Implementing a virtual emergency department to avoid unnecessary emergency department presentations.

OBJECTIVE: EDs are necessary for urgent health concerns; however, many physical ED visits could be better treated in alternate settings. The present study aimed to describe the feasibility, acceptability and effectiveness of a Virtual ED to reduce unnecessary physical ED presentations at a large tertiary health service in Australia. METHODS: This observational study using the RE-AIM framework (Reach, Efficacy, Adoption, Implementation and Maintenance) evaluated the feasibility of a Virtual ED using routinely collected health service data and process-evaluation to assess intervention fidelity and adherence between April 2020 and 31 March 2022. The primary outcome for the present study was the feasibility of the Virtual ED model of care. RESULTS: The Virtual ED received 2080 direct calls for patients with a mean age of 50.3 years, with 70.4% managed in the Virtual ED alone and 29.6% referred for physical ED presentation. Of the 2080 direct referrals, 95.8% were potentially avoidable ED presentations. Of those referred, 28.3% required an admission. Of calls managed entirely by Virtual ED, 18 (1.2%) unexpectedly required a hospital admission within 48 h. General practitioner respondents rated the Virtual ED service as helpful to very helpful. The service had an average of 212 referrals per month, with a 65.2% average growth rate. The Virtual ED service was considered helpful and clinically appropriate, with a high level of ED avoidance. CONCLUSION: The Virtual ED prevented 70% of community triaged patients from presenting to the physical ED, with good uptake from all referrers, supporting the use of virtual care pathways in emergency care management.

Utility and costs of surveillance imaging for low- and very low-risk gastrointestinal stromal tumors.

BACKGROUND: There is limited evidence on the optimal surveillance approach in patients with low- and very low-risk gastrointestinal stromal tumors, resulting in inconsistent and arbitrary approaches to surveillance in this population. In this study, we reviewed our institutional approach to surveillance in patients with low- and very low-risk gastrointestinal stromal tumors and the costs associated with detecting recurrence. METHODS: We retrospectively reviewed consecutive adult patients treated for low- and very low-risk gastrointestinal stromal tumors at our institution from 2010 to 2019. Data collected included patient and tumor characteristics, surgical management, and postoperative follow-up. Surveillance-related expenses were calculated using estimates of average costs obtained from our institution. A cost analysis was performed to evaluate estimated yearly costs based on the surveillance strategy used. RESULTS: There were 60 patients included. The mean age at diagnosis was 63.9 (±12.5) years. The primary tumor was typically in the stomach (73%; n = 44). Computed tomography scan of the abdomen and pelvis with intravenous contrast was the most common surveillance modality (total = 226 scans). No recurrences were identified. Median follow-up duration was 49.0 (interquartile range = 19.5-61.5) months. The mean number of surveillance images per patient was 4 (±2.6). Surveillance imaging was obtained more frequently than just annually in 83% (n = 50) of patients, with an estimated yearly cost of $2,840.77 (interquartile range = $2,273.62-$3,895.92) and no detection of recurrence. CONCLUSION: In this study population, patients with low- and very low-risk gastrointestinal stromal tumors underwent frequent imaging studies for surveillance with little yield and at substantial cost. Further multi-institutional studies on practice patterns and outcomes of surveillance are warranted to better inform standardized surveillance recommendations.

An Organizational Commitment to Diversity, Equity, Inclusion, and Justice: A Multipronged Strategic Approach.

Cedars-Sinai is a sixth continuous Magnet organization in Southern California that embodies inclusive leadership in support of diversity, equity, inclusion, and justice (DEIJ) principles. The organization adheres to a strategic model prioritizing staff sense of belonging, empowerment, engagement, curiosity, and creativity. Employing inclusive leadership, we have implemented strong programs of professional development and continuous learning, innovation, and research. This leadership and these programs have fostered a culture of inquiry, support evidence-driven practice, quality improvement, and staff engagement. Our organization is committed to creating a caring and healing environment that promotes performance. We believe in practicing loving-kindness toward ourselves and others as a core value. Executive leadership support has been a key element in our successful implementation of DEIJ strategies, including employee resource groups, Shared Leadership Councils, transition to practice programs, health equity research, and innovative solutions. These strategies have been shown to yield a significant return on investment.

Surgeon Burnout and Usage of Personal Communication Devices: Examining the Technology "Empowerment/Enslavement Paradox".

INTRODUCTION: Access to patients' electronic medical records (EMRs) on personal communication devices (PCDs) is beneficial but can negatively impact surgeons. In a recent op-ed, Cohen et al. explored this technology "empowerment/enslavement paradox" and its potential effect on surgeon burnout. We examined if there is a relationship between accessing EMRs on PCDs and surgeon burnout. METHODS: This was a cohort study with retrospective and prospective arms. Trainees and attendings with a background in general surgery completed the Maslach Burnout Index for Medical Personnel, a validated survey scored on three areas of burnout (emotional exhaustion, depersonalization, and low personal accomplishment). Data on login frequency to EMRs on PCDs over the previous 6 mo were obtained. Pearson correlation coefficients were calculated to determine if burnout and login frequency were associated. RESULTS: There were 52 participants included. Residents were 61.5% (n = 32) of participants. The mean login frequency over 6 mo was 431.0 ± 323.9. The mean scores (out of 6) for emotional exhaustion, depersonalization, and personal accomplishment were 2.3 ± 1.1, 1.9 ± 1.2, and 4.9 ± 0.8, respectively. There was no correlation between burnout and logins. Residents had higher median depersonalization scores (2.3 versus 1.2, P = 0.03) and total logins (417.5 versus 210.0, P < 0.001) than attendings. Participants who overestimated logins had higher median emotional exhaustion and depersonalization scores than those who underestimated (2.6 versus 1.4, P = 0.03, and 2.4 versus 0.8, P = 0.003, respectively). CONCLUSIONS: Using EMRs on PCDs is common, but frequency of logins did not correlate with burnout scores in this study. However, perception of increased workload may contribute to experiencing burnout.

The Challenge of Advancing Health Equity During a Year of Pandemic and Crisis: Our Organization's Response.

Since its inception, Cedars-Sinai Health System has led with compassion to embody the principles of health equity and the fight against prejudice and racism. Founded in 1902 as Los Angeles' first Jewish hospital, Cedars-Sinai through the years has continued to serve the most vulnerable, disadvantaged, and marginalized communities. In this article, we share a part of our current journey toward advancing health equity during a challenging year of pandemic and crisis (2020-2021).

A Study to Evaluate the Need for Comminution in the Preparation of Food Materials for Testing of Listeria monocytogenes, Staphylococcus Species, and Generic Escherichia coli.

BACKGROUND: Comminution reduces the sampling error arising from distributional heterogeneity of the target contaminant/target analyte in the material, facilitating the selection of a more representative test portion. A laboratory sampling method incorporating comminution prior to selection of the test portion (Sampling Method B) was compared to current sampling methods that used no comminution step (Sampling Method A). OBJECTIVE: This required the development of an efficient process for comminution of food samples prior to removal of the test portion for the detection and isolation of Listeria monocytogenes and the enumeration of Staphylococcus species and Escherichia coli. METHOD: From December 2016 to December 2017, 2742 tests were conducted on 778 unique food samples. For all food samples, a test portion (TPA) was first removed using Sampling Method A, and then the remainder of the material was comminuted and a second test portion (TPB) was removed using Sampling Method B and tested alongside the first portion. RESULTS: Across all food matrices and microbial targets, 17 additional targets were detected using only Sampling Method B, and positive detections of target analytes increased by 77% using Sampling Method B from the test portions taken using Sampling Method A. CONCLUSION: Utilizing a sample preparation method that includes a comminution step resulted in an increased number of pathogen detections. HIGHLIGHTS: The introduction of a comminution step in the preparation of food samples for detection of three common microbial contaminants resulted in an increase in the rate of detection of natural contaminates in a variety of ready to eat foods. An efficient aseptic process for commutation that can be adapted to a wide range of laboratory settings was identified.

Using parallelized incremental meta-docking can solve the conformational sampling issue when docking large ligands to proteins.

BACKGROUND: Docking large ligands, and especially peptides, to protein receptors is still considered a challenge in computational structural biology. Besides the issue of accurately scoring the binding modes of a protein-ligand complex produced by a molecular docking tool, the conformational sampling of a large ligand is also often considered a challenge because of its underlying combinatorial complexity. In this study, we evaluate the impact of using parallelized and incremental paradigms on the accuracy and performance of conformational sampling when docking large ligands. We use five datasets of protein-ligand complexes involving ligands that could not be accurately docked by classical protein-ligand docking tools in previous similar studies. RESULTS: Our computational evaluation shows that simply increasing the amount of conformational sampling performed by a protein-ligand docking tool, such as Vina, by running it for longer is rarely beneficial. Instead, it is more efficient and advantageous to run several short instances of this docking tool in parallel and group their results together, in a straightforward parallelized docking protocol. Even greater accuracy and efficiency are achieved by our parallelized incremental meta-docking tool, DINC, showing the additional benefits of its incremental paradigm. Using DINC, we could accurately reproduce the vast majority of the protein-ligand complexes we considered. CONCLUSIONS: Our study suggests that, even when trying to dock large ligands to proteins, the conformational sampling of the ligand should no longer be considered an issue, as simple docking protocols using existing tools can solve it. Therefore, scoring should currently be regarded as the biggest unmet challenge in molecular docking.

Exposure to aflatoxin and fumonisin in children at risk for growth impairment in rural Tanzania.

Growth impairment is a major public health issue for children in Tanzania. The question remains as to whether dietary mycotoxins play a role in compromising children's growth. We examined children's exposures to dietary aflatoxin and fumonisin and potential impacts on growth in 114 children under 36 months of age in Haydom, Tanzania. Plasma samples collected from the children at 24 months of age (N = 60) were analyzed for aflatoxin B1-lysine (AFB1-lys) adducts, and urine samples collected between 24 and 36 months of age (N = 94) were analyzed for urinary fumonisin B1 (UFB1). Anthropometric, socioeconomic, and nutritional parameters were measured and growth parameter z-scores were calculated for each child. Seventy-two percent of the children had detectable levels of AFB1-lys, with a mean level of 5.1 (95% CI: 3.5, 6.6) pg/mg albumin; and 80% had detectable levels of UFB1, with a mean of 1.3 (95% CI: 0.8, 1.8) ng/ml. This cohort had a 75% stunting rate [height-for-age z-scores (HAZ) < -2] for children at 36 months. No associations were found between aflatoxin exposures and growth impairment as measured by stunting, underweight [weight-for-age z-scores (WAZ) < -2], or wasting [weight-for-height z-scores (WHZ) < -2]. However, fumonisin exposure was negatively associated with underweight (with non-detectable samples included, p = 0.0285; non-detectable samples excluded, p = 0.005) in this cohort of children. Relatively low aflatoxin exposure at 24 months was not linked with growth impairment, while fumonisin exposure at 24-36 months based on the UFB1 biomarkers may contribute to the high growth impairment rate among children of Haydom, Tanzania; which may be associated with their breast feeding and weaning practices.

Aflatoxin exposure during the first 36 months of life was not associated with impaired growth in Nepalese children: An extension of the MAL-ED study.

Exposure to aflatoxin, a mycotoxin common in many foods, has been associated with child growth impairment in sub-Saharan Africa. To improve our understanding of growth impairment in relation to aflatoxin and other risk factors, we assessed biospecimens collected in Nepalese children at 15, 24, and 36 months of age for aflatoxin exposure. Children (N = 85) enrolled in the Bhaktapur, Nepal MAL-ED study encompassed the cohort analysed in this study. Exposure was assessed through a plasma biomarker of aflatoxin exposure: the AFB1-lysine adduct. The aflatoxin exposures in the study participants were compared to anthropometrics at each time period (length-for-age [LAZ], weight-for-age [WAZ], and weight-for-length [WLZ] z-scores), growth trajectories over time, age, and breastfeeding status. Results demonstrated chronic aflatoxin exposure in this cohort of children, with a geometric mean of 3.62 pg AFB1-lysine/mg albumin. However, the chronic aflatoxin exposure in this cohort was not significantly associated with anthropometric z-scores, growth trajectories, age, or feeding status, based on the available time points to assess aflatoxin exposure. Low mean levels of aflatoxin exposure and infrequent occurrence of stunting, wasting, or underweight z-score values in this cohort are possible contributing factors to a lack of evidence for an association. Further research is needed to examine whether a threshold dose of aflatoxin exists that could induce child growth impairment.

A risk assessment of dietary Ochratoxin a in the United States.

Ochratoxin A (OTA) is a mycotoxin (fungal toxin) found in multiple foodstuffs. Because OTA has been shown to cause kidney disease in multiple animal models, several governmental bodies around the world have set maximum allowable levels of OTA in different foods and beverages. In this study, we conducted the first exposure and risk assessment study of OTA for the United States' population. A variety of commodities from grocery stores across the US were sampled for OTA over a 2-year period. OTA exposure was calculated from the OTA concentrations in foodstuffs and consumption data for different age ranges. We calculated the margin of safety (MOS) for individual age groups across all commodities of interest. Most food and beverage samples were found to have non-detectable OTA; however, some samples of dried fruits, breakfast cereals, infant cereals, and cocoa had detectable OTA. The lifetime MOS in the US population within the upper 95% of consumers of all possible commodities was >1, indicating negligible risk. In the US, OTA exposure is highest in infants and young children who consume large amounts of oat-based cereals. Even without OTA standards in the US, exposures would not be associated with significant risk of adverse effects.

Chronic aflatoxin exposure in children living in Bhaktapur, Nepal: Extension of the MAL-ED study.

Exposure to aflatoxin, a mycotoxin common in maize and groundnuts, has been associated with childhood stunting in sub-Saharan Africa. In an effort to further our understanding of growth impairment in relation to mycotoxins and other risk factors, biospecimens from a cohort of children enrolled in the Bhaktapur, Nepal MAL-ED study were assessed for aflatoxin exposure at 15, 24, and 36 months of age. Exposure was assessed through a well-established serum biomarker, the AFB1-lysine adduct. In this manuscript, the levels of aflatoxin exposure in the Nepal cohort were compared with those observed in aflatoxin studies, with child growth parameters as a health outcome. Results from this preliminary analysis demonstrated chronic aflatoxin exposure in children residing in Bhaktapur with a geometric mean of 3.62 pg AFB1-lysine/mg albumin. The range of exposure in this population is similar to those in African populations where associations with aflatoxin biomarkers and poor child growth have been observed. Future work will analyze the relationships between aflatoxin levels, growth, and other risk factors collected by the MAL-ED study.

Sequential dietary exposure to aflatoxin B1 and fumonisin B1 in F344 rats increases liver preneoplastic changes indicative of a synergistic interaction.

Dietary co-exposure to aflatoxin B1 (AFB1) and fumonisin B1 (FB1) and their interaction on hepatocellular carcinogenesis is of particular concern in toxicology and public health. In this study we evaluated the liver preneoplastic effects of single and sequential dietary exposure to AFB1 and FB1 in the F344 rat carcinogenesis model. Serum biochemical alterations, liver histopathological changes, and the formation of liver glutathione S transferase positive (GST-P+) foci were the major outcome parameters examined. Compared to the AFB1-only treatment, the FB1-only treatment induced less dysplasia, and more apoptosis and mitoses. Sequential AFB1 and FB1 treatment lead to increased numbers of dysplasia, apoptosis and foci of altered hepatocytes, as compared to either mycotoxin treatment alone. More importantly, sequential exposure to AFB1 and FB1 synergistically increased the numbers of liver GTP-P+ foci by approximately 7.3-and 12.9-fold and increased the mean sizes of GST-P+ foci by 6- and 7.5-fold, respectively, as compared to AFB1- or FB1-only treatment groups. In addition, liver ALT and AST levels were significantly increased after sequential treatment as compared to single treatment groups. The results demonstrate the interactive effect of dietary AFB1 and FB1 in inducing liver GST-P+ foci formation and provide information to model future intervention studies.

Modeling the emetic potencies of food-borne trichothecenes by benchmark dose methodology.

Trichothecene mycotoxins commonly co-contaminate cereal products. They cause immunosuppression, anorexia, and emesis in multiple species. Dietary exposure to such toxins often occurs in mixtures. Hence, if it were possible to determine their relative toxicities and assign toxic equivalency factors (TEFs) to each trichothecene, risk management and regulation of these mycotoxins could become more comprehensive and simple. We used a mink emesis model to compare the toxicities of deoxynivalenol, 3-acetyldeoxynivalenol, 15-acetyldeoxynivalenol, nivalenol, fusarenon-X, HT-2 toxin, and T-2 toxin. These toxins were administered to mink via gavage and intraperitoneal injection. The United States Environmental Protection Agency (EPA) benchmark dose software was used to determine benchmark doses for each trichothecene. The relative potencies of each of these toxins were calculated as the ratios of their benchmark doses to that of DON. Our results showed that mink were more sensitive to orally administered toxins than to toxins administered by IP. T-2 and HT-2 toxins caused the greatest emetic responses, followed by FX, and then by DON, its acetylated derivatives, and NIV. Although these results provide key information on comparative toxicities, there is still a need for more animal based studies focusing on various endpoints and combined effects of trichothecenes before TEFs can be established.

Potential economic losses to the US corn industry from aflatoxin contamination.

Mycotoxins, toxins produced by fungi that colonise food crops, can pose a heavy economic burden to the US corn industry. In terms of economic burden, aflatoxins are the most problematic mycotoxins in US agriculture. Estimates of their market impacts are important in determining the benefits of implementing mitigation strategies within the US corn industry, and the value of strategies to mitigate mycotoxin problems. Additionally, climate change may cause increases in aflatoxin contamination in corn, greatly affecting the economy of the US Midwest and all sectors in the United States and worldwide that rely upon its corn production. We propose two separate models for estimating the potential market loss to the corn industry from aflatoxin contamination, in the case of potential near-future climate scenarios (based on aflatoxin levels in Midwest corn in warm summers in the last decade). One model uses the probability of acceptance based on operating characteristic (OC) curves for aflatoxin sampling and testing, while the other employs partial equilibrium economic analysis, assuming no Type 1 or Type 2 errors, to estimate losses due to proportions of lots above the US Food and Drug Administration (USFDA) aflatoxin action levels. We estimate that aflatoxin contamination could cause losses to the corn industry ranging from US$52.1 million to US$1.68 billion annually in the United States, if climate change causes more regular aflatoxin contamination in the Corn Belt as was experienced in years such as 2012. The wide range represents the natural variability in aflatoxin contamination from year to year in US corn, with higher losses representative of warmer years.

Short-term safety and efficacy of calcium montmorillonite clay (UPSN) in children.

Recently, an association between childhood growth stunting and aflatoxin (AF) exposure has been identified. In Ghana, homemade nutritional supplements often consist of AF-prone commodities. In this study, children were enrolled in a clinical intervention trial to determine the safety and efficacy of Uniform Particle Size NovaSil (UPSN), a refined calcium montmorillonite known to be safe in adults. Participants ingested 0.75 or 1.5 g UPSN or 1.5 g calcium carbonate placebo per day for 14 days. Hematological and serum biochemistry parameters in the UPSN groups were not significantly different from the placebo-controlled group. Importantly, there were no adverse events attributable to UPSN treatment. A significant reduction in urinary metabolite (AFM1) was observed in the high-dose group compared with placebo. Results indicate that UPSN is safe for children at doses up to 1.5 g/day for a period of 2 weeks and can reduce exposure to AFs, resulting in increased quality and efficacy of contaminated foods.