Contextual factors and mechanisms in the implementation of Value Stream Mapping in breast cancer centres - A multiple case study.

INTRODUCTION: Lean, especially Value Stream Mapping is increasingly used in hospitals to optimize processes. This method, which originated in the automotive industry, enables all staff involved in the process to make it more customer-friendly. Despite the widely reported success of Lean projects, they have failed in some cases. This study investigated the contextual factors and mechanisms that contribute to a successful implementation of Value Stream Mapping. METHODS: Value Stream Mapping was applied to the discharge process in four breast cancer centers. A mixed-method approach was used in two steps. First, to verify the successful implementation, defined as time optimization, time measurement was conducted at three points in time and analyzed using an ANOVA. Second, an analysis of contextual factors was combined with a qualitative content analysis of mechanisms based on normalization process theory, using routine data, meeting protocols, field notes, and interview transcripts as data source. RESULTS: At one of the four breast cancer centers, lead- and waiting time were significantly reduced; at the others, these reductions did not occur. Failure/success cannot be explained by the size of the hospital, the number of cases or staffing levels. The variable project team composition is evident, especially leadership involvement. DISCUSSION: A comparative analysis was conducted to identify the factors that led to success. These factors were: participation of all leaders relevant to the process, in the case of the discharge process including medical and nursing leaders; dissemination of the changes from the project team to colleagues including its sense and possibility to discuss it; joint reflection of the implementation process in regular work team meetings. CONCLUSIONS: These results confirm the important role of leadership in implementation projects. Leadership support enabled the mechanisms found. The used combination of theoretical approaches from management research and implementation science determined the interpretation and should be applied more often in implementation science.

Using augmented reality in molecular case studies to enhance biomolecular structure-function explorations in undergraduate classrooms.

Molecular case studies (MCSs) are open educational resources that use a storytelling approach to engage students in biomolecular structure-function explorations, at the interface of biology and chemistry. Although MCSs are developed for a particular target audience with specific learning goals, they are suitable for implementation in multiple disciplinary course contexts. Detailed teaching notes included in the case study help instructors plan and prepare for their implementation in diverse contexts. A newly developed MCS was simultaneously implemented in a biochemistry and a molecular parasitology course at two different institutions. Instructors participating in this cross-institutional and multidisciplinary implementation collaboratively identified the need for quick and effective ways to bridge the gap between the MCS authors' vision and the implementing instructor's interpretation of the case-related molecular structure-function discussions. Augmented reality (AR) is an interactive and engaging experience that has been used effectively in teaching molecular sciences. Its accessibility and ease-of-use with smart devices (e.g., phones and tablets) make it an attractive option for expediting and improving both instructor preparation and classroom implementation of MCSs. In this work, we report the incorporation of ready-to-use AR objects as checkpoints in the MCS. Interacting with these AR objects facilitated instructor preparation, reduced students' cognitive load, and provided clear expectations for their learning. Based on our classroom observations, we propose that the incorporation of AR in MCSs can facilitate its successful implementation, improve the classroom experience for educators and students, and make MCSs more broadly accessible in diverse curricular settings.

Small molecule drug metabolite synthesis and identification: why, when and how?

The drug discovery and development process encompasses the interrogation of metabolites arising from the biotransformation of drugs. Here we look at why, when and how metabolites of small-molecule drugs are synthesised from the perspective of a specialist contract research organisation, with particular attention paid to projects for which regulatory oversight is relevant during this journey. To illustrate important aspects, we look at recent case studies, trends and learnings from our experience of making and identifying metabolites over the past ten years, along with with selected examples from the literature.

Enhancing root coverage and esthetic outcomes in isolated gingival recession using orthodontic intervention and lateral closed tunnel technique: An interdisciplinary prospective case series.

BACKGROUND: Gingival recession (GR) in malposed tooth in association with bone dehiscence and/or fenestration poses a challenge for successful root coverage treatment. Lateral closed tunnel (LCT) technique is particularly useful in isolated GR in mandibular anterior region, where the shallow vestibular depth prevents tension-free coronal mobilization of tissues. METHODS: Twenty patients with GR associated with tooth malposition were treated using a combined orthodontic-periodontic approach with a torquing auxiliary spring followed by LCT technique. RESULTS: The two techniques resulted in a combined recession depth reduction from 3.75 ± 1.14 mm to 0.40 ± 0.50 mm at the end of 6-month study period. The orthodontic intervention led to an increase in labial marginal bone levels, as assessed through cone beam computed tomography (CBCT), while the LCT achieved closure of residual recession defect. Also, an increase of keratinized tissue width from 0.81 ± 0.88 mm at baseline to 3.30 ± 0.67 mm at 6 months was achieved. Mean root coverage percentage (MRC%) of 91.40% + 10.25% was seen, with 11 out of 20 sites (55%) showing complete root coverage (CRC). CONCLUSIONS: Single tooth orthodontic repositioning followed by LCT technique proved effective in successfully managing isolated recession defects in the mandibular anterior gingival region, which often presents challenging mucogingival conditions. The precise single tooth repositioning resulted in labial marginal bone augmentation, while the LCT surgical approach allowed residual defect closure. KEY FINDINGS: Why are these cases new information? Correction of single tooth malposition is achieved before recession coverage treatment to achieve a favorable environment for graft uptake. The reduction in denuded root surface along with the bone remodeling results in increasing the ratio of vascular to avascular region, thus improving the overall prognosis of the treatment. What are the keys to successful management of these cases? The lateral closed tunnel technique involves creating a mucoperiosteal tunnel to close the recession site. Precision is crucial to avoid damage to surrounding tissues. The recipient site should be wider than the width of recession to improve graft vascularity. What are the primary limitations to success in these cases? Limitations may arise when dealing with complex cases, such as multiple teeth involvement or teeth with significant vertical or horizontal bone loss.

Pharmacy Students' Perceived Ability to Implement the Pharmacist's Patient Care Process before and after a Redesigned Case Study Series in the United States.

Since the incorporation of the Pharmacist's Patient Care Process (PPCP) into the American Association of Colleges of Pharmacy standards, the process has been integrated in a variety of ways across curriculums. A two-semester case-based course was redesigned as a four-semester case-based course formally integrating the PPCP. Pharmacy students completing the original, two-semester course series and those completing the first two semesters of the redesigned course were given a voluntary survey to assess their perceived ability to integrate the PPCP into practice after the completion of each course. A total of 107 pharmacy students, 61 students completing the original series and 46 students completing two semesters of the redesigned series, completed the survey. The pharmacy students completing the redesigned, four-semester course series had a significantly higher perception of their ability to integrate the PPCP into patient care compared to the students completing the original series. This included the perceived ability to ask appropriate questions, identify medication-related problems (MRPs), document MRPs, and develop a plan for addressing MRPs. A significant difference was found in the students' perceived ability to ask pertinent questions in an appropriate manner, identifying and documenting MRPs, managing and solving MRPs, and documenting patient interactions. No significant difference was identified regarding the students' perceived ability to document the interaction or ensure that treatment-related plans were implemented. The students' perception regarding the importance of asking pertinent questions, identifying MRPs, and documentation in patient care did not differ between the cohorts. The case-based course series redesigned from two to four semesters with formal integration of the PPCP resulted in an increase in the students' perceptions of their ability to integrate the PPCP into patient care.

Management of Adverse Events Associated with Pomalidomide-Based Combinations in Patients with Relapsed/Refractory Multiple Myeloma.

Multi-agent regimens incorporating immunomodulatory (IMiD®) agents such as thalidomide, lenalidomide, and pomalidomide have become the preferred standard of care for the treatment of patients with multiple myeloma (MM), resulting in improved survival outcomes. Currently, there are three IMiD agents approved for the treatment of MM: thalidomide, lenalidomide, and pomalidomide. Lenalidomide is commonly used to treat patients with newly diagnosed MM and as maintenance therapy following stem cell transplant or after disease relapse. Pomalidomide, the focus of this review, is approved in patients with relapsed/refractory MM (RRMM). Despite survival benefits, IMiD agents each have different safety profiles requiring consideration both prior to starting therapy and during treatment. Adverse event (AE) management is essential, not only to ensure treatment adherence and thus ensure optimal efficacy but also to maintain patient quality of life. Here, we discuss AEs associated with pomalidomide and present five clinically relevant hypothetical case studies in patients with RRMM to provide scenario-driven guidance regarding treatment selection and AE prevention and management in the clinical setting. Lastly, as new treatment approaches continue to be explored in MM, we also discuss novel cereblon E3 ligase modulator (CELMoD™) agents including iberdomide (CC-220) and mezigdomide (CC-92480).

The augmented synthetic control method in public health and biomedical research.

Estimating treatment (or policy or intervention) effects on a single individual or unit has become increasingly important in health and biomedical sciences. One method to estimate these effects is the synthetic control method, which constructs a synthetic control, a weighted average of control units that best matches the treated unit's pre-treatment outcomes and other relevant covariates. The intervention's impact is then estimated by comparing the post-intervention outcomes of the treated unit and its synthetic control, which serves as a proxy for the counterfactual outcome had the treated unit not experienced the intervention. The augmented synthetic control method, a recent adaptation of the synthetic control method, relaxes some of the synthetic control method's assumptions for broader applicability. While synthetic controls have been used in a variety of fields, their use in public health and biomedical research is more recent, and newer methods such as the augmented synthetic control method are underutilized. This paper briefly describes the synthetic control method and its application, explains the augmented synthetic control method and its differences from the synthetic control method, and estimates the effects of an antimalarial initiative in Mozambique using both the synthetic control method and the augmented synthetic control method to highlight the advantages of using the augmented synthetic control method to analyze the impact of interventions implemented in a single region.

Contrasting stances at the crossroads of debugging learning opportunities.

BACKGROUND: Moments of failure during learning present a wide range of opportunities for growth. However, experimental research and meta reviews focused on failure and learning tend to target singular valued learning processes, such as efficient fixes or transfer of conceptual understanding. These analytical decisions conflict with research documenting that teachers and students pursue heterogeneous learning processes following impasses, including preparing to curb recurring problems and preparing for novel impasses. SAMPLE: This work focuses on weekend and summer computer science education workshops for middle school students (roughly ages 10-14) in a large city in the United States. METHOD: Drawing on discursive psychology, interaction analysis and portraiture, we examine the selection and prioritization of five valued learning processes in naturalistic discourse around impasses, especially when students and teachers disagree with one another. In three case studies, our approach blends detailed analyses of conversations with longitudinal portraits of students across a year invested in learning coding. RESULTS: We document how moments of failure not only create openings for numerous learning opportunities, but also occasion argumentation between students and instructors about which valued learning process they view as worthy of prioritizing and pursuing in the moment, including their rationale for foregrounding a particular process. CONCLUSION: We argue that this work throws light on an under-examined, yet central tension around which goals and supports - and whose perspective on those goals and supports - to foreground in research and teaching that pursue productive learning from moments of failure.

Cultural competency in dental education: developing a tool for assessment and inclusion.

PURPOSE/OBJECTIVES: This study aimed to assess the cultural competency content in selected Doctor of Dental Surgery (DDS) courses and to explore the use of an assessment tool that may be used to standardize the integration of cultural competency in the dental school curriculum. METHODS: A survey was sent to course directors to determine the inclusion of four topics related to cultural competence, the mechanisms of inclusion, and their comfort level in teaching the topics in their courses.  A scan of the same courses was conducted with the use of a tool developed from an Expert Panel's recommendations for knowledge, skills, and attitudes (KSA) to be included in curricula for teaching cultural competence. RESULTS: Twenty-one course directors responded.  Fifteen reported they include social determinants of health and twelve include health inequities in their courses. Faculty reported an average of 8.67 comfort level in teaching these topics but there was less comfort level in teaching cultural humility and implicit bias.  Course directors used assignments, case studies, lectures, quizzes, and patient care (clinical courses) to include the topics. The scan of courses showed that the use of the Competencies for General Dentists in course syllabi covered the recommended knowledge, skills, and attitudes for cultural competence. CONCLUSIONS: The rubric was suitable for assessing cultural competency content.  The Competencies for General Dentists in course syllabi will allow the integration of the recommended KSA in dental courses to teach cultural competence.  However, dental faculty may need training in the integration of KSA items in course objectives and content.

[Critical Control Points and Case Studies in the Production of Metal Additive Manufacturing Medical Device].

The critical control points in the production quality management of metal additive manufacturing medical devices, including personnel, hardware, design and development, procurement control, production management and quality control are summarized from the perspective of supervision. The typical cases are analyzed to provide reference for medical device regulatory authorities and enterprises.

Understanding Health Inequalities Research Capacities: Insights and Recommendations From Comparing Two High Income Settings.

Generating evidence on health inequalities (HI) is necessary to raise awareness of these issues, describe and monitor their evolution, analyze their causes, and inform interventions aiming to improve health equity. Yet not all cities and countries have the capacity to produce this type of research. Recent research provides new contextual and causal insights into this research production process, and in-depth understanding on why and how this type of research is produced in certain settings. This article aims to analyze two recent case studies that have uniquely explored this process in two high producers of HI research and high-income country settings to identify learning and distil recommendations, which may be insightful for other settings. Expanding and investing in this line of research is critical, particularly in places with lower HI research output and related capacity, in order to identify key contextual conditions and mechanisms that may enable or hinder this process. This new knowledge could guide the development of new HI research capacity strengthening strategies to foster this research in different settings, worldwide. More understanding is also needed on the relationship between HI research, policy, and action in order to tackle HI.

Evaluating Clinical Safety and Analytical Impact of Subvisible Silicone Oil Particles in Biopharmaceutical Products.

Silicone oil is a commonly used lubricant in pre-filled syringes (PFSs) and can migrate over time into solution in the form of silicone oil particles (SiOPs). The presence of these SiOPs can result in elevated subvisible particle counts in PFS drug products compared to other drug presentations such as vials or cartridges. Their presence in products presents analytical challenges as they complicate quantitation and characterization of other types of subvisible particles in solution. Previous studies have suggested that they can potentially act as adjuvant resulting in potential safety risks for patients. In this paper we present several analytical case studies describing the impact of the presence of SiOPs in biotherapeutics on the analysis of the drug as well as clinical case studies examining the effect of SiOPs on patient safety. The analytical case studies demonstrate that orthogonal techniques, especially flow imaging, can help differentiate SiOPs from other types of particulate matter. The clinical case studies showed no difference in the observed patient safety profile across multiple drugs, patient populations, and routes of administration, indicating that the presence of SiOPs does not impact patient safety.

Implementation of an electronic health record-integrated instant messaging system in an academic health system.

OBJECTIVES: Effective communication amongst healthcare workers simultaneously promotes optimal patient outcomes when present and is deleterious to outcomes when absent. The advent of electronic health record (EHR)-embedded secure instantaneous messaging systems has provided a new conduit for provider communication. This manuscript describes the experience of one academic medical center with deployment of one such system (Secure Chat). METHODS: Data were collected on Secure Chat message volume from June 2017 to April 2023. Significant perideployment events were reviewed chronologically. RESULTS: After the first coronavirus disease 2019 lockdown in March 2020, messaging use increased by over 25 000 messages per month, with 1.2 million messages sent monthly by April 2023. Comparative features of current communication modalities in healthcare were summarized, highlighting the many advantages of Secure Chat. CONCLUSIONS: While EHR-embedded secure instantaneous messaging systems represent a novel and potentially valuable communication medium in healthcare, generally agreed-upon best practices for their implementation are, as of yet, undetermined.

A qualitative synthesis of practice-based learning from case studies on COVID community champion programmes in England, UK.

BACKGROUND: Community-based volunteering supports outbreak management by extending reach into at-risk communities. This paper examines the application of a 'community champions' model in England, UK, during the COVID-19 pandemic. Evidence pre-pandemic shows that community champion interventions tap into social networks to strengthen connections with disadvantaged communities. During the pandemic, the UK government set up a COVID community champions funding award scheme for local authorities to develop local programmes that addressed emerging inequalities. The study aim was to identify transferable learning on community engagement in the pandemic by undertaking a secondary qualitative synthesis of practice-based case studies of local COVID community champion programmes. METHODS: A systematic staged approach for synthesis of practice-based case studies was used. In total, 16 COVID community champion case studies, which were written by practitioners involved in local programme implementation and published by the Local Government Association, were included. Case studies covered aims, programme development and delivery, examples of activities and a discussion of learning. Framework qualitative analysis methods were used to code and organise data prior to cross case analysis. The final stage produced an overarching thematic framework that best represented descriptive and interpretive themes. RESULTS: The results provide an overview of common features of COVID community champion programmes and emergent learning. All local programmes aimed to reduce health inequalities by involving at-risk communities in local prevention efforts, adapting the approach to local priorities. Two levels of community engagement were volunteer mobilisation and subsequent community-based outreach activities. Elements of capacity building, such as training and creation of networks, were common. The synthesis of practice-based learning found that stronger relationships with communities were regarded as a key mechanism to support more equitable prevention strategies. Other learning themes related to champion roles, community engagement strategies and programme implementation. CONCLUSIONS: By focusing on how community champion approaches were applied by local authorities in England during the COVID-19 pandemic, this study contributes to knowledge on volunteer mobilisation as a mechanism to improve public health communication and outreach. Notwithstanding the limitations of experiential evidence, the synthesis of practice-based learning highlights potentially transferable community engagement strategies for health protection and health improvement.

A collaboratively produced model of service design for children and young people with common mental health problems.

BACKGROUND: Little is known about the effectiveness of, and implementation complexities associated with, service delivery models for children and young people (CYP) experiencing 'common' mental health problems such as anxiety, depression, behavioural difficulties and self-harm. This paper outlines how a model for high-quality service design for this population group was developed by identifying available services, their effectiveness, cost-effectiveness and acceptability, and the barriers and enablers to access. METHODS: Sequential, mixed-methods design, combining evidence syntheses (scoping and integrative reviews of the international literature) with primary research (a collective case study in England and Wales). Data from these two elements were collaboratively synthesised in a subsequent model-building phase. RESULTS: The scoping review yielded a service model typology. The integrative review found effectiveness evidence only for four models: collaborative care (the only service model to also have cost-effectiveness evidence), outreach approaches, brief intervention services and an organisational framework called 'Availability, Responsiveness and Continuity'. No service model seemed more acceptable than others. Three case study themes were identified: pathways to support; service engagement; and learning and understanding. The model-building phase identified rapid access, learning self-care skills, individualised support, clear information, compassionate and competent staff and aftercare planning as core characteristics of high-quality services. These characteristics were underpinned by four organisational qualities: values that respect confidentiality; engagement and involvement; collaborative relationships; and a learning culture. CONCLUSIONS: A consistent organisational evidence-base for service design and delivery in CYP's mental health spanning many years appears to have had little impact on service provision in England and Wales. Rather than impose - often inflexible and untested - specific local or national models or frameworks, those commissioning, designing and delivering mental health services for CYP should (re)focus on already known, fundamental components necessary for high-quality services. These fundamental components have been integrated into a collaboratively produced general model of service design for CYP with common mental health problems. While this general model is primarily focused on British service provision, it is broad enough to have utility for international audiences.

Colors in the mind's eye.

The famous "Piazza del Duomo" paper, published in Cortex in 1978, inspired a considerable amount of research on visual mental imagery in brain-damaged patients. As a consequence, single-case reports featuring dissociations between perceptual and imagery abilities challenged the prevailing model of visual mental imagery. Here we focus on mental imagery for colors. A case study published in Cortex showed perfectly preserved color imagery in a patient with acquired achromatopsia after bilateral lesions at the borders between the occipital and temporal cortex. Subsequent neuroimaging findings in healthy participants extended and specified this result; color imagery elicited activation in both a domain-general region located in the left fusiform gyrus and the anterior color-biased patch within the ventral temporal cortex, but not in more posterior color-biased patches. Detailed studies of individual neurological patients, as those often published in Cortex, are still critical to inspire and constrain neurocognitive research and its theoretical models.

How environments can promote active aging: results from a case study of two municipalities in Quebec, Canada.

OBJECTIVES: To address global aging, a paradigm shift is needed from disease prevention and treatment towards active aging, i.e., optimizing opportunities for health, participation, and security as people age. Little is known about how age-friendly environments promote active aging. This study thus aimed to explore how (through which mechanisms and in what contexts) environments can promote active aging and, specifically, positive health, social participation, and health equity. METHODS: Using a realist approach and semi-structured focus groups, a case study was used in two Quebec municipalities known for best fostering active aging. Data also included participants' logbooks, sociodemographic questionnaires, municipalities' sociodemographic profiles, and policy documents. A conceptual framework and thematic content analysis were carried out. RESULTS: A total of 24 participants (9 older adults, 4 health professionals, 3 community-based actors, 5 municipal employees, and 3 elected officials) took part in 5 focus groups. Regarding contexts, both cases were midsize municipalities having an income and education level higher to Quebec's averages with supportive active aging policies. Two main themes explained how the environments promoted active aging: (1) by ensuring proximity through built (urban planning), social (network structures), services (variety and availability of local and outreach resources), and organizational (active listening to older adults' needs for active aging) environments; and (2) by fostering transversality through built (universal accessibility, intergenerational spaces), social (intergenerational opportunities for social participation), and political/organizational (unified and complementary policies) environments. CONCLUSION: To better promote active aging through age-friendly environments, practices should focus on fostering proximity and transversality, and act simultaneously on multiple environments.

RéSUMé: OBJECTIFS: Pour faire face au vieillissement des populations, un changement de paradigme est requis allant de la prévention et du traitement de la maladie vers la promotion d'un vieillissement actif, c.-à.-d. l'optimisation des possibilités de bonne santé, de participation sociale et de sécurité pendant l'avancement de l'âge. Peu d'informations renseignent sur comment les environnements favorisent le vieillissement actif. Cette étude visait donc à explorer comment (par quels mécanismes et dans quels contextes) les environnements favorisent le vieillissement actif et, spécifiquement, la santé positive, la participation sociale et l'équité en santé des aînés. MéTHODES: Selon une approche réaliste et des groupes de discussion semi-dirigés, une étude de cas multiples a été réalisée dans deux municipalités québécoises, reconnues pour favoriser un vieillissement actif. Les données incluaient aussi les journaux de bord et les questionnaires sociodémographiques des participants ainsi que les profils sociodémographiques des municipalités et leurs politiques municipales. Les données ont été traitées à l'aide d'un cadre conceptuel et d'une analyse de contenu thématique. RéSULTATS: Un total de 24 participants (9 aînés âgés de 65 ans ou plus, 4 professionnels de la santé, 3 acteurs communautaires, 5 employés municipaux et 3 élus) ont pris part à un des cinq groupes de discussion. Concernant les éléments de contexte, les deux municipalités étaient de taille moyenne et présentaient des revenus et un niveau de scolarité supérieurs à la moyenne québécoise ainsi que des politiques municipales favorisant un vieillissement actif. Deux thèmes principaux expliquaient comment les environnements favorisaient le vieillissement actif : 1) en assurant la proximité des environnements bâti (aménagement urbain), social (structures des réseaux sociaux), des services (ressources locales et de proximité) et politique/organisationnel (écoute active des besoins des aînés pour un vieillissement actif); et 2) en favorisant la transversalité des environnements bâti (accessibilité universelle, espaces intergénérationnels), social (opportunités intergénérationnelles) et politique/organisationnel (politiques unifiées et complémentaires). CONCLUSION: Pour mieux promouvoir le vieillissement actif grâce à des environnements conviviaux aux aînés, les pratiques doivent privilégier la proximité et les approches transversales, en plus d'agir sur plusieurs environnements simultanément.

Non-Puerperal Adoptive Breastfeeding as Lactational Rescue in the Rohingya Refugee Camp: 2 Case Studies.

INTRODUCTION: Non-puerperal adoptive lactation sometimes requires long preparation and substantial expense for pharmacological intervention to be successful, which are not feasible in refugee camps. Here we report two case studies of non-puerperal adoptive breastfeeding of two infants in the Rohingya Refugee Camp of Cox's Bazar, Bangladesh. MAIN ISSUE: Two non-pregnant, non-breastfeeding caregivers with previous experience of breastfeeding brought two adopted infants-one a 12-day-old female with severe acute malnutrition, and the other a 2-day-old male with normal anthropometric measurements-to a nutritional stabilization center for feeding. After counseling, both families opted for adoptive lactation. MANAGEMENT: Both infants were treated with a modified Action Against Hunger protocol of in-patient management of severe acute malnutrition using the supplementary suckling technique, a procedure to feed the baby with supplementary feed. Diluted F100 was used as the supplementary feed; the energy and protein gained from it were just enough to maintain body physiology and were not responsible for any weight gain. When the infants gained weight, indicating that the caregivers were producing milk, we reduced the supplementary feed as per protocol guidelines. The caregivers were prescribed domperidone and counseled on their ability to breastfeed the infants. The cases required 35 days and 20 days, respectively, for the full establishment of breastfeeding. CONCLUSION: This is the first report of successful adoptive breastfeeding in a refugee camp. With proper counseling and motivation of the caregiver, induced lactation can be started without a preparatory period and with very low-cost intervention.

The contributing factors to suicide in Italian prisons: An 11-year analysis (2010-2020).

BACKGROUND: Suicide is a leading cause of death globally, with approximately 800,000 deaths annually and accounting for 1.5% of all deaths. Risk factors are multifaceted, encompassing individual factors (such as genetics, family history and mental illnesses) and environmental factors (such as economic conditions, social support and life events). In prisons, suicide rates are markedly higher than in the general population, particularly in Italy, where the prisoner suicide rate is approximately 20 times that of the non-incarcerated population. There is, however, little research on suicide in Italian prisons. AIMS: To analyse the characteristics of all people who died by suicide in Italian prisons between 2010 and 2020. METHODS: We carried out a records-based cohort study analysing official data from the Italian Ministry of Justice on prison suicides between 2010 and 2020. The data were cross-referenced and, when required, supplemented with information from Ristretti Orizzonti, a journal specialising in health and living conditions in prisons, as well as from the website of ISTAT (Italian National Statistical Institute), newspapers, radio broadcasts and news agencies. RESULTS: Factors associated with an increased risk of suicide in prisons were nighttime periods, the months of June, July and October, a relatively brief duration of detention (<6 months), having been convicted of murder, male gender, being about 40 years old, having access to hanging materials and being interned (i.e. subjected to the execution of custodial security measures) or awaiting trial. Prison overcrowding was not a risk factor for suicide. CONCLUSION: Our findings hold substantial implications for suicide prevention in Italian prisons as they suggest both characteristics of individuals and characteristics of the institutions that could be taken as risk indicators. This knowledge can inform the development of targeted interventions to manage both individual and environmental factors better, leading to improved prison conditions and reduced suicide rates. Furthermore, our research establishes a foundation for more systematic and in-depth investigations that could further improve suicide prevention strategies in Italian prisons, ultimately influencing policy changes in both practice and research, including perhaps establishing a national database on every completed suicide in prisons.