What influences the public's willingness to report health insurance fraud in familiar or unfamiliar healthcare settings? a cross-sectional study of the young and middle-aged people in China.

INTRODUCTION: Young and middle-aged people are important participants in the fight against health insurance fraud. The study aims to investigate the differences in their willingness to report health insurance fraud and the factors influencing it when it occurs in familiar or unfamiliar healthcare settings. METHODS: Data were obtained from a validated questionnaire from 828 young and middle-aged people. McNemar's test was used to compare the public's willingness to report under the two scenarios. Chi-square tests and multiple logistic regression analysis were used to analyze the determinants of individuals' willingness to report health insurance fraud in different scenarios. RESULTS: Young and middle-aged people were more likely to report health insurance fraud in a familiar healthcare setting than in an unfamiliar one (McNemar's χ²=26.51, P < 0.05). Their sense of responsibility for maintaining the security of the health insurance fund, the government's openness about fraud cases, and the perception of their ability to report had significant positive effects on the public's willingness to report in both settings (P < 0.05). In a familiar healthcare setting, the more satisfied the public is with government measures to protect whistleblowers, the more likely they are to report (OR = 1.44, P = 0.025). Those who perceive the consequences of health insurance fraud to be serious are more likely to report than those who perceive the consequences to be less serious (OR = 1.61, P = 0.042). CONCLUSION: Individuals are more likely to report health insurance fraud in familiar healthcare settings than in unfamiliar ones, in which their awareness of the severity of the consequences of health insurance fraud and their perceived risk after reporting it play an important role. The government's publicizing of fraud cases and enhancing the public's sense of responsibility and ability to maintain the safety of the health insurance fund may be a way to increase their willingness to report, regardless of whether they are familiar with the healthcare setting or not.

Pro-inflammatory diet and depressive symptoms in the healthcare setting.

BACKGROUND: Depression is a highly prevalent disease affecting more than 350 million people and has recently been associated with low-grade chronic inflammation. The role of diet in the development of a pro-inflammatory state was demonstrated in a recent study that found a high Empirical Dietary Inflammatory Index (EDII) score was associated with increased concentrations of circulating plasma inflammatory markers. It is becoming increasingly clear that diet and depression are linked, but the relationship itself has not been determined with absolute certainty. Pharmacologic and device assisted therapies are considered our most advanced treatments for major depressive disorder, though numerous studies suggest that they are not sufficient. Exploring the relationship of a pro-inflammatory diet and depressive symptoms is crucial for a holistic, evidenced-based approach to treating depression. METHODS: Our study investigated this association using the EDII to evaluate the inflammatory potential of diet and Patient Health Questionnaire-9 (PHQ-9) to score depression among healthcare personnel. Results from 631 participants were collected for analysis using REDCap software. RESULTS: High PHQ-9 scores and high EDII scores were significantly correlated (F = 18.32, p < 0.0001) even when accounting for gender, psychiatric diagnosis, physical exercise, and spiritual exercise. CONCLUSIONS: Our findings suggest that anti-inflammatory diets can play a key role in the treatment of depression.

The components of personal passports for people living with dementia in an acute healthcare setting: an integrative review.

AIM: To explore the components of personal passports for people living with dementia in an acute healthcare setting. BACKGROUND: Globally, supporting people with dementia poses a prominent health and social care challenge. Importance for people with dementia in an acute healthcare setting includes social relationships and communication with healthcare staff. A personal passport is an international initiative designed to support the personhood of the person living with dementia. METHODS: This integrative review is based on the methodology of Whittmore and Knafl (2005). The Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist were adhered to. A database search of PubMed, MEDLINE, CINAHL, Scopus and EBSCO databases was systematically performed. RESULTS: This integrative review identified nine research studies on the components of personal passports that met the inclusion and exclusion criteria. A constant comparative method of data analysis identified five key pivotal themes: person-centredness, communication, family/carer involvement, education and leadership. CONCLUSION: The use of personal passports supports the provision of person-centred care for people living with dementia through enhancing the well-being of both the person and their families/caregivers. RELEVANCE TO CLINICAL PRACTICE: Personal passports are an important document and should be determined by the person with dementia, their care needs and the caregiver's role in meeting these needs.

The Influence of Face Masks on Verbal Communication in Persian in the Presence of Background Noise in Healthcare Staff.

Wearing face masks has resulted in verbal communication being more challenging during the COVID-19 pandemic. This study aimed to investigate the effect of face masks on the speech comprehensibility of Persian nurses in healthcare settings. Twenty female nurses from the governmental hospitals randomly participated in an experiment on seven typical commercial face masks at two background noise levels. Nurses' speech intelligibility from a human talker when wearing each face mask was determined based on the speech discrimination score. The vocal effort of nurses wearing each face mask was determined based on the Borg CR10 scale. Based on the linear mixed model, the speech intelligibility of nurses from a human speaker wearing surgical masks, N95 masks, and a shield with face masks were approximately 10%, 20%, and 40-50% lower, respectively, than no-mask conditions (p < 0.01). The background noise decreased the speech intelligibility of nurses by approximately 22% (p < 0.01). The use of a face shield further decreased speech intelligibility up to 30% compared to using a face mask alone (p < 0.01). The vocal efforts of nurses when wearing surgical masks were not significant compared with the baseline vocal efforts (p > 0.05); however, vocal efforts of nurses when wearing N95 and N99 respirators were at an unacceptable level. The face masks had no considerable effect on the speech spectrum below 2.5 kHz; however, they reduced high frequencies by different values. Wearing face masks has a considerable impact on the verbal communication of nurses in Persian. The level of background noise in the healthcare setting can aggravate the effect sizes of face masks on speech comprehensibility.

Risk factors for antibiotic resistance development in healthcare settings in China: a systematic review.

Antibiotic resistance (ABR) threatens the effectiveness of infectious disease treatments and contributes to increasing global morbidity and mortality. In this study, we systematically reviewed the identified risk factors for ABR among people in the healthcare system of mainland China. Five databases were systematically searched to identify relevant articles published in either English and Chinese between 1 January 2003 and 30 June 2019. A total of 176 facility-based references were reviewed for this study, ranging across 31 provinces in mainland China and reporting information from over 50 000 patients. Four major ABR risk factor domains were identified: (1) sociodemographic factors (includes migrant status, low income and urban residence), (2) patient clinical information (includes disease status and certain laboratory results), (3) admission to healthcare settings (includes length of hospitalisation and performance of invasive procedures) and (4) drug exposure (includes current or prior antibiotic therapy). ABR constitutes an ongoing major public health challenge in China. The healthcare sector-associated risk factors was the most important aspect identified in this review and need to be addressed. Primary health care system and ABR surveillance networks need to be further strengthened to prevent and control the communicable diseases, over-prescription and overuse of antibiotics.

Perceived poverty and health, and their roles in the poverty-health vicious cycle: a qualitative study of major stakeholders in the healthcare setting in Hong Kong.

BACKGROUND: Poverty and ill-health are closely inter-related. Existing studies on the poverty-health vicious cycle focus mainly on less developed countries, where the identified mechanisms linking between poverty and ill-health may not fit the situations in developed Asian regions. This study aims to qualitatively explore the perceived mechanisms and drivers of the poverty-health vicious cycle among major stakeholders in the healthcare setting in Hong Kong. METHODS: Data were collected via focus group interviews with social workers (n = 8), chronically ill patients (n = 8), older adults (n = 6), primary care doctors (n = 7) and informal caregivers (n = 10). The transcribed data were then closely read to capture key themes using thematic analyses informed by social constructivism. RESULTS: In this highly developed Asian setting with income inequality among the greatest in the world, the poverty-health vicious cycle operates. Material and social constraints, as a result of unequal power and opportunities, appear to play a pivotal role in creating uneven distribution of social determinants of health. The subsequent healthcare access also varies across the social ladder under the dual-track healthcare system in Hong Kong. As health deteriorates, financial hardship is often resulted in the absence of sufficient and coordinated healthcare, welfare and labour policy interventions. In addition to the mechanisms, policy drivers of the cycle were also discussed based on the respondents' perceived understanding of the nature of poverty and its operationalization in public policies, as well as of the digressive conceptions of disease among different stakeholders. CONCLUSIONS: The poverty-health vicious cycle has remained a great challenge in Hong Kong despite its economic prosperity. To break the cycle, potential policy directions include the adoption of proportionate universalism, social integration and the strengthening of medical-social collaboration.

The validation of organisational culture assessment instrument in healthcare setting: results from a cross-sectional study in Vietnam.

BACKGROUND: Organisational culture (OC) has increasingly become a crucial factor in defining healthcare practice and management. However, there has been little research validating and adapting OCAI (organisational culture assessment instrument) to assess OC in healthcare settings in developing countries, including Vietnam. The purpose of this study is to validate the OCAI in a hospital setting using key psychometric tests and confirmatory factor analysis (CFA). METHODS: This is a cross-sectional study. Self-administered structured questionnaire was completed by 566 health professionals from a Vietnamese national general hospital, the General Hospital of Quang Nam province. The psychometric tests and CFA were utilized to detect internal reliability and construct validity of the instrument. RESULTS: The Cronbach's alpha coefficients (α-reliability statistic) ranged from 0.6 to 0.8. In current culture, the coefficient was 0.80 for clan and 0.60 for adhocracy, hierarchy and market dimension, while in expected culture, the coefficient for clan, adhocracy, hierarchy, and market dimension was 0.70, 0.70, 0.70 and 0.60, respectively. The CFA indicated that most factor loading coefficients were of moderate values ranging from 0.30 to 0.60 in both current and expected culture model. These models are of marginal good fit. CONCLUSIONS: The study findings suggest that the OCAI be of fairly good reliability and construct validity in measuring four types of organisational culture in healthcare setting in resource-constrained countries such as Vietnam. This result is a first step towards developing a valid Vietnamese version of the OCAI which can also provide a strong case for future research in the field of measuring and managing organisational culture.

[COVID-19 in accommodation facilities for dependent elderly, testimony from a healthcare executive]. / La Covid-19 en Ehpad, témoignage d'un cadre de santé.

Sunday, day of rest in a pavilion of Seine-Saint-Denis in this so particular period of confinement because of the coronavirus disease 2019. Time seems to stand still. A healthcare executive shares his experiences at the "Les 4 Saisons" accommodation facility for dependent elderly, located in Bagnolet.

Multicenter Pivotal Clinical Trial of Urine Malaria Test for Rapid Diagnosis of Plasmodium falciparum Malaria.

The need to expand malaria diagnosis capabilities alongside policy requirements for mandatory testing before treatment motivates exploration of noninvasive rapid diagnostic tests (RDTs). We report the outcome of the first cross-sectional, single-blind clinical performance evaluation of a urine malaria test (UMT) for diagnosis of Plasmodium falciparum malaria in febrile patients. Matched urine and finger-prick blood samples from participants ≥2 years of age with fever (axillary temperature of ≥37.5°C) or with a history of fever in the preceding 48 h were tested with UMT and microscopy (as the gold standard). BinaxNOW (Pf and Pan versions) blood RDTs were done to assess relative performance. Urinalysis and rheumatoid factor (RF) tests were conducted to evaluate possible interference. Diagnostic performance characteristics were computed at 95% confidence intervals (CIs). Of 1,800 participants screened, 1,691 were enrolled; of these 566 (34%) were febrile, and 1,125 (66%) were afebrile. Among enrolled participants, 341 (20%) tested positive by microscopy, 419 (25%) were positive by UMT, 676 (40%) were positive by BinaxNOW Pf, and 368 (22%) were positive by BinaxNow Pan. UMT sensitivity among febrile patients (for whom the test was indicated) was 85%, and specificity was 84%. Among febrile children ≤5 years of age, UMT sensitivity was 93%, and specificity was 83%. The area under the receiver-operator characteristic curve (AUC) of UMT (0.84) was not significantly different from that of BinaxNOW Pf (0.86) or of BinaxNOW Pan (0.87), indicating that the tests do not differ in overall performance. Gender, seasons, and RF did not impact UMT performance. Leukocytes, hematuria, and urobilinogen concentrations in urine were associated with lower UMT specificities. UMT performance was comparable to that of the BinaxNOW Pf/Pan tests, making UMT a promising tool to expand malaria testing in public and private health care settings where there are challenges to blood-based malaria diagnosis testing.

Evaluation of opt-out inpatient HIV screening at an urban teaching hospital.

This study evaluated opt-out inpatient HIV screening delivered by admitting physicians, and compared number of HIV tests and diagnoses to signs and symptoms-directed HIV testing (based on physician orders) in the emergency department (ED). The opt-out inpatient HIV screening program was conducted over a one year period in patients who were admitted to the 386-bed University of California San Diego (UCSD) teaching hospital. Numbers of HIV tests and diagnoses were compared to those observed among ED patients who underwent physician-directed HIV testing during the same time period. Survey data were collected from a convenience sample of patients and providers regarding the opt-out testing program. Among 8488 eligible inpatients, opt-out HIV testing was offered to 3017 (36%) patients, and rapid antibody testing was performed in 1389 (16.4%) inpatients, resulting in 6 (0.4% of all tests) newly identified HIV infections (5/6 were admitted through the ED). Among 27,893 ED patients, rapid antibody testing was performed in 88 (0.3%), with 7 (8.0% of all tests) new HIV infections identified. HIV diagnoses in the ED were more likely to be men who have sex with men (MSM) (p = 0.029) and tended to have AIDS-related opportunistic infections (p = 0.103) when compared to HIV diagnoses among inpatients. While 85% of the 150 physicians who completed the survey were aware of the HIV opt-out screening program, 44% of physicians felt that they did not have adequate time to consent patients for the program, and only 30% agreed that a physician is best-suited to consent patients. In conclusion, the yield of opt-out HIV rapid antibody screening in inpatients was comparable to the national HIV prevalence average. However, uptake of screening was markedly limited in this setting where opt-out screening was delivered by physicians during routine care, with limited time resources being the major barrier.

Optimal control of vaccination rate in an epidemiological model of Clostridium difficile transmission.

The spore-forming, gram-negative bacteria Clostridium difficile can cause severe intestinal illness. A striking increase in the number of cases of C. difficile infection (CDI) among hospitals has highlighted the need to better understand how to prevent the spread of CDI. In our paper, we modify and update a compartmental model of nosocomial C. difficile transmission to include vaccination. We then apply optimal control theory to determine the time-varying optimal vaccination rate that minimizes a combination of disease prevalence and spread in the hospital population as well as cost, in terms of time and money, associated with vaccination. Various hospital scenarios are considered, such as times of increased antibiotic prescription rate and times of outbreak, to see how such scenarios modify the optimal vaccination rate. By comparing the values of the objective functional with constant vaccination rates to those with time-varying optimal vaccination rates, we illustrate the benefits of time-varying controls.

HIV stigma intervention in a low-HIV prevalence setting: a pilot study in an Egyptian healthcare facility.

This pilot study is the first to evaluate stigma-reduction intervention in a healthcare setting in Egypt and in the Middle East and North Africa region. It also contributes to knowledge on how to address stigma in low-HIV prevalence settings. A quasi-experimental study design was used to evaluate the effect of anti-HIV stigma intervention in one hospital in Egypt. A control hospital was selected and matched to the intervention hospital by type, size and location. The intervention focused on HIV-related stigma, infection control and medical ethics. Stigma was measured at baseline and at three months post-intervention. A standardized, 10-point scale was developed to measure stigmatizing attitudes and fear-based stigma among participants. Comparisons of overall and job-stratified stigma scores were made across the intervention and control hospitals, before and after the intervention, using two-sample t-test and multivariate regression analysis. Mean stigma scores did not reveal significant differences between the intervention and control hospitals at baseline. After intervention, the overall value-based and fear-based stigma scores were significantly lower in the intervention hospital compared to the control hospital (2.1 and 1.1 compared to 3.8 and 3.2, respectively; p < .001). Context-specific and culturally appropriate HIV stigma-reduction interventions in low-HIV prevalence settings can reduce fear-based and value-based stigma among physicians and nurses.

Use of safety-engineered devices by healthcare workers for intravenous and/or phlebotomy procedures in healthcare settings: a systematic review and meta-analysis.

BACKGROUND: The acquisition of needle-stick injuries (NSI) in a healthcare setting poses an occupational hazard of transmitting blood-borne pathogens from patients to healthcare workers (HCWs). The objective of this study was to systematically review the evidence about the efficacy and safety of using safety-engineered intravenous devices and safety-engineered phlebotomy devices by HCWs. METHODS: We included randomized and non-randomized studies comparing safety-engineered devices to conventional/standard devices that lack safety features for delivering intravenous injections and/or for blood-withdrawal procedures (phlebotomy). The outcomes of interest included NSI rates, and blood-borne infections rates among HCWs and patients. We conducted an extensive literature search strategy using the OVID interface in October 2013. We followed the standard methods for study selection and data abstraction. When possible, we conducted meta-analyses using a random-effects model. We used the GRADE methodology to assess the quality of evidence by outcome. RESULTS: We identified twenty-two eligible studies: Twelve assessed safety-engineered devices for intravenous procedures, five for phlebotomy procedures, and five for both. Twenty-one of those studies were observational while one was a randomized trial. All studies assessed the reduction in NSIs among HCWs. For safety-engineered intravenous devices, the pooled relative risk for NSI per HCW was 0.28 [0.13, 0.59] (moderate quality evidence). The pooled relative risk for NSI per device used or procedure performed was 0.34 [0.08,1.49] (low quality evidence). For safety-engineered phlebotomy devices, the pooled relative risk for NSI per HCW was 0.57 [0.38, 0.84] (moderate quality evidence). The pooled relative risk for NSI per device used or procedure performed was 0.53 [0.43,0.65] (moderate quality evidence). We identified no studies assessing the outcome of blood-borne infections among healthcare workers or patients. CONCLUSION: There is moderate-quality evidence that the use of safety-engineered devices in intravenous injections and infusions, and phlebotomy (blood-drawing) procedures reduces NSI rates of HCWs.

Integrating intervention for substance use disorder in a healthcare setting: practice and outcomes in New York City STD clinics.

OBJECTIVE: This article reports the integration and outcomes of implementing intervention services for substance use disorder (SUD) in three New York City public sexually transmitted disease (STD) clinics. METHODS: The screening, brief intervention, and referral to treatment (SBIRT) service model was implemented in the STD clinics in 2008. A relational database was developed, which included screening results, service dispositions, face-to-face interviews with 6-month follow-ups, and treatment information. RESULTS: From February 2008 to the end of September 2012, 146,657 STD clinic patients 18 years or older were screened for current or past substance use disorders; 15,687 received a brief intervention; 954 received referrals to formal substance abuse treatment; 2082 were referred to substance abuse support services such as Alcoholics Anonymous (AA), and 690 were referred to mental health, social or HIV awareness services. Intervention services delivered through SBIRT resulted in improvements in multiple outcomes at 6 month follow-up. Patients who received interventions had reduced SUD risks, fewer mental health problems, and fewer unprotected sexual contacts. CONCLUSION: Delivery of SUD services in a public health setting represents a significant policy and practice change and benefits many individuals whose SUDs might otherwise be overlooked. Intervention services for substance use disorder were integrated and highly utilized in the STD setting. Further research needs to focus on the long-term impact of SUD interventions in the STD setting, their cost effectiveness, and the extent they are financially sustainable under the new healthcare law.

Performance evaluation of a novel personalized ventilation-personalized exhaust system for airborne infection control.

In the context of airborne infection control, it is critical that the ventilation system is able to extract the contaminated exhaled air within the shortest possible time. To minimize the spread of contaminated air exhaled by occupants efficiently, a novel personalized ventilation (PV)-personalized exhaust (PE) system has been developed, which aims to exhaust the exhaled air as much as possible from around the infected person (IP). The PV-PE system was studied experimentally for a particular healthcare setting based on a typical consultation room geometry and four different medical consultation positions of an IP and a healthy person (HP). Experiments using two types of tracer gases were conducted to evaluate two types of PE: Top-PE and Shoulder-PE under two different background ventilation systems: Mixing Ventilation and Displacement Ventilation. Personalized exposure effectiveness, intake fraction (iF) and exposure reduction (ε) were used as indices to evaluate the PV-PE system. The results show that the combined PV-PE system for the HP achieves the lowest intake fraction; and the use of PE system for the IP alone shows much better performance than using PV system for the HP alone.

Prejudices and perceptions: patient acceptance of mobile technology use in health care.

mHealth is transforming health care, yet few studies have evaluated patient and carer perceptions of the use of smartphones at the patient bedside. In this study, 70 patients and carers answered a short survey on health professionals' use of mobile devices. Half the participants were tolerant of doctors using such devices if it was work-related; others believed it was a distraction and not beneficial to patient care. Changes in practice and patient education may be needed to enable effective use of mobile devices in health.

Grip strength and its determinants among older people in different healthcare settings.

BACKGROUND: low muscle strength is central to geriatric syndromes including sarcopenia and frailty. It is well described in community-dwelling older people, but the epidemiology of grip strength of older people in rehabilitation or long-term care has been little explored. OBJECTIVE: to describe grip strength of older people in rehabilitation and nursing home settings. DESIGN: cross-sectional epidemiological study. SETTING: three healthcare settings in one town. SUBJECTS: hundred and one inpatients on a rehabilitation ward, 47 community rehabilitation referrals and 100 nursing home residents. METHODS: grip strength, age, height, weight, body mass index, number of co-morbidities and medications, Barthel score, Mini-Mental State Examination (MMSE), nutritional status and number of falls in the last year were recorded. RESULTS: grip strength differed substantially between healthcare settings for both men and women (P < 0.0001). Nursing home residents had the lowest age-adjusted mean grip strength and community rehabilitation referrals the highest. Broadly higher grip strength was associated in univariate analyses with younger age, greater height and weight, fewer comorbidities, higher Barthel score, higher MMSE score, better nutritional status and fewer falls. However, after mutual adjustment for these factors, the difference in grip strength between settings remained significant. The Barthel score was the characteristic most strongly associated with grip strength. CONCLUSIONS: older people in rehabilitation and care home settings had lower grip strength than reported for those living at home. Furthermore grip strength varied widely between healthcare settings independent of known major influences. Further research is required to ascertain whether grip strength may help identify people at risk of adverse health outcomes within these settings.

Healthcare Experience of Pediatric Patients with Autism Spectrum Disorders in Saudi Arabia: A Cross-Sectional Study.

Children with autism spectrum disorder (ASD) face several challenges in the healthcare setting. This study defines the challenges experienced by children with autism in hospitals in Saudi Arabia. A cross-sectional study was conducted using a questionnaire for guardians of autistic children in outpatient clinics, autism support groups, and rehabilitation centers. A total of 199 participants were included. The medical procedures causing the most anxiety to children were injections and getting their blood drawn (68.3%), vital sign measurement (41.6%), and height and weight measurement (37.8%). Long waiting hours (44.1%), increased sensory stimuli (33.2%), and overcrowding of hospital staff (27.9%) were stress-inducing in the healthcare environment. The guardians recommended that loud noises (44.7%), crowdedness (41.2%), and long waiting hours (42.1%) be avoided. The nonverbal children experienced significantly higher levels (p < 0.001) of agitation, irritability, and outbursts during doctor visits than their verbal counterparts. The children with intellectual disabilities were more tense and unresponsive during doctor visits (33.3%) than their intellectually able counterparts, who more frequently were calm and responsive (44.9%) during visits. Most patients with ASD face hardships during hospital visits. Nonverbal patients and those with intellectual disabilities have a higher tendency for hospital setting anxiety-induced outbursts, which may be eased by avoiding loud noise and overcrowding.

Fourteen Deaths from Suspected Heparin Overdose in an Italian Primary-Level Hospital.

Healthcare-related homicidal cases are not novel within the medical-legal landscape, but investigations are often made difficult with the scarcity of material evidence related to the crime. For this reason, it is necessary to carefully analyze the clinical documentation and employ ancillary forensic resources such as radiology, histopathology, and toxicology. In the presented scenario, the observation of 14 deaths from abnormal bleeding in a First-Level Italian Hospital revealed the administration of massive doses of heparin by a nurse. On behalf of the Judicial Authority, a multidisciplinary medical team investigated the case through the following steps: a thorough review of the clinical documentation, exhumation of the bodies belonging to the deceased patients, performing PMCT and autopsy, and collecting tissue samples for histopathological, immunohistochemical, and toxicological investigations. All the analyzed cases have been characterized by the observation of fatal hemorrhagic episodes not explained with the clinical conditions of the patients, confirmed using autopsy observations and the histological demonstration of the vitality of the lesions. However, due to the limited availability of biological material for the toxicological analysis, the indirect evidence from hematological analyses in hospitalized patients was crucial in demonstrating heparin overdose and its link to the recorded deaths. The present scenario demonstrates the fundamental importance of a multidisciplinary approach to cases of judicial interest related to the healthcare context. Therefore, the illustrated methodologies can be interpreted as an operational framework for similar future cases.