error. Excessive testing can lead to added economic burden and addressing underutilization is precarious as clinicians often fail to order the tests that would improve diagnosis, prognosis, and management. Methods: A retrospective analysis of errors in test orders of thyroid function testing (TFT) in 321 pregnant women suspected of clinical and subclinical thyroid disorders was performed. Test selection was evaluated, and determinations were made about the extent of overutilization and underutilization of TFTs in reviewing each individual patient case by a Doctorate in Clinical Laboratory Science (DCLS) scholar. Results: About 77% (247 cases) of the cases were found to have errors associated with test ordering for TFT. Of the cases reviewed, 18% cases were associated with overutilization, 53% of the cases were associated with underutilization, and 7% were associated with both (overutilization and underutilization). The annual cost burden because of ordering unnecessary tests was estimated to be approximately $13,000. The cost burden from errors resulting from not ordering a test would be of much greater magnitude but was difficult to estimate because underutilization has a ripple effect and may cause prolonged hospital stays, unnecessary medical bills, and delayed/missed diagnosis leading to poor outcomes for patients. Conclusions: This study evaluated whether proper utilization of TFT were made at maternal health clinic locations of a large academic medical center in pregnant women to diagnose thyroid disorder and reported the issue of wastage of resources in the clinical laboratory. The study findings show significant errors in ordering of TFT for pregnant women in more than 75% of the cases that was based on evidence-based review of patient cases. [ABSTRACT FROM AUTHOR]

Background: Racial and ethnic disparities in access to hip and knee total joint arthroplasty (TJA) and postoperative outcomes have wide-reaching implications for patients and the health care system. The aim of this study is to evaluate the effect of ethnicity on clinical outcomes and complications following revision hip and knee TJA.Methods: A single-institution, retrospective analysis of a consecutive series of 4424 revision hip and knee TJA patients was evaluated. Student's t-test and chi-squared analysis were used to identify significant differences in patient demographics and clinical outcomes between Caucasians and various ethnic minorities, including African Americans, Hispanics, and Asians.Results: When compared with white patients, African American patients demonstrated a significantly higher BMI (P = .04), ASA score (P = .04), length of hospital stay (P = .06), and postoperative infection rates (P = .04). Hispanics demonstrated a significantly higher BMI (P = .04), when compared with white patients, alongside a significantly higher risk for postoperative infection (P < .01). African American demonstrated a significantly higher ASA score (P = .02; P = .03), when compared with Hispanics and Asians, alongside a significantly increased length of stay (P = .01) and higher risk for postoperative infection (P = .02).Conclusion: The study findings demonstrate an underutilization of revision TJA by ethnic minority groups, suggesting that disparities in access to orthopedic surgery increase from primary to revision surgery despite higher failure rates of minority ethnic groups reported after primary TJA surgery. In addition, inferior postoperative outcomes were associated with African Americans and Hispanics, when compared to white patients, with African Americans demonstrating the highest risk of postoperative complications. [ABSTRACT FROM AUTHOR]

Background: COVID-19 has adversely affected the different aspects of work and society. Due to the decline in economic activity globally, employees were exposed to conditions in which they were forced to work for reduced working hours leading to an increase in time-related underemployment., Objective: The goal of the present study was to determine the extent of time-related underemployment and the rate of unutilized labor resource in the Agro-based Industry., Methodology: This study was conducted with 500 middle-level and lower-level executives working in the Textile Industry and Food and Beverage Industry. Time-related underemployment is defined as a situation in which employees worked for less than 48 hours per week and were available and willing to work for additional hours. It was measured with both objective and subjective measures. Data was analyzed through percentages, mean, t-test, independent t-test, and chi-square., Results: Results showed that Time-related underemployment in the Food and Beverage Industry was 5.00% as compared to the Textile Industry with 3.08%. The majority of employees were moderately underemployed both in the Textile Industry and Food and Beverage Industry. The rate of unutilized labor resource was more in Textile Industry (9.9%) as compared to Food and Beverage Industry (9.2%). However, the difference in both the industries was found to be insignificant (p > 0.05)., Conclusion: COVID-19 has exposed many workers to the disadvantageous position of working fewer hours than the pre-determined threshold hours for full-time work. Therefore, proper strategies need to be adopted to properly use the labor resource of the economy.

(1) Background: The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recommend that every person aged six months and over receive the influenza vaccine every year. Previous studies indicate that rural-area residents have less access to preventative health care services. This study aims to examine the variation in influenza vaccine use among rural and urban counties in Florida. (2) Methods: The study studied 24,116 participants from the Behavioral Risk Factor Surveillance System database. The study included only patients who live in Florida. We performed logistic regression analysis using survey procedures available in SAS®. Our regression model assessed the association between receiving the influenza vaccine and county status, age, income level, education level, and health coverage. We used ArcGIS software to create prevalence and vaccination maps. (3) Results: Of the total number of the study participants, 45.31% were residents of rural counties, and 54.69% were residents of urban counties. The logistic regression model showed no significant association between residing in rural counties and not receiving influenza vaccine in the past year (−0.05560, p-value = 0.0549). However, we found significant associations between not receiving influenza vaccine and age, high education level, and not having health care coverage (−0.0412, p-value < 0.0001; −0.04462, p-value = 0.0139; and 0.4956, p-value < 0.0001, respectively). (4)Conclusions: Our study did not find an association between influenza vaccine use among rural and urban residence. Increasing age, higher education, and having health care insurance had positive associations with influenza vaccine use.

Is it possible for over and under tourism to occur simultaneously at the same destination? This research will show that this paradoxical situation is possible. To illustrate this, the archipelago of Nueva Tabarca, close to the mature tourist area of the Costa Blanca in Alicante (Spain), is studied. In spite of its rich heritage and evident nonseasonal potential, this island enclave presents an uneven tourist use in time and space. This allows us to speak of massiveness and saturation, typical of over-tourism, while at the same time a part of the island space of undoubted quality remains underused throughout the year, and that there is also a calmer tourist consumption, which would allow us to speak of sub-tourism. To demonstrate this, a methodology based on participant observation and semi-structured interviews with social and tourist agents will be used, which will make it possible to contrast the data offered by indirect sources. Far from being a singular case, this study offers an analysis that can be extrapolated to other places and microdestinations, which are visited massively due to their proximity to consolidated tourist areas. [ABSTRACT FROM AUTHOR]

To test whether: (1) psychiatrists will prescribe clozapine more often if they can delegate the monitoring tasks to an advanced nurse practitioner (ANP), (2) clozapine monitoring by an ANP is at least as safe as monitoring by a psychiatrist. Patients from 23 Dutch outpatient teams were assessed for an indication for clozapine. ANPs affiliated to these teams were randomized to Condition A: clozapine monitoring by an ANP, or Condition B: monitoring by the psychiatrist. The safety of monitoring was evaluated by determining whether the weekly neutrophil measurements were performed. Staff and patients were blinded regarding the first hypothesis. Of the 173 patients with an indication for clozapine at baseline, only seven in Condition A and four in Condition B were prescribed clozapine (Odds Ratio = 2.24, 95% CI 0.61–8.21; p = 0.225). These low figures affected the power of this study. When we considered all patients who started with clozapine over the 15-month period (N = 49), the Odds Ratio was 1.90 (95% CI 0.93–3.87; p = 0.078). With regard to the safety of the monitoring of the latter group of patients, 71.2% of the required neutrophil measurements were performed in condition A and 67.3% in condition B (OR = 0.98; CI = 0.16–3.04; p = 0.98). Identifying patients with an indication for clozapine does not automatically lead to improved prescription rates, even when an ANP is available for the monitoring. Clozapine-monitoring performed by an ANP seemed as safe as that by a psychiatrist. [ABSTRACT FROM AUTHOR]

Patients with drug‐resistant epilepsy (DRE) rarely achieve seizure freedom with medical therapy alone. Despite being safe and effective for select patients with DRE, epilepsy surgery remains heavily underutilized. Multiple studies have indicated that the overall rates of surgery in patients with DRE have stagnated in recent years and may be decreasing, even when hospitalizations for epilepsy‐related problems are on the rise. Ultimately, many patients with DRE who might otherwise benefit from surgery continue to have intractable seizures, lacking access to the full spectrum of available treatment options. In this article, we review the various factors accounting for the persistent underutilization of epilepsy surgery and uncover several key themes, including the persistent knowledge gap among physicians in identifying potential surgical candidates, lack of coordinated patient care, patient misconceptions of surgery, and socioeconomic disparities impeding access to care. Moreover, factors such as the cost and complexity of the preoperative evaluation, a lack of federal resource allocation for the research of surgical therapies for epilepsy, and difficulties recruiting patients to clinical trials all contribute to this multifaceted dilemma. [ABSTRACT FROM AUTHOR]

Despite nearly free health services offered by the Universal Coverage Scheme (UCS), the UCS services have been found to be underutilized. Thus, this study, employing the concept of unmet health needs, investigated factors and reasons for the underutilization. Specifically, performing logistic models with the national health survey of 2015, we analyzed who and why did not utilize the UCS services in availability, accessibility, and acceptability perspectives of the services. The study results indicated that among UCS beneficiaries who needed care, about 45% and 7% did not utilize the UCS outpatient and inpatient services, respectively. These non-users had a relatively higher socioeconomic status. Specifically, they were more likely to be high-income, employed, not chronically-ill, or urban people. Availability-related (e.g., long wait-time and unavailability due to emergencies) and acceptability-related reasons (e.g., time constraints and uncertainty of service quality) were major barriers of access to the UCS services. Although the UCS, by this study, was found to work better for socially vulnerable people, there are still concerns that some people, who actually wanted to use the UCS services, might be ultimately forced to use other private services due to such barriers. Particularly, employed people who have time constraints during daytime and people who need inpatient services due to emergencies are our main concerns. In the short term, the public-private partnership should be strengthened to support the urgent needs of emergency cases. In the long term, the expansion of the UCS services boundary should be continued by the National Health Development Plan. [ABSTRACT FROM AUTHOR]

Abstract Background Inhaled corticosteroids (ICSs) are cornerstone therapy for persistent asthma. However, underutilization of ICSs is common and little is known about factors contributing toward this undesirable use. Methods A cross-sectional study was conducted through interview and chart review among persistent asthmatic patients attending chest clinic of Tikur Anbessa Specialized Hospital from 1 May to 31 September 2014. A total of 131 eligible patients who attended the clinic during study period were included in the study. A multivariate logistic regression was used to examine the association between independent and dependent variables. Results Overall, extent of underutilization of ICSs was found to be 68%. Monthly income, comorbidity and types of ICSs products prescribed showed significant association with reported underutilization. Patients’ reported reasons for underutilization includes; unaffordability (44%), using only when symptoms exacerbate (21%), fear of side effects (10%), practitioners’ recommendation (10%) and unavailability of ICSs in the local market (7%). Physicians also stated unaffordability, fear of side effects and dependency, lack of local guideline for asthma management and unavailability of ICSs as the contributing factors. Conclusion In this setting, extent of underutilization of ICSs was found to be high and seems the result of complex interaction of various factors. Financial problem combined with inconsistent availability of ICSs in the local market, patients’ poor knowledge of asthma and ICSs, negative attitude toward ICSs, absence of local guidelines for asthma management are found to be essential elements dictating an extent of ICSs use.

Inappropriate laboratory test selection in the form of overutilization as well as underutilization frequently occurs despite available guidelines. There is broad approval among laboratory specialists as well as clinicians that demand management strategies are useful tools to avoid this issue. Most of these tools are based on automated algorithms or other types of machine learning. This review summarizes the available demand management strategies that may be adopted to local settings. We believe that artificial intelligence may help to further improve these available tools.

Per American Brachytherapy Society guidelines, cT1-2N0 penile cancers <4 cm in diameter are excellent candidates for curative brachytherapy. Using that criterion, we evaluated national patterns of care and predictors of use of radiation techniques using the National Cancer Database. The National Cancer Database was queried for men with cT1-2N0 penile cancers <4 cm in size. Comparative statistics for treatment modality were generated using bivariate logistic regression analysis. Among 1235 cases eligible for analysis, median age was 69 years. Median tumor size was 2.0 cm. 95.8% of men underwent surgery alone, with 91 (7.4%) undergoing radical penectomy, 673 (54.5%) partial penectomy, and 419 (33.9%) cosmesis-preserving surgical procedure. Only 4 (0.3%) men were treated with brachytherapy alone, 48 (3.9%) with external-beam radiation therapy (EBRT) alone, and 8 (0.6%) with EBRT after surgery. Surgical margins were positive in 118 (9.6%) patients, 14 of whom received adjuvant EBRT (11.9%) and two adjuvant brachytherapy (1.7%). There was no difference in demographic or clinical characteristics in groups treated with surgery vs. radiation (all p > 0.2). Age >70, lesions >2 cm, and T2 tumors were more likely to undergo non–organ-preserving therapy vs. radiation or a cosmesis-preserving procedure (all p < 0.05). The propensity-matched 5-year survival was not different between definitive radiation vs. surgery (61.6% vs. 62.2%, p = 0.70). Men with penile-preserving eligible lesions in the United States are overwhelmingly treated with surgery. Penile-preserving radiation techniques including brachytherapy and EBRT are underutilized and should be offered as curative interventions. [ABSTRACT FROM AUTHOR]

Purpose: This survey was performed to determine the availability of epilepsy surgery, and understand the limiting factors to epilepsy surgery in ASEAN countries with total of 640 million population.Method: A cross-sectional survey was completed by national representatives in all ASEAN countries (Brunei, Cambodia, East Timor, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand, and Vietnam).Results: Overall facilities for initial epilepsy pre-surgical evaluation are available in most countries, but further non-invasive and invasive investigations are limited. Three countries (Brunei, Cambodia, and East Timor) have no epilepsy center, and 2 countries (Laos, Myanmar) have level 2 centers doing tumor surgery only. Level-3 epilepsy centers are available in 6 countries (Indonesia, Malaysia, Philippine, Singapore, Thailand, Vietnam); only 5 countries (Indonesia, Malaysia, Philippine, Singapore, Thailand) has at least one level-4 epilepsy care facility. Indonesia with 261 million population only has one level 3 and another level 4 center. The costs of presurgical evaluation and brain surgery vary within and among the countries. The main barriers towards epilepsy surgery in ASEAN include lack of expertise, funding and facilities.Conclusions: Epilepsy surgery is underutilized in ASEAN with low number of level 3 centers, and limited availability of advanced presurgical evaluation. Lack of expertise, facilities and funding may be the key factors contributing to the underutilization. [ABSTRACT FROM AUTHOR]

The dramatic growth of HTTP adaptive streaming (HAS) traffic represents a practical challenge for service providers in satisfying the demand from their customers. Achieving this in a network where multiple players share the network capacity has so far proved hard because of the bandwidth competition among the HAS players. This competition is exacerbated by the bandwidth overestimation that is introduced due to the isolated and selfish behavior of theHAS players. Each player strives individually to select themaximum bitratewithout considering the co-existing players or network resource dynamics. As a result, the HAS players suffer from video quality instability, quality unfairness, and network underutilization or oversubscription, and the players observe a poor quality of experience (QoE). To address this issue, we propose a fully distributed game theory and consensus-based collaborative adaptive bitrate solution for shared network environments, termed Game Theory and consensus-based Approach for Cooperative HAS delivery systems (GTAC). Our solution consists of two-stage games that run in parallel during a streaming session.We extensively evaluate GTAC on a broad set of trace-driven and real-world experiments. Results show that GTAC enhances the viewer QoE by up to 22%, presentation quality stability by up to 24%, fairness by at least 31%, and network utilization by 28% compared to the well-known schemes. [ABSTRACT FROM AUTHOR]

Background: Guidelines recommend neoadjuvant therapy (NT) for clinical stage II-III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood.Methods: The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010-2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I-III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes.Results: Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1-98.0%), facility NT rates varied twofold (43.9-95.9%), and they were correlated (r = 0.58; P < 0.001). Local staging omission and NT omission were independently associated with positive margins and decreased OS.Conclusions: Local staging omission is a common care process in over half of cases of omitted NT. These data emphasize the need for quality improvement efforts directed at providing facilities feedback about their local staging rates. [ABSTRACT FROM AUTHOR]