Reduction Criteria Research Articles

Attitudes about withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide, and physician assisted suicide: a cross-sectional survey among the general public in Croatia

BackgroundThere has been no in-depth research of public attitudes on withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. The aim of this study was to examine these attitudes and their correlation with sociodemographic characteristics, religion, political orientation, tolerance of personal choice, trust in physicians, health status, experiences with death and caring for the seriously ill, and attitudes towards death and dying.MethodsA cross-sectional study was conducted on a three-stage random sample of adult citizens of the Republic of Croatia, stratified by regions, counties, and locations within those counties (N = 1203). In addition to descriptive statistics, ANOVA and Chi-square tests were used to determine differences, and factor analysis (component model, varimax rotation and GK dimensionality reduction criterion), correlation analysis (Bivariate correlation, Pearson’s coefficient) and multiple regression analysis for data analysis.Results38.1% of the respondents agree with granting the wishes of dying people experiencing extreme and unbearable suffering, and withholding life-prolonging treatment, and 37.8% agree with respecting the wishes of such people, and withdrawing life-prolonging treatment. 77% of respondents think that withholding and withdrawing procedures should be regulated by law because of the fear of abuse. Opinions about the practice and regulation of euthanasia are divided. Those who are younger and middle-aged, with higher levels of education, living in big cities, and who have a more liberal worldview are more open to euthanasia. Assisted suicide is not considered to be an acceptable practice, with only 18.6% of respondents agreeing with it. However, 40.1% think that physician assisted suicide should be legalised. 51.6% would support the dying person’s autonomous decisions regarding end-of-life procedures.ConclusionsThe study found low levels of acceptance of withholding or withdrawing life-prolonging treatment, euthanasia, assisted suicide and physician assisted suicide in Croatia. In addition, it found evidence that age, level of education, political orientation, and place of residence have an impact on people’s views on euthanasia. There is a need for further research into attitudes on different end-of-life practices in Croatia.

Vibration and stability characteristics of functionally graded sandwich plates with/without porosity subjected to localized edge loadings

This article investigates the influence of porosity and localized edge loads on the vibration and buckling characteristics of functionally graded material (FGM) plates using the finite element (FE) method. The analysis is carried out by choosing a single-layer FGM and two different types of FGM sandwich plates in such a way that there is no material discontinuity along the thickness direction. The porosity imperfections are accounted for in this study as criteria of stiffness reduction and are incorporated using modified power law distribution. The vibration and buckling responses are studied by considering four types of localized edge loads on plates with different porosity distributions. The application of different types of localized edge loads on the plate leads to the development of nonuniform in-plane stresses. Hence, they are computed first by using a dynamic approach before obtaining the buckling loads. The accuracy of the FE formulation is first validated for FGM plates by comparing the natural frequencies and the critical buckling loads obtained in the present investigation with the solutions already available in the literature. After validating the accuracy, detailed parametric studies have been performed on plates with varying volume fraction exponent, porosity distribution, porosity index, side-to-thickness ratio, load width ratio, aspect ratio, and support condition, and the results are presented with appropriate conclusions. A probabilistic sensitivity analysis is carried out to identify the significant parameter affecting the buckling load and natural frequency of porous FGM plates subjected to localized edge loads, which considerably aids in the design of the FGM plates.

Capability of Different Multi-Criteria Decision-Making Techniques in the Performance Assessment of the Hospitals in Terms of Medical Waste Management.

Background:Assessing the performance of hospitals in waste management requires considering several criteria of different types. The multiplicity of the criteria and how they are weighed and, ultimately, the ranking of hospitals; are among the most complex challenges faced by the environmental health authorities. This research tried to assess the capability of four commonly used multi-criteria decision-making methods, as well as a hybrid technique for performance assessment of six hospitals in Tehran City, Iran, in 2018 regarding waste management.Methods:The effective criteria and sub-criteria were identified by reviewing the relevant literature. The data collection tool was a self-constructed checklist developed based upon the identified criteria and sub-criteria and analysis of the collected data was done in MATLAB software. The sample hospitals were ranked based on the scores given to the management performance of hospitals.Results:The final rankings by the different techniques did not differ significantly. According to the results of the hybrid method, among six studied hospitals, the top three hospitals were Hospital C, B, and A respectively, regarding hospital waste reduction criteria. These hospitals generally had an acceptable performance in terms of waste management, especially waste disinfection and separation at the origin.Conclusion:In assessing the performance and ranking of hospitals in terms of waste management, hybrid multi-criteria decision-making techniques can be used as a useful tool in waste management planning. By identifying the areas in need of corrective actions and choosing the appropriate strategy, they pave the way for improving the performance of hospitals in the field of waste management.

Prior direct oral anticoagulant dosage and outcomes in patients with acute ischemic stroke and non-valvular atrial fibrillation: A sub-analysis of PASTA registry study

Background and purposePrescribing under-dose direct oral anticoagulants (DOACs) for non-valvular atrial fibrillation (NVAF) is alerted to increase cardiovascular events or death. However, the association between dose selection of DOACs and the clinical course remains unclear. This study aimed to propose a novel criterion for selecting the DOAC dose and investigate clinical characteristics of ischemic stroke (IS) under this criterion. MethodsWe assessed the pooled prospective multicenter registry data of stroke patients taking anticoagulant agents, including IS patients with NVAF and prior DOAC usage. The recommended dose according to the reduction criteria of each DOAC and the selected dose were identified for each patient, and patients were categorized into four groups: no alternative low-dose, selecting low-dose appropriately with all DOACs applicable for reduction criteria; selected low-dose, selecting low-dose appropriately or inappropriately despite at least one DOAC inapplicable for reduction criteria; selected standard-dose, appropriate standard-dose use; and absolute over-dose, inappropriate standard-dose regardless of criteria. We investigated the effects of dose selection of DOACs on short-term poor functional outcomes. Results322 patients were included in the analysis. The prevalence of no alternative low-dose, selected low-dose, selected standard-dose, and absolute over-dose was 74 (23%), 144 (45%), 89 (27%), and 15 (5%), respectively. Multivariable analysis found that the selected low-dose group showed significantly poorer functional outcomes than the selected standard-dose group only in patients without renal dysfunction (OR, 2.60; 95% CI, 1.17–6.00; P = 0.0186). ConclusionsSelecting a low dose DOAC might be associated with poor functional outcomes in patients without renal dysfunction.

Evaluation of a novel therapeutic education programme for people with alcohol use disorder in France: a mixed-methods intervention study protocol (ETHER)

BackgroundETHER (“Education THEérapeutique pour la Réduction des dommages en alcoologie” or Therapeutic education for alcohol-related harm reduction) is a multicentre community-based mixed-methods study, which aims to evaluate the effectiveness of the innovative therapeutic patient education (TPE) programme ‘Choizitaconso’ in a sample of French people with alcohol use disorder (people with AUD). Choizitaconso teaches people with AUD psychosocial skills to help them (re)establish controlled drinking and reduce alcohol-related harms. Recruitment started in October 2019. We present here the protocol of the ETHER study.MethodsETHER’s quantitative component involves a 6-month controlled intervention study which evaluates Choizitaconso’s effectiveness by comparing 30 people with AUD following the programme with a control group of 60 people with AUD not enrolled in it, using a questionnaire co-constructed by the research team and members of the people with AUD community. Thirty-four alcohol-related harms are assessed and summed to provide an individual measure of the ‘harm burden’ from consuming alcohol (primary outcome). Secondary outcomes are anticipated and internalized stigma, alcohol consumption measures, craving for alcohol, coping strategies, health-related quality of life, self-confidence to control or abstain from drinking, treatment self-regulation, anxiety and depressive symptoms, alcohol-related neuropsychological impairments, and capabilities (a measure of wellbeing in adults). Data will be collected in face-to-face and phone-based interviews at enrolment and 6 months later. Linear regression models will be used to assess the impact of the TPE programme on changes in the primary and secondary outcomes, while adjusting for other correlates and confounders. The study’s qualitative component comprises semi-structured interviews with 16 people with AUD who have already completed the TPE programme at least 6 months before the interview. Qualitative interviews will be analysed using thematic analysis.Results and conclusionsETHER is the first evaluation study of an innovative TPE programme specifically designed to reduce alcohol-related harms and reach controlled drinking in France. The involvement of the people with AUD community in selecting which experienced and perceived alcohol-related harms to measure ensures that ETHER will provide healthcare staff and researchers with a relevant set of harm reduction criteria for use in future research. Finally, ETHER will provide scientific justification for implementing novel alcohol-related harm reduction approaches and champion controlled drinking as a therapeutic goal.Trial registration ClinicalTrials.gov, NCT03954054. Registered 17 May 2019—Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT03954054?cond=alcohol&cntry=FR&city=Marseille&draw=1&rank=1.

A Proposed Uncertainty Reduction Criterion of Renewable Energy Sources for Optimal Operation of Distribution Systems

Power system operation and planning studies face many challenges with increasing of renewable energy sources (RESs) penetration. These challenges revolve around the RESs uncertainty and its applications on probabilistic forecasting, power system operation optimization and power system planning. This paper proposes a novel and effective criterion for uncertainties modeling of the RESs as well as system loads. Four sorting stages are applied for the proposed uncertainty cases reduction. Added to that, it proposes three different uncertainty reduction strategies for obtaining different accuracy and speed options. The proposed reduction strategies are tested on medium and large scale distribution systems; IEEE 69-bus and 118-bus systems. The obtained results verify the effectiveness of the proposed criterion in uncertainties modeling in distribution systems with acceptable level of accuracy.

Considering "Trifecta" as a Single Outcome when Comparing Robotic With Open Partial Nephrectomy: A Mathematical Model of Volume Conservation and Systematic Review.

Trifecta represents a composite outcome reflecting the quality level of treatment in nephron sparing surgery. However, there is substantial heterogeneity concerning the criteria required for its fulfilment. The present study aimed to highlight the potential of a unified view for the different definitions of trifecta when comparing robotic and open approaches in partial nephrectomy. A systematic literature search was carried out for all relevant comparative studies published until April 2022. Trifecta definitions were clustered according to two criteria for postoperative renal function reduction. The first set as an upper limit the 10% decrease in the estimated glomerular filtration rate, while the second set as an upper limit 25 min of ischemia. To mathematically investigate the point of intersection between the above two groups, a suitable model of volume conservation equations was formulated. A total of 11 studies were investigated for their methodological features and grouped accordingly. The ischemic zone volume surrounding the tumor resection site emerged as the central parameter connecting the two main definitions. Specifically, for patients with solitary renal masses, a given change in the value of one parameter resulted in a fixed change in the value of the other. The two main definitions of the "trifecta outcome" extracted from the international literature represent the two sides of the same coin. Thus, trifecta achievement rates could be utilized by future studies as aggregate data to yield a quantitative estimate of the comparative effect between robotic and open approaches in partial nephrectomy procedures.

Indications and Outcomes of the Kocher-Langenbeck Surgical Approach in the Management of Acetabular Fractures in a Resource Limited Setting

The Kocher-Langenbeck (K-L) approach is the ‘workhorse’ of surgery for acetabular fractures needing posterior fixation. It is indicated for most of these fractures for proper surgical technique and optimal outcome. We therefore evaluated the outcome of surgically treated acetabular fractures through the K-L approach in our setting with limited resources. 57 patients were operated by the K-L approach during the 3-year study period. The most common indications of this approach were: posterior wall (38.6%) and transverse + posterior wall fractures (36.8%). Based on Matta’s criteria of fracture reduction, 81 % were judged anatomic, 16% imperfect and 3 % poor. A surgery waiting time of 8 to 14 days after injury, significantly favoured anatomic fracture reduction. The MAP score was excellent in 72 % and unacceptable in 10.6 %. Factors associated with poor outcomes were poor fracture reduction and the development of early post-operative complications. Iatrogenic sciatic nerve palsy (ISNP) was the most significant post-operative complication (19.3%). The levering of Hohmann retractors in the sciatic notches was the major risk factor for developing ISNP, compared to the use of sciatic nerve retractors. Other early and late complications included surgical site infections (12.3%) and heterotopic ossification (8.8 %), respectively. The overall outcome following surgery by the K-L approach is satisfactory. However, there is need to ameliorate the technique, especially at the level of instrumentation, to limit post-operative complications.

Percutaneous Fixation of Metatarsals Fractures with Kirchner’s Wire, Comparison of Antegrade and Retrograde Technique

Category:Trauma; Midfoot/ForefootIntroduction/Purpose:The antegrade intramedullary nailing technique with Kirchner’s wire (K-wire) (EAK) for the management of metatarsal fractures (MTT) is recent and with few reports. Our objective was to evaluate and compare the clinical results among patients operated on in our center for MTT fractures using the EAK technique versus the traditional retrograde technique (ERK).Methods:Retrospective, analytical study. We reviewed the cases of patients with a diagnosis of MTT fracture and surgical indication operated with EAK or ERK between February 2010 and January 2016. First and fifth metatarsal fractures were excluded from the analysis, as well as patients in which a fixation method other than K-wire was used. Demographic data, clinical and radiological results were recorded. A total of 34 patients (34 feet, 70 metatarsals) were analyzed and were divided into two groups: Group 1, operated with EAK (15 feet, 22 metatarsals), and Group 2, operated with ERK (19 feet, 48 metatarsals). Statistical analysis was carried out with Fisher's exact test and Mann-Whitney U test for non-parametric variables, with fixed statistical significance at p <0.05.Results:The median age was 37 years [IQR = 51-25.25], p = 0.128. Both groups presented similar soft tissue involvement (p = 1,000), similar associated injury rate (20.0% vs 42.1%, p = 0.271), and similar proportions of diaphyseal and neck fractures (p = 0.659 and p = 0.733 respectively). The group operated with the EAK technique presented a lower report of metatarsalgia (6.7% (1) vs 47.3% (9), p = 0.020), shorter rest time since injury (94 days [IQR = 129-82] vs 144 days [IQR = 210-122], p = 0.002) and shorter time to full load (7 weeks [IQR = 9-6] vs 10 weeks [IQR 12.5-8.5], p = 0.002). EAK and ERK did not show differences in criteria for poor reduction (p = 1.00), number of re-interventions (p = 0.560), infections (p = 0.492), or metatarsophalangeal stiffness (p = 0.451).Conclusion:Metatarsal fracture fixation with EAK presented a lower rate of metatarsalgia and shorter rest time compared to ERK, demonstrating similarity in terms of quality of reduction and complication rate.

Life cycle energy consumption and environmental assessment for utilizing biofuels in the development of a sustainable transportation system in Ethiopia

Ethiopia’s transportation sector is currently dominated by internal combustion engine vehicles running using imported petroleum oil. Due to shortages in hard currency, a rising economy and population growth, and rapid industrialization, energy security to meet the national demand for transport is a quite severe problem. As a result, Ethiopia is strengthening its effort to look for clean alternative energy sources, such as biofuels and electricity. Ethiopia’s biofuel program relies on cane molasses-based ethanol and jatropha based biodiesel for blending into conventional petroleum fuels. In order to investigate the sustainability of Ethiopian biofuel production and use in transportation fuels in terms of their energy balance and environmental impacts, well-to-wheel (WTW) analysis was conducted. The WTW energy saving, greenhouse gas (GHG) emission reduction benefits and criteria air pollutants of blending different commonly used ratios of ethanol with gasoline, biodiesel with diesel and electricity mix (mostly (90%) from hydropower) were analysed in the Ethiopian situation. It is found that both ethanol and biodiesel production has shown net energy gain and reductions in GHG emissions which indicates sustainability and, therefore, could be good substitutes for petroleum fuels if their production pathways are properly managed and implemented. Flexible fuel vehicles (FFVs) fuelled with a blend of 85% ethanol and 15% gasoline (E85) could save 65% fossil fuels and 29% of GHG emission reductions compared to neat gasoline vehicles. Compared to neat diesel vehicles, a blend of 20% biodiesel and 80% diesel (B20) powered vehicles could save 15% fossil energy and could remove 12% of GHG emissions per kilometre driven. Hybrid electric vehicles (HEV) and plug-in hybrid electric vehicles (PHEV) with biofuels (ethanol and biodiesel), gasoline, and diesel showed higher savings of fossil fuel energy and less GHG emissions in every scenario.

Rivaroxaban and apixaban in patients with atrial fibrillation; a real-world data.

This study aims to analyze the real-life data of patients who were prescribed rivaroxaban and apixaban and to emphasize the points that we think will make a difference compared to randomized controlled studies. The patients who accepted to participate in the study in whom rivaroxaban (15-20 mg) and apixaban (2.5-5 mg) were started with the diagnosis of atrial fibrillation between 01 January 2018 and 31 December 2019 and whose records were fully accessed through the hospital automation system were included in the study. One hundred and ninety-four (48.5%) of a total of 400 patients using rivaroxaban and apixaban were women. The mean age was 73.34 ± 10.45 years, and the age range was 41-98. There was no significant difference in terms of demographic characteristics, background information of the patients, and the medications. Drug-induced complications and mortality rates were also similar. The GFR change rates of the patients in both groups were similar even though the initial GFRs were significantly higher in rivaroxaban group. The mean age and ejection fractions of the patients using rivaroxaban 15 mg were found to be lower than those of patients using rivaroxaban 20 mg whereas the mean systolic blood pressure and HAS-BLED score were found to be higher. Ischemic stroke and mortality rates were higher in patients using 15 mg rivaroxaban than patients using 20 mg rivaroxaban. The rates of nonmajor bleeding in patients using rivaroxaban 15 mg were lower compared to those using 20 mg, and this difference was statistically significant. Stroke rates were found to be higher and to have similar bleeding rates compared to major clinical studies in our real-life analysis. However, high ischemic cerebrovascular event and low nonmajor bleeding rates are remarkable in low dose use of rivaroxaban. It is clear that there is a need to consider existing dose reduction criteria in terms of correct prescribing.

Sustainable and resilient supplier selection: the case of an Indonesian coffee supply chain

Supplier selection has become one of the core elements of supply chain management because suppliers affect a company's bottom line and supply chain performance directly. Supplier selection is a complex decision-making process that includes multiple criteria and a set of supplier alternatives. This study integrates the dimensions of sustainability and resilience into the supplier selection process. The aim is to propose a systematic supplier selection framework to help companies categorize suppliers based on their sustainability and resilience performance and select the ones that perform well on those two dimensions. We use a novel multi-criteria decision-making method (MCDM), the Best-Worst Method (BWM), to solve the complex decision-making process of coffee supplier selection in a local roastery in Indonesia. The data was collected from two groups: experts regarding the coffee supply chain in Indonesia and a decision-maker at a coffee roastery in Indonesia. The result shows that the economic criteria for sustainability performance and risk reduction criteria for resilience performance are the most important supplier selection criteria for both groups. There are no significant differences between the importance evaluations of criteria by both group of experts, which indicates that the supplier selection process of the company aligns with the expert perspective.

Midshaft clavicle fracture with hypertrophy of the fractured end

Abstract Introduction: Midshaft clavicle fractures are common fractures, but clavicle fractures with hypertrophy of the fractured end are rare. To the best of our knowledge, there are no reports describing this peculiar form of fracture. Patient concerns: A 68-year-old woman was admitted to the orthopedic department for treatment of left shoulder joint swelling and pain with limited mobility for 1 day duration She had a history of falls and an old left distal radius fracture, but no history of left shoulder joint swelling, pain, and limited mobility. Diagnosis: 1. Midshaft fracture of the left clavicle 2. Motor neuron injury 3. Multilevel cervical intervertebral disc herniation. 4. Brain atrophy 5. Old left distal radius fracture. Interventions: Surgical treatment was performed after detailed preoperative evaluation. During surgery, the clavicle fracture was anatomically reduced under direct vision (unusually, the fracture end was displaced during intraoperative fluoroscopy). After fracture reduction, one eight-hole locking plate was fixed with three locking screws at each end of the fracture. After the surgery, the patient was instructed to perform rehabilitation training. Outcomes: The sutures were removed on the 12th postoperative day, and the incision wound healing was good. Follow-up at one month after surgery revealed no swelling or pain at the left clavicle fracture site and both active and passive ranges of motion of the left shoulder joint were good. Conclusion: For clavicle fractures with hypertrophy of the fractured ends in the elderly, after excluding pathological fractures caused by tumors, satisfactory results can be obtained as long as strong internal fixation is achieved. In the midshaft clavicle fracture with hypertrophy of the fractured end, whether to achieve the reduction criteria under direct vision or intraoperative fluoroscopy imaging should be determined on the basis of the patient's actual condition. Motor neuron injury may promote the healing of clavicle fractures due to restricted motor function that promotes fracture healing.

ADAPTIVE STRATIFIED SAMPLING FOR NONSMOOTH PROBLEMS

Science and engineering problems subject to uncertainty are frequently both computationally expensive and feature non-smooth parameter dependence, making standard Monte Carlo too slow, and excluding efficient use of accelerated uncertainty quantification methods relying on strict smoothness assumptions. To remedy these challenges, we propose an adaptive stratification method suitable for non-smooth problems and with significantly reduced variance compared to Monte Carlo sampling. The stratification is iteratively refined and samples are added sequentially to satisfy an allocation criterion combining the benefits of proportional and optimal sampling. Theoretical estimates are provided for the expected performance and probability of failure to correctly estimate essential statistics. We devise a practical adaptive stratification method with strata of the same kind of geometrical shapes, cost-effective refinement satisfying a greedy variance reduction criterion. Numerical experiments corroborate the theoretical findings and exhibit speedups of up to three orders of magnitude compared to standard Monte Carlo sampling.

A Markov regime‐switching Cholesky GARCH model for directly estimating the dynamic of optimal hedge ratio

AbstractA Markov regime‐switching Cholesky GARCH (RSCHAR) model is proposed for directly estimating the optimal hedge ratio. The basic structure of RSCHAR is to transform the original series into a vector of orthogonal factors using Cholesky decomposition and fit these factors with regime‐switching dynamics. RSCHAR specifies directly the regime‐switching dynamic of conditional hedge ratio instead of recovering it indirectly from the estimated conditional covariance matrix. An estimation procedure is proposed for estimating RSCHAR. The empirical results reveal that RSCHAR exhibits superior effectiveness for multiple futures hedging based on the criterion of variance reduction, lower partial moment, and model confidence set.

Abstract 12248: Dosing of Direct Oral Anticoagulants in Patients With Non-Valvular Atrial Fibrillation and Renal Dysfunction

Introduction: Reduced doses of direct oral anticoagulants (DOACs) are approved to prevent bleeding complications in specified populations of patients with non-valvular atrial fibrillation (NVAF). Little is known about the accuracy of DOAC dosing in patients with renal dysfunction. Hypothesis: We hypothesized that NVAF patients with renal dysfunction would be more likely to receive an inappropriate dose of a DOAC compared with patients with normal renal function. Methods: We examined all patients who had at least two claims for NVAF between 2015 and 2017 in the Symphony Health claims dataset. We defined under-dosing as patients treated with a reduced dose without meeting label specified criteria for dose reduction, and excess dosing as patients treated with a full dose despite meeting criteria for dose reduction. We performed a logistic regression model to measure the effect of CrCl on DOAC dosing. Results: Among 86,919 patients with NVAF and CHA 2 DS 2 -VASc &gt; 2, 12.3% were underdosed and 5.0% were excess dosed. Patients who received excess-dosed or under-dosed DOACs were older and more likely to have comorbidities such as heart failure or history of prior stroke (all p&lt;0.001), compared with patients who were appropriately dosed. Among patients with CrCl &gt; 60 ml/min, under-dosing occurred in 9% of patients, highest among patients treated with edoxaban (18%) and rivaroxaban (10.4%). Under-dosing rates were higher among patients with CrCl 30-59 ml/min, especially for apixaban and dabigatran ( Table) . Excess dosing occurred in approximately 1 in 5 patients with CrCl &lt;30 ml/min. For every 10 unit decrease in CrCl, the odds of the patient receiving an inappropriately dosed DOAC increased by 27%. Conclusions: Incorrect DOAC dosing was observed in a substantial number of patients with NVAF in this large national study. Dosing errors occurred more frequently in patients with lower renal function, suggesting the need for efforts to improve effective and safe dosing of DOACs.

Carfilzomib Is Safe in Elderly Patients with Multiple Myeloma but Thrombotic Microangiopathy Is Underestimated in Clinical Practice

IntroductionCarfilzomib (K or Cfz) is a widely used second-generation proteasome inhibitor for patients with multiple myeloma (MM). However, despite the numerous positive clinical results, there were only a few “real-world” studies, particularly among elderly patients. Avoiding Cfz for the elderly may be based on a potential selection bias to avoid rare but serious cardiovascular adverse events (CVAEs) associated with Cfz. Moreover, although Cfz-associated thrombotic microangiopathy (TMA) has been recently recognized, the incidence rate of TMA varied from less than 1% to 5.0%. To determine the efficacy of Cfz and occurrence of CVAEs in the elderly patients and the incidence of TMA, we reviewed 96 patients, including 28 elderly patients (aged ≥76 years) at our center. All participants or their family members provided written informed consent for inclusion in the study. The study was conducted according to the Declaration of Helsinki and approved by the ethical review board of our institute.MethodsCfz was administered in the same protocol as in each clinical trial. The choice of the Cfz regimen and the criteria for dose reduction, including dexamethasone use, were based on the patient's background and discretion of the treating physician.Severe CVAEs were defined as events of grade ≥3 including heart failure, acute coronary syndrome, relative reduction in the left ventricular ejection fraction ≥20% from baseline, QT prolongation (corrected QT: ≥501 ms), and hypertension (systolic blood pressure of ≥160 mm Hg and/or diastolic blood pressure of ≥100 mm Hg, requiring two or more additional intensive medications than before) that were observed within three months after the initiation of Cfz therapy. The diagnosis of TMA was made as follows: when clinical findings were consistent with microangiopathic hemolytic anemia, such as thrombocytopenia, progressive anemia with schistocytes, elevated lactate dehydrogenase, and other differential diseases, including bacteremia or tumor progression, could be excluded.ResultsThe patients' median age at Cfz initiation was 71 (range, 30-91) years. In total, 96 (100%), 86 (89.6%), 22 (22.9%), and 23 (23.9%) patients received bortezomib, lenalidomide, daratumumab, and autologous stem cell transplantation before Cfz therapy.Until the end of the study, 13 CVAEs (13.5%) of grade ≥3 were observed, including 2 (11.1%), 1 (11.1%), and 10 (15.2%) in patients who received Kd (Cfz and dexamethasone), DKd (Daratumumab, Cfz, and dexamethasone), and KRd (Cfz, lenalidomide, and dexamethasone), respectively. Despite the use of appropriate supportive care, grade ≥3 AEs resulting in Cfz withdrawal were noted in 25 patients: CVAEs in 11, thrombocytopenia in 4, TMA in 3, and infection in two patients. Notably, one patient with end-stage myeloma who received KRd 20/27 mg/m 2 died of CVAE on day 10 of cycle 1.At Cfz initiation, 28 patients were aged 76-80 (n=14) and ≥81 years (n=14) (Fig. 1). Three elderly patients had severe CVAEs (10.7%). The median numbers of prior chemotherapy to Cfz, time to next treatment, and overall survival from Cfz initiation were 2.5, 28.0, and 41.1 months, respectively. Although 10 patients (35.7%) discontinued Cfz therapy due to disease progression, only four patients (14.3%) discontinued Cfz owing to grade ≥3 AEs, including TMA (n = 1) and CVAEs (n = 3).Overall, five patients (5.2%) showed TMA. All patients received Kd-based regimens upon TMA development (Kd, n = 2 and DKd, n = 3). The median age of the patients who developed TMA was 74 years, and the Cfz dose was 20/27 in 1, 20/36 in 1, and 20/56 mg/m 2 in three patients. Although three patients developed TMA during the first Cfz cycle (on days 11, 16, and 21, respectively), two patients received KRd therapy before the Kd therapy that caused TMA. Two patients required temporary dialysis and four patients discontinued Cfz therapy. Eculizumab was administered in a patient and a kidney biopsy showed that the lumen of most glomerular capillaries was occluded by fibrin thrombi (Fig. 1). Furthermore, the vessel in the vascular pole of the glomerulus had necrotic lesions, suggesting drug-induced and complement-mediated TMA.ConclusionCfz could be used safely in the elderly patients. The incidence of CVAEs by Cfz in elderly patients was similar to that in the entire cohort. The incidence of TMA was 5.2%, and Cfz-induced TMA should be carefully considered, particularly in patients using high-dose Cfz. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Evaluation of the Economic Profitability of Using Renewable Energy Sources in Agro-Industrial Companies

The study of the impact of the availability of renewable energy sources (RES) on the competitiveness and cost reduction opportunities is an actual objective for agro-industrial enterprises in the present time. The purpose of this paper was to develop a methodological approach based on a questionnaire survey, an integrated indicator of enterprise competitiveness, a model for assessing energy conservation costs, and regression analysis combined with a hierarchical synthesis of 20 Russian agro-industrial companies. The solution of the problem of nonlinear optimization of agro-industrial companies made it possible to determine the excess of the competitiveness criterion over the criterion of energy conservation cost reduction as a result of the use of RES. The conducted regression analysis showed a close relationship between the competitiveness of the companies under study and the availability of RES. Modeling and hierarchical synthesis of the study results confirmed that the use of RES in the activities of agro-industrial companies stimulates their competitive potential reflected by the competitiveness index and minimizes energy conservation costs. It was also found that there is an inverse regression relationship with a high degree of correlation between the provision of RES and the cost of energy-saving measures. Hence, it can be argued that a greater emphasis on the provision of Russian agro-industrial enterprises with RES can lead to their more sustainable and efficient development due to increased competitiveness and better cost reduction strategies.

125 Reducing Displaced Forearm Fractures in Children: Are we following the guidelines?

Abstract Primary Subject area Emergency Medicine - Paediatric Background Forearm fractures account for 45% of pediatric fractures, mainly involving the distal third of the forearm. Some will be displaced, requiring a closed reduction and plaster cast immobilization. Re-displacement during follow-up is reported in 7 to 35% of the cases. Objectives To identity discrepancies between hospital guidelines and patient management for forearm fracture reduction in children aged 1 to 17. Design/Methods This retrospective case series was conducted by a medical audit committee of CHU Sainte-Justine for the purpose of improving quality of care. This project aimed to evaluate the clinical course following closed reduction of forearm fractures in patients presenting to the emergency department (ED) or to the orthopedic clinic in a pediatric tertiary care centre. Children aged 1 to 17 years old presenting between January 1 and December 31 2019 were considered for this study. We selected a convenience sample of 50 consecutive cases and reviewed their medical and radiological data from first consultation through follow-ups. The management of these cases was evaluated against established hospital guidelines for primary or secondary fracture reduction (primary outcome). The angulation and displacement of fractures were measured using original imaging taken prior to reduction, and at follow-up. At their last appointment, all patients’ range of motion and angulation were assessed. Complications of sedation and immobilization were also reviewed. Descriptive statistics were performed for all variables. Results From the 106 radiologic files retrieved of closed forearm fracture reduction using fluoroscopy, a convenient sample of 50 cases was reviewed. The mean age was 7 years and 60% of them were boys. Forty-eight (96%) had an initial fracture reduction consistent with the local practice guideline for need of reduction. Sedation adverse events were noted in 10 patients (20%), most often nausea, but no severe adverse event was identified. According to the local practice guideline, 13 (26%) patients suffered re-displacement at follow-up. Of these, 3 underwent a second closed reduction, 4 had a gypsotomy, and 6 had no attempt at a second reduction. Five patients (10%) had a second reduction during follow-up, despite the displacement not meeting the local guideline criteria for reduction. Cast-related issues were reported in 14 patients (28%), with the molding technique accounting for most of the problems observed. At their final follow-up, 40 patients (80%) had an excellent or good functional outcome. In the remaining 10 (20%), the range of motion was more limited, but measurements were done for many of them following immediate cast removal. Forty patients (80%) had either a normal or near normal alignment at their final follow-up. In the remaining 10 (20%), none of these patients had an angulation greater than 20 degrees. Conclusion From this audit of patients presenting with displaced forearm fractures in a pediatric tertiary care centre, the initial management of patients was in accordance with the established guidelines of practice in 96% of cases. Re-displacements at follow-up were identified in a quarter of patients. Nonetheless, angulation and the final range of motion of the wrist were favorable shortly after cast removal. Further improvement in the management could be achieved by improving the technique of cast immobilization.

Final Report of NRG Oncology RTOG 0022: A Phase I/II Study of Conformal and Intensity Modulated Radiation for Oropharyngeal Cancer

Final Report of NRG Oncology RTOG 0022: A Phase I/II Study of Conformal and Intensity Modulated Radiation for Oropharyngeal Cancer