Business Days Research Articles

New Content Formats in Digital Communications

The emergence of new media channels goes hand in hand with the advent of new content formats and their subsequent rise in popularity. The digital era brings forth numerous new formats, with short video content currently emerging as the winner in terms of interaction, popularity, and return on investment (ROI) for content creators. This analysis examines a combination of psychological, lifestyle, and practical factors to explain why online users find this type of content so appealing and why the number of content creators joining this trend is increasing in the coming years. Social media with short video formats is studied from the perspectives of attachment theory and the socio-technical approach, which are useful in revealing the psychological motivators for online users actively seeking this type of content. Scientific literature about subjective feelings of engagement provides guidance on the fragmented workday and the usefulness of short-format content to fill small breaks in a busy day. From a practical standpoint, considering recent statistics on mobile usage, short-format content, especially vertical video, is faster, easier, and cheaper to create. At the same time, it is highly appealing, easy to distribute, and convenient to consume on smartphones without rotating the screen.

Mental Health Guidance and Support Bot

In an era characterized by the relentless pace of life and the escalating challenges to mental well-being, the emergence of the Mental Health Support Bot represents a revolutionary advancement in addressing the universal struggle with stress, anxiety, and depression. This abstract delves deeper into the conceptualization, methodology, results, and broader implications of this virtual companion, highlighting its transformative impact on the landscape of mental health support. The Mental Health Support Bot is rooted in the synergy of cutting-edge artificial intelligence and a profound understanding of the nuanced nature of mental health challenges. Its conceptualization arises from the recognition that these challenges are not confined to specific demographics but are pervasive, transcending geographical, cultural, and temporal boundaries. The bot is designed to be a dynamic and responsive virtual companion that tailors its approach to the unique needs of each individual user. Powered by advanced artificial intelligence, the Support Bot employs adaptive algorithms that continuously learn and evolve based on user interactions. The profound impact of the Mental Health Support Bot is reflected in its ability to transcend traditional limitations of mental health support systems. Its continuous accessibility, operating 24/7, ensures that users can seek assistance whenever the need arises, breaking down the temporal constraints of conventional models. Moreover, the bot's adaptability to users' schedules, whether during quiet moments in the night or amid the rush of a busy day, enhances the likelihood of individuals seeking timely assistance. The results signify a paradigm shift in mental health support, moving towards a more user-centric and proactive approach.

Hemapheresis Clinic Scheduling Quality Improvement Project

Abstract Introduction/Objective Outpatient (OP) Red blood cell exchange (RCE) therapy is used to treat patients with severe manifestations of sickle cell disease. Like any blood transfusion, a patient must have an active type and screen, drawn 24 to 72 hours prior to scheduled RCE procedure. UIH Hemapheresis clinic performs several types of apheresis procedures treating sickle cell disease, kidney transplant rejection and autoimmune disorders. Outpatient clinic staff perceived that most RCE procedures are scheduled disproportionately between Wednesday through Friday, which creates an unbalanced schedule that is lighter on Monday and Tuesday, and heavier Wednesday through Friday. The study's objective was to determine if there is a significant difference between the number of outpatient procedures scheduled on the different days of the week. If significant differences are identified, processes may be improved to schedule a more balanced OP clinic week. Potential benefits may include a more balanced patient to nursing staff ratios which can improve patient care and more efficient RBC utilization which can ease workload across multiple cross-functional departments such as nursing staff, reference labs and in-house blood bank staff. Methods/Case Report The UIH Epic Hemapheresis Clinic schedule was searched to identify how many total OP procedures, including RCE, were scheduled each day of the week between 01AUG2021 – 31JUL2022. Only OP procedures occurring in complete five-day weeks were included. Weekends and weeks having clinic closures for holidays were excluded Results (if a Case Study enter NA) Our study show that the lowest number of OP RCE (mean 1.4) and total number of OP procedures (mean 2.6) were on Monday. Wednesday is the busiest day with overall averaging 3.5 total procedures (Standard Deviation: 1.56). However, Friday is the most variable, with the largest SD for both RBCX (SD 1.4) and Total number of procedures (SD 1.7). Conclusion Contributing factors to low procedure volume on Monday are likely multifactorial. Some patients may prefer not to come to the hospital on Saturday for type and screen, while some may forget they need labs. Transportation issues are another factor. One intervention the clinic has implemented is automatic appointment call reminders. Staff encourage patients or caregivers to sign up for the EPIC MyChart app which also notifies patients of upcoming appointments. Future studies need to be conducted to address other bottlenecks within the scheduling workflow and to determine ways to optimize patient appointment adherence.

Differing Definitions of Vaso-Occlusion in Clinical Studies of Sickle Cell Disease Can Result in Differing Outcomes

Background: Frequent episodes of vaso-occlusion are the hallmark of sickle cell disease (SCD), but the definition of what constitutes a vaso-occlusive episode is not consistently applied across clinical trials, creating challenges in evaluating and comparing efficacy results among different therapies. Here, we compare vaso-occlusion endpoint definitions from clinical trials for various therapies, including genetic therapies, and use clinical trial data to demonstrate the potential for outcomes differences based on differing definitions of vaso-occlusive episodes. Methods: We reviewed completed and ongoing clinical trials and published articles using endpoints assessing the reduction or elimination of vaso-occlusive crisis/events, including trials of (i) exagamglogene autotemcel (exa-cel, CRISPR/Cas-9 based genome editing treatment), (ii) lovotibeglogene autotemcel (lovo-cel, gene addition therapy), (iii) L-glutamine, (iv) voxelotor, (v) hydroxyurea (HU) and (vi) crizanlizumab. Outcomes related to vaso-occlusion were compared across variables including care setting, care duration, treatments, and complications. Data from the CLIMB SCD-121 trial of exa-cel in patients aged 12 to 35 years with severe SCD (data cut as of 10 Feb 2023) were evaluated using different published definitions of vaso-occlusion. Results: The most substantial differences in vaso-occlusion endpoint definitions were associated with frequency and duration of visits to medical facilities for acute pain and inclusion of specific SCD specific complications. Definitions of vaso-occlusions for acute pain related events differed across studies. The definitions of severe vaso-occlusive crises for exa-cel (severe VOC; exa-cel), sickle cell pain-related crises (SCPC; crizanlizumab and L-glutamine), and VOC (VOC; voxelotor) include events with medical facility visits of any duration (severe VOC and SCPC) or medical records of a patient being seen or contacting a physician within 1 business day of an event (VOC), whereas the definition of severe vaso-occlusive events (severe VOE; lovo-cel) requires a ≥ 24-hour hospital or emergency room (ER) observation unit visit or ≥2 visits to a day unit or ER over 72 hours. Vaso-occlusion definition for HU (painful crisis) required a facility visit of ≥4 hours duration. All endpoints include acute chest syndrome and priapism; however, the definition of severe VOE requires ≥4 visits to a medical facility for priapism to meet criterion, while others require only a single visit. The exa-cel phase 3 trial in SCD employs a broad and inclusive definition for severe VOC which counts each individual medical facility visit, regardless of frequency or duration of hospitalization. Based on this, 19 out of 20 patients (95%) met the primary endpoint of freedom from severe VOCs for at least 12 consecutive months (95% CI, 75.1%, 99.9%; P<0.0001). However, when the primary endpoint was analyzed using the severe VOE definition, all patients (20/20; 100.0%) were free from severe VOEs for at least 12 consecutive months (95% CI: 83.2%, 100.0%; P<0.0001). Conclusions: Requirements for health care facility visits in the definitions of severe VOC (exa-cel), VOC, and SCPC were more broadly inclusive and include events that would not be counted in the definitions of severe VOE (lovo-cel) or painful crisis. Clinically, support for this observation comes from our analysis of exa-cel SCD pivotal clinical trial data using these different definitions, which showed the number of patients free from vaso-occlusive episodes changed depending on the definition of vaso-occlusion employed. These results show differences in vaso-occlusion definitions have the potential to impact assessments of treatment efficacy across different SCD therapies.

CTNI-69. REAL-TIME DRUG SCREENING AND GENOMIC TESTING TO DETERMINE INDIVIDUALIZED TREATMENT PLANS IN CHILDREN AND YOUNG ADULTS WITH RELAPSED MEDULLOBLASTOMA: PRELIMINARY REPORT OF PNOC027

Abstract While current upfront multi-modal treatment for medulloblastoma is effective in many cases, for patients who relapse or don’t respond to initial therapy, effective treatment options are limited and novel therapeutic approaches are needed. The Pacific Pediatric Neuro-Oncology Consortium (PNOC) PNOC027 clinical trial investigates a precision medicine approach that combines real-time drug screening with whole exome and RNA sequencing of fresh tumor tissue to inform individualized treatment recommendations for children and young adults with relapsed medulloblastoma. The primary endpoint is to determine the feasibility of incorporating real time drug screening with DNA/RNA sequencing of tumor to develop a treatment regimen of up to 4-drug of FDA approved agents within 21 business days of tumor acquisition. To this end, freshly isolated cells from relapsed medulloblastoma tumor tissue undergo high-throughput drug screening using a platform of 232 clinically available compounds in parallel with multi-omic genomic analyses to predict individualized tumor response to treatment. Drug responses are assessed after 72 hours of drug exposure and the results yield drug prioritizations based on cytotoxicity and predicted blood-brain barrier permeability. Drugs from different classes are selected based on results from drug screening and molecular analyses combined with patient age, prior treatments, and other medical conditions. Four patients have been enrolled to date and viable tissue samples have been successfully collected and analyzed with treatment recommendations rendered within 21 business days for all patients. The five drug classes with the highest in vitro responses on the drug screen are HDAC inhibitors, proteosome inhibitors, anthracyclines, DNA crosslinkers and kinase inhibitors. PNOC027 demonstrates preliminary feasibility of real-time drug screening combined with DNA/RNA sequencing to inform targeted therapy selection for patients with relapsed medulloblastoma in clinically relevant timeframes. The trial is informing an expanded precision-based approach for relapsed medulloblastoma and the impact of genetic and epigenetic alterations on treatment response.

Rapid care transition: Implementation of an undiagnosed cancer clinic.

80 Background: There is a critical need to address potential delays in care for patients (pts) with new, undiagnosed cancer in academic medical centers that operate on a subspecialty clinic model. To bridge this gap, we established an Undiagnosed Cancer Clinic (UCC) staffed by oncology physicians and advanced practice providers (APP) to provide rapid access to specialty-led diagnostic work-up, symptom management, and disease education with the transition to subspecialists at a final diagnosis. Methods: A referral process was created, and specified provider template allocation (2 slots/week increased to 5) with a goal of referral to visit time <3 business days. A nurse navigator facilitates diagnostic procedures and helps overcome barriers to care. We collected data on time from referral to UCC visit, demographics, diagnosis, and symptoms managed. Results: Prior to the UCC, median wait time for undiagnosed pts at our institution was 17 days (range 7-49) over a 4-month historical cohort (n=14). In the first 9 months of the UCC, 52 patients were seen, with a decrease in median wait time to 5 business days (range 1-21); when excluding 13 pts who requested delays or were hospitalized, wait time was 3 business days (range 1-7). Referrals increased over time from 1 to 8 per month, most from primary care providers (PCP) (31%) and emergency department (ED) (25%). Demographics include race: 65% White, 25% Black/African American, 10% Other; ethnicity: 13% Hispanic; language: 90% English, 8% Spanish, and 2% Other. The most common cancers diagnosed were gastrointestinal (35%), lymphoma (12%), genitourinary (8%), and breast (8%); 79% of solid tumor pts had metastatic disease. No cancer was identified in 15%. 58% had at least one ED visit before UCC visit, and 8% between UCC visit and establishing care with a subspecialty team. Symptoms requiring intervention were present in 63% at the time of visit, including pain, nausea, vomiting, diarrhea, and constipation. 8% of those diagnosed were referred to hospice. Conclusions: The UCC is a high-value means of specialty-led care to work up a presumed cancer diagnosis while offering symptom management and patient-centered goals of care. A team of oncology providers and clinical navigation team decreased wait time and increased access in an outpatient setting, had a low rate of ED visits following UCC-established care, and provided support and coordination of care with the ability to address barriers for marginalized communities. We are actively partnering with EDs and PCPs to expand the reach of our UCC to a broader population.

Implementation of a national cancer subspecialist virtual consult pilot in an integrated health system.

143 Background: Over 65,000 new cancer patients are diagnosed nationally each year at Kaiser Permanente (KP), with 12.7 million members in 9 states and the District of Columbia. KP developed the Cancer Expert Review Program (the Program) to connect oncologists with cancer subspecialists across the enterprise. The Program provides consultation and a chart note viewable by the patient within 2 business days. Methods: The Program was piloted from October 2022 to June 2023 for medical oncology patients with breast, gastrointestinal (GI), genitourinary (GU), sarcoma, thoracic, hematology, central nervous system (CNS), melanoma, head & neck, and gynecologic oncology (GYN) diagnoses or a need for molecular/genomic testing. Medical oncologists from Hawaii, Georgia, and Southern California submitted requests for virtual consults to designated cancer subspecialists using HealthConnect, KP’s EPIC system. Consulting physicians had direct access to the medical records for each patient, including pathology and imaging. Oncologists informed patients of the service and discussed the rendered opinion as part of shared decision-making. Implementation outcomes of feasibility and acceptability were evaluated. Providers were surveyed about perceptions of the service using an internally developed questionnaire. The time from consult request to completion was measured. Results: 108 consults (67.5%) were provided by individual subspecialists, while 22 consults (14%) were reviewed by multiple experts or a multidisciplinary team. 140 consults (87.5%) were completed within 2 business days. Of the 44 oncologists who requested a consult, 12 responded to a physician survey. 85% of physicians rated satisfaction with the service as “satisfied” or “extremely satisfied”. 75% said the advice helped to develop the treatment plan. Half of physicians reported the advice changed the original treatment or approach either “somewhat” or “to a great extent.” Half of physicians indicated that if this internal program were not available, they would have referred their patient to a non-Kaiser Permanente provider for a consultation. Conclusions: Implementation of a national cancer subspecialist virtual consult pilot within an integrated health system demonstrated the feasibility and acceptability of timely expert consults with high physician satisfaction. The Program facilitates subspecialist care in collaboration with the patient’s trusted general oncologist, keeping care close to home.Additional research is needed to understand the long-term implementation and quality outcomes of the Program.[Table: see text]

Friendship as Medicine.

Social isolation is a risk factor for many diseases and overall increased mortality. Alternatively human connection has been noted to lead to healthier lives and longevity. Medical clinicians need to be more aware of this condition and consider how to prescribe friendship. This is not just an issue for the elderly; many Americans are being ravaged by being alone. There are many organizations that we can refer our patients to in order to make connections. This lesson is one we as physicians need to embrace ourselves as loneliness during our busy days is affecting us too.

Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke.

Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging. As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months. We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge. Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.

Multidisciplinary Institutional Guidelines for Workflow Efficiency in Optimizing Patient Start Time.

Radiation Oncology is a field which is reliant on the intradisciplinary team and efficient completion of respected tasks. The purpose of this study was to analyze institutional workflow efficiency by comparing current practices to team-member expectations. To measure workflow efficiency, the Aria database was queried to find sessions for treatment plans with a CT Sim image and a first treatment date between 2/23/2021 and 12/15/2022. The course, plan, prescription, image series, the associated "Provider Contouring" task, and the most recent consult appointment prior to the sim date were used to determine various workflow times using business days: (1) Consult to Sim, (2) Sim to Contour, (3) Contour to Plan, (4) Plan to Physics QA, (5) Physics QA to First Treatment. For these items, except for (3) Contour to Plan, the time points used to determine when a task was completed was based on timestamps of the actual work done rather than the associated task completion timestamp. For contouring, the completion timestamp was used. Additionally, for each treatment plan, a workflow category was assigned based on the prescription site and technique, the course and plan intents and IDs, and the activity code for the treatment associated with the session assigned to the plan. Regarding the objective analysis from the various personnel within the intradisciplinary team, an internal survey was conducted analyzing what each member of the intradisciplinary team deems as appropriate timing for task completion. The mean time from simulation to treatment start for palliative treatment was 3.67 days (306 treatment plans). For definitive 3D and IMRT plans, the mean simulation to treatment time were 7.85 and 9.71 days, respectively (200 3D and 261 IMRT treatment plans). Mean time for lung SBRT plans were 11.98 days (65 plans). Survey analysis within the intradisciplinary team for appropriate timing of palliative treatments were as follows: Physicians: 5.88 days, Dosimetrists: 1.25 days, Radiation Therapists: 1.31 days, Nursing: 3.25 days. Survey analysis of definitive 3D and IMRT plans were as follows: Physicians: 10 and 10.5 days, Dosimetrists: 3 and 6 days, Radiation Therapists: 3.75 and 5.75 days, Nursing: 8.5 and 8.5 days, respectively. Survey analysis of lung SBRT simulation to treatment demonstrated: Physicians: 12.5 days, Dosimetrists: 6 days, Radiation Therapists: 6.75 days, Nursing: 9.25 days. Analysis of our internal workflow demonstrates efficiency in total time from simulation to treatment across various modalities when compared to published data. Interestingly, when comparing our current workflow efficiency to team member expectations, there are discrepancies in the analysis of the definitive 3D and IMRT as well as lung SBRT. These variations may be due to the interdisciplinary team not having a complete understanding of the various workflow responsibilities of other team members.

The Anatomy and Evolution of a Quality Proton Therapy Plan Check Process: An Institutional Review.

There exists limited standard guidance from the physics community on the optimal way to ensure high-reliability proton therapy treatments. Following the guidance of AAPM MPPG 4a/4b and Task Groups 100/275, our institution has developed, implemented, and maintained strategies over the last five years to streamline workflows, enable more complex treatments, standardize procedures, and manage risk from slip or omission type errors in proton therapy. The evolution and success of that is observed from an institutional analysis of past operations data. From the outset, standard care paths were used to sequence our workflows. These chains of tasks were well-defined and timestamped upon completion for every patient. Over five years, additional multiple interventions were implemented including clinical site standardization, checklists, root cause analysis, and failure mode identification. These were used to counter environmental variables with potential to disrupt timelines like growing patient volume, staffing demands, and new technique adoptions. These interventions went through extensive design, validation, and continuous improvement phases by the entire clinical team. Using ARIA v15.5, task timestamp data from the past 5 years were mined for physics proton-specific planning tasks and used to compute how early/late each task was in comparison to the expected due time. Average and standard deviation data were computed and used to create control charts. This coupled with the average time per year was cross-referenced with interventions to determine the impact on plan preparation timelines. Over 5 years, the standard care path length reduced from 16 to 13 business days. The greatest impact on timelines was observed from standardizing clinical site guidelines. This minimized variability in task times and allowed the creation of checklists. By standardizing, we identified slack as well the need for new tasks. Overall, the average days late or early went from on-average late to on-average early (Table 1). The control charts indicate that many tasks stabilized in recent years. Furthermore, these interventions allowed us to safely increase the complexity of our proton plans using Monte Carlo dose calculations, 4D-optimization, robustness standards, repainting, and increased beams with no slippage in overall timelines. Clinical site standardization, checklists, consistent process re-evaluation, and a team attitude of continuous improvement allowed us to improve control of our processes while simultaneously expanding treatment complexity and meeting the goals of our quality management plan.

The Inpatient Consultation Experience in Radiation Oncology: A Contemporary Evaluation of a Single Academic Institution

Participating in an inpatient consultation service is an essential aspect of radiation oncology residency training. However, there are no reports in the literature describing the inpatient on-call experience. To better describe the clinical burden and define the learning opportunities associated with inpatient consultation service participation, inpatient on-call data were tracked and assessed. From July 1, 2022, through Dec. 31, 2022, radiation oncology residents covering the on-call pager for the inpatient consultation service spanning two hospitals at a single academic institution prospectively self-reported the total number of pages, new consultations, inpatient treatment starts, and treatment indications. Patient billing records and paging logs were reviewed to confirm self-reported cases and track the number of business days between simulation and the first fraction of treatment. A new inpatient consultation was defined as a novel encounter requiring independent evaluation; as such, patients admitted during an ongoing course of radiotherapy who continued the planned course while inpatient were not included. During the initial six months of tracking, on-call residents received a total of 607 pages with an average of 23.1 pages per week (range: 14-38). Of these pages, 212 were for new inpatient consultations with an average of 8.1 consultations per week (range: 2-15). Out of these 212 new consultations, 75 patients (35%) were treated on an inpatient basis. Nine patients (12%) received their first fraction of treatment on the same day as simulation, 13 (17%) on the next day, 11 (15%) two days after, 22 (29%) three days after, and 20 (27%) four or more days after simulation. The most common indications for urgent treatment were malignant spinal cord compression (27%), brain metastases (24%), tumor-related bleeding (8%), malignant obstruction of the airway or vasculature (8%), painful bone metastases (7%), and heterotopic ossification prophylaxis (7%). The most common primary sites of disease were leukemia/lymphoma (16%), gastrointestinal (13%), breast (11%), lung (9%), gynecologic (9%), sarcoma (9%), and benign (9%). Each individual resident's caseload differed greatly in quantity, indication, treatment site, and primary site over this six-month time period. In this longitudinal analysis at a single academic institution, the radiation oncology inpatient consultation service experience was highly variable and diverse in clinical volume and treatment indication on a week-to-week and resident-to-resident basis. Exposure to radiation oncology emergencies is a vital component of residency training. However, the unpredictable nature of inpatient on-call scenarios can lead to variable educational experiences. Tracking inpatient on-call cases during residency may help identify areas needing improvement to enhance both patient care and residency training.

Feasibility of Cognitive-Sparing Stereotactic Radiosurgery for Brain Metastases: Initial Report of Phase II COG-SRS Trial

Radiotherapy at high doses leads to white matter (WM) and hippocampal injury which can cause cognitive decline. We designed the first, to our knowledge, evidence-based cognitive sparing brain SRS trial for patients with limited brain metastases. In this report we analyze feasibility of cognitive-sparing SRS, utilizing dose constraints for eloquent WM tracts and bilateral hippocampi. This is a single-institution phase II NCI-funded clinical trial (NCT04343157) of cognitive-sparing brain SRS; eloquent regions of interest (ROI) and associated cognitive domains are outlined in Table 1. Patients underwent high-resolution quantitative diffusion and volumetric MRI at baseline and post-SRS follow-up. Comprehensive neurocognitive assessment was performed at baseline and 3 months post-SRS by a neuropsychologist evaluating different neurocognitive domains (Table 1). Clinical processing/workflow was largely automated with robust, validated segmentation tools of eloquent WM tracts and the hippocampi. Single fraction dose constraints to WM tracts were 12 Gy Dmax and 8.4 Gy to hippocampi with 3 and 5 fraction equivalent doses, based on our prior NTCP studies. Patient accrual, follow up imaging and neurocognitive testing is still active. To date, n = 59 patients and 114 lesions have been treated with cognitive-sparing Linac-based SRS on trial. Median age is 63 years. Lung cancer was the most common primary (35.6%), along with breast cancer (23.7%) and melanoma (15.3%). Patients had 1-4 brain metastases; median prescription dose was 24 Gy/1, 27 Gy/3, or 30 Gy/5 depending on target volume. Most patients were treated < 7 business days from MRI. Cognitive endpoints have been collected on 89.5% of patients. Cognitive sparing constraints were met in 79.3% of plans while maintaining standard clinical SRS plan indices and coverage benchmarks. 38.9% of the plans that failed to meet the Dmax constraint kept D0.03cc under constraints. Plans going over constraints had tumors overlying or within 1 mm of eloquent ROIs. Local control for treated lesions at 6 months was 97.9% and 95.7% at 12 months. Distant intracranial control was 68.1% at 6 and 12 months. Median OS was 18 months. Cognitive-sparing SRS treatment planning was successfully implemented for the majority of treated lesions with excellent local control. Mitigation of damage to eloquent structures has potential to further reduce cognitive decline after SRS. Full neurocognitive outcomes will be reported after accrual and testing are complete.

Matheuristic approaches to the green sequencing and routing problem

The paper addresses the green sequencing and routing problem, which consists in determining the best sequence of locations to visit within a warehouse for storing and/or retrieval operations, using a fleet composed of both electric vehicles, e.g., equipped with a lithium-ion battery, and conventional vehicles, i.e., with an internal combustion engine. We present a Mixed-Integer Linear Programming formulation to the problem and propose two matheuristics based on suitable decompositions of the mathematical formulation. The two matheuristics have been tested on a pool of small-medium size instances and their performance has been compared to the one of a third matheuristic, previously proposed for the case of conventional vehicles only and here suitable extended to deal with the green aspects of the problem. The performed analysis allowed one to identify the most promising matheuristic in terms of some standard computational indicators, i.e., computing time and percentage optimality gap, as well as in terms of some qualitative aspects of the solutions agreed with a reference company. Such a most promising algorithm has then been further tested to gather some technical insights on what makes the problem hard to solve, as well as to outline some managerial insights. Moreover, its performance has been tested on a pool of real instances comprising ordinary days (with a usual amount of operations to perform) and extremely busy days, showing its efficacy and efficiency also in the considered real application context.

Pengaruh Antrean Dan Tundaan Kendaraan Terhadap Penggunaan Bahan Bakar Pengoperasian Palang Pintu Kereta

Transportation is the movement of people or goods using tools or vehicles from the place of origin to the destination. A level crossing is a meeting or intersection of a road with a railroad. Closing the doorstop causes the flow of traffic on the road to stop until the train passes which results in queues and vehicle delays which have an impact on fuel consumtion. This study aims to determine queues, vehicle delays and their effect on fuel use.This study uses a quantitative method with data obtained from the field, namely closing duration data, vehicle queue duration data, queue length data and vehicle volume data. data were obtained from the field for 7 days and the 3 busiest days were selected, namely Monday, Wednesday and Saturday, then analyzed using multiple linear regression.Based on the analysis, the average queue length of vehicles at level crossings on Jl. Hayam Wuruk on Monday is 71.368 m, Wednesday is 68.263 meters, and Saturday is 79.947 m. Data on average vehicle delays at level crossings on Jl. Hayam Wuruk on Monday was 281 seconds, Wednesday was 211 meters, and Saturday was 238.453 seconds. The ATIS – India method of the fuel use equation model is Y = - 0.717 + 0.005 X1 + 0.003 X2.

Stock price momentum modeling using social media data

Alternative data has rapidly gained popularity as a means of observing investor reactions to current stock market events, analyzing sector movements, and developing investment strategies. Signals observed from alternative data may add valuable information to conventional market analysis, especially when there exists some information asymmetry in the market, to which small-cap stocks are particularly sensitive. Our research uses alternative textual data obtained from social media to predict the price momentum of small-cap stocks, which are known to be sensitive to market events and retail investors’ reactions. We directly address the challenges in the analysis of texts, especially in the Korean language, such as the use of jargon, acronyms, and typos, by taking a two-fold approach to preprocessing. Then, we extract the social keywords and label them by two standards: word momentum and correlation with stock price movement. Using these social keywords as social indicators derived from the retail investors trading small-cap stocks, in addition to the conventional technical indicators, we propose a price momentum forecast model which classifies whether the closing price of a given small-cap stock will increase by more than 10% in the next 5 business days. Experimental results show that our approach successfully extracts social keywords that play a significant role in determining the price momentum in the market, and our selected social indicators are intuitive to human understanding. Furthermore, we consider example investment scenarios and run tests by training various classifiers with the social indicators and computing cumulative returns. Our results are very promising and show that the investment scenarios with social indicators outperform the benchmark considerably. We anticipate that our work will expand the scope of using alternative data for stock market analysis and price momentum forecasts by incorporating social indicators extracted from social media.

The Impact of Information Technology on the Performance of Commercial Banks Through the Faithful Representation of Accounting Information System

Purpose: The aim of this study is to investigate the impact of IT on banking performance through RF of AIT. Theoretical framework: Business companies and institutions strive to work in a shorter amount of time, which makes information technology an important and necessary way to reach their goals and develop their business day by day. It assumes that they have a positive and significant impact on performance. Methodology: Data on five major banks in the Kurdistan Region of Iraq has been gathered. An ARDL model for estimation has been used. Findings: It is revealing that both IT and RF jointly have a significant impact on performance in the short and long run by 97% and 109%, respectively. Research, Practical &amp; Social implications: banks adopt IT in order to compete in the market and improve the skills of their employees through training on advanced IT and facilities. Originality: This study examined and identified the performance of commercial banks in the shed of AIS through RF. Beside of the impact of AIS; RF has a great role in performance and AIS as well.

Distribution of equine and food animal emergency caseload by time of day, day of week, time of year, holiday, and phase of moon at an academic ambulatory and referral hospital.

Determine the association of time of day, day of week, time of year, holiday, and phase of moon on academic ambulatory and hospital emergency caseload for equine and food animal species. Retrospective study. Large animal teaching hospital emergency service. Equine and food animals. None. The hospital database was searched for after-hours on-farm and in-hospital emergencies seen from 2014 to 2020. Variables included date and time of admission, species (equine or food/fiber animal [FA]), and hospital service (field or in-hospital). The association of the caseload with time of day, day of week, day of year (holiday, full moon, or new moon), and season of year was defined and examined. The majority of equine field-based emergencies occurred on the weekend, in contrast to 44.8% of hospital cases. Most equine emergencies occurred between 4:00p.m. and midnight on weekdays and between 8:00a.m. and 4:00p.m. on weekends for both field (89.1% and 46.9%) and hospital (82.8% and 48%) services. The same was true for FA cases on the farm (90% and 49.2%) and in the hospital (85% and 51.4%). More equine cases (67%) were seen in the field than FA. Winter had the fewest emergency cases for all species and locations, and spring had the most for FA. The majority of holiday equine emergencies were seen in the field (62.2%), but the majority of holiday FA emergencies were seen in the hospital (66.3%). Moon phase had no significance on caseload for all species and locations. Saturdays and Sundays were the busiest days for all species and services. Winter was the slowest time for emergencies for all species and services. Most emergencies were seen between 4:00p.m. and midnight on weekdays and between 8:00a.m. and 4:00p.m. on Sundays and Saturdays.

Competency building in a busy working day for librarians and for libraries

Medical librarians know very well that they must build new competencies to offer relevant services and develop new library services. In a workshop at the EAHIL conference 2023, suggestions for competency building, and how libraries can build competency, were discussed. Positive and enthusiastic participants came up with many ideas: different types of clubs, webinars and courses, knowledge sharing with colleagues, regularly block out time, or just solve your tasks in a new way. The experiences showed that competency building in a busy work schedule is possible. The initiatives have in common that they portray an attitude to learn more, but also the willingness to organise activities and share competency with colleagues.

The Determination of Ethanol Levels in Facial Freshener Using the NIR Spectroscopy and Chemometric Method

A facial freshener, also known as toner, is a cosmetic product that is commonly used to invigorate the face after a busy day. Ethanol serves as a key component in toner, serving multiple purposes such as being a solvent, preservative, and antimicrobial agent. However, it's important to note that toner formulated for normal skin types typically contain ethanol in small concentrations, adhering to a limit of not more than 10%. Therefore, this study aims to determine ethanol levels in toner using the NIR spectroscopy and chemometric techniques. The NIR spectra of the simulated samples were correlated with ethanol concentration using chemometric calibration model. The calibration models used were partial least square (PLS), principal component regression (PCR), and support vector regression (SVR). The calibration model was validated by leave one out cross validation (LOOCV) as well as the external validation, and the precision and accuracy of the method was evaluated. Among the calibration models, the PLS model exhibited the best performance, yielding an impressive R2 0.9976; with an RMSEC value of 0.4364 and RMSECV value of 0.4704. The internal validation yield R2 value more than 0.99 and RMSE of less than 0,4198. Furthermore, external validation showed the R2 and RMSEP value of 0.989 and 0.920 respectively. The %recovery and RSD value were 101.2% and 0.129%. Comparing ethanol measurements obtained through the NIR chemometric method with those obtained using gas chromatography as the reference method, no significant difference was observed at a 95% confidence levels, as indicated by a significance value of 0.231.