A Simulation Modelling Study of Referral Distribution Policies in a Centralized Intake System for Surgical Consultation.

Delays beyond recommended wait times, especially for specialist services, are associated with adverse health outcomes. The Alberta Surgical Initiative aims to improve the referral wait time-the time between a referral is received at the central intake to the time a specialist sees the patient. Using the discrete event simulation modelling approach, we evaluated and compared the impact of four referral distribution policies in a central intake system on three system performance measures (number of consultations, referral wait time and surgeon utilization). The model was co-designed with clinicians and clinic staff to represent the flow of patients through the system. We used data from the Facilitated Access to Surgical Treatment (FAST) centralized intake referral program for General Surgery to parameterize the model. Four distribution policies were evaluated - next-available-surgeon, sequential, "blackjack," and "kanban." A sequential distribution of referrals for surgical consultation among the surgeons resulted in the worst performance in terms of the number of consultations, referral wait time and surgeon utilization. The three other distribution policies are comparable in performance. The "next available surgeon" model provided the most efficient and robust model, with approximately 1,000 more consultations, 100 days shorter referral time and a 14% increase in surgeon utilization. Discrete event simulation (DES) modelling can be an effective tool to illustrate and communicate the impact of the referral distribution policy on system performance in terms of the number of consultations, referral wait time and surgeon utilization.

Alarming levels of stigma toward generalized dystonia: A cross-cultural comparison.

INTRODUCTION: Although stigma has been linked to poor quality of life, studies examining its prevalence in dystonia are lacking. Our objective was to determine prevalence and predictors of stigma against generalized dystonia in diverse cultural settings. METHOD: Participants were 273 (65.9% female) patients and visitors approached at primary care clinics from three populations: León, Nicaragua (92 participants); a mostly-Hispanic Clinic in Omaha, NE USA (85 participants); and a mostly-non-Hispanic population in Omaha, Nebraska (96 participants). Participants learned about generalized dystonia, epilepsy and schizophrenia through reading a small vignette and viewing videos, followed by a questionnaire designed to identify stigma. We compared levels of stigma between dystonia and other conditions at different sites and measured variables that could affect them. RESULTS: Prevalence of stigma was high toward dystonia (33.00%), similar to epilepsy and lower than schizophrenia. The results showed a complex relationship between the studied variables and level of stigma, especially with age. Female gender predicted more stigmatizing answers. Country of origin, level of education and self-identification of Hispanic ethnicity did not affect stigma. Learning more personal information about the dystonia patient decreased dystonia, a proof that unjustified preliminary negative judgment was present. CONCLUSIONS: Stigma against generalized dystonia was very prevalent across all the communities studied. Demographic and socio-cultural variables had different correlations to level of stigma, underlying the complexity of this problem. The alarming levels of stigma against dystonia justify further studies on how to minimize its impact on our patients.

Inducing neurite outgrowth by mechanical cell stretch.

Establishing extracellular milieus to stimulate neuronal regeneration is a critical need in neuronal tissue engineering. Many studies have used a soluble factor (such as nerve growth factor or retinoic acid [RA]), micropatterned substrate, and electrical stimulation to induce enhanced neurogenesis in neuronal precursor cells. However, little attention has been paid to mechanical stimulation because neuronal cells are not generally recognized as being mechanically functional, a characteristic of mechanoresponsive cells such as osteoblasts, chondrocytes, and muscle cells. In this study, we performed proof-of-concept experiments to demonstrate the potential anabolic effects of mechanical stretch to enhance cellular neurogenesis. We cultured human neuroblastoma (SH-SY5Y) cells on collagen-coated membrane and applied 10% equibiaxial dynamic stretch (0.25 Hz, 120 min/d for 7 days) using a Flexcell device. Interestingly, cell stretch alone, even without a soluble neurogenic stimulatory factor (RA), produced significantly more and longer neurites than the non-RA-treated, static control. Specific neuronal differentiation and cytoskeletal markers (e.g., microtubule-associated protein 2 and neurofilament light chain) displayed compatible variations with respect to stretch stimulation.