Lessons Learned with Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery: A Long Term Regional Network Experience.

OBJECTIVE: This enhanced recovery programme (ERP) aimed to achieve early recovery for patients undergoing major surgery. Results of a standardised ERP protocol for open infrarenal abdominal aortic aneurysm (AAA) repair within a hub and spoke regional network are presented. METHODS: In this monocentric prospective study (January 2004 - December 2021), consecutive AAAs (≥ 55 mm) were included in the ERP (patient discharge on post-operative day [POD] 4). The four phases of the ERP were pre-admission, pre-operative, intra-operative, and post-operative. Exclusion criteria were BMI > 35 kg/m2, functional capacity < 4 MET, previous aortic or abdominal surgery, and life expectancy < 5 years. Transperitoneal surgery was undertaken with routine AAA resection, graft interposition, and closure. RESULTS: Consecutive patients (n = 778) were enrolled into the study (mean age 72.3 ± 3.2 years; n = 712 men); 160 (20.5%) were treated in spoke hospitals. Median follow up was 78 (IQR 28, 128) months; median length of stay, procedure time, and blood loss were 4 days (IQR 3, 5), 190 min (IQR 170, 225), and 564 mL (IQR 300, 600). Infrarenal clamping and tube graft configuration were used in 96.5% (n = 751) and 72.5% (n = 564) of patients; 30 day mortality and complication rates were 0.4% (n = 3) and 9.2% (n = 72). Discharge after POD 4 occurred in 15.0%, and most significant predictors for discharge after POD 4 were haemotransfusion, re-intervention, and ileus over 3 days. Overall survival was: 98.2% at 1 year, 85.0% at 5 years, and 59.9% at 10 years. Freedom from re-intervention was 97.9% at 1 year, 94.1% at 5 years, and 86.8% at 10 years. Short and long term outcomes were comparable between hub and spoke hospitals. CONCLUSION: The ERP protocol was associated with low short and long term mortality and complication rates. Future studies should apply the ERP protocol to other vascular centres.

What could improve surgical data system at health facilities with high surgical volume in Ethiopia?

BACKGROUND: The effective management of surgical and anesthesia care relies on quality data and its readily availability for both patient-centered decision-making and facility-level improvement efforts. Recognizing this critical need, the Strengthening Systems for Improved Surgical Outcomes (SSISO) project addressed surgical care data management and information use practices across 23 health facilities from October 2019 to September 2022. This study aimed to evaluate the effectiveness of SSISO interventions in enhancing practices related to surgical data capture, reporting, analysis, and visualization. METHODS: This study employed a mixed method, pre- post intervention evaluation design to assess changes in data management and utilization practices at intervention facilities. The intervention packages included capacity building trainings, monthly mentorship visits facilitated by a hub-and-spoke approach, provision of data capture tools, and reinforcement of performance review teams. Data collection occurred at baseline (February - April 2020) and endline (April - June 2022). The evaluation focused on the availability and appropriate use of data capture tools, as well as changes in performance review practices. Appropriate use of registers was defined as filling all the necessary data onto the registers, and this was verified by completeness of selected key data elements in the registers. RESULTS: The proportion of health facilities with Operation Room (OR) scheduling, referral, and surgical site infection registers significantly increased by 34.8%, 56.5% and 87%, respectively, at project endline compared to baseline. Availability of OR and Anesthesia registers remained high throughout the project, at 91.3% and 95.6%, respectively. Furthermore, the appropriate use of these registers improved, with statistically significant increases observed for OR scheduling registers (34.8% increase). Increases were also noted for OR register (9.5% increase) and anesthesia register (4.5% increase), although not statistically significant. Assessing the prior three months reports, the report submissions to the Ministry of Health/Regional Health Bureau (MOH/RHB) rose from 85 to 100%, reflecting complete reporting at endline period. Additionally, the proportion of surgical teams analyzing and displaying data for informed decision-making significantly increased from 30.4% at baseline to 60.8% at endline period. CONCLUSION: The implemented interventions positively impacted surgical data management and utilization practice at intervention facilities. These positive changes were likely attributable to capacity building trainings and regular mentorship visits via hub-and-spoke approach. Hence, we recommend further investigation into the effectiveness of similar intervention packages in improving surgical data management, data analysis and visualization practices in low- and middle-income country settings.

Understanding health systems challenges in providing Advanced HIV Disease (AHD) care in a hub and spoke model: a qualitative analysis to improve AHD care program in Malawi.

BACKGROUND: Despite tremendous progress in antiretroviral therapy (ART) and access to ART, many patients have advanced human immunodeficiency virus (HIV) disease (AHD). Patients on AHD, whether initiating ART or providing care after disengagement, have an increased risk of morbidity and mortality. The Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) launched an enhanced care package using a hub-and-spoke model to optimize AHD care in Malawi. This model improves supply availability and appropriate linkage to care. We utilized a hub-and-spoke model to share health facility challenges and recommendations on the AHD package for screening and diagnosis, prophylaxis, treatment, and adherence support. METHODS: This qualitative study assessed the facility-level experiences of healthcare workers (HCWs) and lay cadres (LCs) providing AHD services to patients through an intervention package. The study population included HCWs and LCs supporting HIV care at four intervention sites. Eligible study participants were recruited by trained Research Assistants with support from the health facility nurse to identify those most involved in supporting patients with AHD. A total of 32 in-depth interviews were conducted. Thematic content analysis identified recurrent themes and patterns across participants' responses. RESULTS: While HCWs and LCs stated that most medications are often available at both hub and spoke sites, they reported that there are sometimes limited supplies and equipment to run samples and tests necessary to provide AHD care. More than half of the HCWs stated that AHD training sufficiently prepared them to handle AHD patients at both the hub and spoke levels. HCWs and LCs reported weaknesses in the patient referral system within the hub-and-spoke model in providing a linkage of care to facilities, specifically improper referral documentation, incorrect labeling of samples, and inconsistent availability of transportation. While HCWs felt that AHD registers were time-consuming, they remained motivated as they thought they provided better patient services. CONCLUSIONS: These findings highlight the importance of offering comprehensive AHD services. The enhanced AHD program addressed weaknesses in service delivery through decentralization and provided services through a hub-and-spoke model, improved supply availability, and strengthened linkage to care. Additionally, addressing the recommendations of service providers and patients is essential to improve the health and survival of patients with AHD.

Fertility preservation service for children and young adults at high risk of infertility; the hub and spoke model.

PURPOSE: To evaluate the evolution of fertility preservation surgery in children and young adults at high risk of infertility from a single centre to a networked 'Hub and Spoke' service. METHODS: A case note review of patients referred for ovarian or testicular cryopreservation between Jan 2013 and Dec 2023. Demographic data, procurement numbers, and site of procurement were collected. Specialist feedback was obtained to identify the challenges faced. RESULTS: Over time, the number of referrals increased from 4 to 349 patients per year with the number of Spoke centres rising to 36 ovarian and 16 testicular. In 2013-2014; 100% of procurement was ovarian as compared to 2023; 51% ovarian, 49% testicular. Of the 395 referrals in 2021, 81% (n = 319) went on to have procurement and storage of tissue. Between 2013 and 2016, 96% of cases were performed at the Hub. In 2023, 53/349 (15%) cases were performed at the Hub with the remaining 296 (85%) procured at Spoke sites. Surgical issues such as access to theatre, variation and availability of surgical equipment, thermal injury to ovarian tissue and variation in the size of the testicular specimen were identified. CONCLUSION: The Hub and Spoke model successfully delivers treatment to patients close to home as safely possible within their local treatment centre.

Strategies to increase primary care provider capacity for hepatitis C care: The California ECHO-PLUS study.

Expanding capacity to screen and treat those infected with the hepatitis C virus (HCV) is an essential element of the global elimination strategy. We evaluated the hub-and-spoke Project ECHO training versus telementoring models to educate, train and support HCV care by primary care providers in 13 targeted counties in northern California. A novel provider engagement strategy was used. Provider engagement and retention, time to readiness to treat HCV, and knowledge and confidence were the outcomes of interest. 94 participants from 60 unique clinics in the target counties participated in the ECHO-PLUS programme; 39.4% were physicians, 48.9% were advanced practice providers, and 11.7% were nurses. The median (range) participation time was 5 (1-49) hours. Confidence scores (minimum score = 13 and maximum score = 65) increased by a mean of 14.0 (SD:8.2) and 11.4 (SD:12.0) points for the hub-and-spoke and telementoring programmes, respectively (p = .53), with the largest changes in confidence seen in treating patients per guidelines, managing side effects and in serving as a consultant for HCV in their clinic. Among 24 participants with data on time to treatment, median time from beginner to experienced was 8 h (IQR:6-12) for hub-and-spoke and 2 h (IQR:1-2.4) for the telementoring programme (p = .01). A 'boots on the ground' approach to recruiting HCV champions was effective within rural communities. Both tele-ECHO hub-and-spoke and telementoring approaches to training primary care providers yielded increase in knowledge and confidence in HCV care and amplified the number of patients who were screened and treated. Telementoring accelerated the timeline of novice providers being 'ready to treat'.

A hub-and-spoke model to deliver effective access to chimeric antigen receptor T-cell therapy in a public health network: the Catalan Blood and Tissue Bank experience.

BACKGROUND AIMS: To describe and analyze whether a hub-and-spoke organizational model could efficiently provide access to chimeric antigen receptor (CAR) T-cell therapy within a network of academic hospitals and address the growing demands of this complex and specialized activity. METHODS: The authors performed a retrospective evaluation of activity within the Catalan Blood and Tissue Bank network, which was established for hematopoietic stem cell transplantation to serve six CAR T-cell programs in academic hospitals of the Catalan Health Service. Procedures at six hospitals were followed from 2016 to 2021. Collection shipments of starting materials, CAR T-cell returns for storage and infusions for either clinical trials or commercial use were evaluated. RESULTS: A total of 348 leukocytapheresis procedures were performed, 39% of which were delivered fresh and 61% of which were cryopreserved. The network was linked to seven advanced therapy medicinal product manufacturers. After production, 313 CAR T-cell products were shipped back to the central cryogenic medicine warehouse located in the hub. Of the units received, 90% were eventually administered to patients. A total of 281 patients were treated during this period, 45% in clinical trials and the rest with commercially available CAR T-cell therapies. CONCLUSIONS: A hub-and-spoke organizational model based on an existing hematopoietic stem cell transplantation program is efficient in incorporating CAR T-cell therapy into a public health hospital network. Rapid access and support of growing activity enabled 281 patients to receive CAR T cells during the study period.

Current territorial organization for access to revascularization therapies for acute ischemic stroke in the Veneto region (Italy) from 2017 to 2021.

INTRODUCTION: To evaluate the access to treatments with intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT) in acute ischemic stroke patients admitted to stroke units (SUs) of Veneto region (Italy) according to current "hub-and-spoke" model from 2017 to 2021. PATIENTS AND METHODS: We retrospectively analyzed data on treatments with IVT and/or MT for stroke patients admitted to the 23 SUs (6 Hubs and 17 Spokes) of the 6 macro-areas including 9 local sanitary units (LSUs) and 2 hospitals. RESULTS: We reported 6093 treatments with IVT alone, 1114 with IVT plus MT, and 921 with MT alone. Number of stroke unit (SU) beds/100,000 inhabitants ranges from 2.3 to 2.8, and no difference was found among different macro-areas. Number of treatments/100,000 inhabitants/year ranges from 19 to 34 for IVT alone, from 2 to 7 for IVT plus MT, and from 2 to 5 for MT alone. Number of IVT alone/SU bed/year ranges from 9 to 21 in the Hub and from 6 to 12 in the Spokes. Rate of IVT plus MT in patients directly arrived in the same LSU's Hub ranges from 50 to 81%, likewise the one of MT alone ranges from 49 to 84%. CONCLUSIONS: Treatment target rates of IVT and MT set by Action Plan for Stroke in Europe 2018-2030 has been globally exceeded in the Veneto region. However, the target rate of MT and access revascularization treatments is heterogeneous among different macro-areas. Further efforts should be made to homogenize the current territorial organization.

The Italian hub-and-spoke network for the emergency neurology management.

OBJECTIVE: The aim of the present study was to assess emergency neurology management in Italy by comparing patients admitted to the hub and spoke hospitals. METHODS: Data obtained from the annual Italian national survey (NEUDay) investigating the activity and facilities of neurology in the emergency room conducted in November 2021 were considered. Information for each patient who received a neurologic consultation after accessing the emergency room was acquired. Data on facilities were also gathered, including hospital classification (hub vs spoke), number of consultations, presence of neurology and stroke unit, number of beds, availability of neurologist, radiologist, neuroradiologist, and instrumental diagnostic accessibility. RESULTS: Overall, 1,111 patients were admitted to the emergency room and had neurological consultation across 153 facilities (out of the 260 Italian ones). Hub hospitals had significantly more beds, availability of neurological staff, and instrumental diagnostic accessibility. Patients admitted to hub hospital had a greater need for assistance (higher number of yellow/red codes at neurologist triage). A higher propensity to be admitted to hub centers for cerebrovascular problems and to receive a diagnosis of stroke was observed. CONCLUSIONS: The identification of hub and spoke hospitals is strongly characterized by the presence of beds and instrumentation mainly dedicated to acute cerebrovascular pathologies. Moreover, the similarity in the number and type of accesses between hub and spoke hospitals suggests the need to look for adequate identification of all the neurological pathologies requiring urgent treatment.

Efficacy of recanalization therapy for ischemic stroke: multicenter hospital network experience.

PURPOSE: Stroke is a leading cause of long-term disability with high mortality rate in the first year after the event. In Campania, mechanical thrombectomy treatment significantly increases in the last 3 years, as well as hospitals delivering acute stroke treatments. The aim of this study is to demonstrate how a full opening of our stroke network improves stroke management and stroked patients' survival in Campania. MATERIAL AND METHODS: In Federico II University Hospital of Naples acting as a HUB center of 7 peripheral SPOKE hospitals in regional territory, 68 patients with acute ischemic stroke were evaluated with NIHSS and m-RS clinical scores and neuroradiological ASPECT scores, from January 1 to December 31, 2021. At hospital discharge, NIHSS score and three months after m-RS score were re-assessed to evaluate the therapeutic effects. RESULTS: Forty-two of 68 patients (63%) admitted to our hub center had ischemic acute stroke at CT evaluation; 29 patients had ASPECT score > 7 (69%), and 6 a score < 7 (14%). At admission, NIHSS score mean value was 10.75, and m-RS score mean value was 0.74. At discharge, NIHSS score mean value was 7.09. After three months, m-RS score mean value was 0.74. DISCUSSION: The inter-company agreement between Federico II University and several peripheral hospitals allows an absolute and relative increase in endovascular mechanical thrombectomy and intravenous thrombolysis procedures, with a relative prevalence of mechanical thrombectomy. A regional implementation of the stroke multi-disciplinary care system is hardly needed to ensure the optimum treatment for the largest number of patients, improving patient's outcome.

Design of multimodal hub-and-spoke transportation network for emergency relief under COVID-19 pandemic: A meta-heuristic approach.

When COVID-19 suddenly broke out, the epidemic areas are short of basic emergency relief which need to be transported from surrounding areas. To make transportation both time-efficient and cost-effective, we consider a multimodal hub-and-spoke transportation network for emergency relief schedules. Firstly, we establish a mixed integer nonlinear programming (MINLP) model considering multi-type emergency relief and multimodal transportation. The model is a bi-objective one that aims at minimizing both transportation time consumption and transportation costs. Due to its NP-hardness, devising an efficient algorithm to cope with such a problem is challenging. This study thus employs and redesigns Grey Wolf Optimizer (GWO) to tackle it. To benchmark our algorithm, a real-world case is tested with three solution methods which include other two state-of-the-art meta-heuristics. Results indicate that the customized GWO can solve such a problem in a reasonable time with higher accuracy. The research could provide significant practical management insights for related government departments and transportation companies on designing an effective transportation network for emergency relief schedules when faced with the unexpected COVID-19 pandemic.

A systematic scoping review of undergraduate nursing hub-and-spoke placement models.

BACKGROUND: While nursing education has been forecast to continue to grow, placement capacity is now the key factor precluding growth in supply. AIMS: To provide a comprehensive understanding of hub-and-spoke placements and their ability to increase placement capacity. METHOD: A systematic scoping review and narrative synthesis were used (Arksey and O'Malley, 2005). PRISMA checklist and ENTREQ reporting guidelines were followed. FINDINGS: The search returned 418 results. After a first and second screen 11 papers were included. Results suggest that hub-and-spoke models were generally evaluated favourably by nursing students, with a range of benefits reported. However, many of the studies included in the review were small and of low quality. CONCLUSION: Given the exponential increase in applications to study nursing, hub-and-spoke placements appear to have the potential to better meet these increased demands, while also providing a number of benefits.

Radioimaging and Demographic Profiles of Patients with Spontaneous Intracerebral Hemorrhage: A Need for the Pragmatic Referral System.

Referring patients with severe medical conditions, like brain stroke, from small or rural hospitals to tertiary care centers is often overexploited leading to a kind of defensive medicine. The issue of a patient referral system remains unaddressed in Nepal. In this article, we investigated the legitimacy of referring patients with spontaneous intracranial hemorrhage (ICH) from country peripheral hospitals to the leading tertiary neurological center in Nepal. We found that 81 out of the 130 ICH patients reviewed in the study were referred. We further show that the classifiers to be considered most in the decision-making on the patient referral are as follows: hematoma volume, midline shift found in radioimaging, ventricular extension of bleeding, and appearance of hydrocephalus. An improper referral of the patient to the tertiary care center decreases limited resources of healthcare services in low-income countries. We believe the study reflects a prevailing belief among healthcare professionals that the current referral system could be improved with the inception of the "hub and spoke" model of healthcare. In this model, a network of secondary health institutions, capable of offering limited treatment, would refer ICH patients to an anchor tertiary institution, respecting the proper dichotomization of patients based on the clinical classifiers. We conclude that the use of the "hub and spoke" model, legitimizing the patient referral system, is posed to offer medical benefits for patients hit by a stroke and would be economically viable for both patients and healthcare services.

Aneurismal subarachnoid hemorrhage during the COVID-19 outbreak in a Hub and Spoke system: observational multicenter cohort study in Lombardy, Italy.

BACKGROUND: Lombardy was the most affected Italian region by the first phase of the COVID-19 pandemic and underwent urgent reorganization for the management of emergencies, including subarachnoid hemorrhage from a ruptured cerebral aneurysm (aSAH). The aim of the study was to define demographics, clinical, and therapeutic features of aSAH during the COVID-19 outbreak and compare these with a historical cohort. METHODS: In this observational multicenter cohort study, patients aged 18 years or older, who were diagnosed with aSAH at the participating centers in Lombardy from March 9 to May 10, 2020, were included (COVID-19 group). In order to minimize bias related to possible SAH seasonality, the control group was composed of patients diagnosed with aSAH from March 9 to May 10 of the three previous years, 2017-2018-2019 (pre-pandemic group). Twenty-three demographic, clinical, and therapeutic features were collected. Statistical analysis was performed. RESULTS: Seventy-two patients during the COVID-19 period and 179 in the control group were enrolled at 14 centers. Only 4 patients were positive for SARS-CoV-2. The "diagnostic delay" was significantly increased (+ 68%) in the COVID-19 group vs. pre-pandemic (1.06 vs. 0.63 days, respectively, p-value = 0.030), while "therapeutic delay" did not differ significantly between the two periods (0.89 vs. 0.74 days, p-value = 0.183). Patients with poor outcome (GOS at discharge from 1 to 3) were higher during the COVID-19 period (54.2%) compared to pre-pandemic (40.2%, p = 0.044). In logistic regression analysis, in which outcome was the dichotomized Glasgow Outcome Scale (GOS), five variables showed p-values < 0.05: age at admission, WFNS grade, treatment (none), days in ICU, and ischemia. CONCLUSIONS: We documented a significantly increased "diagnostic delay" for subarachnoid hemorrhages during the first COVID-19 outbreak in Lombardy. However, despite the dramatic situation that the healthcare system was experiencing, the Lombardy regional reorganization model, which allowed centralization of neurosurgical emergencies such as SAHs, avoided a "therapeutic delay" and led to results overall comparable to the control period.

Collaborative health systems ECHO: The use of a tele-education platform to facilitate communication and collaboration with recipients of state targeted response funds in Pennsylvania.

Background: The opioid epidemic continues to erode communities across Pennsylvania (PA). Federal and PA state programs developed grants to establish Hub and Spoke programs for the expansion of medications for opioid use disorders (MOUD). Employing the telementoring platform Project ECHO (Extension for Community Health Outcomes), Penn State Health engaged the other seven grant awardees in a Collaborative Health Systems (CHS) ECHO. We conducted key informant interviews to better understand impact of the CHS ECHO on health systems collaboration and opioid crisis efforts. Methods: For eight one-hour sessions, each awardee presented their unique strategies, challenges, and opportunities. Using REDCap, program characteristics, such as number of waivered prescribers and number of patients served were collected at baseline. After completion of the sessions, key informant interviews were conducted to assess the impact of CHS ECHO on awardee's programs. Results: Analysis of key informant interviews revealed important themes to address opioid crisis efforts, including the need for strategic and proactive program reevaluation and the convenience of collaborative peer learning networks. Participants expressed benefits of the CHS ECHO including allowing space for discussion of challenges and best practices and facilitating conversation on collaborative targeted advocacy and systems-level improvements. Participants further reported bolstered motivation and confidence. Conclusions: Utilizing Project ECHO provided a bidirectional platform of learning and support that created important connections between institutions working to combat the opioid epidemic. CHS ECHO was a unique opportunity for productive and convenient peer learning across external partners. Open dialogue developed during CHS ECHO can continue to direct systems-levels improvements that benefit individual and population outcomes.

Artificial intelligence applied to cardiovascular imaging, a critical focus on echocardiography: The point-of-view from "the other side of the coin".

Cardiovascular imaging has achieved a crucial role in the management of cardiovascular diseases. In this field, echocardiography advantages include wide availability, portability, and affordability, at a relatively low cost. However, echocardiographic assessment requires highly trained operators, and implies high observer variability, as compared with the other cardiac imaging modalities. Hence, artificial intelligence might be extremely helpful. From the point-of-view of the peripheral "Spoke" Hospital potential user ("the other side of the coin"), artificial intelligence development appears very slow in the clinical arena. Many limitations are still present, and require full involvement, cooperation, and coordination of professional operators into Hub-and-Spoke network.

Hub-and-spokes practices of blended learning: trajectories of emergency remote teaching in Brunei Darussalam.

The recent global pandemic has conveyed emergency remote teaching (ERT) specifically the blended approach, an indispensable alternative teaching and learning delivery in formal schools. In Brunei secondary schools, the blended learning approach formed the core 'Continuity Learning Plan' for instruction along with the mandated educational changes accruing to the social and economic challenges of the twenty-first century learning system. Its widespread adaptation underlies teachers' transitional initiatives and practices which must have reshaped the structural climate and relational dynamics of conventional instruction. Espousing the continuous learning model, this paper envisages to investigate the adaptive-related practices of Bruneian secondary school teachers and learners employing blended learning. Qualitative research approach with semi-structured interview was adopted in the study with respondents comprising of 18 teachers and 13 students. Thematic coding and recursive analysis of data revealed seven (7) dimensions or centre points of blended learning and teaching practices, namely: technological, interactive and effectiveness, added value, feasibility, pedagogical, institutional support and evaluation of success. In general, results suggest the Hub-and- Spokes model that organic support, integrated implementation and professional readiness are germane to the adaption of a functional and manageable blended delivery approach.

Knowing what you need to know in advance: The neural processes underpinning flexible semantic retrieval of thematic and taxonomic relations.

Semantic retrieval is flexible, allowing us to focus on subsets of features and associations that are relevant to the current task or context: for example, we use taxonomic relations to locate items in the supermarket (carrots are a vegetable), but thematic associations to decide which tools we need when cooking (carrot goes with peeler). We used fMRI to investigate the neural basis of this form of semantic flexibility; in particular, we asked how retrieval unfolds differently when participants have advanced knowledge of the type of link to retrieve between concepts (taxonomic or thematic). Participants performed a semantic relatedness judgement task: on half the trials, they were cued to search for a taxonomic or thematic link, while on the remaining trials, they judged relatedness without knowing which type of semantic relationship would be relevant. Left inferior frontal gyrus showed greater activation when participants knew the trial type in advance. An overlapping region showed a stronger response when the semantic relationship between the items was weaker, suggesting this structure supports both top-down and bottom-up forms of semantic control. Multivariate pattern analysis further revealed that the neural response in left inferior frontal gyrus reflects goal information related to different conceptual relationships. Top-down control specifically modulated the response in visual cortex: when the goal was unknown, there was greater deactivation to the first word, and greater activation to the second word. We conclude that top-down control of semantic retrieval is primarily achieved through the gating of task-relevant 'spoke' regions.

White matter basis for the hub-and-spoke semantic representation: evidence from semantic dementia.

The hub-and-spoke semantic representation theory posits that semantic knowledge is processed in a neural network, which contains an amodal hub, the sensorimotor modality-specific regions, and the connections between them. The exact neural basis of the hub, regions and connectivity remains unclear. Semantic dementia could be an ideal lesion model to construct the semantic network as this disease presents both amodal and modality-specific semantic processing (e.g. colour) deficits. The goal of the present study was to identify, using an unbiased data-driven approach, the semantic hub and its general and modality-specific semantic white matter connections by investigating the relationship between the lesion degree of the network and the severity of semantic deficits in 33 patients with semantic dementia. Data of diffusion-weighted imaging and behavioural performance in processing knowledge of general semantic and six sensorimotor modalities (i.e. object form, colour, motion, sound, manipulation and function) were collected from each subject. Specifically, to identify the semantic hub, we mapped the white matter nodal degree value (a graph theoretical index) of the 90 regions in the automated anatomical labelling atlas with the general semantic abilities of the patients. Of the regions, only the left fusiform gyrus was identified as the hub because its structural connectivity strength (i.e. nodal degree value) could significantly predict the general semantic processing of the patients. To identify the general and modality-specific semantic connections of the semantic hub, we separately correlated the white matter integrity values of each tract connected with the left fusiform gyrus, with the performance for general semantic processing and each of six semantic modality processing. The results showed that the hub region worked in concert with nine other regions in the semantic memory network for general semantic processing. Moreover, the connection between the hub and the left calcarine was associated with colour-specific semantic processing. The observed effects could not be accounted for by potential confounding variables (e.g. total grey matter volume, regional grey matter volume and performance on non-semantic control tasks). Our findings refine the neuroanatomical structure of the semantic network and underline the critical role of the left fusiform gyrus and its connectivity in the network.

Impacts of innovation in dental care delivery and payment in Medicaid managed care for children and adolescents.

BACKGROUND: We evaluated a 14-county quality improvement program of care delivery and payment of a dental care organization for child and adolescent managed care Medicaid beneficiaries after 2 years of implementation. METHODS: Counties were randomly assigned to either the intervention (PREDICT) or control group. Using Medicaid administrative data, difference-in-difference regression models were used to estimate PREDICT intervention effects (formally, "average marginal effects") on dental care utilization and costs to Medicaid, controlling for patient and county characteristics. RESULTS: Average marginal effects of PREDICT on expected use and expected cost of services per patient (child or adolescent) per quarter were small and insignificant for most service categories. There were statistically significant effects of PREDICT (p < .05), though still small, for certain types of service: (1) Expected number of diagnostic services per patient-quarter increased by .009 units; (2) Expected number of sealants per patient-quarter increased by .003 units, and expected cost by $0.06; (3) Total expected cost per patient-quarter for all services increased by $0.64. These consistent positive effects of PREDICT on diagnostic and certain preventive services (i.e., sealants) were not accompanied by increases in more costly service types (i.e., restorations) or extractions. CONCLUSION: The major hypothesis that primary dental care (selected preventive services and diagnostic services in general) would increase significantly over time in PREDICT counties relative to controls was supported. There were small but statistically significant, increases in differential use of diagnostic services and sealants. Total cost per beneficiary rose modestly, but restorative and dental costs did not. The findings suggest favorable developments within PREDICT counties in enhanced preventive and diagnostic procedures, while holding the line on expensive restorative and extraction procedures.

Head injury care in a low- and middle-income country tertiary trauma center: epidemiology, systemic lacunae, and possible leads.

BACKGROUND: Although head injury (HI) from low- and middle-income countries (LMIC) heavily contributes to the global disease burden, studies are disproportionately less from this part of the world. Knowing the different epidemiological characteristics from high-income nations can target appropriate prevention strategies. This study aims to provide a comprehensive overview of the clinico-epidemiological data of HI patients, focusing on the existing challenges with possible solutions from a developing nation's perspective. METHODS: This is a prospective, registry-based, observational study of HI in an Indian tertiary trauma-care center over 4 years. Various clinico-epidemiological parameters, risk factors, and imaging spectrum were analyzed in a multivariate model to identify the challenges faced by LMIC and discuss pragmatic solutions. RESULTS: The study included a large-volume cohort of 14,888 patients. Notably, half of these patients belonged to mild HI, despite most were referred (90.3%) cases. Only one-third (30.8%) had severe HI. Less than a third reached us within 6 h of injury. Road traffic accidents (RTA) accounted for most injuries (61.1%), especially in the young (70.9%). Higher age, males, RTA, helmet non-usage, drunken driving, systemic injuries, and specific imaging features had an independent association with injury severity. CONCLUSIONS: The study represents the much-needed, large-volume, epidemiological profile of HI from an LMIC, highlighting the suboptimal utilization of peripheral healthcare systems. Strengthening and integrating these facilities with the tertiary centers in a hub and enhanced spoke model, task sharing design, and efficient back-referrals promise effective neurotrauma care while avoiding overburden in the tertiary centers. Better implementation of road safety laws also has the potential to reduce the burden of HI.