Placental HTRA1 cleaves α1-antitrypsin to generate a NET-inhibitory peptide.

Neutrophil extracellular traps (NETs) are important components of innate immunity. Neonatal neutrophils (polymorphonuclear leukocytes [PMNs]) fail to form NETs due to circulating NET-inhibitory peptides (NIPs), cleavage fragments of α1-antitrypsin (A1AT). How fetal and neonatal blood NIPs are generated remains unknown, however. The placenta expresses high-temperature requirement serine protease A1 (HTRA1) during fetal development, which can cleave A1AT. We hypothesized that placentally expressed HTRA1 regulates the formation of NIPs and that NET competency changed in PMNs isolated from neonatal HTRA1 knockout mice (HTRA1-/-). We found that umbilical cord blood plasma has elevated HTRA1 levels compared with adult plasma and that recombinant and placenta-eluted HTRA1 cleaves A1AT to generate an A1AT cleavage fragment (A1ATM383S-CF) of molecular weight similar to previously identified NIPs that block NET formation by adult neutrophils. We showed that neonatal mouse pup plasma contains A1AT fragments that inhibit NET formation by PMNs isolated from adult mice, indicating that NIP generation during gestation is conserved across species. Lipopolysaccharide-stimulated PMNs isolated from HTRA1+/+ littermate control pups exhibit delayed NET formation after birth. However, plasma from HTRA1-/- pups had no detectable NIPs, and PMNs from HTRA1-/- pups became NET competent earlier after birth compared with HTRA1+/+ littermate controls. Finally, in the cecal slurry model of neonatal sepsis, A1ATM383S-CF improved survival in C57BL/6 pups by preventing pathogenic NET formation. Our data indicate that placentally expressed HTRA1 is a serine protease that cleaves A1AT in utero to generate NIPs that regulate NET formation by human and mouse PMNs.

Neutrophil extracellular trap inhibition improves survival in neonatal mouse infectious peritonitis.

BACKGROUND: Treatment of neonatal peritonitis and sepsis is challenging. Following infection, neutrophils elaborate neutrophil extracellular traps (NETs)-extracellular lattices of decondensed chromatin decorated with antimicrobial proteins. NETs, however, can augment pathogenic inflammation causing collateral damage. We hypothesized that NET inhibition would improve survival in experimental neonatal infectious peritonitis. METHODS: We induced peritonitis in 7 to 10-day-old mice by intraperitoneal injection with cecal slurry. We targeted NETs by treating mice with neonatal NET-Inhibitory Factor (nNIF), an endogenous NET-inhibitor; Cl-amidine, a PAD4 inhibitor; DNase I, a NET degrading enzyme, or meropenem (an antibiotic). We determined peritoneal NET and cytokine levels and circulating platelet-neutrophil aggregates. Survival from peritonitis was followed for 6 days. RESULTS: nNIF, Cl-amidine, and DNase I decreased peritoneal NET formation and inflammatory cytokine levels at 24 h compared to controls. nNIF, Cl-amidine, and DNase I decreased circulating platelet-neutrophil aggregates, and NET-targeting treatments significantly increased survival from infectious peritonitis compared to controls. Finally, nNIF administration significantly improved survival in mice treated with sub-optimal doses of meropenem even when treatment was delayed until 2 h after peritonitis induction. CONCLUSIONS: NET inhibition improves survival in experimental neonatal infectious peritonitis, suggesting that NETs participate pathogenically in neonatal peritonitis and sepsis. IMPACT: 1. Neutrophil extracellular trap formation participates pathogenically in experimental neonatal infectious peritonitis. 2. NET-targeting strategies improve outcomes in a translational model of neonatal infectious peritonitis. 3. NET inhibition represents a potential target for drug development in neonatal sepsis and infectious peritonitis.

Service design activities in health services: A systematic literature review based on ecosystem perspective and transformative approach.

Service Design (SD) represents a breakthrough in searching for solutions to health systems challenges, but the activities that support these solutions remain underexplored. This research investigates how SD has been applied in the healthcare sector based on two conceptual models: multilevel ecosystem perspective and SD transformative approach. First, we conducted a systematic literature review in eight comprehensive databases in March 2021. Eligibility criteria returned 990 articles filtered by a search protocol, resulting in 47 studies. After this, we identified 23 studies (49%) with a transformative approach through a thematic analysis. Also, the analysis of these 23 studies allowed the identification of five key aspects necessary for enabling a transformative character of SD initiatives: (1) identification of all the actors that make up the provision of healthcare services, (2) identification of users by ecosystem level, (3) knowledge about the SD tools arsenal, (4) use of technology, and (5) applying the Experience-Based Design and Co-Design (EBD/EBCD) approach. The study underlines the role of management for the success of SD in the health sector and suggests an instrument (checklist) to help managers implement SD initiatives successfully.

Initiatives to reduce the waiting time to initiate oncological treatment: a scoping literature review.

Objective: To identify the managerial actions proposed and employed to reduce the waiting time to initiate oncological treatments in the public health system and its application in Latin America. Method: We searched seven databases in December 2020. Search terms were conceptualized into three groups: waiting time, cancer, and terms related to public sector. The eligibility criteria included theoretical or empirical academic articles written in English, Spanish, or Portuguese, that focused on managerial solutions to face oncological healthcare queues' dilemma. Results: The search returned 1 255 articles, and 20 were selected and analysed in this review. Results show that most of the proposals are related to the process and people dimensions. The actions related to the process dimension were mainly associated with programming new treatment pathways and integrating cancer systems. People's dimension initiatives referred mostly to task forces and groups of specialists. Some initiatives were related to implementing technological solutions and the technology dimension, mainly concerning radiotherapy devices' acquisition. Conclusion: Few studies focus on analysing actions to minimize waiting time to initiate oncological treatments. The prevalence of conceptual and illustrative case studies indicates the lack of research maturity on this theme. Future studies should focus on setting the field's theoretical foundations, considering the existing paradigms, or developing new ones. There is a need for empirical studies applying a multidisciplinary approach to face the oncological treatment waiting time challenge and proposing new and innovative initiatives.

Using data envelopment analysis and the bootstrap method to evaluate organ transplantation efficiency in Brazil.

Brazil has the most extensive public program for organ transplantation in the world, and the Brazilian National Health System (SUS) provides full coverage of all costs involved in organ donation, transplants, and post-transplant. Despite the relevance of the subject and the shortage of organs for transplants, transplantation process efficiency assessments are still uncommon in Brazil and abroad. This study aims to evaluate the efficiency of the Brazilian states and the Federal District in transforming potential organ donors into actual donations. We applied data envelopment analysis (DEA) in conjunction with the bootstrap technique, using organ transplantation data from 2018. The bootstrap methods applied (bootstrap technique, the bootstrap-biased scores of efficiency, and the bootstrap bias-corrected scores of efficiency) allow to obtain a confidence interval for DEA scores and provide greater robustness to studies based on DEA methodology. The bootstrap bias-corrected model indicates that there is significant room for improvement in terms of converting potential donors into actual donors. The mean corrected score is 0.55, signalizing that altogether the Brazilian states could maximize in 45% the number of transplanted organs without necessarily increasing the pool of potential donors. The study provides insights into the Brazilian processes of organ donation and transplantation, helping to identify locations in need of resource allocation improvements. Given the scarcity of studies with a joint application of DEA and bootstrap techniques in this crucial health activity, we also intend to methodologically contribute to this type of benchmark analysis, emphasizing the importance of considering measurement errors, randomness, and bias at DEA models.

Comparison of Oropharyngeal Dysphagia in Brazilian Children with Prenatal Exposure to Zika Virus, With and Without Microcephaly.

Severe brain damage associated with Zika-related microcephaly (ZRM) have been reported to result in oropharyngeal dysphagia (OPD); however, it is unknown if OPD presents in children with prenatal Zika virus (ZIKV) exposure but only mild or undetectable abnormalities. The aims of this study were: to compare the frequency and characteristics of OPD in children with ZRM and in children without microcephaly born to mothers who tested polymerase chain reaction positive (PCR+) for ZIKV during pregnancy; and to investigate the concordance of caregiver reports of OPD with the diagnosis from the clinical swallowing assessment (CSA). Between Mar/2017 and May/2018, we evaluated 116 children (n = 58 with microcephaly, n = 58 children without microcephaly born to ZIKV PCR + mothers) participating in the Microcephaly Epidemic Research Group (MERG) cohort of children born during the 2015-2016 ZIKV epidemic in Pernambuco, Brazil. To assess OPD we used: a CSA; a clinical assessment of the stomatognathic system; and a questionnaire administered to caregivers. The frequency of OPD was markedly higher in children with ZRM (79.3%) than in the exposed but normocephalic group (8.6%). The children with microcephaly also presented more frequently with anatomic and functional abnormalities in the stomatognathic system. There was a high degree of agreement between the caregiver reports of OPD and the CSA (κ = 0.92). In conclusion, our findings confirm that OPD is a feature of Congenital Zika Syndrome that primarily occurs in children with microcephaly and provide support for policies in which children are referred for rehabilitation with an OPD diagnosis based on caregiver report.

Preserving Vascular Integrity Protects Mice against Multidrug-Resistant Gram-Negative Bacterial Infection.

The rise in multidrug-resistant (MDR) organisms portends a serious global threat to the health care system with nearly untreatable infectious diseases, including pneumonia and its often fatal sequelae, acute respiratory distress syndrome (ARDS) and sepsis. Gram-negative bacteria (GNB), including Acinetobacter baumannii, Pseudomonas aeruginosa, and carbapenemase-producing Klebsiella pneumoniae (CPKP), are among the World Health Organization's and National Institutes of Health's high-priority MDR pathogens for targeted development of new therapies. Here, we show that stabilizing the host's vasculature by genetic deletion or pharmacological inhibition of the small GTPase ADP-ribosylation factor 6 (ARF6) increases survival rates of mice infected with A. baumannii, P. aeruginosa, and CPKP. We show that the pharmacological inhibition of ARF6-GTP phenocopies endothelium-specific Arf6 disruption in enhancing the survival of mice with A. baumannii pneumonia, suggesting that inhibition is on target. Finally, we show that the mechanism of protection elicited by these small-molecule inhibitors acts by the restoration of vascular integrity disrupted by GNB lipopolysaccharide (LPS) activation of the TLR4/MyD88/ARNO/ARF6 pathway. By targeting the host's vasculature with small-molecule inhibitors of ARF6 activation, we circumvent microbial drug resistance and provide a potential alternative/adjunctive treatment for emerging and reemerging pathogens.

Hospital accreditation impact on healthcare quality dimensions: a systematic review.

PURPOSE: To systematically review the impact of hospital accreditation on healthcare quality indicators, as classified into seven healthcare quality dimensions. DATA SOURCE: We searched eight databases in June 2020: EBSCO, PubMed, Web of Science, Emerald, ProQuest, Science Direct, Scopus and Virtual Health Library. Search terms were conceptualized into three groups: hospitals, accreditation and terms relating to healthcare quality. The eligibility criteria included academic articles that applied quantitative methods to examine the impact of hospital accreditation on healthcare quality indicators. STUDY SELECTION: We applied the PICO framework to select the articles according to the following criteria: Population-all types of hospitals; Intervention-hospital accreditation; Comparison-quantitative method applied to compare accredited vs. nonaccredited hospitals, or hospitals before vs. after accreditation; Outcomes-regarding the seven healthcare quality dimensions. After a critical appraisal of the 943 citations initially retrieved, 36 studies were included in this review. RESULTS OF DATA SYNTHESIS: Overall results suggest that accreditation may have a positive impact on efficiency, safety, effectiveness, timeliness and patient-centeredness. In turn, only one study analyzes the impact on access, and no study has investigated the impact on equity dimension yet. CONCLUSION: Mainly due to the methodological shortcomings, the positive impact of accreditation on healthcare dimensions should be interpreted with caution. This study provides an up-to-date overview of the main themes examined in the literature, highlighting critical knowledge-gaps and methodological flaws. The findings may provide value to healthcare stakeholders in terms of improving their ability to assess the relevance of accreditation processes.

Risk factors for central line-associated bloodstream infection in pediatric oncology patients with a totally implantable venous access port: A cohort study.

BACKGROUND: Totally implantable venous access ports (TIVAPs) are used for prolonged central venous access, allowing the infusion of chemotherapy and other fluids and improving the quality of life of children with cancer. TIVAPs were developed to reduce the infection rates associated with central venous catheters; however, infectious events remain common and have not been fully investigated in pediatric oncology patients. PROCEDURE: A retrospective cohort was formed to investigate risk factors for central line-associated bloodstream infection (CLABSI) in pediatric cancer patients. Sociodemographic, clinical, and TIVAP insertion-related variables were evaluated, with the endpoint being the first CLABSI. A Kaplan-Meier analysis was performed to determine CLABSI-free catheter survival. RESULTS: Overall, 188 children were evaluated over 77,541 catheter days, with 94 being diagnosed with CLABSI (50%). Although coagulase-negative staphylococci were the pathogens most commonly isolated, Gram-negative microorganisms (46.8%) were also prevalent. In the multivariate analysis, factors that increased the risk for CLABSI were TIVAP insertion prior to chemotherapy (risk ratio [RR] = 1.56; P < 0.01), white blood cell count less than 1,000 mm-3 on the day of implantation (RR = 1.64; P < 0.01), and chronic malnutrition (RR = 1.41; P < 0.05). Median time without CLABSI following TIVAP insertion was 74.5 days. CONCLUSIONS: Risk factors for CLABSI in pediatric cancer patients with a TIVAP may be related to the severity of the child's condition at catheter insertion. Insertion of the catheter before chemotherapy and unfavorable conditions such as malnutrition and bone marrow aplasia can increase the risk of CLABSI. Protocols must be revised and surveillance increased over the first 10 weeks of treatment.

[Efficiency indicators to assess the organ donation and transplantation process: systematic review of the literature]. / Indicadores de eficiência no processo de doação e transplante de órgãos: revisão sistemática da literatura.

OBJECTIVE: To search the literature and identify indicators used to monitor and control the organ donation and transplantation process and to group these indicators into categories. METHOD: In November 2014, a systematic review of the literature was carried out in the following databases: Biblioteca Virtual em Saúde (BVS), EBSCO, Emerald, Proquest, Science Direct, and Web of Science. The following search terms (and the corresponding terms in Brazilian Portuguese) were employed: "efficiency," "indicators," "organ donation," "tissue and organ procurement," and "organ transplantation." Of the 344 articles retrieved, 23 original articles published between 1992 and 2013 were selected and reviewed for analysis of efficiency indicators. RESULTS: The review revealed 117 efficiency indicators, which were grouped according to similarity of content and divided into three categories: 1) 71 indicators related to organ donation, covering mortality statistics, communication of brain death, clinical status of donors and exclusion of donors for medical reasons, attitude of families, confirmation of donations, and extraction of organs and tissues; 2) 22 indicators related to organ transplantation, covering the surgical procedure per se and post-transplantation follow-up; and 3) 24 indicators related to the demand for organs and the resources of hospitals involved in the process. CONCLUSIONS: Even if organ transplantation is a recent phenomenon, the high number of efficiency indicators described in the literature suggests that scholars interested in this field have been searching for ways to measure performance. However, there is little standardization of the indicators used. Also, most indicators focus on the donation step, suggesting gaps in the measurement of efficiency at others points in the process. Additional indicators are needed to monitor important stages, such as organ distribution (for example, organ loss indicators) and post-transplantation aspects (for example, survival and quality of life).

Meaning of sustainability of innovations in healthcare organizations: A systematic review.

BACKGROUND: There is pressure on healthcare organizations to provide high-quality care to all patients while innovating the way care is delivered. As they take on the challenge of delivering high-quality, innovative services, any gains made tend to stall before a radical change impacts key outcomes given the difficulty in sustaining innovations over time. METHODS: A systematic search was performed in 5 electronic databases using the PRISMA structure that resulted in 1313 articles, of which 260 were duplicated, leaving 1053 articles. After reading their abstracts, 877 had an inadequate scope for analysis because they did not deal with research on the sustainability of innovations. After a full assessment of the remaining 176 articles, only 10 studies met the inclusion criteria with the snowball strategy generating one additional paper, leading to 11 empirical studies. A theoretical discussion and the proposition of a framework were used to analyze the data. RESULTS: Studies in university hospitals shed light on determining sustainability factors of innovations not yet fully explored such as the meaning given by individuals to innovation, culture, partnerships, and multidisciplinary collaboration, which complement the literature. This research sought to contribute to the dialogue between management theory and practice in studies on the sustainability of health innovations based on experiences observed in university hospitals. Health managers can verify how sustainability relates to the challenges presented and identify a path that helps them overcome the limitations imposed on the process. The literature shows that the understanding of sustainability as a mediating dimension can collaborate in sustained innovations in order to allow managers to identify actions related to the individual-organization dimension that may be compromising the process and thus act in a more efficient, assertive way in determining the factors that sustain ongoing innovations. CONCLUSIONS: A relevant point is that innovation sustainability needs to be an objective to be achieved where managers/individuals must incorporate this perspective of innovation continuity since the beginning of the process, otherwise this may represent a greater propensity for discontinuity. This analysis can potentially be applied in university hospitals, but it can also be applicable to other types of hospitals and public or private institutions as long as it is an organization that adopts, implements, and seeks to sustain innovations in service delivery.

Filarial disease in the Brazilian Amazon and emerging opportunities for treatment and control.

Following the successful eradication of Wuchereria bancrofti, there are now just three species of conventional microfilaremic human filarial parasites endemic to the Brazilian Amazon region: Mansonella ozzardi, Mansonella perstans and Onchocerca volvulus. The zoonotic filarial parasite Dirofilaria immitis is also found in the Amazon region as are several sylvatic filarial parasites, some of which have been recorded causing zoonoses and some of which have never been recorded outside the region. Onchocerca volvulus is only found in the Amazonia onchocerciasis focus in the Brazilian state of Roraima where it affects the people of the Yanomami tribe living around the densely forested Venezuela border region. Mansonella ozzardi is by far the most common filarial parasite in Brazil and has a broad but patchy distribution throughout the western Amazon region. Recorded in the Brazilian states of Acre, Roraima, Matto Grosso, and within almost every municipality of Amazonas state, it is believed that pollution of the urban stream and river systems prevents the development of the simuliid vectors of M. ozzardi and explains the parasite's reduced distribution within urban areas and an absence of recent reports from the state capital Manaus. Decades of WHO-led periodic ivermectin treatment of Yanomami tribe's people have resulted in the partial suppression of O. volvulus transmission in this focus and has also probably affected the transmission of M. ozzardi in the region. Mansonella perstans, O. volvulus and very probably M. ozzardi infections can all be treated and most likely cured with a 4-6-week treatment course of doxycycline. The Brazilian Ministry of Health does not, however, presently recommend any treatment for mansonellosis infections and thus parasitic infections outside the Amazonia focus are typically left untreated. While the long treatment courses required for doxycycline-based mansonellosis therapies preclude their use in control programmes, new fast-acting filarial drug treatments are likely to soon become available for the treatment of both onchocerciasis and mansonellosis in the Amazon region. Filarial disease management in the Brazilian Amazon is thus likely to become dramatically more viable at a time when the public health importance of these diseases is increasingly being recognized.

Efficacy and safety of induction chemotherapy in oral cavity cancer: An eight-year experience at a Portuguese reference center.

BACKGROUND: Induction chemotherapy has been described as an option in locally advanced oral cavity squamous cell carcinoma when the surgical morbidity is expected to be high. This work aimed to evaluate the outcome and safety of induction chemotherapy in this setting. METHODS: We performed a retrospective and observational study including patients with oral cavity squamous cell carcinoma, treated with induction chemotherapy between January 2010 and December 2018. Outcomes included induction chemotherapy toxicity, treatment response, disease-free survival and overall survival. RESULTS: A total of 108 oral cavity squamous cell carcinoma patients were included. Ninety-six (88.9%) had stage IV disease, while 12 (11.1%) had stage III. Eighty-four patients (80.8%) achieved at least a partial response to induction chemotherapy at clinical evaluation, and 75 (72.1%) at radiological evaluation. Seventy-eight patients have been proposed for subsequent definitive treatments, with no differences obtained in prognosis, when comparing surgical to non-surgical approaches. In patients treated with definitive treatments, improved five-year disease-free survival was obtained if at least a clinical (56.3%; p=0.001) or radiological (52.9%; p=0.001) partial response was achieved after induction chemotherapy. Similarly, superior five-year overall survival was verified for those achieving at least clinical (51.1%; p<0.0001) or radiological (52.6%; p=0.001) partial response. Also, accomplishing a pathologic complete response (n=22.6%) significantly improved disease-free survival (p=0.039) and overall survival (p=0.005). Grade 3 and 4 toxicities were observed in 52 patients (41.8%). CONCLUSION: Responses to induction chemotherapy predicted prognosis in our population, however important toxicities were observed. Further studies are necessary to identify induction chemotherapy response predictors and subgroups who may benefit from this approach.

Service design for the transformation of healthcare systems: A systematic review of literature.

There is a growing interest in applying the Service Design (SD) approach to innovate and transform healthcare systems. However, comprehensive studies are scarce. This study systematically reviews the literature on SD initiatives towards healthcare system transformation. The research questions are: How has the SD approach been applied to the healthcare sector? To what extent are the SD initiatives contributing to transform the health systems? What are the main challenges faced by SD initiatives to transform the health system? Which are the main stakeholders involved in the process, and how could they change according to the type of initiative? The search was conducted in March 2021 in eight databases and returned 990 articles evaluated through a research protocol, resulting in 47 studies included in this review. These studies were explored through thematic analysis and considering two conceptual models: the SD approach (Patrício et al., 2020) and the ecosystem perspective (Beirão et al., 2017). The findings show that SD initiatives have been implemented at all levels of the ecosystem, but only 49% (47/23 studies) present a transformative character. The SD initiatives challenges were organized into four themes: (1) Planning SD initiatives as a lever in transforming health systems; (2) Using SD tools creatively; (3) Considering the use of new technologies to transform health systems positively, and (4) Facing the challenges of applying the Experience-Based Design and Experience Based in Co-Design approaches in project development. This study is relevant for helping managers and researchers in their efforts to design truly transformative services with a focus on improving health systems and social wellbeing.

The Effect of Educational Initiatives on the Attitude and Knowledge of Health Care Professionals Regarding Organ Donation and Transplantation: An Integrative Literature Review.

BACKGROUND: This integrative literature review synthesizes evidence on the effect of educational initiatives (EI) on the attitude and knowledge of health care professionals regarding organ donation and transplantation (ODT), and the EI effect considering the risks of the ODT process related to the professionals' attitudes and knowledge. METHODS: This search included 8 databases, with search terms across 4 groups: ODT activities, health professionals, attitude/knowledge, and EI. We applied the PICO framework to select articles: Population - health care professionals; Intervention - any EI; Comparison - pre/post or intervention/control designs; and Outcomes - indicators of attitudes or knowledge toward ODT. After the appraisal of 2,221 citations, 21 studies were included in this review. RESULTS: The EI varied to a great extent in terms of format (seminars, workshops, video lectures; online or in-person training), duration (from 15 minutes to 3 months), and the number of participants (from 12 to 1011). The effects reported were positive, increasing professionals' knowledge and attitude regarding the ODT process for all EI formats. Most articles (14; 67%) presented positive results with statistical significance for all indicators analyzed, and the remaining studies (7; 35%) reported statistical significance for some of the indicators analyzed. All EIs focused on donation or post-transplantation activities, lacking studies on the transplantation stage. CONCLUSIONS: Results suggest that different types of EIs may positively affect the attitude and knowledge of health care professionals regarding the ODT process. This study provides an up-to-date overview of the main themes examined in this literature, highlighting critical knowledge gaps and methodological flaws.

Leadership to promote patient safety culture in public hospitals managed by social health organizations.

PURPOSE: This paper aims to identify the kind of internal climate leaders should offer health-care professionals to promote a patient safety culture in public hospitals managed by social health organizations in Brazil. DESIGN/METHODOLOGY/APPROACH: Two surveys were applied to health-care professionals working at three Brazilian public hospitals. The internal climate survey reached 1,013 respondents, and the patient safety culture survey reached 1,302 participants. Both factor and regression analyses were used to analyze the study model and determine how internal climate influences patient safety culture. FINDINGS: Results indicate that to promote a patient safety culture among health-care professionals, leaders should generate an internal climate based on trust to foster pride in working in the hospital. Possibly, the trust dimension is the most important one and must be developed to achieve job satisfaction and provide better services to patients. RESEARCH LIMITATIONS/IMPLICATIONS: All the hospitals studied were managed by the same Organização Social de Saúde. Due to the limited responses concerning the respondents' profiles, demographic variables were not analyzed. PRACTICAL IMPLICATIONS: This research reveals that the trust and pride dimensions can most strongly influence a positive patient safety culture, helping hospital leaders face this huge managerial challenge of consistently delivering high standards of patient safety. ORIGINALITY/VALUE: This research studies the promotion of a patient safety culture in public hospitals managed by social health organizations, characterized by greater flexibility and autonomy in health-care management and by a greater need for accountability.

A Collaborative Approach for the Development of a Standardized Set of Patient-Centered Outcomes in Head and Neck Cancers.

INTRODUCTION: Head and neck cancers remain a significant health burden worldwide. Standardizing the care provided to these patients through the systematic measurement of established indicators is key to improve their outcomes. The aim of this study was to establish a relevant set of outcome indicators in this condition and identify measurement tools and requirements to do so. MATERIAL AND METHODS: One scientific committee and two regional working groups worked in a stepwise manner to narrow down an initial list of potential outcome indicators retrieved from an exhaustive literature review to a smaller set of outcome indicators according to their clinical practice. This was assessed by one representative of a head and neck cancer patient association until a final set of indicators was reached. RESULTS: A total of 164 outcome indicators comprising case-mix, outcomes, and adverse events dimensions were retrieved from the literature. These were reduced to a working set of 79 outcome indicators by the Scientific Committee and divided into seven categories including demographics, clinical status, tumor-related parameters, nutritional status, treatment, health and quality of life parameters and survival. Subsequently, these indicators were further reduced to a set of 50 indicators by the regional working groups and to a set of 49 indicators by the final Scientific Committee assessment. Finally, the discussed indicators were appraised by a head and neck cancer patient association, which added the 'rehabilitation' category, a key parameter to these patients. CONCLUSION: An initial set of outcome indicators for head and neck cancer was systematically developed aiming to standardize the care provided to these patients across institutions at national level and identify measurement tools and requirements to measure those indicators. This standard set should be continuously improved and consistently adopted in the different clinical and national settings.

Hidradenocarcinoma of the Female Breast: A Surgical Approach to a Rare Skin Tumor.

Clear-cell hidradenocarcinomas are extremely uncommon sweat gland tumors with a predilection for the head and neck. In the limited number of articles reporting breast involvement, the primary focus concerns this entity's histological and immunohistochemical characteristics. Since hidradenocarcinomas of the breast have the potential to resemble a primary breast carcinoma closely, diagnosis may be challenging. Therefore, the authors report the first case of hidradenocarcinoma of the breast, which features its macroscopic morphology. In addition, to increase physicians' awareness of this rare neoplasm, the article also aims to detail its surgical approach.