Alternative Management Strategies Research Articles

Staged ventricular recruitment and biventricular conversion following single-ventricle palliation in unbalanced atrioventricular canal defects

ObjectiveRestoration of biventricular circulation is an alternative management strategy in unbalanced atrioventricular canal defects (uAVCDs), especially in patients with risk factors for single-ventricle palliation (SVP) failure. When ventricular volume is inadequate for biventricular circulation, recruitment procedures may accommodate its growth. In this study, we review our uAVCD experience with biventricular conversion (BIVC) after prior SVP. MethodsThis is a single-institution, retrospective cohort study of uAVCD patients who underwent BIVC after SVP, with staged recruitment (staged) or primary BIVC (direct) between 2003 to 2018. Mortality, unplanned reinterventions, imaging, and catheterization data were analyzed. ResultsSixty-five patients underwent BIVC from SVP (17 stage 1, 42 bidirectional Glenn, and 6 Fontan). Decision for conversion was based on poor SVP candidacy (n = 43) or 2 adequately sized ventricles (n = 22). Of the 65 patients, 20 patients underwent recruitment before conversion. The staged group had more severe ventricular hypoplasia than the direct group, reflected in prestaging end-diastolic volume z scores (–4.0 vs –2.6; P < .01), which significantly improved after recruitment (–4.0 to –1.8; P < .01). Median follow-up time was 1.0 years. Survival and recatheterizations were similar between both groups (hazard ratio, 0.9; 95% CI, 0.2-3.7; P = .95 and hazard ratio, 1.9; 95% CI, 0.9-4.1; P = .09), but more reoperations occurred with staged approach (hazard ratio, 3.1; 95% CI, 1.3-7.1; P = .01). ConclusionsBiventricular conversion from SVP is an alternative strategy to manage uAVCD, particularly when risk factors for SVP failure are present. Severe forms of uAVCDs can be converted with staged BIVC with acceptable mortality, albeit increased reinterventions, when primary BIVC is not possible.

Evaluating performance of data-limited management procedures in an ecosystem perspective: A case study for Larimichthys crocea (Sciaenidae) in the Min River Estuary, China

Management Strategy Evaluation (MSE) evaluates the performance of alternative management strategies. However, the potential ecosystem effects of the management procedures (MPs) are less evaluated. As one of the four top commercial marine fisheries of China, the fishery of the large yellow croaker Larimichthys crocea (LYC) collapsed in the late 1980s due to the exceeded fishing pressure on spawning and over-wintering aggregations. Long-term and large scale restocking programs for the recovery of LYC fishery have been conducted widely along the eastern coast of China, but its ecosystem impacts and ecological carrying capacity (ECC) were not well understood and assessed. The species-specific assessment and management for LYC fishery were lack due to limited data availability. In this study, an Ecopath model was built as the operating model in MSE to evaluate the effects of MPs for the LYC fishery and estimate the LYC ECC in the Min River Estuary to explore the optimal management measure. A total of 12 candidate MPs were identified and tested, including 5 input controls (2 fishing-effort-based and 3 length-based) and 7 catch-based output controls. A 20-year simulation showed that only 4 MPs fully achieved the performance criteria in maintaining biomass and avoiding further overfishing, including curE75 (75 % of current fishing effort levels), minlenLopt1 (the minimum length of retention for maximizing biomass), matlenLim (fishing retention-at-length related to the maturity curve: 100 %) and matlenLim2 (fishing retention-at-length related to the maturity curve: 110 %). The Min River Estuary ecosystem could support up to 17 kg/km2 of LYC. The Ecosim model projects that the LYC biomass increased over 20 % after the application of curE75, and over 37 % with the combination of curE75 and national fishing moratorium policy after the 20-year simulation. The combination of releasing, fishing effort reduction and fishing moratorium is the optimal measure within current management systems for the recovery of LYC fishery in the Min River Estuary. This study provides an ecosystem-based fishery management approach to plan and evaluate restocking programs using data-limited methods and MSE for the LYC and other fisheries.

PENGELOLAAN BERKELANJUTAN PERIKANAN TANGKAP IKAN SARDINELLA DI PERAIRAN JEMBRANA BERDASARKAN ANALISIS SWOT DAN ANALYTICAL HIERARCHICAL PROSESS (AHP) DI KABUPATEN JEMBRANA

This research aimed to examine and analyze the problems that occur in the management of sustainable captured fisheries, especially Sardinella fish in Jembrana Regency, in order to determine alternative strategies in management through SWOT analysis and Priority scale through Analytical Hierarch Process (AHP). The alternative determination of the sustainable management strategy of lemuru fish based on SWOT analysis includes IFAS matrix, with a strength score of 1.51 and a weakness of 1.26, the difference between a strengths and weaknesses value of 0.25 (x). The EFAS matrix has an opportunity score of 1.59 and a threat score of 1.30, the difference between the opportunity and threat factors is 0.29 (y). SWOT analysis diagram is located in quadrant one, which is a progressive strategy or SO Strategy using all the power available to echieve or get the greatest opportunity. Policy Determination based on AHP for sustainable management of lemuru fish in Jembrana Regency, Criterion 7 becomes the first priority with a value of 22%, namely cooperating with relevant agencies related to data and information collection of reliable and integrated capture fisheries in accordance with technological developments, in order to streamline activities and maximize the catch.&#x0D; Keywords: AHP, Fisheries Management, Sustainable, SWOT analysis.

Analysis of the Use of Pharmacy Graduates in TaskShifting as an Alternative Management Strategy in Healthcare Organizations

Analysis of the Use of Pharmacy Graduates in TaskShifting as an Alternative Management Strategy in Healthcare Organizations

PENGELOLAAN HUTAN MANGROVE BERBASIS MASYARAKAT DI DESA BUDENG, KECAMATAN JEMBRANA, KABUPATEN JEMBRANA

The mangrove forest in Budeng Village is managed by local communities by forming farmer groups. The interaction of the people of Budeng Village in mangrove management, this will determine the sustainability of the mangrove area in the future. It is necessary to have the right strategy in mangrove management by following the rules of balance and sustainability. The purpose of this study is to analyze changes in mangrove forest cover, find out the perception and participation of the community in mangrove forest management and develop an ideal mangrove forest management strategy. Data collection includes using literal studies, observations, questionnaires and Forum Group Discussion. Samples in this study was 30 people. Data analysis was performed using SWOT matrix and QSPM matrix. The condition of mangrove forests in Budeng Village is relatively good, there is an increased in mangrove forest cover covering an area of 36 ha in the period from 2016 to 2021. The level of community perception in mangrove forest management excellent categories and the level of community participation is in high categories. The general strategy on mangrove forest management in Budeng Village is growth strategy. Based on the results of the SWOT analysis, there are 14 alternative strategies for mangrove forest management in Budeng Village with a priority strategy based on the results of the Total Attractiveness Score calculation is to increase the role and commitment of local governments in mangrove forest management in Budeng Village.&#x0D; Keywords: mangroves; perception; participation; strategy; management

Identification and utilization of a new Bacillus amyloliquefaciens XY-1 against Fusarium head blight.

Fusarium head blight (FHB) is a global wheat grain disease caused by Fusarium graminearum. Biological control of FHB is considered to be an alternative disease management strategy that is environmentally benign, durable, and compatible with other control measures. In this study, to screen antagonistic bacteria with the potential to against FHB, 45 strains were isolated from different tissues of wheat. Among them, seven strains appeared to effectively inhibit F. graminearum growth, the antagonistic bacterium named XY-1 showed a highly antagonistic effect against FHB using dual culture assays. The strain XY-1 was identified as Bacillus amyloliquefaciens by 16S rDNA sequence. Antibiotic tolerance of antagonistic bacteria showed that XY-1 had antagonistic activity against Colletotrichum gloeosporioides, Rhizoctonia solani, Sclerotium rolfsii, and Alternaria alternata. Nutrition tests showed that the most suitable carbon and nitrogen sources were glucose and beef extract, respectively. The optimum growth temperature and pH value were 28 ℃ and 7.4. Antibiotics tolerance cultivation showed that XY-1 had strong resistance to Chloramphenicol and Ampicillin. Wheat spikes inoculation antagonism tests showed that strain XY-1 displayed strong antifungal activity against F. graminearum. Our study laid a theoretical foundation for the application of strain XY-1 as a biological agent in the field to control FHB.

Catheter-Directed Interventions for the Treatment of Lower Extremity Deep Vein Thrombosis.

Lower extremity deep vein thrombosis (DVT) leads to significant morbidity including pain, swelling, and difficulty walking in the affected limb. If left untreated, DVT increases the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE), and post thrombotic syndrome (PTS). The objective of this review was to identify catheter-directed interventions and their success rates for the treatment of lower extremity DVT. A comprehensive search of current and emerging catheter-directed interventions for lower extremity DVT treatment was conducted in PubMed and Google Scholar. Clinical trials, retrospective and prospective observational studies, and case reports were identified to classify percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), and pharmacomechanical CDT (PCDT) devices based on their mechanism of action and indication of use. Catheter-directed interventions such as PMT, CDT, and PCDT offer an alternative therapeutic strategy for DVT management, particularly in patients with limb-threatening conditions and absolute contraindications to anticoagulants. Currently, there are limited guidelines for the use of mechanical and pharmacomechanical devices because of the lack of clinical evidence available for their use in treatment. Future studies are required to determine the short and long-term effects of using catheter-directed interventions as well as their effectiveness in treating acute versus subacute and chronic DVT.

Towards resilience-based management of marine capture fisheries

The world faces major risks in ensuring the sustainability and on-going socio-economic benefits from its marine capture fisheries (MCFs). Key drivers of risks for MCFs include: overharvesting, bycatch, illegal fishing, habitat loss and damage, climate change, and marine pollution. These risks threaten the livelihoods of the hundreds of millions of households and the nutrition of billions of people who depend on fish as a key source of protein. Resilience-based management offers an approach to respond to risks. Here, we review how might resilience contribute to the sustainability of fish stocks and evaluate the implications for net economic returns under alternative management strategies. Our focus is in three parts. First, we review: (1) rights-based management; (2) marine protected areas; and (3) ecosystem-based management. Second, we discuss how resilience-based management complements existing management approaches and describe the findings of emerging resilience research in four different fisheries. Third, we highlight the knowledge gaps and practice gaps that emerge from the review.

Climate-driven shifts in growth and maturity induce changes to the population and fishery dynamics of a high-value crustacean

Climate change is fueling unprecedented warming in marine environments. Crustaceans demonstrate strong physiological responses to rising temperatures including smaller molt increments, more frequent molting, and decreased size-at-maturity (SAM). Despite the potential for these changes to affect population and fisheries dynamics, there is limited research quantifying potential impacts. This is concerning, as crustacean fisheries are becoming increasingly important globally. Using an individual-based model for the valuable American lobster (Homarus americanus) fishery in the Gulf of Maine (GOM), we sought to address pressing questions about how climate-driven changes to growth and maturity could impact the population and fishery dynamics. To do so, we used counterfactual simulations informed by the literature and an expert survey to quantify the effects of smaller molt increments, increased molting, and decreased SAM on lobster spawning stock biomass (SSB) and landings. We found that all three changes to life history, combined, increased the SSB and landings relative to the base case. Notably, SSB in the terminal year of the time-series was 278.3%, 505.1%, and 748.5% greater than the base case under small, moderate, and extreme changes, respectively, to life history. However, when molt increment size and molting probability were changed but SAM was not, SSB and landings decreased relative to the base case, emphasizing the importance of SAM as a driver of productivity. Overall, these findings indicate that climate-driven changes to growth and maturity may favorably impact the population and fishery dynamics of lobster, contributing to sustained fishery yield in the GOM. This study emphasizes the utility of simulating the effects of climate-forced life history change for informing climate-ready fisheries management. Future work should explore the effects of other climate-driven life history changes alongside alternative management strategies for lobster and other crustaceans.

Perioperative Nephrectomy Outcomes for Patients with Liver Disease: Implications for Liver Transplant Candidates

ObjectiveTo improve the management of cirrhotic patients diagnosed with new renal masses, we used a nationally representative cohort to assess the perioperative outcomes of nephrectomy in the setting of liver disease. The incidences of liver disease and renal masses are both rising in the US. Delaying liver transplantation to address other health concerns may have life changing consequences in these patients, thus these results help to guide treatment decisions at this critical junction in care. MethodsA retrospective study of the 2016-2019 Nationwide Readmissions Database was performed in adults undergoing nephrectomy for non-emergent indications. Outcomes were compared between 3 cohorts: no chronic liver disease (no CLD), chronic liver disease (CLD), and decompensated cirrhosis (DC). Mixed regression models were used to evaluate the association between CLD and DC with outcomes of interest including morbidity, mortality, readmission rates, non-home discharges, length of stay, and costs. ResultsA total of 183,362 patients were evaluated. The mortality rate in the DC cohort (7%) was higher than with CLD (0.4%) and no CLD (0.3%), (P <.001). DC was associated with higher mortality (OR 8.29, 95% CI 4.07 - 16.88), postoperative bleeding requiring transfusion (OR 5.55, 95% CI 3.72 - 8.26), non-home discharge (OR 5.12, 95% CI 3.16 - 8.30) and readmission (OR 1.79, 95% CI 1.09 - 2.94) compared to no CLD. The DC cohort had the greatest length of stay and costs. ConclusionPatients undergoing nephrectomy with DC have increased morbidity, mortality, readmission rates, non-home discharges, LOS and costs. Alternative management strategies may be considered in these patients.

Prevention and Management of Sickle Cell Pain Crises: Lessons Learned from Older Adults with Sickle Cell Disease

Background Innovations in medicine over the last fifty years have extended the median lifespan of people living with sickle cell disease (SCD) from 14 years to as long as 61 years in cohorts from academic centers. There is a paucity of information on the experiences preventing and managing vaso-occlusive pain crises by older adults with SCD. Older adults with SCD have decades of experience navigating pain and other complications of SCD. They have a wealth of knowledge about how to care for themselves, which can be shared with a younger generation of those with SCD. The purpose of this study was to describe strategies used by older adults (≥50 years) to prevent and manage pain crises. Methods We enrolled 19 men and women at least 50 years old from a single comprehensive sickle cell center in the Southeastern United States. We conducted semi-structured qualitative interviews by phone or in person. A single interviewer asked open-ended questions about the participant's experiences living with SCD and strategies they feel helped them live a long life. Participants described strategies they have adopted to cope with and prevent pain crises. A commercial service transcribed audio-recordings of the interviews verbatim. We used conventional content analysis to code the transcripts. Results The mean age of participants was 58 years (range 50-71). Over half (53%) had HbSS genotype, 37% had HbSC, and 11% had HbSβ+-thalassemia. Almost half (45%) were hospitalized and 63% had an emergency room visit in the last year. Most participants (84%) were on short-acting and 37% were on long-acting opiates. The majority (58%) reported current use of hydroxyurea. During the interview participants discussed strategies used to prevent and manage their pain crises. There were two major themes. (Figure 1) Theme 1 was "Strategies for Pain Prevention", which centered on methods they adopted throughout their lives to help prevent pain crises. Participants described that when they were younger pain medicine was not readily available, causing them to focus on strategies to prevent pain crises. They often relied on their parents to set limits on their activity levels to avoid having a crisis. When they reached adulthood, they learned to advocate for themselves by communicating their limitations. Having a good support system to encourage them to rest also helped. Most participants emphasized the importance of moving at their own pace and slowing down when they needed to. They discussed how knowing their triggers helped avoid a pain crisis or manage it better on their own. Sometimes simply sleeping once they felt a pain crisis coming on could help avert a crisis. Avoiding stressful situations, emotional triggers, temperature extremes, being underdressed, sitting long periods, and dehydration helped to prevent pain crises. Most participants described how a healthy diet and exercise were key in the prevention of pain crises. Eating fruits and vegetables, avoiding sugary drinks, excessive alcohol, and processed foods helped reduce pain episodes. They described low impact exercises they engaged in such as walking, yard work, and cycling. Theme 2 was "Strategies for Managing Pain” which included using pharmacological and non-pharmacological methods. One of the most important strategies participants mentioned was to rest as soon as a pain crisis started. For some, physical activity helped relieve pain, while for others, it was a trigger for a crisis. The strategies adopted also included hydration, heating pads, resting, distraction techniques, and avoiding stress as much as possible. Alternative pain management strategies that were reported included acupuncture, massage, and aquatic therapy. While pain medication was useful, many participants stated that they did not like being prescribed pain medicine without other therapies. Conclusion The growing population of older adults with SCD have a wealth of knowledge that can benefit younger adults with SCD to prevent and manage pain crises. Strategies they have learned through a lifetime of experience living with SCD have given them a unique insight into how to best cope with pain crises. In future research we will evaluate how best to share approaches developed by people with SCD for preventing and managing SCD complications. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Emergency Department Experience and the Use of Non-Pharmacologic Treatment for Acute Pain Among Patients with Sickle Disease

Background: Appropriate management for patients presenting to the Emergency Department (ED) with acute pain from vaso-occlusive episodes (VOE) primarily includes treatment with parenteral opioid and non-opioid analgesia and fluids if the episode is uncomplicated. Non-pharmacological strategies that significantly affect non-physical aspects of behavioral, social, and cultural life, have been studied for pain treatment in sickle cell patients; however, the data on the effectiveness of these methods are limited. Objectives: This work aims to assess the overall ED experience among patients seeking care for acute VOE. We also aim to assess any effective alternative pain management strategies used by patients to treat their acute pain symptoms. Methods: We conducted ED follow up assessments for patients who sought care in the ED for acute pain from vaso-occlusive episodes from January 1, 2022- July 15, 2022. These were brief individual phone interviews. The semi-structured interview guide was created using a hospital specific patient experience questionnaire in addition to questions pertaining to pain management in the acute and day-to-day settings, demographic data including, age, sex, emergency department visit characteristics (length of stay (LOS), emergency severity index assignment (ESI), time to first opioid). The interviews were analyzed using a framework matrix analysis. This qualitative data reduction technique was used to review, summarize, and classify the interview data. NVivo 20 qualitative data analysis software includes a framework matrix tool used to manage data and facilitate this analysis in which participant comments about key content were aggregated and entered for review. Results: Overview: Among the 21 patients who met study criteria, eight participants are included in this analysis. Six participants identified as male, and two participants identified as female. ED Experience: Patients rated their ED care from a 3/10 to a 10/10 (avg 6.4, +/- 2.6). Common themes included prolonged wait times for pain management (6/8 participants). Five of the eight patients interviewed expressed gratitude for the care provided though noted some room for improvement. One participant noted "they could have been nicer to me. It's like they don't talk to each other" (2/8 participants). Patients also expressed frustration when intravenous access issues arise and compounding delays in treatment. Pain management: Three of the eight patients interviewed reported using scheduled opioids (oxycodone-5 patients, and methadone-2 patients) at home every 3-8 hours. One patient declined to answer questions about home opioid use. All patients received hydromorphone for acute management in the ED. Two of the eight patients expressed knowledge of their care coordination pain management plan. Alternative pain management: Five of the eight patients used heat or hot packs as their primary alternative pain management and specifically referenced this as an intervention that they would find helpful in the ED. Two patients prioritized distractions such as video games or other screen time. One patient relied on family support, massages, and meditation. Conclusions: Patients experiencing acute pain from VOE rely on the ED for care. Optimizing that care will not only improve patient's health, but also their well-being. Considering complementary alternatives for acute pain management including heat therapy (packs, blankets) as well as massage (heated chair) or distractions (video games, reading or movies) may provide additional benefits while patients seek care for acute pain crises.

RADT-13. CLINICAL OUTCOMES COMPARING RADIOSURGERY TECHNIQUES FOR MANAGING LARGE BRAIN METASTASES

Abstract INTRODUCTION Large brain metastases (BM) are associated with poor local control with single-fraction radiosurgery (SRS) alone. We sought to compare outcomes with various alternative management strategies to assess disease control rates. METHODS Consecutive patients diagnosed with BM ≥ 2 cm in maximum diameter between 3/2019-2/2021 and treated at a single tertiary institution were included. Primary endpoints included freedom-from-local-failure (FFLF) calculated on a per-lesion basis from the date of initial intervention to local failure, and overall survival (OS). Kaplan-Meier analysis and the log-rank test were used. RESULTS 86 patients with 102 large BM met inclusion criteria. The median age was 66 years (range: 31-98), median KPS was 90 (50-100), and 57.8% were female. The most common primary tumor was lung in 40 (39.2%) lesions. The median tumor volume was 9.7 cm3 (2.1-35.5 cm3) and the median maximum tumor diameter was 3.3 cm (2.9-5.6 cm). 37 (36.3%) lesions were treated with staged-SRS, 31 (30.4%) with resection and postoperative-SRS, 21 (20.6%) with preoperative-SRS and resection, and 13 (12.7%) with fractionated-SRS (FSRS). Lesions treated with preoperative-SRS or postoperative-SRS were associated with higher rates of no- or stable-extracranial disease, and larger tumor volumes (preoperative-SRS: median 14.5 cm3 [4.2-33.1]; postoperative-SRS: 18.0 cm3 [2.5-35.5]; FSRS: 5.9 cm3 [2.1-24.6]; staged-SRS: 6.5 cm3 [2.2-27.8]).With a median follow-up of 15.6 months, 12 (11.8%) local failures and 42 (41.2%) deaths occurred. 1-year FFLF and OS for entire cohort were 85.6% (95% CI: 77.9-93.3%) and 64.4% (95% CI: 54.7-74.1%), respectively. The 1-year FFLF (p=0.542)/OS (p=0.043) rates were 94.1%/100% for preoperative-SRS, 84.0%/43.4% for staged-SRS, 81.8%/74.1% for FSRS, and 81.5%/63.4% for postoperative-SRS, respectively. CONCLUSION Although limited by patient numbers, selection bias, and high attrition rate, preoperative-SRS had the numerically most favorable outcomes, supporting this approach for large BM. Prospective evaluation is warranted to determine the optimal management strategy.

Can Beauveria bassiana reduce the root lesion nematode, Pratylenchus thornei, infection on wheat?

BackgroundLimited number of control methods against root-lesion nematodes has increased the search for alternative management strategies. Due to secondary metabolites such as toxins and enzymes secreted by the entomopathogenic fungus, Beauveria bassiana, the number of studies on nematicidal potentials on many plant parasitic nematodes has increased. Almost no work was done on the nematicidal activity of B. bassiana, which is widely used as a bio-insecticide, on the root lesion nematode, Pratylenchus thornei, commonly found on wheat in Turkey. In the present study, it was aimed to determine the pathogenicity of two native B. bassiana isolates (BIM-001 and BY2) obtained from Turkey against P. thornei on wheat under controlled conditions.ResultsSpore suspension of B. bassiana isolates affected P. thornei soil, root, final nematode density and reproduction rate at different degrees according to spore concentration. The soil, root, total nematode density, and reproduction rate in the control on İkizce cv. were 1234.0 adult + larvae/500 g soil, 1105.0 adult + larvae/per pot, 2341.0 (soil + root density) and 5.8 (PF(final nematode density/PI (initial inoculum density)), respectively. It was determined that these parameter values were at the lowest at 108 spore/ml than other concentrations in both isolates of B. bassiana. In 108 spore/ml concentrations of BIM-001 isolate, while P. thornei soil, root, total nematode density, and reproduction rate on İkizce were 641.7 adult + larvae/500 g soil, 930.9 adult + larvae/per pot, 1572.6 (soil + root density) and 3.9 (PF/PI), respectively, these parameter values were found to be 645.2 adult + larvae/500 g soil, 849.0 adult + larvae/per pot, 1492.2 (soil + root density) and 3.6 (PF/PI) at 108 spore/ml concentrations of BY2 isolate. It was observed that the reproduction rate of P. thornei decreased at 108 spore/ml concentration of BIM-001 and BY2 isolates compared to the control.ConclusionNative B. bassiana isolates of BIM-001 and BY2 reduced P. thornei on wheat and the concentration was important for the pathogenicity of B. bassiana. While the reproduction rate of P. thornei at 108 and 107 spores/ml concentrations in both isolates decreased than the control. At 106 spore/ml concentration it was found similar to the control. Even though B. bassiana is known as an effective biocontrol agent against insects and some plant-parasitic nematodes, more detailed studies should be done on its effect on P. thornei.

Laparoscopic transversus abdominis plane block reduces postoperative opioid requirements after laparoscopic cholecystectomy

BackgroundSurgeons directly contribute to the over-prescription of opioids. Alternative postoperative pain management strategies are necessary to reduce opioid dispensation and combat the opioid epidemic. We set out to examine the effectiveness of a laparoscopic transversus abdominis plane block on reducing opioid requirements after laparoscopic cholecystectomy. MethodsIn a retrospective cohort analysis, we compared opioid naïve patients who underwent an elective, outpatient laparoscopic cholecystectomy with a transversus abdominis plane block with patients who underwent a laparoscopic cholecystectomy alone between January 2018 and June 2021 at a single institution. Patient characteristics, perioperative pain scores, and postoperative analgesic requirements were compared between cohorts. ResultsThere were 200 patients included in the study (laparoscopic cholecystectomy with a transversus abdominis plane block, n = 100; laparoscopic cholecystectomy alone, n = 100). The average postoperative pain scores in the postanesthesia care unit were equivalent between the groups (laparoscopic cholecystectomy with a transversus abdominis plane block = 3.39 versus laparoscopic cholecystectomy alone = 4.17, P = .12), with the mean postanesthesia care unit opioid requirements significantly lower in patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block (12.1 vs 20.4 oral morphine equivalents, P < .001). Patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block were prescribed fewer opioids on discharge (mean 77.5 vs 92.9 oral morphine equivalents, P < .05) and reported using a lower proportion of their opioid prescription at follow-up (83.2% vs 100%, P < .001). Of the patients receiving laparoscopic cholecystectomy with a transversus abdominis plane block, 65% reported using over-the-counter pain medications compared with 82% of patients receiving laparoscopic cholecystectomy alone (P < .001). ConclusionPerforming a laparoscopic transversus abdominis plane block during elective laparoscopic cholecystectomy is a safe and effective strategy to reduce postoperative opioid requirements for the treatment of acute postoperative pain.

How are vineyards management strategies and climate-related conditions affecting economic performance? A case study of Chilean wine grape growers

In wine grape production, growers decide between alternative management strategies of the vineyard that have direct consequences on competitiveness. The aim of this study is to evaluate the impact on economic performance of four management strategies: training system, reserve quality production, irrigation method, and mechanization of labors. The data used in the study comes from face-to-face interviews to 336 wine grape growers of Central Chile, which was complemented with climatic variables retrieved from Geographic Information Systems. A log-log regression model of total value product (TVP) for the main variety grown in the vineyard was estimated, using production factors, vineyards’ attributes, management strategies and climate-related conditions as explanatory variables. An interesting contribution of this study is the identification of TVP functions for land, fertilizers, fungicides, other agrochemicals, labor, and age of vines. Our results show that the training system has the most impact on TVP, where tendone-trained vineyards demonstrated 63% higher TVP than those vertically trained when holding all other variables constant. Reserve quality production also has a positive effect on TVP, increasing it by 25% compared to vineyards producing varietal quality grapes. In contrast, the use of pressurized irrigation systems and mechanization in harvesting do not present a significant effect on TVP. The findings of this paper represent an advance in the understanding of the economic performance factors associated with wine grape growing and could serve to guide on-farm decisions and sectoral policies in pursuing the competitive development of wine grape growers.

Integrating multiple aspects of human–elephant conflict management in Dong Nai Biosphere Reserve, Vietnam

Human–elephant conflict (HEC) is a multifaceted complex phenomenon, and managing it requires multiple strategies. However, HEC remains prevalent in tropical areas due to a lack of “synergy of options”. Establishing synergistic HEC management strategies is thus crucial. We applied a choice experiment to capture the preference heterogeneity of the human population in Dong Nai Biosphere Reserve, Vietnam, regarding synergistic HEC management strategies and evaluate their marginal willingness to participate (MWTP) under multiple scenarios of HEC management. The following characteristics were found to affect this human population’s preferences regarding a HEC management program: 1) their attitude toward elephant conservation, 2) education and income level, and 3) employment status. Three promising guide scenarios were suggested based on the positive-preference attributes regarding HEC management. Among these, the scenario of a human–elephant coexistence program generated the highest MWTP compared to the scenarios of ‘building HEC prevention and mitigation’ and ‘protecting elephants and forest’. These outcomes can help managers adopt sustainable policies for mitigating HEC and facilitating human–elephant coexistence. • The CE technique is used to identify a research framework for HEC management. • Locals prefer alternative HEC management strategies. • The integration of multiple aspects boosts the effectiveness of HEC management. • A scenario emphasizing human–elephant coexistence is most preferred by locals.

Combining organic and conservation agriculture to restore biodiversity? Insights from innovative farms in Belgium and their impacts on carabids and spiders

Conservation and organic agriculture are two alternative crop management strategies associated with environmental impact reduction, leading theoretically to more biodiversity and higher ecological functioning, underpinning better ecosystem service delivery. The combination of these two farming strategies is increasingly seen as an opportunity to mitigate shortcomings of each of them taken individually. However, combining organic and conservation agriculture is undeniably challenging, since it leaves nocurativeoption (neither synthetic pesticides nor soil plowing) for pest control (phytophagous, pathogens, and weeds). Hence, the latter must be ensured by effective restoration of predatory communities. The present research investigated the potential of combining organic and conservation agriculture to support two major ground-dwelling natural enemy communities: carabids and spiders. We used pitfall traps to sample these two communities in paired adjacent cereal fields conducted under organic-conservation (OC) and conventional (CV) agriculture in Belgium. Community assemblages were significantly different across system types, both in terms of species diversity and functional trait diversity. OC parcels showed higher alpha and beta species diversities for both carabids and spiders and species composition differed between OC and CV parcels. OC systems were associated with higher variation of species assemblages among parcels than CV systems Functional traits also differed across system types for both groups. We found more herbivorous and granivore carabids in OC parcels, and more predator species in CV parcels. We found larger spiders, more hunting spiders and more wetland spiders in OC parcels, whereas we found more web weavers and more forest spiders in CV ones. Functional diversity was higher in OC parcels for carabids, but not for spiders. In brief, OC parcels supported more diverse communities, both taxonomically and functionally. These outcomes show that OC systems are promising systems to support these natural enemy communities. Further studies should assess whether combining organic and conservation agricultural enables sufficient pest control levels to achieve high levels of food production and farmers income.

Minor stall modifications and outdoor access can help improve dairy cow welfare in tie-stalls

Tie-stalls are the most confining method of housing for dairy cows and remain commonly used to house cows in many countries. Finding methods to improve animal welfare through housing modifications and alternative management strategies are of increasing importance. Twelve tie-stall dairy farms in Ontario and Quebec, Canada were visited four times in a 12 month period. Visits were spread to observe the effects of pasture (visit 1), short-term effects of stall modifications (visit 2), effects of winter confinement (visit 3), and final measures after 1 year (visit 4). Lameness, injuries, cow cleanliness, lying and rising behaviors, and production parameters were assessed at each visit. Outdoor access had the largest effect: cows with access to pasture had a lower prevalence of various outcome measures throughout all four visits. Also, cows in modified stalls had a higher prevalence of dirty udders compared to cows in unmodified stalls, but only on farms that provided outdoor access. Although applying minor stall modifications to tie-stalls can help improve aspects of animal welfare, providing year-round outdoor access may represent a more effective method; the continued provision of time outside the stall helps maintain the positive impact of outdoor/pasture access on the welfare of tie-stall dairy cows.

Management of older patients with unexplained, recurrent, traumatic syncope and bifascicular block: Implantable loop recorder versus empiric pacemaker implantation-Results of a propensity-matched analysis.

In patients with unexplained syncope and bifascicular block (BFB), syncope may be caused by intermittent atrioventricular (AV) block. When a correlation between syncope and bradyarrhythmia is not documented in these patients, 2 alternative management strategies can be adopted: (1) empiric pacemaker (PM) implantation or (2) long-term continuous electrocardiographic monitoring by implantable loop recorder (ILR). The purpose of this study was to compare the risk of syncope recurrence associated with empiric PM implantation or ILR monitoring. A prospective, multicenter, observational study enrolled consecutive patients with unexplained, recurrent, traumatic syncope and BFB who underwent ILR monitoring or empiric PM implantation. The risk and causes of syncope recurrence were assessed and compared between the 2 groups. Individual 1:1 propensity matching of baseline characteristics was performed. A total of 309 consecutive patients (age 77.2 ± 12.2 years; 60.8% male) were enrolled. Propensity matching yielded 89 matched pairs. After median follow-up of 33 months, empiric PM implantation was associated with a significantly lower risk of syncope recurrence than ILR monitoring (19.1 vs 46.1%; P <.001). A total of 35 patients (39.3%) who underwent ILR monitoring developed bradyarrhythmias (68.6% paroxysmal AV block) requiring PM implantation during follow-up. Excluding bradyarrhythmic syncope, the most frequent causes of syncope recurrence in both study groups were reflex syncope and orthostatic hypotension. In patients with unexplained, recurrent, traumatic syncope and BFB, empiric PM implantation significantly reduced the risk of syncope recurrence in comparison with ILR monitoring. A high rate of patients who underwent ILR monitoring developed bradyarrhythmias requiring PM implantation.