The Pitfalls of Overtreatment: Why More Care is not Necessarily Beneficial

A pre-trained language model for emergency department intervention prediction using routine physiological data and clinical narratives

INTRODUCTION

The urgency and complexity of emergency room (ER) settings require precise and swift decision-making processes for patient care. Ensuring the timely execution of critical examinations and interventions is vital for reducing diagnostic errors, but the literature highlights a need for innovative approaches to optimize diagnostic accuracy and patient outcomes. In response, our study endeavors to create predictive models for timely examinations and interventions by leveraging the patient's symptoms and vital signs recorded during triage, and in so doing, augment traditional diagnostic methodologies.

METHODS

Focusing on four key areas-medication dispensing, vital interventions, laboratory testing, and emergency radiology exams, the study employed Natural Language Processing (NLP) and seven advanced machine learning techniques. The research was centered around the innovative use of BioClinicalBERT, a state-of-the-art NLP framework.

RESULTS

BioClinicalBERT emerged as the superior model, outperforming others in predictive accuracy. The integration of physiological data with patient narrative symptoms demonstrated greater effectiveness compared to models based solely on textual data. The robustness of our approach was confirmed by an Area Under the Receiver Operating Characteristic curve (AUROC) score of 0.9.

CONCLUSION

The findings of our study underscore the feasibility of establishing a decision support system for emergency patients, targeting timely interventions and examinations based on a nuanced analysis of symptoms. By using an advanced natural language processing technique, our approach shows promise for enhancing diagnostic accuracy. However, the current model is not yet fully mature for direct implementation into daily clinical practice. Recognizing the imperative nature of precision in the ER environment, future research endeavors must focus on refining and expanding predictive models to include detailed timely examinations and interventions. Although the progress achieved in this study represents an encouraging step towards a more innovative and technology-driven paradigm in emergency care, full clinical integration warrants further exploration and validation.

Physiotherapy-led care versus physician-led care for persons with low back pain: A systematic review

OBJECTIVE

To summarise the evidence on the effect of physiotherapy-led versus physician-led care on clinical outcomes, healthcare use, and costs in persons with low back pain.

DATA SOURCES

PubMed, Web of Science, CINAHL, Embase, and PEDro were systematically searched with the latest search performed in July 2024. Reference lists of articles were hand-searched.

REVIEW METHODS

Studies comparing clinical outcomes, healthcare use, or costs between adults with low back pain first consulting a physiotherapist and those first consulting a physician were included. Methodological quality was assessed with the Newcastle-Ottawa Scale. Study design, clinical setting, patient characteristics, and group effects were extracted. Findings on outcomes assessed in two or more studies were synthesised narratively. Certainty of evidence was determined using the GRADE approach.

RESULTS

Eighteen studies comprising 1,481,980 persons with low back pain were included. Most studies were non-randomised retrospective or prospective cohort studies. In primary care (15 studies), consistent evidence, though of mostly very low certainty, indicated that physiotherapy-led care leads to higher patient satisfaction, less use of medication, injections and imaging, fewer physician's visits, lower total healthcare costs, and less sick leave compared to physician-led care, without increased harm. In emergency care (three studies), evidence of very low certainty showed that physiotherapy-led care leads to shorter waiting and treatment times, and fewer hospital admissions.

CONCLUSION

Physiotherapy-led care is a clinically, time- and cost-effective care pathway for low back pain, although the certainty of evidence was overall very low. Further high-quality research with a greater focus on clinical outcomes is warranted.

Utilization and features of rehabilitation and health services for persons with spinal cord injury

BACKGROUND

The increasing prevalence of individuals experiencing disabilities underscores the importance of rehabilitation. Nevertheless, healthcare systems are already facing financial constraints, which makes it imperative to strive for a more efficient delivery of services. The first step, however, is to understand how the provision of services behaves for patients with different characteristics.

AIM

To determine the most frequently used healthcare services in the (sub)acute phase of rehabilitation of patients with spinal cord injury/disease (SCI/D) and the link with patient characteristics.

DESIGN

Observational cohort study.

POPULATION

This study analyzes the clinical data of patients discharged from a specialized SCI hospital and rehabilitation center in Switzerland.

METHODS

We implemented a compound risk model to estimate the total amount of healthcare services used, defined by length of stay (LOS) and the units per day of health services (sub)acute phase of rehabilitation.

RESULTS

The study included 403 individuals with SCI/D. The analysis of the intensity and severity of healthcare services across different patient and injury characteristics revealed differences in the intensity of healthcare use and variations in the length of stay (LOS). Male patients with a low SCIM upon admission tended to use healthcare services more extensively than female patients. In terms of etiology, therapies were employed more intensively for patients with traumatic SCI (TSCI). In addition, the analysis revealed that variations in the intensity of healthcare services used were more significant than those adjusted for LOS. Ultimately, similar patient groups received comparable quantities of healthcare services at the end of treatment.

CONCLUSIONS

This population-based study provides information for a better understanding of the determinants of health service use during the (sub)acute rehabilitation phase of individuals with SCI/D. When analyzing LOS, intensity, and severity of services, it shows that the use of healthcare services significantly differs for the level of SCIM at admission, age groups, sex, and etiology. However, the variation among individual patients also suggests the presence of other influential modifiers that were not considered in this analysis.

CLINICAL REHABILITATION IMPACT

The approach outlined enables a systematic follow-up of this data analysis by enriching the computed data with additional details about the patient, the patient's treatment, and outcomes.

TB prevention activities in the WHO European Region

BACKGROUND

TB preventive treatment (TPT) is the primary available healthcare intervention to reduce the risk of progression from TB infection to TB disease. The WHO Regional Office for Europe established the European Prevention and Systematic Screening Initiative to End TB (PASS) to scale up activities related to the programmatic management of TPT. In the absence of a system to measure and monitor preventive activities, a baseline assessment survey was carried out to provide a reference to monitor the scale-up of the intervention.

METHODS

This was a semi-structured survey including 52 questions that was developed, implemented in the WHO-hosted LimeSurvey data form and sent to focal points in the 55 countries and territories in the European Region between September and October 2023. The questions covered TPT, systematic screening and infection prevention and control.

RESULTS

A total of 28 questionnaires were returned, corresponding to an overall 51% response rate. Most national policies for TPT and TB screening are in line with the latest WHO guidelines. However, implementation of TB screening, prevention, and infection control activities is lagging. Results are presented separately for high-priority and low-priority countries.

CONCLUSION

The survey identified several important areas that the PASS initiative will focus on to accelerate efforts towards reaching the targets set at the 2027 UN High-Level Meeting on TB for preventive therapy in the European Region. This will require a massive scale-up of efforts and larger investments, as well as coordinated approaches and interventions across the 'cascade' of prevention, from the identification of target populations to the completion of treatment.

The evolution of the treatment of non-small cell lung cancer: A shift in surgical paradigm to a more individualized approach

Surgical treatment is an integral part of the comprehensive therapeutic methods for lung cancer, especially for early-stage non-small cell lung cancer (NSCLC). With a deeper understanding of the disease, we found that lung cancer is more commonly detected in young females. For regions of Asia, more lung cancer has been detected in early-stage GGO-dominant non-smokers. Therefore, surgical strategies have also been reformed commensurate with the shift of the disease spectrum. However, the pursuit of lung-sparing individualized approaches has raised worldwide attention. Suitable surgical treatment within the curative time window is recommended to maximize the long-term benefit. This article summarizes the shift in surgical treatment for small NSCLCs and hopes to enlighten further innovations to fill in the gaps between the unmet needs and a more individualized approach.

Hospital Rating Organizations' Quality and Patient Safety Scores: Analysis of Result Discrepancies

BACKGROUND

In the USA, multiple organizations rate hospitals based on quality and patient safety data, but few studies have analyzed and compared the rating results.

OBJECTIVE

Compare the results of different US hospital-rating organizations.

DESIGN

Observational data analysis of US acute care hospital ratings.

PARTICIPANTS

Four rating organizations: Hospital Compare® (HC), Healthgrades® (HG), The Leapfrog Group® (Leapfrog), and US News and World Report® (USN).

MAIN MEASURES

We analyzed the level of concordance (similar ranking), discordance (difference of 1 or more rankings), and severe discordance (difference of two or more rankings), as well as differences and correlations between the scores.

KEY RESULTS

From Feb 1 to Oct 3, 2023, we analyzed data from 2,384 hospitals. In Leapfrog, there were 688 hospitals (29%) with Grade A, 652 (27.3%) with B, 885 (37.1%) with C, 153 (6.4%) with D, and 6 (0.3%) with F. For HC, 333 hospitals (14%) had five stars, 676 (28.4%) four, 695 (29.2%) three, 502 (21.4%) two, and 171 (7.2%) one-star. In ratings between HC and Leapfrog, discordance was 70%, and severe discordance was 25.1%. USN ranked 469 hospitals (19.7%). Within the USN-ranked hospital group, there was a 62% discordance and 19.8% severe discordance between HC and Leapfrog. The analysis of orthopedic procedures from HG and USN showed discordance ranging from 48 to 61.2%.

CONCLUSION

The rating organizations' reported metrics were highly discordant. A hospital's ranking by one organization frequently did not correspond to a similar ranking by another. The methodology and included timeline and patient population can help explain the differences. However, the discordant ratings may confuse patients and customers.

Analysing false-positive errors when Australian radiographers use preliminary image evaluation

INTRODUCTION

Diagnostic errors in the emergency departments can have major implications on patient outcomes. Preliminary Image Evaluation (PIE) is a brief comment written by a radiographer describing an acute or traumatic pathology on a radiograph and can be used to complement referrer's image interpretation in the absence of the radiologist report. Currently, no studies exist that focus their analysis on false-positive (FP) errors in PIE. The purpose of this study was to investigate the regions of the body that cause the most FP errors and recognise other areas in image interpretation that may need additional attention.

METHODS

A longitudinal retrospective clinical audit was conducted to determine the accuracy of radiographer PIE's over 5 years from January 2016 to December 2020. PIE's were compared to the radiologist report to assess for diagnostic accuracy. FP and unsure errors were further categorised by anatomical region and age.

RESULTS

Over this period, a sample size of 11,090 PIE audits were included in the study demonstrating an overall PIE accuracy of 87.7%. Foot, ankle and chest regions caused the most FP errors, while ankle, shoulder and elbow caused the most unsure cases. 76% of the unsure cases were negative for any pathology when compared to the radiologist report. The paediatric population accounted for 21.3% of FP cases and 33.6% of unsure cases.

CONCLUSION

Findings in this study should be used to tailor education specific to radiographer image interpretation. Improving radiography image interpretation skills can assist in improving referrer diagnostic accuracy, thus improving patient outcomes.

Epidemiology of Renal Replacement Therapy for Critically Ill Patients across Seven Health Jurisdictions

INTRODUCTION

Acute kidney injury (AKI) requiring treatment with renal replacement therapy (RRT) is a common complication after admission to an intensive care unit (ICU) and is associated with significant morbidity and mortality. However, the prevalence of RRT use and the associated outcomes in critically patients across the globe are not well described. Therefore, we describe the epidemiology and outcomes of patients receiving RRT for AKI in ICUs across several large health system jurisdictions.

METHODS

Retrospective cohort analysis using nationally representative and comparable databases from seven health jurisdictions in Australia, Brazil, Canada, Denmark, New Zealand, Scotland, and the USA between 2006 and 2023, depending on data availability of each dataset. Patients with a history of end-stage kidney disease receiving chronic RRT and patients with a history of renal transplant were excluded.

RESULTS

A total of 4,104,480 patients in the ICU cohort and 3,520,516 patients in the mechanical ventilation cohort were included. Overall, 156,403 (3.8%) patients in the ICU cohort and 240,824 (6.8%) patients in the mechanical ventilation cohort were treated with RRT for AKI. In the ICU cohort, the proportion of patients treated with RRT was lowest in Australia and Brazil (3.3%) and highest in Scotland (9.2%). The in-hospital mortality for critically ill patients treated with RRT was almost fourfold higher (57.1%) than those not receiving RRT (16.8%). The mortality of patients treated with RRT varied across the health jurisdictions from 37 to 65%.

CONCLUSION

The outcomes of patients who receive RRT in ICUs throughout the world vary widely. Our research suggests that differences in access to and provision of this therapy are contributing factors.

Medical Maximizing Preferences and Beliefs About Cancer Among US Adults

Importance

Medical overutilization contributes to significant health care expenditures and exposes patients to questionably beneficial surgery and unnecessary risk.

Objectives

To understand public attitudes toward medical utilization and the association of these attitudes with beliefs about cancer.

Design, Setting, and Participants

In this cross-sectional survey study conducted from August 26 to October 28, 2020, US-based, English-speaking adults were recruited from the general public using Prolific Academic, a research participant platform. Quota-filling was used to obtain a sample demographically representative of the US population. Adults with a personal history of cancer other than nonmelanoma skin cancer were excluded. Statistical analysis was completed in July 2022.

Main Outcome and Measures

Medical utilization preferences were characterized with the validated, single-item Maximizer-Minimizer Elicitation Question. Participants preferring to take action in medically ambiguous situations (hereafter referred to as "maximizers") were compared with those who leaned toward waiting and seeing (hereafter referred to as "nonmaximizers"). Beliefs and emotions about cancer incidence, survivability, and preventability were assessed using validated measures. Logistic regression modeled factors associated with preferring to maximize medical utilization.

Results

Of 1131 participants (mean [SD] age, 45 [16] years; 568 women [50.2%]), 287 (25.4%) were classified as maximizers, and 844 (74.6%) were classified as nonmaximizers. Logistic regression revealed that self-reporting very good or excellent health status (compared with good, fair, or poor; odds ratio [OR], 2.01 [95% CI, 1.52-2.65]), Black race (compared with White race; OR, 1.88 [95% CI, 1.22-2.89]), high levels of cancer worry (compared with low levels; OR, 1.62 [95% CI, 1.09-2.42]), and overestimating cancer incidence (compared with accurate estimation or underestimating; OR, 1.58 [95% CI, 1.09-2.28]) were significantly associated with maximizing preferences. Those who believed that they personally had a higher-than-average risk of developing cancer were more likely to be maximizers (23.6% [59 of 250] vs 17.4% [131 of 751]; P = .03); this factor was not significant in regression analyses.

Conclusions and Relevance

In this survey study of US adults, those with medical maximizing tendencies more often overestimated the incidence of cancer and had higher levels of cancer-related worry. Targeted and personalized education about cancer and its risk factors may help reduce overutilization of oncologic care.

Aseptic versus clean technique during wound management? Systematic review with meta-analysis

The management of wounds by health professionals usually involves aseptic technique. An alternative is the use of clean techniques where the risk of infection is minimised but use of non-sterile materials is considered permissible. This systematic review and meta-analysis compares these two approaches. Nine studies met the inclusion criteria. Overall risk of bias was judged to be low. The random-effects relative risk of infection for clean dressings rather than aseptic dressings was 0.86 (95% CI 0.67, 1.12). There was little evidence of statistical heterogeneity, although the small number of infections in either group resulted in wide confidence intervals. The 95% prediction interval for future studies was 0.63, 1.18. There was therefore no evidence showing inferiority of clean techniques compared to aseptic methods. Before clinical studies are undertaken with higher risk procedures, laboratory simulations should explore safety by investigating the potential for pathogen transmission at each stage in the dressing procedure.

Stretching oneself too thin and facing ethical challenges: Healthcare professionals' experiences during the COVID-19 pandemic

BACKGROUNDS

Most countries are facing increased pressure on healthcare resources. A better understanding of how healthcare providers respond to new demands is relevant for future pandemics and other crises.

OBJECTIVES

This study aimed to explore what nurses and doctors in Norway reported as their main ethical challenges during two periods of the COVID-19 pandemic: February 2021 and February 2022.

RESEARCH DESIGN

A longitudinal repeated cross-sectional study was conducted in the Western health region of Norway. The survey included an open-ended question about ethical challenges among doctors and nurses in hospital departments. Free-text comments were analysed using Systematic Text Condensation and also presented in a frequency table.

ETHICAL CONSIDERATIONS

Ethical approval was granted by the Regional Research Ethics Committee in Western Norway (131,421). All participants provided consent when participating in the study.

RESULTS

In 2021, 249 and in 2022, 163 healthcare professionals responded to the open-ended question. Nurses and doctors reported three main categories of ethical challenges related to the COVID-19 pandemic: (1) barriers that hindered them in acting as they ethically would have wanted to do; (2) priority-setting dilemmas linked to overtreatment, transfer of resources and ranking patient needs; and (3) workload expansion threatening work-life balance and employees' health. Category one comprised of resource barriers, regulatory barriers, system barriers, and personal barriers. Regulatory barriers, especially visitor restrictions for next-of-kin, were the most frequently reported in 2021. Resource barriers, related to the increased scarcity of qualified staff, were most frequently reported in 2022. Clinicians stretched themselves thin to avoid compromising on care, diagnostics, or treatment.

CONCLUSIONS

Developing clinicians' ability to handle and cope with limited healthcare resources is necessary. To foster resilience and sustainability, healthcare leaders, in collaboration with their staff, should ensure fair priority-setting and initiate reflections among doctors and nurses on what it implies to provide 'good enough' care.

Chronic Obstructive Pulmonary Disease Overdiagnosis and Overtreatment: A Meta-Analysis

This meta-analysis of observational studies aimed at estimating the overall prevalence of overdiagnosis and overtreatment in subjects with a clinical diagnosis of Chronic Obstructive Pulmonary Disease (COPD). MedLine, Scopus, Embase and Cochrane databases were searched, and random-effect meta-analyses of proportions were stratified by spirometry criteria (Global Initiative for COPD (GOLD) or Lower Limit of Normal (LLN)), and setting (hospital or primary care). Forty-two studies were included. Combining the data from 39 datasets, including a total of 23,765 subjects, the pooled prevalence of COPD overdiagnosis, according to the GOLD definition, was 42.0% (95% Confidence Interval (CI): 37.3-46.8%). The pooled prevalence according to the LLN definition was 48.2% (40.6-55.9%). The overdiagnosis rate was higher in primary care than in hospital settings. Fourteen studies, including a total of 8183 individuals, were included in the meta-analysis estimating the prevalence of COPD overtreatment. The pooled rates of overtreatment according to GOLD and LLN definitions were 57.1% (40.9-72.6%) and 36.3% (17.8-57.2%), respectively. When spirometry is not used, a large proportion of patients are erroneously diagnosed with COPD. Approximately half of them are also incorrectly treated, with potential adverse effects and a massive inefficiency of resources allocation. Strategies to increase the compliance to current guidelines on COPD diagnosis are urgently needed.

Patients With Hypertrophic Cardiomyopathy and Normal Genetic Investigations Have Few Affected Relatives

BACKGROUND

Current guidelines recommend that relatives of index patients with hypertrophic cardiomyopathy (HCM) are offered clinical investigations to identify individuals at risk of adverse disease complications and sudden cardiac death. However, the value of family screening in relatives of index patients with a normal genetic investigation of recognized HCM genes is largely unknown.

OBJECTIVES

The purpose of this study was to perform family screening among relatives of HCM index patients with a normal genetic investigation to establish the frequency of familial disease and the clinical characteristics of affected individuals.

METHODS

Clinical and genetic investigations were performed in consecutive and unrelated HCM index patients. Relatives of index patients who did not carry pathogenic/likely pathogenic variants in recognized HCM genes were invited for clinical investigations.

RESULTS

In total, 60% (270 of 453) of HCM index patients had a normal genetic investigation. A total of 80% of their relatives (751 of 938, median age 44 years) participated in the study. Of these, 5% (34 of 751) were diagnosed with HCM at baseline, whereas 0.3% (2 of 717 [751-34]) developed the condition during 5 years of follow-up. Their median age at diagnosis was 57 years (IQR: 51-70 years). Two-thirds (22 of 36) were diagnosed following family screening, whereas one-third (14 of 36) had been diagnosed previously because of cardiac symptoms, a murmur, or an abnormal electrocardiogram. None of the affected relatives experienced adverse disease complications. The risk of SCD was low.

CONCLUSIONS

Systematic family screening of index patients with HCM and normal genetic investigations was associated with a low frequency of affected relatives who appeared to have a favorable prognosis.

Interpretation of the Patient Health Questionnaire 9 in High-Impact Chronic Pain: Do We Measure Depressive Symptoms the Way We Think?

OBJECTIVES

Depression is prevalent among patients with chronic pain and may impact pain management. An accurate assessment is, however, complicated by overlapping symptoms. This study investigated how patients with high-impact chronic pain interpreted and responded to the Patient Health Questionnaire 9 (PHQ-9) to identify problematic items and causes hereof.

MATERIALS AND METHODS

Cognitive interviews using the Three-Step Test-Interview procedure were conducted during the completion of the PHQ-9 in 33 patients with high-impact chronic pain referred to interdisciplinary treatment. Responses were analyzed using 4 coding categories: (1) "congruent" (response consistent with intention); (2) "incongruent" (response not consistent intention); (3) "ambiguous" (response both congruent and incongruent or insufficient to evaluate congruency); and (4) "confused" (response with confused or misunderstood statements). Next, the content of responses to problematic items was analyzed to identify causes for noncongruency, and encountered response difficulties were identified across all items.

RESULTS

Three items (items 2, 6, and 9) performed as intended (>97% congruent responses), while 7 items (items 1, 3, 4, 5, 7, 8, and 10) were identified as problematic (<50% congruent responses). Problematic items had 1 or more issues: Responses were based on (1) pain-related issues or (2) other (non-pain) factors unrelated to depression, or item structure caused response difficulties due to wordings, reversion, or having 2 questions in 1.

DISCUSSION

Problematic items limit the construct validity of the PHQ-9, leaving an increased risk of inflated depression scores in high-impact chronic pain. Identified problems should guide future revisions to enhance validity and screening accuracy for the benefit of both research and clinical practice.

Understanding Discordant Perceptions of Disease Severity Between Physicians and Patients With Eczema and Psoriasis Using Structural Equation Modeling

Importance

Patients and physicians often have differing opinions on the patient's disease severity. This phenomenon, termed discordant severity grading (DSG), hinders the patient-physician relationship and is a source of frustration.

Objective

To test and validate a model explaining the cognitive, behavioral, and disease factors associated with DSG.

Design, Setting, and Participants

A qualitative study was first performed to derive a theoretical model. In this subsequent prospective cross-sectional quantitative study, the qualitatively derived theoretical model was validated using structural equation modeling (SEM). Recruitment was conducted between October 2021 and September 2022. This was a multicenter study in 3 Singapore outpatient tertiary dermatological centers. Dermatology patients and their attending physicians were recruited by convenience sampling. Patients were aged 18 to 99 years with psoriasis or eczema of at least 3 months' duration and recruited only once. The data were analyzed between October 2022 to May 2023.

Main Outcomes and Measures

The outcome was the difference between global disease severity (0-10 numerical rating scale with a higher score indicating greater severity) as independently scored by the patient and the dermatologist. Positive discordance was defined as patient-graded severity more than 2 points higher (graded more severely) than physicians, and negative discordance if more than 2 points lower than physicians. Confirmatory factor analysis followed by SEM was used to assess the associations between preidentified patient, physician, and disease factors with the difference in severity grading.

Results

Of the 1053 patients (mean [SD] age, 43.5 [17.5] years), a total of 579 (55.0%) patients were male, 802 (76.2%) had eczema, and 251 (23.8%) had psoriasis. Of 44 physicians recruited, 20 (45.5%) were male, 24 (54.5%) were aged between 31 and 40 years, 20 were senior residents or fellows, and 14 were consultants or attending physicians. The median (IQR) number of patients recruited per physician was 5 (2-18) patients. Of 1053 patient-physician pairs, 487 pairs (46.3%) demonstrated discordance (positive, 447 [42.4%]; negative, 40 [3.8%]). Agreement between patient and physician rating was poor (intraclass correlation, 0.27). The SEM analyses showed that positive discordance was associated with higher symptom expression (standardized coefficient B = 0.12; P = .02) and greater quality-of-life impairment (B = 0.31; P < .001), but not patient or physician demographics. A higher quality-of-life impairment was in turn associated with lower resilience and stability (B = -0.23; P < .001), increased negative social comparisons (B = 0.45; P < .001), lower self-efficacy (B = -0.11; P = .02), increased disease cyclicity (B = 0.47; P < .001), and greater expectation of chronicity (B = 0.18; P < .001). The model was well-fitted (Tucker-Lewis: 0.94; Root Mean Square Error of Approximation: 0.034).

Conclusions and Relevance

This cross-sectional study identified various modifiable contributory factors to DSG, increased understanding of the phenomenon, and set a framework for targeted interventions to bridge this discordance.

The Need for Green and Responsible Medical Informatics and Digital Health: Looking Forward with One Digital Health

One Health is an important initiative to view the world in a more integrative sense of our health and environment. Digital Health provides essential support to all of us as healthcare professionals and customers. One Digital Health (ODH) combines both One Health and Digital Health to provide a technologically integrative view. ODH gives an essential place to the environment and ecosystems. Thus, health technologies and digital health must be "green" and eco-friendly as much as possible. We suggest in this position paper examples of developing and implementing ODH-related concepts, systems, and products with a respectful consideration of the environment. For humans and animals, developing cutting-edge technologies to improve wellness and healthcare is critical. Nevertheless, we can learn from One Health that digitalization and so One Digital Health must be built to implement green, eco-friendly, and responsible thinking.

Treatment of Hyperhidrosis: An Update

Hyperhidrosis is a dermatosis presenting as pathologically excessive focal or generalized sweating. The stigmatizing nature of hyperhidrosis may cause patients to feel embarrassment and apprehension about their symptoms and experience a significant decrease in well-being. Severe cases of hyperhidrosis can also increase the risk of developing psychiatric and somatic comorbidities. Conventional non-surgical treatments of hyperhidrosis include aluminum salts, iontophoresis, botulinum toxin injections, and oral glycopyrronium. In recent years, new topical anticholinergic medications and devices have emerged that may improve the patients' symptoms and even prevent the development of comorbidities. The treatment of hyperhidrosis can be a complex matter and may require the combination of several therapies. The purpose of this paper was to firstly review the literature on existing non-surgical treatment options for hyperhidrosis, and secondly provide a stepwise approach to investigating and treating patients with hyperhidrosis.

Machine learning-based suggestion for critical interventions in the management of potentially severe conditioned patients in emergency department triage

Providing timely intervention to critically ill patients is a challenging task in emergency departments (ED). Our study aimed to predict early critical interventions (CrIs), which can be used as clinical recommendations. This retrospective observational study was conducted in the ED of a tertiary hospital located in a Korean metropolitan city. Patient who visited ED from January 1, 2016, to December 31, 2018, were included. Need of six CrIs were selected as prediction outcomes, namely, arterial line (A-line) insertion, oxygen therapy, high-flow nasal cannula (HFNC), intubation, Massive Transfusion Protocol (MTP), and inotropes and vasopressor. Extreme gradient boosting (XGBoost) prediction model was built by using only data available at the initial stage of ED. Overall, 137,883 patients were included in the study. The areas under the receiver operating characteristic curve for the prediction of A-line insertion was 0·913, oxygen therapy was 0.909, HFNC was 0.962, intubation was 0.945, MTP was 0.920, and inotropes or vasopressor administration was 0.899 in the XGBoost method. In addition, an increase in the need for CrIs was associated with worse ED outcomes. The CrIs model was integrated into the study site's electronic medical record and could be used to suggest early interventions for emergency physicians.