Hospital Nacional de Niños

Process mining (PM) in the healthcare sector is a key discipline in terms of improving processes based on the data stored in clinical information systems. This discipline has been complemented by other techniques, such as process simulation (PS), in order to facilitate decision-making across the sector. In turn, this has enhanced the management of organizational indicators and strengthened the analysis, optimization, and improvement of processes. However, the combination of PM and PS in healthcare still presents a number of challenges, including the incorporation of additional medical specialties, the involvement of healthcare experts, the optimization of data quality, and the promotion of further research that seeks to strengthen the combination of these two areas. The present paper contributes to overcoming these challenges by introducing PROcess Mining & Simulation for Healthcare Analysis: PROMSHA-Methodology, a methodology that provides the necessary steps for process analysis by combining PM and PS in the field of healthcare. The methodology herein addresses certain challenges related to the quality of medical data and includes the participation of experts. To evaluate the usefulness of PROMSHA, a case study was conducted in the pediatric ophthalmology department of a Costa Rican hospital, in which PM techniques were applied to detect spaghetti models and repetitive activities, as well as to identify the causes of waiting lists and bottlenecks by means of several simulated scenarios.

OBJECTIVES:To evaluate the methodological quality of hospital-specific paediatric sepsis clinical practice guidelines (CPGs) from sites participating in an international study using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool and to assess the consistency of treatment recommendations and concordance with the Surviving Sepsis Campaign 2020 (SSC 2020) international reference standard. DESIGN:Cross-sectional appraisal of hospital-specific CPGs. SETTING:Hospital sites participating in the Sepsis Epidemiology in Paediatric Acute Care International Study across five continents. PARTICIPANTS:Hospital-specific CPGs for the acute care management of paediatric sepsis. INTERVENTIONS:Hospital-specific CPGs were appraised independently using the AGREE II tool and classified as high, moderate or low quality. Consistency across guidelines and concordance with SSC 2020 were assessed for 12 key treatment recommendations. MAIN OUTCOME MEASURES:AGREE II domain scores and overall quality rating; consistency of treatment recommendations across hospital-specific CPGs; concordance of individual CPGs with SSC 2020. RESULTS:14 hospital-specific CPGs from 13 countries were included. All were rated as low methodological quality overall; the rigour of development (range: 0-50%) and editorial independence (0-58%) were the lowest scoring AGREE II domains. CPG concordance with SSC 2020 ranged from 42% to 100%; consistency across the 12 treatment recommendations ranged from 43% (steroid indications) to 93% (initial laboratory investigations, time to antibiotics and fluid bolus volume). CONCLUSIONS:Despite all hospital-specific CPGs across an international cohort being of low methodological quality, most aligned with SSC 2020 for key time-critical recommendations. Clinically important variations existed in fluid resuscitation composition and timing of steroid administration. TRIAL REGISTRATION NUMBER:ACTRN12621000920097.

Yellow fever remains a major public health threat in endemic and re-emerging regions of Africa and South America, with recent outbreaks highlighting persistent gaps in prevention and surveillance. Pregnant women represent a particularly vulnerable population, yet the epidemiology, clinical impact, and preventive strategies for yellow fever in pregnancy are insufficiently characterized. Physiological and immunological changes during gestation may influence host responses to infection; however, current evidence does not demonstrate increased susceptibility to or severity of yellow fever during pregnancy. Adverse materno-fetal outcomes, including miscarriage, stillbirth, preterm birth, and, in rare cases, perinatal transmission, have been reported but remain poorly characterized. Diagnostic challenges, overlapping clinical presentations with other arboviral and hepatic diseases, and limited access to specialized care further complicate clinical management in many endemic settings. This perspective provides a comprehensive overview of yellow fever in pregnancy during the 2024–2026 outbreak in the Americas, including a risk-stratification framework for prevention. We summarize current evidence on epidemiology, pathophysiology, diagnosis, and supportive care, and examine prevention strategies with particular emphasis on vaccination. Accumulated observational evidence and substantial real-world experience have not demonstrated an increased risk of serious adverse events and generally support the effectiveness of yellow fever vaccination during pregnancy when administered with appropriate clinical judgment. In high-risk settings, the benefits of maternal immunization clearly outweigh theoretical concerns, supporting a flexible, risk-based approach, despite relatively limited evidence. We also discuss national and international policies, post-pregnancy booster recommendations, and the importance of integrating vaccination assessment into antenatal care. Finally, we highlight critical knowledge gaps and research priorities, including the need for prospective registries and strengthened pharmacovigilance. Coordinated clinical and public health strategies are essential to protect maternal and neonatal health and to reduce the burden of yellow fever in endemic and re-emerging settings.