[Restoration of the labial barcode by simultaneous "one shot" injection of botulinum toxin-hyaluronic acid in the same syringe]. / Restauration du code barre labial par injection simultanée « one shot ¼ toxine botulique-acide hyaluronique dans une même seringue.

The purpose of this technique is to offer patients wishing a labial restoration without morphological changes a simple, fast, discreet, comfortable, adaptable and reversible method by combining the two compounds most used in aesthetic medicine, botulinum toxin and hyaluronic acid. The originality of this combination is based on their mixing in the same syringe and their injection with cannula through a paracommissural approach which makes it possible to treat the entire upper lip in a very homogeneous manner. Botulinum toxin diffuses directly into the underlying muscle layer; hyaluronic acid allows to unfold the damaged cutaneous fan. The useful reciprocal dose of the two products remains intuitive; for starting barcodes the dose of botulinum toxin will be 8-10 Speywood units (4 Allergan units), for those already marked at rest 10-20 Speywood units (4-8 Allergan units); the hyaluronic acid will be chosen according to the depth of the wrinkles. We present a series of 63 patients with an average age of 67 years with a result deemed positive in 79% of cases. The incidents reported are generally due to excessive doses of botulinum toxin which can lead to the classic incidents of fluid leaks in this location (6%). The expected efficacy of the treatment depends on that of the components used (four to six months) but prolonged results have been regularly observed (up to 18 months). All complementary resurfacing treatments have been discarded here since the aim pursued is that of a natural labial restoration allowing an immediate return to socio-professional activities.

Preparation of informative wafers (info-wafers) by combination of 3D printing, code design and photopolymerization.

3D printing is used in manufacturing of personalized and customized medications. Moreover, information technology has been integrated with 3D printing, which builds the basis of informative medications. Here, clonidine hydrochloride (CH) was formulated in informative wafers (info-wafers) by combination of 3D printing, code design and photopolymerization. Braille code (recognized by blind persons), bar code, and quick response (QR) code were used for the design of info-wafers. A code positive mold was 3D-printed with rigid resins by stereolithography, which was transformed to the silicone negative mold by thermal polymerization. A homogeneous CH suspension in N-vinyl pyrrolidone was casted into the negative mold followed by photopolymerization to form CH info-wafers. The bulgy parts of info-wafers were painted with edible ink except for Braille code info-wafers. The CH in info-wafers maintained the amorphous state, which was demonstrated by X-ray diffraction. The amorphous CH had rapid dissolution. Bar code info-wafers were scanned by smartphone though only simple information was obtained. QR code info-wafers were smartphone-scanned to link a website that contained sufficient information such as the instruction of CH application and the collection of patient information. Info-wafers provide online drug information and use instructions for patients to make the treatment standardization and normalization.

Analytical and clinical performance of different platforms simultaneously detecting 15 antinuclear antibodies.

BACKGROUND: Antinuclear antibodies (ANAs) are invaluable biomarkers for the diagnosis of autoimmune diseases (AIDs). This study aims to compare the performances of line immunoassay (LIA), multiplex bead-based flow fluorescent immunoassay (MBFFI), and magnetic bar code immunofluorescence assay (MBC-IF) to detect ANA-Profile-15S. METHODS: In total, 184 samples from AID patients and 50 healthy controls (HCs) were collected. Fifteen ANAs (anti-dsDNA, nucleosome, histone, Sm, PCNA, ribosomal-P, SS-A/Ro52, SS-A/Ro60, SS-B/La, centromere B [CENP-B], Scl-70, U1-snRNP, AMA-M2, Jo-1, and Pm/Scl) were subjected to parallel detection by the LIA, MBFFI, and MBC-IF. The consistency between assays was analyzed. The discrepant results were further examined by chemiluminescent immunoassay (CLIA). RESULTS: Anti-SS-A/Ro52 and SS-A/Ro60 autoantibodies were the most common autoantibodies in ANA positive-profiles, and were detected with equal efficiency by the LIA, MBFFI, and MBC-IF (p = 0.101 and p = 0.732, respectively). The three assays showed excellent agreement (consistency range: 66.5%-97.5%), and total consistency was 85.8%. The MBFFI and MBC-IF assays were in good agreement in terms of ANA-Profile-15S determination; the kappa coefficient ranged from 0.59 to 0.95, except for the PCNA and PM-Scl. Of the 262 re-assessed divergent results, 124 (47.33%) were positive on CLIA; the various autoantibodies exhibited variable patterns. More importantly, the ANA-Profile-15S results of the MBFFI and MBC-IF accurately identified patients with AID; the area under the curves ranged from 0.642 to 0.919. CONCLUSIONS: The novel MBFFI and MBC-IF assay performed well in detecting ANA-Profile-15S. The application of MBFFI and MBC-IF play important roles in laboratory diagnosis of AIDs.

QR code model: a new possibility for GPCR phosphorylation recognition.

G protein-coupled receptors (GPCRs) are the largest family of membrane proteins in the human body and are responsible for accurately transmitting extracellular information to cells. Arrestin is an important member of the GPCR signaling pathway. The main function of arrestin is to assist receptor desensitization, endocytosis and signal transduction. In these processes, the recognition and binding of arrestin to phosphorylated GPCRs is fundamental. However, the mechanism by which arrestin recognizes phosphorylated GPCRs is not fully understood. The GPCR phosphorylation recognition "bar code model" and "flute" model describe the basic process of receptor phosphorylation recognition in terms of receptor phosphorylation sites, arrestin structural changes and downstream signaling. These two models suggest that GPCR phosphorylation recognition is a process involving multiple factors. This process can be described by a "QR code" model in which ligands, GPCRs, G protein-coupled receptor kinase, arrestin, and phosphorylation sites work together to determine the biological functions of phosphorylated receptors. Video Abstract.

Typing of alpha and beta coronaviruses by DNA barcoding of NSP12 gene.

Since the spread of the COVID-19 pandemic, the world paid attention to coronaviruses (CoVs) evolution and their diverged lineages because many researches studies supposed that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is evolutionarily developed from a lineage of bats CoVs. This is due to the ability of some mutant CoVs to transmit from a host to different hosts. For this reason, there are many fears about the pathogenicity of the upcoming variants of CoVs. Thus, it is important to get a rapid and economic technique for typing a wide range of human and animal CoVs species for following up their mutant transmission. Therefore, the present study aims at approaching a simple design of DNA barcoding of a wide range of mammals' CoVs (including alpha and beta CoVs), by universal amplification of a species-specific sequence inside a conserved gene (NSP12) followed by amplicon sequencing. The in silico evaluation involved 96 nucleotide sequences of different CoVs (18 alpha CoVs and 78 beta CoVs), and was applied experimentally into the lab on 5 human CoVs isolates; 3 of them belong to beta CoVs (OC43, MERS, and SARS-CoV-2) and 2 are alpha CoVs (229E and NL63). The results indicated that the designed universal primers are able to amplify 332 bp of a taxonomic region inside the NSP12 coding sequence that facilitates the identification and classification of mammals' CoVs upon the resulting phylogenetic tree.

Nutrition Support Therapies on the Medication Administration Record: Impacts on Staff Perception of Nutrition Care.

BACKGROUND: It has been reported that many hospitals in the United States have fragmented and ineffective ordering, administration, documentation, and evaluation/monitoring of nutrition therapies. This paper reports on a project to investigate if perceived hospital staff awareness and documentation of nutrition support therapies (NSTs) improves by including them as part of the medication administration record (MAR). METHODS: Surveys were conducted with nursing staff, physicians, and dietitians before and after adding NSTs to the MAR to evaluate the perceived impact on the outcome of interest. The outcomes of interest include nurses' perception of ease of finding information, awareness of an order, and ability to assess administration and documentation and dietitian, nurse, and physician staff perceptions of impact of intervention on aspects of the nutrition care process. RESULTS: After adding NST to the MAR, nursing staff perceived improvement in knowing that their patient had an oral nutritional supplement (ONS) order (P = .01), when and how much product was last administered (P = .01), and documentation of the type of product consumed (P = .01) and volume of product consumed (P = .01). The majority of dietitian and nurses surveyed reported perceived improvement in placing and finding ONS orders, in administration of ONS, in ability to evaluate patient nutrition status, and in ONS intake and a positive impact on clinical practice. CONCLUSION: Inclusion of NST in the MAR presents an innovative solution to enhance staff awareness of ordered therapies and perception of improved documentation of nutrition interventions for hospitalized patients.

A new Eumerus hoverfly (Diptera: Syrphidae) from Namibia and South Africa, with notes on similar species.

Within the pollinator family Syrphidae, Eumerus Meigen, 1822 is a diverse genus with over 70 species recorded in the Afrotropical Region. A new species is described here from Namibia and South Africa. Adults are small to medium size flies, with spur-like expansions in the metatarsomeres 2 and 3. DNA sequences of the Cytochrome c oxidase subunit I (COI) gene were obtained from Namibian specimens. This is only the second Eumerus species documented from Namibia, where it was recorded from The National Botanic Garden, Windhoek. The new species is compared with similar species such as Eumerus vestitus Bezzi, 1912, for which a lectotype is designated. In addition, a new and preliminary morphological concept of the Eumerus obliquus group is proposed and a key to its African species is provided.

Identificación molecular de Dípteros de importancia forense con el gen (COI Barcode), La Paz Bolivia / Molecular identification of Diptera of forensic importance with the gene (COI Barcode), La Paz Bolivia

Resumen Una de las dificultades encontradas es la correcta identificación de insectos asociados a la descomposición cadavérica, por la cual ha llevado a buscar y generar nuevas herramientas en biología molecular que facilitan la determinación de especímenes para la estimación del Intervalo Post-Mortem de una forma efectiva y certera a partir de estadios inmaduros; la colecta y taxonomía morfológica de Dípteros se realizaron en primera instancia y posteriormente se utilizó el sistema de Códigos de Barras (COI Barcode) para la identificación molecular de insectos problema por medio del gen mitocondrial COI en cualquier fase del ciclo biológico. Identificando tres especies de adultos con una probabilidad de correspondencia del 100%; los especímenes: Sarconesia versicolor de la Familia Calliphoridae y Fannia sp., no fueron hallados en las bases de datos mundiales del GenBank y del Boldsystems, siendo necesario su actualización realizando patrones de sucesión cronológica de fauna cadavérica en diferentes zonas geográficas, cuya práctica se aplicaría en las investigaciones criminales.

Abstract One of the difficulties encountered is the correct identification of insects associated with cadaveric decomposition, which has led to the search and generation of new tools in molecular biology that facilitate the determination of specificities for the modification of the Post-Mortem Interval in an effective and accurate from immature stages; the collection and morphological taxonomy of Diptera were made in the first instance and then the Bar Code System (COI Barcode) was used for the molecular identification of problem insects by means of the mitochondrial COI gene in any phase of the biological cycle. Identifying three species of adults with a probability of 100% correspondence; the specimens: Sarconesia versicolor of the Calliphoridae Family and Fannia sp., were not found in the world databases of the GenBank and the Boldsystems, being necessary to update them by chronological succession patterns of cadaveric fauna in different geographical areas, whose practice would be applied in criminal investigations.

The Effect of Implementing Bar-Code Medication Administration in an Emergency Department on Medication Administration Errors and Nursing Satisfaction.

INTRODUCTION: Bar-code medication administration has been shown to reduce medication errors in inpatient settings with limited studies on its use in emergency departments. In addition, no studies have evaluated nursing satisfaction with implementing bar-code medication administration in an emergency department. This study was designed to determine the impact of implementing bar-code medication administration in an emergency department on medication errors and nursing satisfaction. METHODS: This is a before-and-after study, with no control group, of a bar-code medication administration intervention conducted in a community hospital emergency department. Direct observation was used to compare medication error rates before and 3 months after implementing bar-code medication administration. The Medication Administration System-Nurses Assessment of Satisfaction survey was used to assess the impact on nursing satisfaction before and 1 month after bar-code medication administration implementation. RESULTS: A total of 676 medication administrations were observed in the period before bar-code medication administration implementation and 656 after. The medication administration error rate preimplementation was 2.96% with "wrong dose" errors being the most common. After bar-code medication administration implementation, the medication administration error rate fell to 0.76%, a relative reduction of 74.2% (Fisher exact P < 0.01). The average (SD) Medication Administration System-Nurses Assessment of Satisfaction score preimplementation was 2.60 (0.75) and improved to 2.29 (0.66) (t = 2.00, P = 0.05) 1 month post implementation. DISCUSSION: Implementing bar-code medication administration in a community emergency department was associated with a decrease in medication administration errors and an improvement in Medication Administration System-Nurses Assessment of Satisfaction scores. The results of this study suggest a benefit of bar-code medication administration in reducing medication administration errors and improved nursing satisfaction in the emergency department.

A bio-bar-code photothermal probe triggered multi-signal readout sensing system for nontoxic detection of mycotoxins.

Herein, a photothermal triggered multi-signal readout (MSR) system was innovatively established with great convenience for low-cost and sensitive point-of-care testing (POCT). In this sensing system, an intelligent multi-signal readout interface (MSRI) with multidimensional response-ability to thermal stimulus was developed and utilized as a sensing element. A bio-bar-code photothermal probe peptides@H2N-HCNTs acted as a target associated photothermal agent anchored on MSRI via competitive reaction. The multi-signal assay of target was realized under the driven of 808 nm laser, photo-to-thermal conversion effect of photothermal probe caused dramatically thermal energy increase on MSRI. As a result, the competitive recognition events were translated into several detectable signals on MSRI, including a local temperature elevation, a visual color change from blue to green as well as weight loss on MSRI, all of these signals were proportional to the target concentration. This assay has been successfully applied in field work for detecting zearalenone (ZEN), a common mycotoxin in grain food, with linear ranger from 10-7 ng/mL to 10-1 ng/mL and detection limits of 1.06 × 10-7 ng/mL. Combination of the different signal principles was expected to result in more reliable and precise results. Accordingly, this creatively designed MSR-system not only provided a platform for sensitive monitor of mycotoxin but also offered new method for reliable and affordable personal assays in daily life and low-resource setting.

Sensitive detection of streptomycin in milk using a hybrid signal enhancement strategy of MOF-based bio-bar code and target recycling.

A MOF-based bio-bar code material was synthesized and firstly applied to develop an electrochemical streptomycin (STR) aptasensor. By using MOF-based bio-bar code and enzyme-assisted target recycling for dual-signal amplification, highly sensitive detection of STR was achieved. The sensing surface was simply fabricated by immobilizing a mixed monolayer of thiolated cDNA/aptamer duplexes (dsDNA) and 6-mercapto-1-hexanol (MCH) on the gold nanoparticle modified screen printed carbon electrode (Au/SPCE). The presence of target STR caused highly efficient removal of the aptamers from dsDNA assisted by Exo I enzyme. Then MOF-based bio-bar codes were backfilled to achieve the adsorption of electroactive Ru(NH3)63+ (RuHex) on electrode surface. The electrochemical signal of the surface-confined RuHex was used for quantitation. The analytical performance for STR was satisfactory with a wide linear range of 0.005-150 ng mL-1, a low detection limit of 2.6 pg mL-1 and a good selectivity towards other three antibiotics. Moreover, the application of this aptasensor for determination of STR in real milk samples was also realized. With these merits, this dual-signal amplification assay might provide one of the effective ways for food safety monitoring.

The influence of peer beliefs on nurses' use of new health information technology: A social network analysis.

Implementation of health information technology fails at an alarming rate because intended users often choose not to use it. Implementation theory and frameworks suggest that social networks may influence individuals' use, but empirical study remains limited. Furthermore, neither theory nor research has identified whose beliefs within the network matter most for implementation. We examine the relationship between an individual's system use and the beliefs of his or her peers. We assess the relationship for two peer groups: the entire group of peers and the subset that shares the individual's beliefs about the system. We used data collected from an academic hospital in the United States that had recently implemented a bar code medication administration system, a technology meant to increase medication safety. We administered a survey to nurses (N = 207) in six clinical units approximately 3-5 months (April-June 2013) after the "go-live" of the system to identify peer groups and beliefs about system usefulness. We calculated mean peer belief for the entire peer group and sharedness of belief using a homophily measure. From the hospital's electronic health record system, we obtained nurses' system use during the 3-month data collection period. We used multivariable linear regression to examine relationships. We found no effect of mean peer beliefs on individual system use. However, sharedness of belief about usefulness was positively associated with individual system use. Individuals' own positive belief was only associated with greater system use when shared with peers. Our findings indicate a significant role of social networks in implementation, and specifically that shared beliefs between an individual and his or her peer network may be critical to implementation success, more so than the beliefs across the entire peer group. Reinforcement by the social network appears to dictate whether individuals' own beliefs translate into system use.

Topological View of Flows Inside the BOLD Spontaneous Activity of the Human Brain.

Spatio-temporal brain activities with variable delay detectable in resting-state functional magnetic resonance imaging (rs-fMRI) give rise to highly reproducible structures, termed cortical lag threads, that propagate from one brain region to another. Using a computational topology of data approach, we found that persistent, recurring blood oxygen level dependent (BOLD) signals in triangulated rs-fMRI videoframes display previously undetected topological findings, i.e., vortex structures that cover brain activated regions. Measure of persistence of vortex shapes in BOLD signal propagation is carried out in terms of Betti numbers that rise and fall over time during spontaneous activity of the brain. Importantly, a topology of data given in terms of geometric shapes of BOLD signal propagation offers a practical approach in coping with and sidestepping massive noise in neurodata, such as unwanted dark (low intensity) regions in the neighborhood of non-zero BOLD signals. Our findings have been codified and visualized in plots able to track the non-trivial BOLD signals that appear intermittently in a sequence of rs-fMRI videoframes. The end result of this tracking of changing lag structures is a so-called persistent barcode, which is a pictograph that offers a convenient visual means of exhibiting, comparing, and classifying brain activation patterns.

Dermoscopy - a simple and rapid in vivo diagnostic technique for tinea incognito.

Tinea incognito resulting from corticosteroid abuse is becoming very common in the tropics. Its diagnosis is tricky owing to its confusing morphology, as well as practical and technical issues associated with mycological tests. Dermoscopy has now evolved as a novel diagnostic tool for diagnosing tinea incognito in such challenging situations, since the typical hair changes such as Morse-code hairs, deformable hairs, translucent hairs, comma and cork screw hairs, and perifollicular scaling may be seen despite steroid use, irrespective of mycological results.

Optimization of a microarray for fission yeast.

Bar-code (tag) microarrays of yeast gene-deletion collections facilitate the systematic identification of genes required for growth in any condition of interest. Anti-sense strands of amplified bar-codes hybridize with ~10,000 (5,000 each for up- and down-tags) different kinds of sense-strand probes on an array. In this study, we optimized the hybridization processes of an array for fission yeast. Compared to the first version of the array (11 µm, 100K) consisting of three sectors with probe pairs (perfect match and mismatch), the second version (11 µm, 48K) could represent ~10,000 up-/down-tags in quadruplicate along with 1,508 negative controls in quadruplicate and a single set of 1,000 unique negative controls at random dispersed positions without mismatch pairs. For PCR, the optimal annealing temperature (maximizing yield and minimizing extra bands) was 58°C for both tags. Intriguingly, up-tags required 3 higher amounts of blocking oligonucleotides than down-tags. A 1:1 mix ratio between up- and down-tags was satisfactory. A lower temperature (25°C) was optimal for cultivation instead of a normal temperature (30°C) because of extra temperature-sensitive mutants in a subset of the deletion library. Activation of frozen pooled cells for >1 day showed better resolution of intensity than no activation. A tag intensity analysis showed that tag(s) of 4,316 of the 4,526 strains tested were represented at least once; 3,706 strains were represented by both tags, 4,072 strains by up-tags only, and 3,950 strains by down-tags only. The results indicate that this microarray will be a powerful analytical platform for elucidating currently unknown gene functions.

Dermoscopy - a simple and rapid in vivo diagnostic technique for tinea incognito

Abstract Tinea incognito resulting from corticosteroid abuse is becoming very common in the tropics. Its diagnosis is tricky owing to its confusing morphology, as well as practical and technical issues associated with mycological tests. Dermoscopy has now evolved as a novel diagnostic tool for diagnosing tinea incognito in such challenging situations, since the typical hair changes such as Morse-code hairs, deformable hairs, translucent hairs, comma and cork screw hairs, and perifollicular scaling may be seen despite steroid use, irrespective of mycological results.

Analysis of Zingiberaceae in E'mei Area Using ITS2 Sequences / 中国实验方剂学杂志

Objective: To evaluate the use of ITS2 sequences as DNA barcode to identify the Zingiberaceae medicinal plants from E'mei area. Method: The genomic DNAs were extracted from 43 Zingiberaceae medicinal plant samples from Sichuan E'mei area. The ITS2 sequences of these samples were amplified and bidirectionally sequenced by PCR. 40 ITS2 sequences were downloaded from the GenBank,and then the interspecific and intraspecific genetic distances were calculated and analyzed by using MEGA 6.0 to construct Neighbor-joining (NJ) tree; TAXON DNA software was also used to analyze intraspecific and interspecific variations and barcoding gaps. The differences in secondary structure of the ITS2 sequences were predicted and compared. Result: The minimum interspecific distance in Zingiberaceae samples was greater than the maximum intra specific distance,with obvious barcoding gap. The NJ tree showed that the samples were clustered into five different branches,Alpinia,Curcuma,Globba,Hedychium,and Zingiber respectively,and further cluster into sub-branches. Significant differences were also present in the secondary structures of ITS2 between different samples. Conclusion: ITS2 sequences as DNA barcode can be used to conduct accurate and rapid identification of the Zingiberaceae plants and clearly figure out the phylogenetic relationship among them,providing guidance for the study of the distribution of medicinal plants of this genus,as well as theoretical basis for the quality control,medication safety and rational development of Zingiberaceae medicinal plants in E'mei area.

Optimization of a microarray for fission yeast

Bar-code (tag) microarrays of yeast gene-deletion collections facilitate the systematic identification of genes required for growth in any condition of interest. Anti-sense strands of amplified bar-codes hybridize with ~10,000 (5,000 each for up- and down-tags) different kinds of sense-strand probes on an array. In this study, we optimized the hybridization processes of an array for fission yeast. Compared to the first version of the array (11 µm, 100K) consisting of three sectors with probe pairs (perfect match and mismatch), the second version (11 µm, 48K) could represent ~10,000 up-/down-tags in quadruplicate along with 1,508 negative controls in quadruplicate and a single set of 1,000 unique negative controls at random dispersed positions without mismatch pairs. For PCR, the optimal annealing temperature (maximizing yield and minimizing extra bands) was 58℃ for both tags. Intriguingly, up-tags required 3× higher amounts of blocking oligonucleotides than down-tags. A 1:1 mix ratio between up- and down-tags was satisfactory. A lower temperature (25℃) was optimal for cultivation instead of a normal temperature (30℃) because of extra temperature-sensitive mutants in a subset of the deletion library. Activation of frozen pooled cells for >1 day showed better resolution of intensity than no activation. A tag intensity analysis showed that tag(s) of 4,316 of the 4,526 strains tested were represented at least once; 3,706 strains were represented by both tags, 4,072 strains by up-tags only, and 3,950 strains by down-tags only. The results indicate that this microarray will be a powerful analytical platform for elucidating currently unknown gene functions.

Implementation of Bar-Code Medication Administration to Reduce Patient Harm.

OBJECTIVE: To assess the impact of implementing bar-code medication administration (BCMA) technology on the rate of medication administration errors in the inpatient setting, specifically those that affect the patient and result in harm. PATIENTS AND METHODS: Implementation of the new technology began in September 2008 in a staged rollout of 4 or 5 units at a time in 11 separate waves. All corresponding medication administrations and voluntarily reported medication-related adverse events from March 1, 2007, through September 30, 2013, were included for analyses. Adherence to the use of BCMA technology and the number of adverse events were tracked and compared across the preimplementation period through follow-up. Actual errors, not potential errors, were included in the analysis. RESULTS: After the BCMA technology was introduced, reported medication administration errors decreased by 43.5%. More importantly, the rate of harmful medication errors decreased from 0.65 per 100,000 medications preintervention to 0.29 per 100,000 medications postintervention. This resulted in a 55.4% decrease in actual patient harm events. None of the errors at category E or higher was caused by BCMA factors. CONCLUSION: Consistent use of BCMA technology improves patient safety by decreasing the number of patients harmed by medication administration errors.

[Barcode Based Full Process Management of High-Cost Consumables for Operating Theatres].

Driven by the development of medical technology and the increasing workload of hospitals, high-cost medical consumables are playing an ever more important role. Operating theatres, as the biggest consumer of high-cost consumables, cannot afford to manage the consumables in a detailed manner under the traditional approaches of management. This article elaborates on the complete management of the high-cost consumables with the help of bar code technology. Information management of high-cost consumables has brought about higher work efficiency, streamlined management process, greater medical safety and higher economic viability of hospitals.