BACKGROUND: Ambulance clinicians use pre-alerts to inform receiving hospitals of the imminent arrival of a time-critical patient considered to require immediate attention, enabling the receiving emergency department (ED) or other clinical area to prepare. Pre-alerts are key to ensuring immediate access to appropriate care, but unnecessary pre-alerts can divert resources from other patients and fuel \'pre-alert fatigue\' among ED staff. This research aims to provide a better understanding of pre-alert decision-making practice.
METHODS: Semi-structured interviews were conducted with 34 ambulance clinicians from three ambulance services and 40 ED staff from six receiving EDs. Observation (162 hours) of responses to pre-alerts (n=143, call-to-handover) was also conducted in the six EDs. Interview transcripts and observation notes were imported into NVIVO and analysed using thematic analysis.
RESULTS: Pre-alert decisions involve rapid assessment of clinical risk based on physiological observations, clinical judgement and perceived risk of deterioration, with reference to pre-alert guidance. Clinical experience (pattern recognition and intuition) and confidence helped ambulance clinicians to understand which patients required immediate ED care on arrival or were at highest risk of deterioration. Ambulance clinicians primarily learnt to pre-alert \'on the job\' and via informal feedback mechanisms, including the ED response to previous pre-alerts. Availability and access to clinical decision support was variable, and clinicians balanced the use of guidance and protocols with concerns about retention of clinical judgement and autonomy. Differences in pre-alert criteria between ambulance services and EDs created difficulties in deciding whether to pre-alert and was particularly challenging for less experienced clinicians.
CONCLUSIONS: We identified potentially avoidable variation in decision-making, which has implications for patient care and emergency care resources, and can create tension between the services. Consistency in practice may be improved by greater standardisation of guidance and protocols, training and access to performance feedback and cross-service collaboration to minimise potential sources of tension.

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BACKGROUND: Adrenal incidentalomas (AIs) are found in 3%-4% of abdominal computed tomography scans. Timely evaluation of their functional status and malignant potential is necessary to guide nonoperative surveillance or surgery. This study aims to evaluate the adherence of referring service patterns to the American Association of Endocrine Surgeons and American Association of Clinical Endocrinologists guidelines for the biochemical workup of AIs at a tertiary surgical clinic.
METHODS: We conducted a retrospective study of 125 patients evaluated for AIs at the endocrine surgery clinic between 2017 and 2022. Information on patient demographics, referral source, and reasons for referral was collected. The appropriateness of the biochemical workup for AIs by referring physicians was assessed. Statistical analyses included chi-square and Kruskal-Wallis tests.
RESULTS: Referrals came from endocrinologists (44.8%), other subspecialists (31.2%), and primary care physicians (PCPs) (19.2%). Among 125 patients, diagnoses included benign adrenal masses (52.8%), aldosteronomas (10.4%), cortisol-secreting tumors (15.2%), pheochromocytomas (12.8%), and metastatic masses (4.0%). Endocrinologists were more likely to conduct a complete biochemical workup compared to other subspecialties and PCPs (P < 0.001). Eighty-three (66.4%) patients underwent adrenalectomy, with those referred by endocrinologists more likely to undergo surgery than those referred by other subspecialties and PCPs (P < 0.001). There was no significant difference in the time from the initial clinic visit to surgery by referral source (P > 0.05).
CONCLUSIONS: Over half of AIs referrals to the endocrine surgery clinic came from subspecialists and PCPs rather than endocrinologists. Familiarizing all referring physicians with American Association of Endocrine Surgeons/Association of Clinical Endocrinologists guidelines may reduce undiagnosed functional AI cases and facilitate timely surgical management.

BACKGROUND: Once the World Health Oraganization (WHO) generic surgical checklist has been standardized and following the itinerary proposed, it is up to the different specialties to continue advancing in the improvement and adjustment of the checklists to their specific procedures.
METHODS: Through a Failure Mode and Effects Analysis (FMEA) in which professionals from the surgical area of ​​the Torrecárdenas University Hospital, Jaén Hospital Complex and Gregorio Marañón General University Hospital participated, aspects that threaten patient safety in spine surgery and that are not included in the WHO generic surgical checklist were proposed. The authors scored each of the proposed items incrementally based on the degree of suitability. Based on the score obtained, they selected those who would be incorporated into the specific safety checklist.
RESULTS: A total of twenty-one candidate items were proposed to be part of the specific check list. These obtained scores between 15 and 11 points. After scoring them, it was decided to include the thirteen best rated in the definitive surgical checklist, seven of them in the initial phase, two in the phase prior to the incision and another four in the final part of the checklist prior to the completion of the procedure.
CONCLUSIONS: Professionals in the surgical area of ​​Neurosurgery can identify aspects not included in the generic checklist whose non-compliance can affect patient safety in spine surgery to at least the same extent as those included in WHO checklist. It is possible to propose a specific complementary checklist for spinal surgery, responsible for collecting aspects related to safety and success in these procedures.

BACKGROUND: Adult cancer survivors are at a heightened risk for secondary primary differentiated thyroid carcinoma (2-DTC). The characteristics and outcomes of 2-DTC remain poorly understood.
OBJECTIVE: We aim to explore the characteristics and outcomes of 2-DTC.
METHODS: We retrospectively analyzed data from the SEER database (2000-2017). 2-DTC was divided into 25 subgroups based on the prior primary malignancies (PPMs). Baseline characteristics were compared using the Chi-square test. Multivariable logistic analysis was used to identified if PPMs associated with aggressive DTC characteristics. DTC-specific and cancer-specific mortality were analyzed using univariable and multivariable competing risk regression model.
RESULTS: There were 138,555 1-DTC and 9,253 2-DTC patients were identified. 2-DTC patients were predominantly older, male, and white compared to first primary DTC (1-DTC) (all P < 0.05). In multivariable logistic regression analysis, only four types of PPMs were associated with higher rates of DTC aggressive characteristics, while 19 types exhibited lower rates (all P < 0.05). In multivariable competing risk analysis, 2-DTC showed no mortality risk in stages I (SHR: 1.16, 95% CI: 0.65-2.07) and II (SHR: 0.67, 95% CI: 0.45-1.01), but a protective role in stages III (SHR: 0.47, 95% CI: 0.27-0.83) and IV (SHR: 0.72, 95% CI: 0.52-0.99). Most PPMs that developed into 2-DTC had a lower risk of DTC-specific death than 1-DTC, but many PPMs had a higher risk of cancer-specific death.
CONCLUSIONS: Given the characteristics and outcomes of 2-DTC, aggressive treatment for 2-DTC, particularly for PPM with a high mortality risk, may not be advisable.

BACKGROUND: Dual eligible beneficiaries are a vulnerable population who often experience inferior access to care and outcomes compared to non-dual eligible beneficiaries. The Oncology Care Model (OCM) is an alternative payment model that aims to improve coordination and quality of care in beneficiaries receiving chemotherapy and thus may improve care for dual eligible beneficiaries with cancer.
METHODS: We used 100% Medicare claims data from 2014 through 2019 and included beneficiaries with bladder, breast, esophageal, colorectal, kidney, lung, pancreatic, or prostate cancer receiving chemotherapy. We constructed multivariable difference-in-differences regression models to evaluate the effect of OCM participation on healthcare utilization and quality of care at the end-of-life among dual eligible beneficiaries. We also compared healthcare utilization and quality of care outcomes to non-dual eligible beneficiaries.
RESULTS: We identified 3,043,944 episodes of care among 1,260,892 unique Medicare beneficiaries. Ten percent of all beneficiaries (n = 126,758) were dual eligible and 64,087 (22%) of episodes among dual eligible patients were in an OCM participating practice. We noted no effect of OCM participation on healthcare utilization or end-of-life quality of care for dual eligible beneficiaries. However, we observed higher rates of hospitalization, emergency department visits, intensive care unit stays, and a lower number of office visits among dual eligible beneficiaries compared to non-dual eligible beneficiaries.
CONCLUSIONS: Participation in OCM was not associated with improvements in quality of care or healthcare utilization for dual eligible beneficiaries. Dual eligible beneficiaries experience lower quality of care across several measures compared to non-dual eligible beneficiaries. Focused policies and incentives may be necessary to address disparities within emerging health reforms.

BACKGROUND: Active surveillance for cervical intraepithelial neoplasia grade 2 (CIN2) has been implemented recently in many countries, including the Nordic countries. In Denmark, the only eligibility criterion for active surveillance for CIN2 is that the woman should be of reproductive age. With this study, we aimed to evaluate clinical and socioeconomic characteristics in women with CIN2 managed by active surveillance or large loop excision of the transformation zone (LLETZ) and to evaluate temporal changes in the clinical management of CIN2.
METHODS: We conducted a Danish nationwide study using data from healthcare registries. All female residents aged 18-40 years, diagnosed with incident CIN2 from January 1, 1998, to February 29, 2020, were included. We collected data on age, index cytology result, year of CIN2 diagnosis, region of residence, civil status, HPV vaccination status, and socioeconomic position indicators. The variables were tabulated overall and by management group (active surveillance vs. LLETZ). To evaluate time trends, we used joinpoint regression to calculate the annual percentage change (APC), including 95% confidence intervals (CI).
RESULTS: Of the 27 536 women with CIN2 included, 12 500 (45.4%) underwent active surveillance, and 15 036 (54.6%) underwent a LLETZ. Women undergoing active surveillance were younger, more often HPV-vaccinated, and more likely to have a normal/low-grade index cytology result than women undergoing LLETZ. Socioeconomic position indicators did not differ. Over time, the proportion of women undergoing active surveillance increased from 21.7% in 2004 to 73.6% in 2019 (APC 9.7, 95% CI 8.1-11.4). The proportion of women undergoing active surveillance aged <30 declined over time (APC -2.2, 95% CI -2.9 to -1.5). The proportion of women with normal/low-grade index cytology increased slightly to 51.6% in 2019 (APC 0.8, 95% CI 0.4-1.3).
CONCLUSIONS: The use of active surveillance for CIN2 has increased over the past two decades in Denmark. Observed differences in characteristics between women undergoing active surveillance vs LLETZ are likely related to indications for clinical management.

Background/Objectives: Chest X-ray (CXR) is currently the most used investigation for clinical follow-up after major noncardiac thoracic surgery. This study explores the use of lung ultrasound (LUS) as an alternative to CXR in the postoperative management of patients who undergo major thoracic procedures. Methods: The patients in our cohort were monitored with both a CXR and a lung ultrasonography after surgery and the day after chest drain removal. The LUS was performed by a member of the medical staff of our unit who was blinded to both the images and the radiologist\'s report of the CXR. Findings were compared between the two methods. Results: In the immediate postoperative evaluation, 280 patients were compared, finding general agreement between the two procedures at 84% (kappa statistic, 0.603). The LUS showed a sensibility of 84.1%, a specificity of 84.3%, a positive predictive value (PPV) of 60.9%, and a negative predictive value (NPV) of 94.8%. We evaluated 219 out of 280 patients in the postdrainage-removal setting due to technical issues. Concordance between the methods in the postdrainage-removal setting was 89% (kappa statistic, 0.761) with the LUS demonstrating an 82.2% sensibility, a 93.2% specificity, a PPV of 85.7%, and an NPV of 91.3%. Conclusions: The results of this study showed a substantial agreement between LUS and CXR, suggesting that the LUS could reduce the number of X rays in certain conditions. The high NPV allows for the exclusion of PNX and pleural effusion without the need to expose patients to radiation. Discrepancies were noted in cases of mild pneumothorax or modest pleural effusion, without altering the clinical approach.

Multigene panels can analyze high and moderate/intermediate penetrance genes that predispose to breast cancer (BC), providing an opportunity to identify at-risk individuals within affected families. However, considering the complexity of different pathogenic variants and correlated clinical manifestations, a multidisciplinary team is needed to effectively manage BC. A classification of pathogenic variants included in multigene panels was presented in this narrative review to evaluate their clinical utility in BC. Clinical management was discussed for each category and focused on BC, including available evidence regarding the multidisciplinary and integrated management of patients with BC. The integration of both genetic testing and counseling is required for customized decisions in therapeutic strategies and preventative initiatives, as well as for a defined multidisciplinary approach, considering the continuous evolution of guidelines and research in the field.

Among numerous public health actions, the Prevention Departments of Local Health Authorities take charge of the migrant asylum-seeking population for health assessments, for the implementation of preventive activities, and for any consequent actions. This report describes two cases of tuberculosis in Belluno Province managed by a multidisciplinary team made up of healthcare workers that involved numerous diagnostic, clinical, and prophylactic implications, as well as an analysis of the epidemiological aspects related to the incidence of cases along the migration route. Although the cases occurred in a northeastern Italian territory, the management methods described here may represent good practices to share on this operational line, which can promote the strengthening of cooperation between Health Authorities and Emergency Reception Centers to correctly identify cases of active tuberculosis that may not have been initially screen-detected.