Malpractice or masterful practice?Navigating vicarious liability in healthcare

In the intricate landscape of healthcare,vicarious liability looms large,shaping the responsibilities and actions of healthcare practitioners and administrators alike.Illustrated by a poignant scenario of a medication error,this article navigates the complexities of vicarious liability in healthcare.It explains the legal basis and ramifications of this theory,emphasizing its importance in fostering responsibility,protecting patient welfare,and easing access to justice.The paper explores the practical effects of vicarious responsibility on day-to-day operations,leadership practices,and decision-making processes via the eyes of senior consultants,junior doctors,and hospital administrators.Through comprehensive insights and real-world examples,it underscores the imperative of fostering a culture of accountability,communication,and quality care to navigate the intricate web of liabilities inherent in modern healthcare.

Pattern of Referral of Obstetric Patients at a Tertiary Care Hospital in Southern Nigeria

Background: Health challenges that are difficult to manage at primary health centres should be referred to secondary health facilities, and if untreated, to the tertiary hospitals. A good referral should include the patient’s biography, such as age, gender, tribe, religion, occupation, medical history, the reason for the referral, treatments received, and clinical diagnosis. Objectives: To evaluate the referral patterns, indications for referrals, and feto-maternal outcomes for obstetric patients who were referred to the University of Port Harcourt Teaching Hospital. Materials and Methods: A prospective study of patients admitted to the Obstetric unit from January 1, 2021, to December 31, 2022. Data was collected from patients while on admission or clinic visits and recorded in an excel spread sheet. Data was analyzed with the Statistical Package for Social Sciences (SPSS) version 25. Results: Of the 3469 patients were admitted to the obstetric unit, 1476 and 1993 were admitted in 2021 and 2022, respectively. Most (70.35%) of the patients were in the 20-34 years age group, parity 1-4 was the most frequent (66.49%), while 85.39% of patients were booked. 10.46% of the booked patients were referred from other facilities, whereas 89.54% of patients were booked at our facility from the onset. Most common indications of referrals were previous caesarean section (CS) at term (40.09%) and hypertensive disorders of pregnancy (17.59%). The outcome for 2021 indicated 17 maternal deaths, 132 fetal deaths and 1010 live births, giving maternal mortality ratio (MMR) as 1810.44 per 100,000 live births and perinatal mortality ratio (PMR) of 130.7 per 1000 births respectively. In 2022, there were 17 maternal deaths, 130 fetal deaths and 1297 deliveries, giving a MMR of 1399 per 100,000 live births and a PMR of 100.2 per 1000 births. Conclusion: The pattern of referral among obstetric patients in this study shows that a lot of the patients do not get adequate care at the lower cadre of the referral system, hence adequate facilities should be made available in primary and secondary health centres to tackle obstetric emergencies.

Determination of Liability for Violation of “Sexual Autonomy” and Compensation for Mental Damages

At the legislative level in China,there has been insufficient theoretical preparation to explicitly include“sexual autonomy”within the scope of general personality rights.In handling the increasing number of disputes related to violations of“sexual autonomy,”judicial biases have emerged during the trial process when courts determine the attribute of the right to“sexual autonomy.”This situation necessitates a clear legal analysis of the concept and attributes of“sexual autonomy”to establish its essential attribute as a personality right,and,from the perspective of legal doctrine,enable the justification of the right to“sexual autonomy”as either a general personality right or other personality interests,thereby providing theoretical support for courts to“adjudicate according to law.”By delineating and categorizing instances of violations of“sexual autonomy,”the constitutive elements and fundamental characteristics of such violations can be clarified.By examining the legal norms governing civil litigation and civil litigation associated with criminal cases concerning violations of“sexual autonomy,”the responsibility determination,remedies,and existing regulatory loopholes regarding violations of“sexual autonomy,”especially in cases involving both criminal and civil matters,can be defined.Based on this foundation,the legal basis,determination mechanism,and compensation standards for claiming compensation for mental damages resulting from violations of“sexual autonomy”can be elucidated.

Risk Assessment of an Environmental Liability in the Commercialization of Hydrocarbons-A Secondary Publication

The risk analysis evaluates the probability of occurrence with the impact of said risks.In the hydrocarbon sector,an environmental liability is an improperly abandoned facility,soil contaminated by spills or others.The objective of this work is to define a risk management plan.The characterization of the residue and the area was carried out.Hazardous events were identified:overflow spill,soil contamination by infiltration,as well as radiant heat and suffocating and toxic fumes from a fire.The matrix method was applied considering the probability of occurrence against vulnerability.The danger of infiltration implied a high level of risk.The risk management plan was drawn up,its main action being the liquidation of the pool and the sanitation of the area.

Spontaneous combustion liability of coal and coal-shale: a review of prediction methods

This study presents a review of the various methods to predict the spontaneous combustion liability of coal and coal-shale. The relative propensity of coal to undergo self-heating can be established by different methods. These methods are well established in their usage, but the fact that no particular test method has become a standard to predict the spontaneous combustion liability indicates that doubt still exists as to the validity of all of them. The underlying principle of all the tests is that the more readily the coal undergoes exothermic oxidation, the more liable it is to self-heat. Comprehensive studies that centres on the international position on research being conducted by academics, different research institutes and industries on spontaneous combustion of coal and coal mine fires were evaluated. Relationships between the geochemical analysis (proximate and ultimate analysis, forms of sulphur, petrographic properties, X-ray diffraction and X-ray fluorescence) and spontaneous combustion testing methods (numerical and experimental approaches) used to predict the spontaneous combustion liability of coal were reviewed. The combination of these tests provides a better understanding of the mechanism that controls the spontaneous combustion phenomena. However, irrespective of the extensive studies that have been conducted over time, spontaneous combustion is still a major problem in the coal value chain.

Description and Factors Affecting the Referral of Presumptive Tuberculosis Patients in China

To describe and analyze the factors affecting the referral of presumptive tuberculosis patients between health-care facilities that are not affiliated with the National TB Control Program （NTP） and NTP-designated medical facilities in China, we carried out a retrospective study based on data collected in the Tuberculosis Information Management System in 2015. Out of 324,221 presumptive pulmonary tuberculosis （PTB） cases reported by non-NTP health-care facilities, 302,006 （93.1%） reported cases successfully arrived at designated medical facilities and 22,215 cases （6.9%） were lost to follow-up. The arrival rate of presumptive cases among male patients （92.9%） was slightly lower than that among female ones （93.7%）, and this difference is statistically significant. The majority （73.3%） of reported cases were local permanent residents. Migrants have a higher risk of being lost to follow-up compared with local residents （adjusted odds ratios 4.126 and 5.003, respectively）. Compared with farmers and herdsmen, pre-school children, unemployed laborers, retirees, and people with other occupations （adjusted odds ratios 2.361, 1.274, 1.068, and 1.993, respectively） had higher rates of loss to follow-up during the referral and tracing processes. In conclusion, this study demonstrates that the high referral rate of presumptive TB cases from non-NTP health-care facilities to designated medical facilities in China is due to implementation of effective active case identification strategies. In addition, migrant populations, pre-school children, unemployed laborers, and retirees were identified as high-risk groups that contribute to the loss to follow-up.

Replenishment policy and inventory optimization for supply-hub with liability period consideration

A replenishment decision-making model for supply-hub is firstly established from the angle of supplier, and optimal replenishment decision of the supplier is analyzed. Then, inventory optimization model for supply-hub is formulated from the angle of the manufacturer, and the optimization algorithm for obtaining optimal inventory levels is given. The result shows that liability period decides the share of the inventory cost between two sides in supply chain. With the increase of liability period, the service level has been quickly reduced even though the manufacturer's cost has been cut down by transferring the inventory cost to the supplier. As to the safety inventory, if the lower bound of components safety inventory increases, the supplier's cost will rise up more slowly than the liability period does, while the service levels increases as the safety inventory's lower bound is raised.

Proposing a novel comprehensive evaluation model for the coal burst liability in underground coal mines considering uncertainty factors

Coal burst is a severe hazard that can result in fatalities and damage of facilities in underground coal mines.To address this issue,a robust unascertained combination model is proposed to study the coal burst hazard based on an updated database.Four assessment indexes are used in the model,which are the dynamic failure duration(DT),elastic energy index(WET),impact energy index(KE)and uniaxial compressive strength(RC).Four membership functions,including linear(L),parabolic(P),S and Weibull(W)functions,are proposed to measure the uncertainty level of individual index.The corresponding weights are determined through information entropy(EN),analysis hierarchy process(AHP)and synthetic weights(CW).Simultaneously,the classification criteria,including unascertained cluster(UC)and credible identification principle(CIP),are analyzed.The combination algorithm,consisting of P function,CW and CIP(P-CW-CIP),is selected as the optimal classification model in function of theory analysis and to train the samples.Ultimately,the established ensemble model is further validated through test samples with 100%accuracy.The results reveal that the hybrid model has a great potential in the coal burst hazard evaluation in underground coal mines.

Analysis of spontaneous combustion liability indices and coal recording standards/basis

The characterization of the physical and chemical properties of coal on a standard provides an understanding of its characteristics towards spontaneous combustion.The trend of linear relationships between coal recording standards(%air-dried(ad),%dry(db)and%dry ash free(daf)basis)of 30 selected coal samples from the Witbank coalfields and spontaneous combustion liability indices were evaluated.The spontaneous combustion liability indices of these samples were evaluated by crossing point temperature(XPT),Stage II Slope,FCC(Feng,Chakravorty,Cochrane)and the Wits-Ehac tests,while the coal properties were determined from the proximate and ultimate analyses.The results obtained from these coal properties were related to different liability indices to develop trends of linear relationships using regression analysis.The ad basis indicated higher correlation coefficients than the db and daf basis for the XPT and FCC index,while the daf showed higher correlation coefficients than the ad and db basis for the Wits-Ehac index.It was found that the trend of linear relationships of these coal properties differs from one liability index to the next.The XPTs showed a better trend followed by the Stage II Slope on the coal properties among the spontaneous combustion liability indices evaluated.

Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

Epidemiologic Profile of Maternal Deaths in Two Referral Hospitals in Cameroon

Introduction: Our objective was to compare the epidemiologic profile of maternal mortality in two structures serving as referral levels of care in Cameroon. Methodology: This cross-sectional, comparative study took place at the maternities of the Yaoundé Central Hospital (YCH) and the Bamenda Regional Hospital (BRH) from December 1st 2014 to May 31st 2015, a 6 months’ period. The medical records of deceased women over 5 years, from January 2010 to December 2014, were collected. We calculated the MMR (Maternal mortality rate) and studied the causes and risk factors associated with maternal death. The Epi info software 3.5.4 was used to analyze data with a significance level of P < 0.05. Results: The maternal mortality ratio (MMR) was 964 and 247 per 100,000 live births for YCH and BRH, respectively. More deaths occurred within the aged group range 20 to 34 years, 76.8% at YCH and 64.7% at BRH. At YCH, 70.7% of these patients were referrals versus 32.4% at BRH. Complication from abortion was often implicated at BRH (P = 0.007;OR = 0.31;CI = 0.13 - 0.74). Others causes were hemorrhage (YCH = 43.4%;BRH = 35.5%), hypertensive diseases (YCH = 17.2%;BRH = 14.7%) and infections (YCH = 8.1%;BRH = 17.6%). At YCH time elapsed from admission to death was <3 h (P = 0.005;OR = 6.63;CI = 1.49 - 29.5). Conclusion: Both hospitals have similar causes of maternal deaths, differing only in the context within which the deaths occurred. Improving access to good quality health care, satisfying unmet needs for family planning, availability of blood products and the establishment of health insurance could decrease the maternal mortality rate.

The Epidemiological Characteristics of Beijing Lineage Mycobacterium tuberculosis from a National Referral Center in China

Our study was to investigate the epidemiological characteristics of M.tuberculosis from a national tuberculosis referral center in China. All strains isolated from TB patients, were genotyped by the RD105 deletion, 8 and 51 SNP loci and VNTR. The high differentiation SNPs of modern Beijing strains were analyzed for protein function and structure. 413 M. tuberculosis were included. Of 379 Beijing lineage M. tuberculosis, ＇modern＇ and ＇ancient＇ strains respectively represented 85.5% （324/379） and 14.5% （55/379）. Rv2494 （V48A） and Rv0245 （Sl03F） were confirmed as high differentiation SNPs associated with modern strains. In a word, Modern Beijing lineage M.tuberculosis was dominant and the structural models suggested that modern sub-lineage may more easily survive in ＇extreme＇ host condition.

Hard exudates referral system in eye fundus utilizing speeded up robust features

In the paper a referral system to assist the medical experts in the screening/referral of diabetic retinopathy is suggested. The system has been developed by a sequential use of different existing mathematical techniques. These techniques involve speeded up robust features（SURF）, K-means clustering and visual dictionaries（VD）. Three databases are mixed to test the working of the system when the sources are dissimilar. When experiments were performed an area under the curve（AUC） of 0.9343 was attained. The results acquired from the system are promising.

Reliability of a Tissue Microarray in Detecting Thyroid Transcription Factor-1 Protein in Lung Carcinomas

OBJECTIVE To compare the expression of the thyroid transcription factor-1 （TTF-1） in human normal adult type Ⅱ alveolar epithelial cells, embryonic pneumocytes and cancer cells of lung carcinoma and metastatic lymph nodes using a tissue microarray （TMA） along with paired conventional full sections, and to investigate the reliability of tissue microarrays in detecting protein expression in lung carcinoma. METHODS A lung carcinoma TMA including 765 cores was constructed. TTF-1 protein expression in both TMA and paired conventional full sections were detected by the immunohistochemical SP method using a monoclonal antibody to TTF-1. A PU （Positive Unit） of TTF-1 protein was assessed quantitatively by the Leica Q500MC image analysis system with results from the paired conventional full sections as controls. RESULTS There was no significance between TMA and paired conventional full sections in TTF-1 expression in different nuclei of the lung tissue. CONCLUSION TTF-1 protein expression in lung carcinoma detected by TMA was highly concordant with that of paired full sections. TMA is a reliable method in detecting protein expression.

Age-determined referral criteria of myopia for large-scale vision screening

Background: This study aimed to explore the best screening measure of myopia and its associated optimal referral criteria for children aged between 6 and 16.Methods: After informed consent of cycloplegia was obtained, a total of 6,321 children aged between 6 and 16 from 53 primary or junior middle schools in Jiading District of Shanghai were included in our populationbased study. Receiver operating characteristic(ROC) curve was performed to determine the best cutoff points, sensitivities and specii cities of different screening tests, including uncorrected visual acuity(UCVA), noncycloplegic autorefraction(NCAR) and the combination of these two tests.Results: There was significant difference in prevalence of myopia between boys and girls(χ~2=6.358, P=0.012). Compared with children of low age, the prevalence of older children was significantly higher(χ~2=1,386.404, P<0.001). For the combination of UCVA and NCAR, the best cutoff point was UCVA less than or equal to 0.2 logarithm of minimum angle of resolution(MAR)(20/30) and NCAR spherical equivalent refraction(SER) less than or equal to -0.75 diopters(D), with associated sensitivity and specificity of 75.0% and 85.0%, respectively, which were higher than those of UCVA and NCAR alone. After stratified by age, the best cutof points were varied among children. The accuracy for children aged between 9 and 12 was higher than that for other ages.Conclusions: The best screening measure of myopia was the combination of UCVA and NCAR. The optimal referral criteria of myopia for children should be age-determined.

Magnetic sphincter augmentation: Optimal patient selection and referral care pathways

Outcomes associated with magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD) have been reported,however the optimal population for MSA and the related patient care pathways have not been summarized.This Minireview presents evidence that describes the optimal patient population for MSA,delineates diagnostics to identify these patients,and outlines opportunities for improving GERD patient care pathways.Relevant publications from MEDLINE/EMBASE and guidelines were identified from 2000-2018.Clinical experts contextualized the evidence based on clinical experience.The optimal MSA population may be the 2.2-2.4% of GERD patients who,despite optimal medical management,continue experiencing symptoms of heartburn and/or uncontrolled regurgitation,have abnormal pH,and have intact esophageal function as determined by high resolution manometry.Diagnostic work-ups include ambulatory pH monitoring,high-resolution manometry,barium swallow,and esophagogastroduodenoscopy.GERD patients may present with a range of typical or atypical symptoms.In addition to primary care providers (PCPs) and gastroenterologists (GIs),other specialties involved may include otolaryngologists,allergists,pulmonologists,among others.Objective diagnostic testing is required to ascertain surgical necessity for GERD.Current referral pathways for GERD management are suboptimal.Opportunities exist for enabling patients,PCPs,GIs,and surgeons to act as a team in developing evidence-based optimal care plans.

Trends in the International Regime of Liability and Compensation for Oil Pollution Damage

Since the entry into force of the International Convention on liability and compensation for oil spill damage, there have been many discussions on the improvement of this regime. Based on the existing tworegimes, the writer tried to analysis the advantages of the new regimes and foresee the trends of the international regime of liability and compensation for oil pollution damage.

Knowledge and practices of primary care physicians on the current referral system of diabetic retinopathy in Islamabad and Rawal-Pindi, Pakistan

AIM: To assess the current knowledge and practices in diabetic eye care and referral system regarding diabetic retinopathy(DR) in health centers of Islamabad and RawalPindi. METHODS: A cross-sectional study was carried out in 4 government and private health centers in RawalpindiIslamabad from May 2018 to Oct. 2018. A total of 38 Primary Care Physicians(general practitioners, family physicians, and internists) were recruited out of which data for 2 were either not returned, or were missing partially. Data were collected through a 27-item consented & validated, multiple-choice questionnaire based on physician characteristics, knowledge and practice of diabetic eye care and challenges faced due current DR referral system. Descriptive analyses for all variables were performed including, mean and standard deviation. Analytical analyses were also conducted to study association between different study variables. RESULTS: Mean scores of knowledge for general practitioners, family physicians, and internists were 41.7%, 42.0% and 46.6% respectively. A lack of knowledge, and suboptimal practices were observed regarding signs, symptoms, screening, testing, evaluation and referral of DR regardless of physicians’ specialty, or years in practice. Lack of expertise regarding direct ophthalmoscopy, interpretation of findings, and referral to an ophthalmologist were noted. Physicians who performed consultation and counselling according to patients’ needs referred more patients to an ophthalmologist than those who restricted their consultationto a fixed amount of time and had more patients per unit time(P=0.01). Physicians who had taken care of less than 5 number of patients with DR marked less incorrect answers with no significantly greater number or correct answers compared to physicians who had taken care of more than 5 number of patients with DR(P=0.044). An association of more than 5 patients with DR taken care of with more need based patient consultation and counselling was also noted(P=0.017). An evaluation of the current referral system for DR revealed major loopholes in the health care infrastructure, proper guidelines, properly functioning equipment, check and balances, and lack of guidance to physicians regarding acquiring and updating knowledge regarding DR. CONCLUSION: Lack of updated and adequate knowledge, practices among primary care physicians, and suboptimal diabetic eye care and referral system have contributed to late presentation of DR. Interventions are needed to improve current diabetic eye care, and knowledge and practices of primary care physicians.

Analysis of Referrals for Mandibular Advancement Appliances for Sleep Apnoea

Aim: This article investigates the increasing awareness of Obstructive Sleep Apnoea (OSA) as a potentially serious health risk and highlights the role of the dentist in managing mild to moderate OSA cases which can be improved with an intra-oral mandibular advancement appliance. Methods: Data from referrals to a Prosthodontic Unit from 01-01-2019 to 18-8-2022 were analysed. Results: A total of 240 consecutive referrals to an NHS hospital where a patient was fitted with a mandibular advancement appliance (MAA) were analysed and 160 (67%) were male and 80 (33%) were female. The mean age in years was 52 (2019), 50 (2020), 52 (2021) and 51 (2022). Mean age of male referrals was 51 and female referrals was 53. Conclusion: There are a large number of patients with OSA seeking a dental device and practitioners should be aware of this treatment modality to help the medical team manage OSA. Clinical relevance: Dentists may need to have a greater understanding of OSA and be able to provide MAAs.

A Study Protocol on the Evaluation of Referral Strategies for Inflammatory Arthritis in Primary Care Patients at the Level of Healthcare Organization, Patient Relevant Outcomes and Costs

Background: Considering the importance of getting the right patient at the right location to maintain and optimize quality of life of inflammatory arthritis patients, appropriate referral by general practitioners is essential. This study aims to assess the effect and cost effectiveness of different referral strategies for inflammatory arthritis in primary care patients. Methods: This study follows a cluster randomized controlled trial design. General practitioners from primary care centers in Southwest-The Netherlands are randomly assigned to either one of the two strategic interventions for referring adult patients who are in the opinion of the general practitioner suspected of inflammatory arthritis: 1) Standardized digital referral algorithm based on existing referral models PEST, CaFaSpA and CARE;2) Triage by a rheumatologist in the local primary care center. These interventions will be compared to a control group, e.g. usual care. The primary outcome is the percentage of patients diagnosed with inflammatory arthritis by the rheumatologist. Secondary outcomes are quality of life as a patient reported outcome, work participation and healthcare costs. These data, including demographic and clinical parameters, are prospectively collected at baseline, three, six, and twelve months. Discussion: If this study can demonstrate improvements in appropriate referrals to the rheumatologist, thereby improving cost-effectiveness, there is sufficient supporting evidence to implement one of the referral strategies as a standard of care. Finally, with these optimization strategies a higher quality of care can be achieved, that might be of value for all patients with arthralgia. Trial Registration: NCT03454438, date of registration: March 5, 2018. Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT03454438?term=NCT03454438&draw=1&rank=1.