Application of Queuing Analytic Theory to Decrease Waiting Times in Emergency Department: Does it Make Sense?

Background: Patients who receive care in an emergency department (ED), are usually unattended while waiting in queues. Objectives: This study was done to determine, whether the application of queuing theory analysis might shorten the waiting times of patients admitted to emergency wards. Patients and Methods: This was an operational study to use queuing theory analysis in the ED. In the first phase, a field study was conducted to delineate the performance of the ED and enter the data obtained into simulator software. In the second phase, "ARENA" software was used for modeling, analysis, creating a simulation and improving the movement of patients in the ED. Validity of the model was confirmed through comparison of the results with the real data using the same instrument. The third phase of the study concerned modeling in order to assess the effect of various operational strategies, on the queue waiting time of patients who were receiving care in the ED. Results: In the first phase, it was shown that 47.7% of the 3000 patient records were cases referred for trauma treatment, and the remaining 52.3% were referred for non-trauma services. A total of 56% of the cases were male and 44% female. Maximum input was 4.5 patients per hour and the minimum input was 0.5 per hour. The average length of stay for patients in the trauma section was three hours, while for the non-trauma section it was four hours. In the second phase, modeling was tested with common scenarios. In the third phase, the scenario with the addition of one or more senior emergency resident(s) on each shift resulted in a decreased length of stay from 4 to 3.75 hours. Moreover, the addition of one bed to the Intensive Care Unit (ICU) and/or Critical Care Unit (CCU) in the study hospital, reduced the occupancy rate of the nursing service from 76% to 67%. By adding another clerk to take electrocardiograms (ECG) in the ED, the average time from a request to performing the procedure is reduced from 26 to 18 minutes. Furthermore, the addition of 50% more staff to the laboratory and specialist consultations led to a 90 minute reduction in the length of stay. It was also shown that earlier consultations had no effect on the length of stay. Conclusions: Application of queuing theory analysis can improve movement and reduce the waiting times of patients in bottlenecks within the ED throughput

Mortality From Cardiovascular Diseases in Sub-saharan Africa, 1990-2013: A Systematic Analysis of Data From the Global Burden of Disease Study 2013

Cardiovascular disease (CVD) has been the leading cause of death in developed countries for most of the last century. Most CVD deaths, however, occur in low- and middle-income, developing countries (LMICs) and there is great concern that CVD mortality and burden are rapidly increasing in LMICs as a result of population growth, ageing and health transitions. In sub-Saharan Africa (SSA), where all countries are part of the LMICs, the pattern, magnitude and trends in CVD deaths remain incompletely understood, which limits formulation of data-driven regional and national health policies

Sialendoscopy increases saliva secretion and reduces xerostomia up to 60 weeks in Sjogren's syndrome patients:a randomized controlled study

OBJECTIVE: To assess the effect of sialendoscopy of the major salivary glands on salivary flow and xerostomia in patients with Sjögren's syndrome (SS). METHODS: Forty-five patients with SS were randomly assigned to a control group (no irrigation, control, n = 15), to irrigation of the major salivary glands with saline (saline, n = 15) or to irrigation with saline followed by corticosteroid application (triamcinolone acetonide in saline, saline/TA, n = 15). Unstimulated whole saliva flow (UWSF), chewing-stimulated whole saliva flow (SWSF), citric acid-stimulated parotid flow, Clinical Oral Dryness Score (CODS), Xerostomia Inventory (XI) and EULAR SS Patient Reported Index (ESSPRI) scores were obtained 1 week before (T0), and 1, 8, 16, 24, 36, 48 and 60 weeks after sialendoscopy. Data were analysed using linear mixed models. RESULTS: Irrespective of the irrigation protocol used, sialendoscopy resulted in an increased salivary flow during follow-up up to 60 weeks. Significant between-group differences in the longitudinal course of outcomes were found for UWSF, SWSF, XI and ESSPRI scores (P = 0.028, P = 0.001, P = 0.03, P = 0.021, respectively). UWSF at 60 weeks was higher compared with T0 in the saline group (median: 0.14 vs median: 0.10, P = 0.02) and in the saline/TA group (median: 0.20, vs 0.13, P = 0.035). In the saline/TA group SWSF at 48 weeks was higher compared with T0 (median: 0.74 vs 0.38, P = 0.004). Increase in unstimulated salivary flow was also reflected in improved CODS, XI and ESSPRI scores compared with baseline. CONCLUSION: Irrigation of the major salivary glands in patients with SS increases salivary flow and reduces xerostomia

Air pollution and hospitalization due to angina pectoris in Tehran, Iran: A time-series study

Background: Health effects of air pollution have been studied in many different parts of the world. Although a fairly large number of studies have explored the cardiovascular impacts of air pollution, because of its unique location we studied the association between air pollutants and hospital admissions due to angina pectoris in Tehran for the first time. Methods: This is a retrospective time-series study. The variables of the study include the levels of five air pollutants - nitrogen dioxide (NO2), carbon monoxide (CO), ozone (O3), sulfur dioxide (SO2), and particulate matter <10 μm in aerodynamic diameter (PM10) - as independent variables; daily hospitalizations due to angina pectoris in 25 academic hospitals in Tehran as the dependent variable; and mean daily temperature and humidity, seasonality, time trend, and day of the week as potential confounders. All variables were measured during a 5-year period from 21 March 1996 to 20 March 2001. The data of mean daily levels of NO2, CO, O3, SO2, and PM10 were collected from one of the stations of Tehran's Air Quality Control Corp. Data were analyzed using Poisson regression models. Relative risks of angina pectoris admissions were calculated for an increase in 1 mg/m3 for CO and 10 μg/m 3 for the other pollutants. Results: Daily admissions due to angina pectoris were significantly related to the CO level, after controlling for confounder effects. Each unit increase in the CO level caused a 1.00934 increase in the number of admissions (95 CI, 1.00359-1.01512). This association was verified with a lag of 1 day. There was no significant association between the other air pollutants and the number of daily admission due to angina pectoris. Conclusions: We found that with increasing levels of the pollutant CO, the number of admissions due to cardiac angina rose. Ischemic heart disease is the leading cause of death in Iran. Air pollution control will reduce the number of this preventable disease and resulting deaths. © 2004 Elsevier Inc. All rights reserved

A network meta-analysis assessing the effectiveness of various radical and conservative surgical approaches regarding recurrence in treating solid/multicystic ameloblastomas

Multiple treatment approaches have been undertaken to reduce the incidence of recurrence in solid/multicystic ameloblastoma (SMA), both conservative and radical. A network meta-analysis (NMA) was conducted to assess and compare the effectiveness of these various treatment approaches concurrently. This study was reported based on the Preferred Reporting Items for Systematic Reviews for Network Meta-Analysis (PRISMA-NMA) statement. PubMed (MEDLINE), ScienceDirect, Scopus, and Web of Science were searched until August 10, 2021. The NMA was conducted using the STATA program. Of 1153 records identified in the search, seven observational studies with 180 patients were included. Six different treatment approaches were identified. Segmental resection ranked highest for reducing the recurrence rate with the highest SUCRA score (77.7), followed by curettage with cryotherapy (66.9) and marginal resection (49.3). Network inconsistencies and publication bias appeared to be absent. According to the Confidence in Network Meta-Analysis (CINeMa) method, the evidence's certainty was low for all comparisons due to imprecision and within-study bias. In conclusion, this study is the first NMA in the field of ameloblastoma. Segmental resection seemed to be the most effective treatment approach for minimizing recurrence in SMA patients. Nevertheless, weak certainty of evidence makes that the results must be regarded with caution

Health in times of uncertainty in the eastern Mediterranean region, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013. Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically. Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60–80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred. Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts.Ali H Mokdad ... Azmeraw T Amare ... et al

Chronic exposure of gingival fibroblasts to TLR2 or TLR4 agonist inhibits osteoclastogenesis but does not affect osteogenesis

Chronic exposure to periodontopathogenic bacteria such as Porphyromonas gingivalis and the products of these bacteria that interact with the cells of the tooth surrounding tissues can ultimately result in periodontitis. This is a disease that is characterized by inflammation-related alveolar bone degradation by the bone-resorbing cells, the osteoclasts. Interactions of bacterial products with Toll-like receptors (TLRs), in particular TLR2 and TLR4, play a significant role in this chronic inflammatory reaction, which possibly affects osteoclastic activity and osteogenic capacity. Little is known about how chronic exposure to specific TLR activators affects these two antagonistic activities. Here, we studied the effect of TLR activation on gingival fibroblasts (GF), cells that are anatomically close to infiltrating bacterial products in the mouth. These were co-cultured with naive osteoclast precursor cells (i.e., monocytes), as part of the peripheral blood mononuclear cells (PBMCs). Activation of GF co-cultures (GF + PBMCs) with TLR2 or TLR4 agonists resulted in a weak reduction of the osteoclastogenic potential of these cultures, predominantly due to TLR2. Interestingly, chronic exposure, especially to TLR2 agonist, resulted in increased release of TNF-α at early time points. This effect, was reversed at later time points, thus suggesting an adaptation to chronic exposure. Monocyte cultures primed with M-CSF + RANKL, led to the formation of bone-resorbing osteoclasts, irrespective of being activated with TLR agonists. Late activation of these co-cultures with TLR2 and with TLR4 agonists led to a slight decrease in bone resorption. Activation of GF with TLR2 and TLR4 agonists did not affect the osteogenic capacity of the GF cells. In conclusion, chronic exposure leads to diverse reactions; inhibitory with naive osteoclast precursors, not effecting already formed (pre-)osteoclasts. We suggest that early encounter of naive monocytes with TLR agonists may result in differentiation toward the macrophage lineage, desirable for clearing bacterial products. Once (pre-)osteoclasts are formed, these cells may be relatively insensitive for direct TLR stimulation. Possibly, TLR activation of periodontal cells indirectly stimulates osteoclasts, by secreting osteoclastogenesis stimulating inflammatory cytokines