Serum Uric Acid but Not Ferritin Level Is Associated with Hepatic Fibrosis in Lean Subjects with Metabolic Dysfunction-Associated Fatty Liver Disease: A Community-Based Study

Elevated serum ferritin and uric acid levels are common in patients with fatty liver disease. This study assessed the association between serum ferritin and uric acid levels and liver fibrosis in subjects with lean metabolic dysfunction-associated fatty liver disease (MAFLD). This cross-sectional study used data from a community screening examination for metabolic syndrome from December 2018 to September 2019 at Keelung Chang Gung Memorial Hospital. Subjects with lean MAFLD were defined as those with a body mass index (BMI) < 23 kg/m2 and hepatic steatosis according to the MAFLD criteria. A total of 182 lean subjects were included and were divided into lean MAFLD and lean healthy groups. Serum ferritin and uric acid concentrations were positively correlated with liver fibrosis, regardless of whether FIB-4, APRI, or NFS were used as references. Univariate logistic regression analysis showed that age and uric acid were associated with advanced liver fibrosis. After adjusting for potential confounders, only uric acid level was statistically significant in predicting the advanced liver fibrosis (OR = 6.907 (1.111−42.94), p = 0.038) in the lean MAFLD group. We found that an elevated serum uric acid level is an independent factor associated with advanced liver fibrosis in lean MAFLD subjects by noninvasive fibrosis scores.

Development and Evaluation of a Massive Open Online Course on Healthcare Redesign: A Novel Method for Engaging Healthcare Workers in Quality Improvement

Healthcare workers are under increasing pressure to use limited resources more efficiently and improve patient outcomes. Healthcare redesign, a quality improvement methodology derived from the automotive industry, is a proven means of achieving these goals. Continuing Professional Development (CPD) opportunities for nurses seeking to build their capacity for healthcare redesign often come in the form of university courses, which can be costly and prohibitively time-consuming. We developed a Massive Open Online Course (MOOC) with a view to increasing the number of healthcare workers undertaking CPD in healthcare redesign and subsequently using these principles in their workplaces. The aim of the current study is to describe the development of our MOOC and its initial feedback from users. Materials and Methods: The theoretical and practical components of an existing postgraduate award course unit were made fit for purpose by being arranged into six weekly modules, before being transposed to an established learning management platform for MOOCs. Related quizzes, videos and interactive activities were then developed and included in each of these modules. Peer review of this content was completed by subject matter and teaching and learning experts prior to the MOOC being launched. Results: After running for nine months, 578 participants had enrolled in the MOOC, of whom 118 (20%) had followed through to completion. Participants were overwhelmingly from Australia (89%) and identified as female (78%). Preliminary feedback obtained from participants was positive, with 81% of respondents agreeing that they were satisfied with their experience, and 82% intending to apply their knowledge in practice. Conclusions: The MOOC has addressed a learning need by providing a brief and free form of education; learning from its development will help others seeking similar educational solutions. Initial feedback suggests the MOOC has been well-received and is likely to be translated into practice.

Applied lean principles in dental practice

This paper is based on lean principles and how they can apply to dental offices for general dental practitioners and specialists. In addition, this paper highlights how to identify and eliminate waste. This information provides value to the process in a dental office, establishing a platform and roadmap for lean thinking and how these principles can be utilized further in health care for reliable, efficient, and sustainable clinical outcomes.

Relationship of body mass index to clinical outcomes after percutaneous coronary intervention

BACKGROUND

Elevated body mass index (BMI) demonstrates lower all-cause and cardiovascular mortalities compared with normal-weight or lean patients in chronic diseases. This study investigated relationships between BMI and clinical outcomes following percutaneous coronary intervention (PCI) in coronary artery disease (CAD) patients, together with the sex-specific impacts of BMI on mortality.

METHODS

We reviewed 1104 CAD patients who underwent PCI between 2006 and 2015. Patients were divided by BMI into three groups: lean, <18.5 kg/m² ; normal, 18.5-24.9 kg/m² ; and overweight/obese, ≥25 kg/m² . The primary endpoint was all-cause mortality, and the secondary endpoint was 3-point major adverse cardiovascular events (MACE).

RESULTS

Kaplan-Meier survival analysis demonstrated risks of all-cause death, and 3-point MACE were higher in lean patients compared with normal-weight and overweight/obese subjects (log-rank p < .001). Cox proportional hazard modelling showed overweight/obese was significantly associated with all-cause death (hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.48-0.95; p = .03), and lean was significantly associated with 3-point MACE (HR 2.02, 95% CI 1.15-3.53; p = .01). Cox proportional hazard analysis with restricted cubic spline showed non-linear associations between BMI and both all-cause mortality and 3-point MACE (p for effect = .002 and = .003, respectively). No significant interaction was evident between sex and BMI for all-cause mortality (p for interaction = .104) or 3-point MACE (p for interaction =0.122).

CONCLUSIONS

Lean category was associated with adverse outcomes among CAD patients. An obesity paradox regarding the independent association of elevated BMI with reduced mortality after PCI is evident in both males and females.

Nonalcoholic Fatty Liver Disease and Risk of Early-Onset Vasomotor Symptoms in Lean and Overweight Premenopausal Women

The role of nonalcoholic fatty liver disease (NAFLD) in vasomotor symptom (VMS) risk in premenopausal women is unknown. We examined the prevalence of early-onset VMSs according to NAFLD status in lean and overweight premenopausal women. This cross-sectional study included 4242 premenopausal Korean women (mean age 45.4 years). VMSs (hot flashes and night sweats) were assessed using the Korean version of the Menopause-Specific Quality of Life questionnaire. Hepatic steatosis was determined using liver ultrasound; lean was defined as a body mass index of <23 kg/m2. Participants were categorized into four groups: NAFLD-free lean (reference), NAFLD-free overweight, lean NAFLD, and overweight NAFLD. Compared with the reference, the multivariable-adjusted prevalence ratios (PRs) (95% confidence intervals (CIs)) for VMSs in NAFLD-free overweight, lean NAFLD, and overweight NAFLD were 1.22 (1.06−1.41), 1.38 (1.06−1.79), and 1.49 (1.28−1.73), respectively. For moderate-to-severe VMSs, the multivariable-adjusted PRs (95% CIs) comparing NAFLD-free overweight, lean NAFLD, and overweight NAFLD to the reference were 1.38 (1.10−1.74), 1.73 (1.16−2.57), and 1.74 (1.37−2.21), respectively. NAFLD, even lean NAFLD, was significantly associated with an increased risk of prevalent early-onset VMSs and their severe forms among premenopausal women. Further studies are needed to determine the longitudinal association between NAFLD and VMS risk.

'Bringing the Covert into the Open': A Case Study on Technology Appropriation and Continuous Improvement

As end-users, employees appropriate technologies. Technology appropriation is generally conceived as a covert phenomenon. In particular, alternative ways and new purposes for which employees deploy technologies tend to remain hidden. Therefore, the potential of technologies as a source of organizational improvements may remain undisclosed. Continuous improvement (CI) programs, in contrast, are explicitly oriented at disclosing organizational improvements. In essence, CI programs encourage employees to openly discuss how to improve their work practices. Such continuous movements towards novel, often better, ways of working may be perfectly suited to bring the covert nature of technology appropriation into the open. Based on a case study on a personal digital assistant (PDA) in a Belgian nursing home with such a CI program in place, we document and analyze to what extent and why functionalities of the PDA were discussed and further developed. We distinguish between the functionalities that, upon implementation, intended to improve particular work practices, and those that surfaced after the technology had been introduced. To conclude, we point at employees’ perceived usefulness of their work practices and their willingness to improve these, rather than only the technology itself, to further the debate on technology appropriation.

Impact of New Bed Assignment Information System on Emergency Department Length of Stay: An Effect Evaluation for Lean Intervention by Using Interrupted Time Series and Propensity Score Matching Analysis

A long waiting period for available beds in emergency departments (EDs) is the major obstacle to a smooth process flow in ED services. We developed a new bed assignment information system that incorporates current strategies and resources to ease the bottleneck in the service flow. The study’s purpose was to evaluate the effect of the lean intervention plan. We included 54,541 ED patient visits in the preintervention phase and 52,874 ED patient visits in the postintervention phase. Segmented regression analysis (SRA) was used to estimate the level and trend in the preintervention and postintervention phases and changes in the level and trend after the intervention. After the intervention, the weekly length of stay (LOS) for patient visits, admitted patient visits, and nonadmitted patient visits decreased significantly by 0.75, 2.82, and 0.17 h, respectively. The trendline direction for overall patient visits and nonadmitted patient visits significantly changed after the intervention. However, no significant change was noted for admitted patient visits, although the postintervention trend visually differed from the preintervention trend. The concept of lean intervention can be applied to solve various problems encountered in the medical field, and the most common approach, SRA, can be used to evaluate the effect of intervention plans.

Clinical and Laboratory Characteristics of Normal Weight and Obese Individuals with Non-Alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) has had, over the past few decades, a progressively growing prevalence among the general population all over the world, in parallel with metabolic conditions such as type 2 diabetes mellitus (T2DM), dyslipidemia, and obesity. However, NAFLD is also detected in 10−13% of subjects with a body mass index (BMI) ≤ 25 kg/m² (lean-NAFLD), whose major risk factors remain unknown. In this study, we aimed to characterize the clinical features and associated risk factors of lean-NAFLD in comparison with obese-NAFLD patients. Consecutive patients diagnosed with NAFLD by vibration-controlled transient elastography and controlled attenuation parameter were prospectively enrolled. Biological and clinical data obtained from the participants were stratified according to their BMI in two groups: lean-NAFLD and obese-NAFLD. In total, 331 patients (56.8% males) were included in the final analysis. Most of the subjects were obese-NAFLD (n = 258, 77.9%) and had a higher prevalence of T2DM, dyslipidemia, and components of the metabolic syndrome, together with abnormal biological parameters. Regarding liver stiffness measurements, the proportion of subjects with at least significant fibrosis (≥F2) was approximately twofold higher among obese-NAFLD (43.81%) in comparison with lean-NAFLD patients (23.29%). Moreover, obese individuals had a higher risk for liver fibrosis (OR = 2.6, 95%, CI 1.5−4.42, p < 0.001) than lean individuals. Although associated metabolic conditions and at least significant liver fibrosis were present in approximately one-quarter of the patients, these were more frequent among obese-NAFLD patients. Therefore, individualized screening strategies for NAFLD should be established according to BMI.

Implementing a Robust Process Improvement Program in the Neonatal Intensive Care Unit to Reduce Harm

INTRODUCTION

Preventable harm continues to occur with critically ill neonates despite efforts by hospital neonatal intensive care units (NICUs) to improve processes and reduce harm. Attaining significant and sustainable improvements will require training including leadership support, mentoring, and patient family engagement to improve care processes. This paper describes the implementation of a robust process improvement (RPI) program in the NICU to reduce harm.

METHODS

Leaders, staff, and parents were trained in RPI concepts and tools. Multidisciplinary teams including parent members applied the training and received regular mentorship for their improvement initiatives.

RESULTS

Participants (N = 67) completed pretraining and post-training surveys. Training scores (0-10 scale) improved from an average of 4.45-7.60 (p < .001) for confidence in leading process improvement work, 2.36 to 7.49 (p < .001) for RPI knowledge, and 2.19 to 7.30 (p < .001) for confidence in using RPI tools; relative improvement of 71%, 217%, and 233% respectively. Participants applied their RPI training on improvement initiatives that resulted in improvements of central line blood stream infections, very low birth weight infant nutrition, and unplanned extubations.

CONCLUSIONS

Implementing an RPI program in the NICU to reduce harm resulted in significant and sustainable improvements on their improvement initiatives.

Association of genetic variations with NAFLD in lean individuals

BACKGROUND & AIMS

How adiposity influences the effect of genetic variants on non-alcoholic fatty liver disease (NAFLD) in the Asian population remains unclear. We aimed to study the association between genetic risk variants and susceptibility/severity of NAFLD in the lean, overweight and obese individuals.

METHODS

Nine hundred and four community subjects underwent proton-magnetic resonance spectroscopy and transient elastography examination. Lean (<23 kg/m² ), overweight (23-24.9 kg/m² ) and obesity (≥25 kg/m² ) were defined according to the body mass index cut-offs for Asians. NAFLD was defined as intrahepatic triglycerides ≥5%. PNPLA3, TM6SF2, MBOAT7 and 9 other gene polymorphisms were analysed by rhAMP^TM SNP assays.

RESULTS

Five hundred and twenty-nine (58.5%), 162 (17.9%) and 213 (23.6%) subjects were lean, overweight and obese, respectively. The prevalence of NAFLD was 12.4%, 41.4% and 59.1% in the three groups (P < .001). Amongst those with NAFLD, lean subjects (30.3%) were more likely to carry the PNPLA3 rs738409 GG genotype than overweight (17.9%) and obese subjects (17.4%) (P = .003). Compared with the CC genotype, the GG genotype was associated with the greatest increase in the risk of NAFLD in lean subjects (odds ratio [OR] 6.04), compared with overweight (OR 3.43, 95% CI [1.06, 11.14]) and obese subjects (OR 2.51, 95% CI [0.93, 6.78]). Additionally, the TM6SF2 rs58542926 TT genotype was associated with reduced serum triglycerides only in lean subjects. A gene-BMI effect was not observed for the other gene polymorphisms.

CONCLUSIONS

The PNPLA3 rs738409 gene polymorphism has a greater effect on liver fat in Asian lean individuals than in overweight or obese ones.

Relationship between energy intake and growth performance and body composition in pigs selected for low backfat thickness

Genetic selection of pigs over recent decades has sought to reduce carcass fat content to meet consumer demands for lean meat in many countries (e.g.: Australia). Due to the impacts of genetic changes, it is unknown whether the carcass fat measures are still responsive to energy intake. Thus, the present experiment aimed to quantify the relationship between tissue composition and dietary energy intake in finisher pigs selected for low carcass backfat. Intact male and female pigs (n=56 for each sex; PrimegroGenetics, Corowa, NSW, Australia) were fed seven different amounts of an amino acid adequate wheat-based diet containing 14.3 MJ digestible energy (DE)/kg to provide the following daily DE intakes- 25.8, 29.0, 32.6, 35.3, 38.5, 41.5 and 44.2 (ad libitum) MJ DE/d for males, and 25.8, 28.9, 32.0, 35.6, 38.3, 40.9 and 44.5 (ad libitum) MJ DE/d for females between 60 kg and 108 kg live weight. Body composition of anaesthetised pigs was measured using the Dual Energy X-ray Absorptiometry (DXA) method when individual pigs reached 108 kg, and protein, fat and ash deposition rates were calculated. Pigs were slaughtered on the 2nd day post-DXA scan for carcass backfat measurement. The results showed that the carcass backfat thickness (standardized at 83.7 kg carcass) increased by 0.125 mm for every MJ increase in daily DE intake in male pigs (P = 0.004; R2 = 0.130), but carcass backfat of female pigs (standardized at 85.1 kg carcass) was not responsive to daily DE intake. Whole-body fat composition and fat deposition rate increased linearly (both P < 0.01) in male pigs but quadratically (both P < 0.01) in female pigs in response to DE intake. Every MJ increase of daily DE intake increased the rate of daily protein deposition by 3.8 g in intact male pigs (P < 0.001; R2 = 0.781) and by 2.5 g in female pigs (P < 0.001; R2 = 0.643). In conclusion, the selection for low backfat thickness over the last two decades has altered the response of fat deposition and backfat thickness to energy intake, particularly in female pigs. Despite this change, the linear relationship between DE intake and protein deposition rate was maintained in these modern genetics.

Risk factors of nonalcoholic fatty liver disease in lean body mass population: A systematic review and meta-analysis

The pathophysiology and risk factors of nonalcoholic fatty liver disease (NAFLD) among lean patients is poorly understood and therefore investigated. We performed a meta-analysis of observational studies. Of 1175 articles found through searching from Medline/PubMed, Banglajol, and Google Scholar by two independent investigators, 22 were selected. Data from lean (n = 6768) and obese (n = 9253) patients with NAFLD were analyzed; lean (n = 43 398) and obese (n = 9619) subjects without NAFLD served as controls. Age, body mass index, waist circumference, systolic blood pressure, and diastolic blood pressure (DBP) had significantly higher estimates in lean NAFLD patients than in lean non-NAFLD controls. Fasting blood sugar [MD(mean difference) 5.17 mg/dl, 95% CI(confidence interval) 4.14-6.16], HbA1c [MD 0.29%, 95% CI 0.11-0.48], and insulin resistance [HOMA-IR] [MD 0.49 U, 95% CI 0.29-0.68]) were higher in lean NAFLD patients than in lean non-NAFLD controls. All components of the lipid profile were raised significantly in the former group except high-density lipoprotein. An increased uric acid (UA) level was found to be associated with the presence of NAFLD among lean. Cardio-metabolic profiles of nonlean NAFLD patients significantly differs from the counter group. However, the magnitude of the difference of lipid and glycemic profile barely reached statistical significance when subjects were grouped according to lean and nonlean NAFLD. But DBP (slope: 0.19, P < 0.037), HOMA-IR (slope: 0.58, P < 0.001), and UA (slope: 0.36, P = 0.022) were significantly higher if NAFLD was present compared to that of non-NAFLD group. Lean and nonlean NAFLD patients are metabolically similar and share common risk factors.

Standardization of Procedures to Contain Cost and Reduce Variability of Care After the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has changed many aspects of our private and professional routine. In particular, the lockdowns have severely affected the entire healthcare system and hospital activities, forcing it to rethink the protocols in force. We suggest that this scenario, in spite of the new challenges involving so far complex healthcare providers, may lead to the unique opportunity to rethink pathways and management of patients. Indeed, having to resume institutional activity after a long interruption that has completely canceled the previously existing schemes, healthcare providers have the unique opportunity to overcome obsolete and “we have always done in this way” model on the wave of the general desire to resume a normal life. Furthermore, the pandemic has highlighted some flaws in our health system, highlighting those critical issues that most need to be addressed. This article is a review of pre-pandemic literature addressing the use of Lean Six Sigma (LSS) and standardization processes in thoracic surgery to improve efficiency. Our goal is to identify the main issues that could be successfully improved along the entire pathway of a patient from the first referral to diagnosis, hospitalization, and surgical operation up to convalescence. Furthermore, we aim to identify the standardization processes that have been implemented to achieve significant improvements in patient outcomes while reducing costs. The methods and goals that could be used in the near future to modernize our healthcare systems are drawn up from a careful reading and interpretation in light of the pandemic of the most significant review articles in the literature.

A review of non-alcoholic fatty liver disease in non-obese and lean individuals

Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of hepatic disorders. It represents a wide range of chronic liver diseases in patients with no history of significant alcohol consumption, starting with simple steatosis and progressing towards non-alcoholic steatohepatitis, cirrhosis, and ultimately hepatocellular carcinoma. NAFLD is usually associated with type 2 diabetes mellitus, dyslipidemia, metabolic syndrome, and obesity. This disease has mostly been studied in obese individuals; however, it has been widely reported and studied among the lean/non-obese population in recent years. The pathogenesis of NAFLD in non-obese patients is associated with various genetic predispositions, particularly a patatin-like phospholipase domain-containing protein 3 G allele polymorphism, which results in the accumulation of triglyceride in the liver and resistance to insulin. Additionally, dietary factors such as high fructose consumption seem to play a substantial role in the pathology of non-obese NAFLD. Although there is not enough evidence on the treatment of NAFLD in non-obese patients, the standard approach is to advise altering one's lifestyle in order to diminish visceral adiposity. Dietary modification, weight loss, and increased physical activity are highly recommended. We aimed to review and summarize the existing information on the prevalence, pathogenesis, genetic predispositions, diagnosis, and treatment of NAFLD in non-obese patients according to the latest literature.

Utilizing Lean Software Methods To Improve Acceptance of Global eHealth Initiatives: Results From the Implementation of the Basic Emergency Care App

Background

Health systems in low- and middle-income countries face considerable challenges in providing high-quality accessible care. eHealth has had mounting interest as a possible solution given the unprecedented growth in mobile phone and internet technologies in these locations; however, few apps or software programs have, as of yet, gone beyond the testing phase, most downloads are never opened, and consistent use is extremely rare. This is believed to be due to a failure to engage and meet local stakeholder needs and the high costs of software development.

Objective

World Health Organization Basic Emergency Care course participants requested a mobile point-of-care adjunct to the primary course material. Our team undertook the task of developing this solution through a community-based participatory model in an effort to meet trainees’ reported needs and avoid some of the abovementioned failings. We aimed to use the well-described Lean software development strategy—given our familiarity with its elements and its ubiquitous use in medicine, global health, and software development—to complete this task efficiently and with maximal stakeholder involvement.

Methods

From September 2016 through January 2017, the Basic Emergency Care app was designed and developed at the University of California San Francisco. When a prototype was complete, it was piloted in Cape Town, South Africa and Dar es Salaam, Tanzania—World Health Organization Basic Emergency Care partner sites. Feedback from this pilot shaped continuous amendments to the app before subsequent user testing and study of the effect of use of the app on trainee retention of Basic Emergency Care course material.

Results

Our user-centered mobile app was developed with an iterative participatory approach with its first version available within 6 months and with high acceptance—95% of Basic Emergency Care Course participants felt that it was useful. Our solution had minimal direct costs and resulted in a robust infrastructure for subsequent assessment and maintenance and allows for efficient feedback and expansion.

Conclusions

We believe that utilizing Lean software development strategies may help global health advocates and researchers build eHealth solutions with a process that is familiar and with buy-in across stakeholders that is responsive, rapid to deploy, and sustainable.

Cardiometabolic Profile of Different Body Composition Phenotypes in Children

CONTEXT

Cardiometabolic profiles of different body composition phenotypes are poorly characterized in young children, where it is well established that high adiposity is unfavorable, but the role of lean mass is unclear.

OBJECTIVE

We hypothesized that higher lean mass attenuates cardiometabolic risk in children with high fat mass.

METHODS

In 6-year-old children (n = 377) from the Growing Up in Singapore Towards healthy Outcomes (GUSTO) prospective birth cohort, whole-body composition was measured by quantitative magnetic resonance, a novel validated technology. Based on fat mass index (FMI) and lean mass index (LMI), 4 body composition phenotypes were derived: low FMI-low LMI (LF-LL), low FMI-high LMI (LF-HL), high FMI-low LMI (HF-LL), high FMI-high LMI (HF-HL).

MAIN OUTCOME MEASURES

Body mass index (BMI) z-score, fasting plasma glucose, insulin resistance, metabolic syndrome risk score, fatty liver index, and blood pressure.

RESULTS

Compared with the LF-HL group, children in both high FMI groups had increased BMI z-score (HF-HL: 1.43 units 95% CI [1.11,1.76]; HF-LL: 0.61 units [0.25,0.96]) and metabolic syndrome risk score (HF-HL: 1.64 [0.77,2.50]; HF-LL: 1.28 [0.34,2.21]). The HF-HL group also had increased fatty liver index (1.15 [0.54,1.77]). Girls in HF-HL group had lower fasting plasma glucose (-0.29 mmol/L [-0.55,-0.04]) and diastolic blood pressure (-3.22 mmHg [-6.03,-0.41]) than girls in the HF-LL group. No similar associations were observed in boys.

CONCLUSION

In a multi-ethnic Asian cohort, lean mass seemed to protect against some cardiometabolic risk markers linked with adiposity, but only in girls. The FMI seemed more important than lean mass index in relation to cardiometabolic profiles of young children.

Systematic Review of Interventions to Reduce Operating Time in Lung Cancer Surgery

Introduction:

Operating rooms are a scarce resource but often used inefficiently. Operating room efficiency emerges as an important part of maximizing surgical capacity and productivity, minimizing delays, and optimizing lung cancer outcomes. The operative time (time between patient entering and leaving the operating room) is discrete and the one that the surgical team can most directly influence. We performed a systematic review to evaluate the literature and identify methods to improve the efficiency of the intraoperative phase of operations for lung cancer.

Methods:

A literature search (in PubMed, Embase, Cochrane, and Scopus) was performed from inception up to March 9, 2020, according to the methodology described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

Results:

We identified 3 articles relevant to the intraoperative phase of lung cancer operating room efficiency. All 3 were consistent in showing clinically relevant time reductions in the intraoperative phase or procedures relevant to this phase. The authors demonstrated that the application of various improvement methodologies resulted in a substantial reduction in operative time, which was associated with a reduction in complications, and improved staff morale.

Conclusions:

Our systematic review found that various improvement methodologies have the potential to significantly reduce operative time for lung cancer surgery. This increases the value of lung cancer surgery. These findings are consistent with the wider literature on improving surgical efficiency.

Nonalcoholic Fatty Liver Disease: A Global Perspective

The prevalence of nonalcoholic fatty liver disease (NAFLD) has been increasing over the years and is now as high in Asia as in the Western world, so much so that it should no longer be considered a Western disease. In fact, China is expected to have the largest increase in the number of NAFLD cases in the coming years. The increase in prevalence of NAFLD in Asia lags behind that of the Western world; thus, there will be a lag in more severe liver disease in Asia despite a similar prevalence of the disease. NAFLD is more prevalent among patients with diabetes mellitus, which is also an important risk factor for more severe liver disease. Patients with diabetes mellitus thus represent an important target for screening for NAFLD and more severe liver disease. Although the PNPLA3 gene polymorphism is the most studied in NAFLD, it is increasingly clear that the cumulative effect of multiple genes likely predisposes to NAFLD and more severe liver disease in the different ethnic groups, and polygenic risk scores are emerging. Lean NAFLD has been largely reported in Asia but is increasingly recognized worldwide. Multiple risk factors have been identified for the disease that manifests in metabolically unhealthy normal weight individuals; however, it responds to lifestyle intervention, similar to the disease in obese individuals. Lastly, the newer term "metabolic dysfunction-associated fatty liver disease" provides a more accurate reflection of the disease, giving more focus to clinicians and researchers in tackling this increasingly common and challenging disease.

Why industrial methods do not work in healthcare: an analytical approach

Healthcare professionals and managers in hospitals are frequently suggested to learn from industry and business to improve quality and efficiency. However, evidence that the implementation of industrial techniques and business methods has a meaningful effect on patient outcomes is often lacking. An explanation for this phenomenon is thought to be the complexity of the hospital organisation and the diversity of patients. In this article, we use the practice approach to discuss the application of industrial techniques and business methods in healthcare. We employ a practice model that offers three perspectives to understand professional practices: Identity and intrinsic values, Interests of stakeholders, and Ideals and basic beliefs (Triple I). This model demonstrates that the nature of healthcare practices differs strongly from the nature of industrial and business practices. Healthcare has a moral nature that does not let itself be easily organised along technological or business categories. This may provide a fundamental explanation of why industrial techniques and business methods in general will be less successful in healthcare. At the same time, this model invites hospitals to develop innovative approaches that do justice to the identity and intrinsic values of healthcare. In this process, insights from industry and business cannot be copied but have to be used as sources of inspiration.

Different age-related impacts of lean and obesity on cardiovascular prognosis in Japanese patients with cardiovascular risks: The J-HOP (Japan Morning Surge-Home Blood Pressure) Study

The relationship between lean and cardiovascular events has been shown to vary with age, but the relationship between age‐related lean and cardiovascular events in Asia has not been established. We divided patients enrolled in the J‐HOP (Japan Morning Surge‐Home Blood Pressure) study with one or more cardiovascular disease risks into three groups based on their body mass index (BMI): lean (BMI < 21), normal‐weight (21 ≤ BMI <27), and obese (BMI ≥ 27). We stratified the risk of cardiovascular events of lean and obesity compared to normal weight into the patients < 65 years old and those aged ≥ 65 years. A total of 286 cardiovascular disease events were observed during the follow‐up period (73 ± 46 months). Regarding the relationship between BMI and cardiovascular disease risk, both lean and obesity were independent prognostic factors: lean: hazard ratio (HR) 1.43, 95% confidence interval (CI): 1.02‐2.01, p = .040; obesity: HR 1.55, 95%CI: 1.13‐2.12, p = .006. In patients < 65 years old, the risk of cardiovascular disease of the lean patients was lower than that of the normal‐weight patients (HR 0.39, 95%CI: 0.12‐1.29, p = .124) and the risk of obesity patients was significantly higher (HR 1.77, 95%CI: 1.08‐2.92, p = .024). In the patients aged ≥ 65 years, lean was a significant independent factor of cardiovascular events compared to normal‐weight (lean: HR 1.70, 95%CI: 1.18‐2.47, p = .005). In conclusion, lean was an independent predictor of cardiovascular events in patients aged ≥ 65 years.

Process mapping and Lean principles applied to orthognathic surgery

Process mapping in industry is a well-established tool to improve efficiency. It is defined as a quality improvement technique that breaks down a process, or task, into its individual components, or steps, then analyses it. Lean principles are used to reduce waste and produce consistently good outcomes. Improving the operative efficiency of orthognathic surgery has many benefits. There is increasing demand for this complex surgery, and patients have appropriately high expectations with relation to their outcome. There are also increasing pressures for hospitals to reduce costs. In a recent paper by our group (Bowe et al, in press), we have published operating times for orthognathic procedures that are significantly shorter than in previously available series, with an average time for a bimaxillary osteotomy of 2 hours and 19 mins. Through observation of the senior authors' uniform technique, refined from experience of over 2,000 cases, a bimaxillary osteotomy was broken down into individual steps, all arranged in a process-mapped template with which to increase efficiency and results. We show here the multiple small operative efficiencies we have developed, and the Lean surgical principles which we use. This has enabled us to reduce the operative time of these common procedures, without compromising outcomes. This study presents an approach to process map bimaxillary orthognathic operations and shows how the application of Lean principles improves operative efficiency, and produces consistent results.

Application of Lean 6s Methodology in an Engineering Education Environment during the SARS-CoV-2 Pandemic

In this work, the application of the Lean 6S methodology is exposed, which includes the Safety-Security activity in response to the demands caused by the epidemiological situation due to exposure to SARS-CoV-2, as well as its implementation through a standardized process in n higher education environment in the engineering field. The application of methodologies based on lean principles in the organizational system of an educational institution, causes an impact on the demands of organizational efficiency, where innovation and continuous improvement mark the path to success. The Lean 6S methodology, based on the development of six phases, guarantees, thanks to the impact of all its phases and especially of three of them: cleaning, standardize and safety, the control of the health risk against SARS-CoV-2. This guarantee is achieved through the permanent review of safety in the workplace. The areas of selected implementation to verify the effect have been the essential spaces for the development of the teaching activity: center accesses, learning rooms and practical laboratories. The laboratories are adapted to the security and organization conditions that are required in the regulations required by the Occupational Risk Prevention Services against exposure to SARS-CoV-2, since the appropriate protective equipment for the risk level is reviewed, the ordering of the workstations, the class attendance through the shifts organization and the rearrangement of the common places where the maintenance of a minimum interpersonal safety distance between the teaching staff, auxiliary services and students is guaranteed. The effort of the teaching staff in terms of following the established rules is notably increased. To balance this dedication, it is necessary to increase and rely on auxiliary personnel who guarantee rules compliance control in different spaces than the classroom and the laboratory.

Understanding Food Preferences and Their Connection to Health Perception among Lean and Non-Lean Populations in a Rural State

Lipid metabolism and dietary choices directly affect the outcome of overall weight management in both lean and non-lean individuals. However, the perception of consuming spicy foods has diverse meaning among people. To understand this, it is essential to have thorough knowledge on how food preference is tied to health outcomes. The aim of this study is to enhance the understanding of how food preference affects the health outcome and perception in lean and non-lean populations. A mixed methods study was conducted via analysis of consumers’ food choices and compared the data based on age, gender, and body weight. The participants in audio recorded interviews were comprised of residents from a single town in a rural state. The study shows that most participants were aware of the implications that food choices had on their health status and it emphasizes the importance of understanding the differences between consumption of spicy and non-spicy foods. Spicy food consumption was associated with decreased overall portion size as well as increased satisfaction following the meal. Environmental factors, such as the influence of family and friends, impacted spicy food consumption according to most participants. The outcome of the study provides a comprehensive understanding of food preferences from a relatively large exploratory study. The observations made here show rudimentary associations between physical attributes and levels of food consumption. Future studies could further identify how certain attributes relate to food choices and levels of spicy food consumption in greater detail.

UniTwain: A Cost-Effective Solution for Lean Gross Imaging

Background:

Gross imaging of surgical specimens is paramount for the accurate gross examination and diagnosis of disease. Optimized imaging workflow can facilitate consistently high-quality gross photographs, especially in high-volume, metropolitan hospitals such as ours. Most commercial medical gross imaging technology provides ergonomically well-designed hardware, remotely operated cameras, intuitive software interfaces, and automation of workflow. However, these solutions are usually cost-prohibitive and require a large sum of capital budget.

Materials and Methods:

We applied lean techniques such as value stream mapping (VSM) to design a streamlined and error-free workflow for gross imaging process. We implemented a cost-effective technology, UniTwain, combined with high-resolution webcam to achieve the ideal results.

Results:

We reduced the mean process time from 600 min to 4.0 min (99.3% decrease in duration); the median process time was reduced from 580 min to 3.0 min. The process efficiency increased from 20% to 100%. The implemented solution has a comparable durability, scalability, and archiving feasibility to commercial medical imaging systems and costs four times less. The only limitations are manual operation of the webcam and lower resolution. The webcam sensors have 8.2 megapixel (MP) resolution, approximately 12 MP less than medical imaging devices. However, we believe that this difference is not visually significant and the effect on gross diagnosis with the naked eye is minimal.

Conclusions:

To our knowledge, this is the first study that utilized UniTwain as a viable, low-cost solution to streamline the gross imaging workflow. The UniTwain combined with high-resolution webcam could be a suitable alternative for our institution that does not plan to heavily invest in medical imaging.

Applying Lean in Process Innovation in Healthcare: The Case of Hip Fracture

Academic literature and practitioners acknowledge that there is a need to improve efficiency and service quality in the healthcare industry. In Spain, osteoporotic fractures represent a great cost in socio-economic and morbi-mortality terms, hip fracture being the surgical pathology with the second highest consumption of resources. The research questions that govern this study concern the use of Lean principles to identify waste, and an evaluation of the application of an innovative approach in the hip fracture surgery process. A research design based on a case study and action research was developed. Findings relate to (i) the identification of the main types of waste or muda (being the most frequent delay, transportation, over-processing and defects); (ii) the analysis of existing processes based on a Lean approach (identifying opportunities for improvement as a reduction of the number of steps and participants, improving communication, automation, standardization, etc.); and (iii) the application of an innovative process based on the Lean approach and action research in the healthcare industry. This research provides insights for academia, practitioners, management, and society: waste identification and process redesign helps to continue the improvement of operations, increase efficiency, reduce costs, and enhance services, providing benefits to patients, families, hospital employees, and the healthcare system.