Definite Decision Research Articles

The Vanishing Vaquita: A Call for Definitive Action

ABSTRACTThe world's smallest porpoise—the vaquita (Phocoena sinus)—is on the brink of extinction. Endemic to the upper Gulf of California, it has dwindled to fewer than 19 individuals in 2023. The primary source of mortality is drowning in gillnets set for totoaba (a giant croaker fish). Our review of the past 50 years of efforts to simultaneously attain conservation goals for the vaquita and economic and social goals for the fisheries concludes that they have consistently failed to meet the lowest expectations of any stakeholders. The time has therefore come to recognise that the only solution to this problem is to make an immediate and definitive decision: either preserve the vaquita or bolster sustainable fishing in the upper Gulf—and accept the associated social, economic, and political costs of either choice.

P0391 The impact of point of care ultrasound on time to initiating advanced therapy in IBD (GUIDE-IBD): A randomised controlled trial

Abstract Background Intestinal ultrasound is an accurate tool for assessing inflammatory bowel disease activity1. Previous studies showed point-of-care ultrasound (POCUS) can impact treatment decisions in 48% of appointments2. Early diagnosis and treatment improves outcomes in Crohn’s disease (CD). We aimed to investigate if POCUS in the IBD clinic led to earlier initiation of advanced therapies using a randomised controlled trial. Methods Patients attending an IBD clinic at a UK tertiary referral centre with known or suspected IBD (with a high likelihood) were eligible. During the primary clinic appointment clinicians’ investigation and treatment decisions were recorded. Immediately following this they were randomised 1:1 to POCUS or standard of care (SOC). The POCUS group then had further review with an option to alter treatment decisions. The primary end-point was time to initiating definitive therapy (in days) (new/changed immunomodulator, advanced therapy or surgery only). Secondary end-points included clinical score (HBI, SCCAI), calprotectin and patient tolerability. Patients were followed for 12 months. Results 122 patients were enrolled between 1st June and 1st November 2023. Median age was 25 years (16-79) and 50% male with a final diagnosis of 87 CD, 23 UC, 4 IBD-U and 8 non IBD (new referrals). 63 had POCUS and 59 SOC. POCUS was performed by one of two sonographers (one gastroenterologist and one radiologist). 65 (53%) were on advanced therapy or immunomodulators at baseline. 99 (81%) had advanced therapy, immunomodulators or surgery during the study period. Mean time to definitive treatment decision was 43 days with POCUS compared to 92 days in SOC (p<0.01). 65 (53%) patients had a change of, or started a new therapy and mean time to treatment initiation was also significantly shorter in the POCUS group, 75 days, compared to SOC, 131 days (p=0.033). In a sub-group of 20 new referrals, 12 were diagnosed with IBD. Mean time to treatment initiation was shorter with POCUS (82 vs 151 days). Steroid prescriptions at the baseline appointment were significantly higher in the POCUS group, 11/63 vs 2/59 (p = 0.012). Any change to treatment in the POCUS group occurred in 29/63 (46%) patients. Scans took an average of 7.5 minutes with 100% patient acceptability. Conclusion POCUS leads to earlier IBD-related decision making which translates into earlier initiation of effective therapy. This should, in turn, lead to improved care with shorter time to remission and reduced complications. Pathways to incorporate POCUS into routine clinical practice to optimise its effectiveness need further evaluation. This will require collaborative training and working across multiple specialties to effectively deliver this service. References (1)Taylor SA, Mallett S, Bhatnagar G, et al. Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn’s disease (METRIC): a multicentre trial. Lancet Gastroenterol Hepatol. 2018;3(8):548-558. doi:10.1016/S2468-1253(18)30161-4 (2)Bots S, De Voogd F, De Jong M, et al. Point-of-care Intestinal Ultrasound in IBD Patients: Disease Management and Diagnostic Yield in a Real-world Cohort and Proposal of a Point-of-care Algorithm. J Crohns Colitis. 2022;16(4):606-615. doi:10.1093/ecco-jcc/jjab175

P0550 Introducing Intestinal ultrasound in the UK NHS – the first 6-months

Abstract Background Intestinal ultrasound (IUS) has been integrated into inflammatory bowel disease (IBD) practice outside of the UK for several years. The NHS has been slow to adopt this and there is ongoing scepticism with regards to its utility. Methods We performed a retrospective service evaluation to demonstrate the utility of IUS in the NHS. IUS was requested additionally to tests performed as standard of care to enable internal audit. We assessed the proportion of cases where IUS altered decision making. Secondary outcomes included the additional value of IUS to faecal calprotectin (fcal) and the accuracy of IUS in terms of the presence, activity and extent of disease. Similar to the METRIC study,1 IUS accuracy was determined after accounting for all available investigations performed in each patient and recorded as a binary outcome. Where pathology was missed, changes in management were recorded. Data collected included demographic, disease phenotype, body mass index, pregnancy, indication for IUS and scan adequacy. Results We performed 74 IUS on patients with: Crohn’s disease (53) [L1–40; L3–13; B1–11; B2–32; B3–10; p1], ulcerative colitis (17) [E1–2; E2–5; E3–10] and suspected CD (4). Mean age 45.5 years; 45 (61%) female, mean BMI 25.2, pregnant [mean 29/40 weeks] 7 (9.4%). Indications included disease flare (34, 46%), asymptomatic with raised fcal (4, 5%) or disease monitoring (36, 49%). In total, 10 (13%) were deemed inadequate due to (gravid uterus obscuring view [3, 4%), BMI >26 (4, 5%), difficult scan (3, 4%). All 10 patients had mild (6, 8%) or quiescent disease (4, 5%). Table 1 shows the outcomes of the remaining 64 scans. In 52/64 (81%) cases the IUS altered immediate treatment decisions. In 38/64 cases, the IUS added additional value compared to using the subsequently resulted fcal alone. The presence, activity and extent of disease was concordant with standard tests (92%, 92% and 62% of cases, respectively). Missed pathology requiring alternative treatment was identified in 6/63 (9.5%) cases (mild aphthous ulceration seen on VCE [normal MRE] [4], lymphoma [1] and ileorectal anastomotic stricture [1]). The latter two cases required cross-sectional imaging irrespective of the IUS result. Time to definitive treatment decision was reduced by an average of 57 (24-92) days. Conclusion Despite limited experience in IUS, our outcomes are similar to results from the METRIC trial. The NHS should expedite the adoption of IUS to avoid invasive/expensive tests, add value to the clinical consultation and streamline IBD care. References Taylor SA, Mallett S, Bhatnagar G, et al. Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn’s disease (METRIC): a multicentre trial. Lancet Gastroenterol Hepatol 2018;3(8):548-558. (In eng). DOI: 10.1016/s2468-1253(18)30161-4.

Gonadal function and pathology in 17beta-HSD 3 and 5alpha-reductase deficiency.

17β-Hydroxysteroid dehydrogenase 3 deficiency (17β-HSDD) and 5α-reductase type 2 deficiency (5α-RD) are rare 46,XY differences of sex development (DSD). This study aims to enlarge the limited knowledge on long-term gonadal function and gonadal pathology in these conditions. Retrospective multicentre cohort study. Data on phenotype, laboratory results, and hormone treatment were collected from patients aged ≥16 years at time of data collection with genetically confirmed 17β-HSDD and 5α-RD from 10 centres via the I-DSD Registry. If gonadectomy or gonadal biopsy had been performed, pathology reports and/or gonadal tissue or images were collected. All 16 patients with 17β-HSDD were raised female; 1 (6%) changed to male gender at age 14. Three females were treated with gonadotrophin-releasing hormone agonists (GnRHa) to prevent virilisation. Thirteen underwent gonadectomy at median age 8 (range 0-17). None had germ cell (pre)malignancies. Of 14 patients with 5α-RD, 10 (71%) were raised female. Five changed gender at age 7-23, of whom 4 to male gender. One was treated with GnRHa. Six underwent gonadectomy at median age 10 (range 0-31). None had germ cell (pre)malignancies. With gonads in situ, puberty spontaneously progressed. Three were treated with dihydrotestosterone. A significant percentage of individuals with 17β-HSDD and 5α-RD changed gender, and some were treated with GnRHa to prevent virilisation before making a definitive decision about gonadectomy. When left in situ, spontaneous puberty occurs and germ cell (pre)malignancies seem uncommon at least until early adulthood. Together, these data support delaying a decision about gonadectomy until late adolescence in these conditions.

Evaluation of malignancies and F18-FDG PET/CT imaging of patients living with HIV/AIDS in a university hospital

Aim:Human immunodeficiency virus (HIV) can cause tumoral changes in immune cells and lead to the development of AIDS-defining malignancies. As malignancies in HIV-infected individuals tend to be quite aggressive with a worse prognosis, making a definitive and early decision about HIV-related malignancies is very important.Therefore, the aim of this study was to examine HIV-related malignancies in HIV-positive patients and evaluate F-18 FDG PET/CT results. Materials and Methods: This single-centre, retrospective study was conducted on adult patients with HIV infection at a university hospital between January 2018 and December 2022. The demographic data, medication use, viral loads, and F-18 FDG PET/CT results of the patients were accessed retrospectively from the automated hospital records system and patient files. F18-FDG PET/CT images of patients were evaluated for those with suspicion of cancer and staging of cancer. Results: The study included 254 patients (median age: 33±13.8 years, male sex: 81.9%). Malignancy was diagnosed in 3.1% (8/254) of HIV-positive patients. Non-Hodgkin Lymphoma and Kaposi Sarcoma were the most common cancers. F-18 FDG PET/CT was performed in 3.5% (9/254) of patients, of which 2.76% (7/254) had findings suggestive of malignancy. As a result of the biopsy, malignancy was detected in five of these patients, and HIV-related lymphadenopathy was detected in two. In two patients, there were no F-18 FDGPET/CT imaging findings suggestive of malignancy. Conclusion: F-18 FDG PET/CT can be used in in the evaluation of HIV-infected patients with suspected malignancy.

The Burden of Recurrent Head and Neck Squamous Cell Carcinoma Across the United Kingdom: Results From a National Snapshot Study.

To investigate the management of recurrent head and neck squamous cell carcinoma (rHNSCC) and describe survival outcomes. Post hoc subgroup analysis of a retrospective national observational cohort was conducted. All patients with rHNSCC who received a definitive treatment decision between September 1, 2021 and November 30, 2021 were included. Survival analysis was stratified according to subsite, primary versus recurrent disease, and surgical versus nonsurgical treatment. Data from 202 rHNSCC patients were derived from a cohort of 1488 patients submitted by 50 UK centers. Median age was 66 years (IQR 58-74), and 142 (70.3%) were male. The most common recurrence subsites were oropharynx (20.5%), oral cavity (19.5%), larynx (16.4%), and hypopharynx (14.9%). Ninety-three (48.4%) were managed curatively. Surgery was the most common treatment for laryngeal (59.4%), oral cavity (60.5%), hypopharyngeal (44.8%), and oropharyngeal (37.5%) cancers. Two-year overall (OS), disease-free (DFS), disease-specific (DSS), and local recurrence free survival (LRFS) were 41.1%, 39.1%, 42.2%, and 39.3%, respectively. rHNSCC treated with surgery had improved OS (p = 0.0005), DFS (p = 0.012), DSS (p = 0.0003), and LRFS (p = 0.007), over nonsurgical treatments. Compared to primary cancers, rHNSCC presents with more advanced T stage (p < 0.001) and distant metastasis (p < 0.001), receives less curative treatment (p < 0.001), and has worse survival outcomes (all p < 0.001). On multivariate analysis, salvage surgery, radiotherapy, and p16 status were independent prognostic factors of all survival outcomes. Recurrent HNSCC is associated with highrates of incurable disease and worse survival than primary cancers. Surgery remains the most common curative treatment in rHNSCC, however future studies are necessary to improve patient selection and optimize outcomes following salvage treatment.

Securing DNS over HTTPS traffic: a real-time analysis tool

DNS over HTTPS (DoH) is a developing protocol that uses encryption to secure domain name system (DNS) queries within hypertext transfer protocol secure (HTTPS) connections, thereby improving privacy and security while browsing the web. This study involved the development of a live tool that captures and analyzes DoH traffic in order to classify it as either benign or malicious. We employed machine learning (ML) algorithms such as K-Nearest Neighbors (K-NN), random forest (RF), decision tree (DT), deep neural network (DNN), and support vector machine (SVM) to categorize the data. All of the algorithms, namely KNN, RF, and DT, achieved exceptional performance, with F1 scores of 1.0 or above for both precision and recall. The SVM and DNN both achieved exceptionally high scores, with only slight differences in accuracy. This tool employs a voting mechanism to arrive at a definitive classification decision. By integrating with the Mallory tool, it becomes possible to locally resolve DNS, which in turn allows for more accurate simulation of DoH queries. The evaluation results clearly indicate outstanding performance, confirming the tool's effectiveness in analyzing DoH traffic for network security and threat detection purposes.

Integrating geometallurgy in the simulation of processing plant responses and applying policy gradient for shovel allocation in operating mining complexes

ABSTRACT Several short-term planning activities of mining complexes must be addressed simultaneously, such as extraction sequence, equipment allocation, digline definition, and destination decisions. Regarding stochastic mine planning, geological attributes and equipment performance uncertainties are more commonly addressed. However, processing response attributes at the ore treatment facilities also have uncertain components. This paper proposes a high-order simulation of processing plant responses given the blended ore attributes. First, it is included in the grade-control digline approach and later applied to a policy gradient-based framework that allocates shovels. A case study at a gold mining complex illustrates the benefits of the proposed approach.

Reimagining and rebranding advance care planning.

Advance care planning (ACP) has traditionally aimed at ensuring that patients' end-of-life (EOL) wishes are understood and respected. However, recent literature raises concerns about its effectiveness, with many trials indicating that ACP does not significantly improve goal-concordant care, enhance quality of life or reduce healthcare costs. This is because patients' future decisions are influenced by their transient preferences due to projection bias. To remain relevant, ACP requires a radical shift in perspective, implementation and branding. First, ACP's mission must be redefined with a focus on: Educate, Share and Prepare. This perspective emphasises ongoing conversations about patient health and illness, sharing of patients' current values and goals of care and preparation for the future, rather than making definitive future decisions. Second, ACP should be integrated into routine care, normalising these discussions. Simplifying ACP processes and shifting incentives to support shared responsibility among stakeholders can enhance integration. Last, rebranding ACP as 'Advance Care Preparation' can clarify its purpose, distinguishing it from EOL planning and increasing its uptake. This rebranding ensures that ACP meets the evolving needs of patients and their families, ultimately enhancing the quality of care and patient satisfaction. These changes in perspective, implementation and branding can transform ACP into a valuable tool for delivering compassionate, patient-centred healthcare, making it relevant to all individuals.

Effects of Vermicompost and Blended NPSB Fertilizer on Major Physicochemical Properties of Soil and Economy of Maize Production at Bako, Central Ethiopia

Integrated vermicompost and blended NPSB inorganic fertilizer are needed to improve the soil&amp;apos;s fertility status, which can raise output and revenue. Thus, the purpose of the experiment was to ascertain how major physicochemical properties of the soil at Bako were affected by the application of blended NPSB fertilizer and vermicompost. Factorial combinations of four levels of vermicompost (0, 2, 4 and 6 tons ha&amp;lt;sup&amp;gt;-1&amp;lt;/sup&amp;gt;) and four levels of NPSB blended inorganic fertilizer (0, 50, 100 and 150 kg ha&amp;lt;sup&amp;gt;-1&amp;lt;/sup&amp;gt;) were laid out in Randomized Complete Block Design (RCBD) with three replications. The interaction of vermicompost and NPSB blended inorganic fertilizer had significant effects on ear diameter, grain yields, and harvest index and cob weight. The maximum grain yield (7503.7 kg ha&amp;lt;sup&amp;gt;-1&amp;lt;/sup&amp;gt;) was obtained from application of blended NPSB fertilizer at the rate of 100 kg NPSB ha&amp;lt;sup&amp;gt;-1&amp;lt;/sup&amp;gt; and 4 tons ha&amp;lt;sup&amp;gt;-1&amp;lt;/sup&amp;gt; vermicompost rate with a net profit of 104850 birr and 6143% MRR with values to cost ratio of 3.47 birr profit per unit investment for midland maize production at Bako. Therefore, it can be said that the application of 100 kg NPSB ha&amp;lt;sup&amp;gt;-1&amp;lt;/sup&amp;gt; and 4 t vermicompost ha&amp;lt;sup&amp;gt;-1&amp;lt;/sup&amp;gt; was shown to be superior in terms of both grain yield and economic advantage, and it is therefore tentatively advised for use. To come to a definitive decision, the experiment needs to be repeated across a number of years, as this study was only conducted during one season at one site.

Ongoing decision-making dilemma for treatment of de novo spinal infections: a comparison of the Spinal Infection Treatment Evaluation Score with the Spinal Instability Spondylodiscitis Score and Spine Instability Neoplastic Score.

De novo spinal infections are an increasing medical problem. The decision-making for surgical or nonsurgical treatment for de novo spinal infections is often a non-evidence-based process and commonly a case-by-case decision by single physicians. A scoring system based on the latest evidence might help improve the decision-making process compared with other purely radiology-based scoring systems or the judgment of a single senior physician. Patients older than 18 years with an infection of the spine who underwent nonsurgical or surgical treatment between 2019 and 2021 were identified. Clinical data for neurological status, pain, and existing comorbidities were gathered and transferred to an anonymous spreadsheet. Patients without an MR image and a CT scan of the affected spine region were excluded from the investigation. A multidisciplinary expert panel used the Spine Instability Neoplastic Score (SINS), Spinal Instability Spondylodiscitis Score (SISS), and Spinal Infection Treatment Evaluation Score (SITE Score), previously developed by the authors' group, on every clinical case. Each physician of the expert panel gave an individual treatment recommendation for surgical or nonsurgical treatment for each patient. Treatment recommendations formed the expert panel opinion, which was used to calculate predictive validities for each score. A total of 263 patients with spinal infections were identified. After the exclusion of doubled patients, patients without de novo infections, or those without CT and MRI scans, 123 patients remained for the investigation. Overall, 70.70% of patients were treated surgically and 29.30% were treated nonoperatively. Intraclass correlation coefficients (ICCs) for the SITE Score, SINS, and SISS were 0.94 (95% CI 0.91-0.95, p < 0.01), 0.65 (95% CI 0.91-0.83, p < 0.01), and 0.80 (95% CI 0.91-0.89, p < 0.01). In comparison with the expert panel decision, the SITE Score reached a sensitivity of 96.97% and a specificity of 81.90% for all included patients. For potentially unstable and unstable lesions, the SISS and the SINS yielded sensitivities of 84.42% and 64.07%, respectively, and specificities of 31.16% and 56.52%, respectively. The SITE Score showed higher overall sensitivity with 97.53% and a higher specificity for patients with epidural abscesses (75.00%) compared with potentially unstable and unstable lesions for the SINS and the SISS. The SITE Score showed a significantly higher agreement for the definitive treatment decision regarding the expert panel decision, compared with the decision by a single physician for patients with spondylodiscitis, discitis, or spinal osteomyelitis. The SITE Score shows high sensitivity and specificity regarding the treatment recommendation by a multidisciplinary expert panel. The SITE Score shows higher predictive validity compared with radiology-based scoring systems or a single physician and demonstrates a high validity for patients with epidural abscesses.

Admissibility of a Third Party to Raise Objections to a Tax Assessment Made by a Definite Tax Decision

Admissibility of a Third Party to Raise Objections to a Tax Assessment Made by a Definite Tax Decision

Analisis Penerapan Akuntansi Manajemen Terhadap Kinerja Keuangan Perusahaan

The aim of this research is to analyze the Application of Management Accounting to Company Financial Performance. This research uses qualitative research with a literature study research method. The research results show that the application of management accounting which includes finance, production and marketing will help each division manager start and make definite decisions. So the application of management accounting needs to be implemented on an ongoing basis with the aim of implementing maximum financial performance for each company. Focusing on financial performance, management accounting will provide precise information based on company data in financial reports and journals which will also be used as insight into non-financial performance. The usefulness of executive bookkeeping relies on the idea of ​​proper administration and bookkeeping, in introducing monetary data that is useful for the organization to carry out the most practical arrangement, supervision, direction and portion of assets, thus requiring good administration. The application of accounting management in a company found that to see financial performance it was necessary to measure financial conditions using data and information from the company's annual financial report each year.

Evaluation of carcinogenic risk of heavy metals due to consumption of rice in Southwestern Iran

Pollution by heavy metals is a serious global problem due to its toxicity, abiotic characteristics, abundant sources, and cumulative behavior. On the other hand, considering the importance of rice consumption as an important part of nutrition in Lordegan and Ahvaz cities, this study was conducted to evaluate the carcinogenic risk of heavy metals lead, cadmium, zinc, nickel and in local Champa rice cultivated in these two cities. 16 Champa rice samples were collected from the fields of Lordegan and Ahvaz cities. The elements were read in three replicates by Varian 710-ES atomic emission device. The results showed that the concentration of cadmium and nickel in the cultivated rice in the two studied cities was within the range of the national standard of Iran and the Codex standard. Carcinogenic risk values for lead, cadmium and nickel in Champa Lordegan and Ahvaz rice were within the safe range. Also, the non-carcinogenic risk for these heavy metals in the two studied areas was less than 1 and was in the safe range. Rice pollution in Champa in Ahvaz can be due to the industrial nature of this city, and in Lordegan, it is due to pollution through pesticides, chemical fertilizers, and transportation. Long-term consumption of contaminated rice may endanger the health of residents of these areas. It is recommended to carry out regular and up-to-date monitoring strategies in these two cities to prevent the entry of these toxic heavy metals into the human food chain. Also, more studies are needed to evaluate the complete scenario and make definitive decisions.

Accuracy and reproducibility of forensic tire examination decisions

Tire impression evidence can be a valuable tool during a crime scene investigation—it can link vehicles to scenes or secondary locations, and reveal information about the series of events surrounding a crime. The interpretation of tire impression evidence relies on the expertise of forensic tire examiners. To date, there have not been any studies published that empirically evaluate the accuracy and reproducibility of decisions made by tire impression examiners. This paper presents the results of a study in which 17 tire impression examiners and trainees conducted 238 comparisons on 77 distinct questioned impression-known tire comparison sets (QKsets). This study was conducted digitally and addressed examinations based solely upon the characteristics of the tire impression images provided. The quality and characteristics of the impressions were selected to be broadly representative of those encountered in casework. Participants reported their decisions using a multi-level conclusion scale: 68% of responses were class associations (Association of Class Characteristics or Limited Association of Class), 21% were definitive decisions (ID or Exclusion), 8% were probable decisions (High Degree of Association or Indications of Non-Association), and 3% were neutral responses (Not Suitable or Inconclusive). Although class associations were the most reported response type, when definitive decisions were reported, they were often correct: 96% of IDs and 89% of Exclusions were consistent with ground truth regarding the source of the known tire in the QKset. Overall, we observed 4 erroneous definitive decisions (3 Exclusions on mated QKsets; 1 ID on a nonmated QKset) and 1 incorrect probable decision (Indications of Non-Association on a mated QKset). Decision rates were notably associated with both quality (lower quality questioned impressions were more likely to result in class associations) and dimensionality (2D questioned impressions were more likely to result in definitive decisions), which were correlated factors. Although the study size limits the precision of the measured rates, the results of this study remain valuable to the forensic science and legal communities and provide empirical data regarding examiner performance for a discipline that previously did not have any such estimates.

Core needle biopsy: an efficacious adjunct to cytological diagnosis in thyroid tumours suspected of anaplastic carcinoma - single-centre experience.

Ultrasound-guided fine- needle aspiration biopsy (FNAB) remains the primary method for diagnosing thyroid nodules, providing adequate information for definitive diagnosis and treatment decisions in most cases. However, cytological examinations sometimes yield inconclusive or non-diagnostic results. For rapidly growing tumours with suspected malignancy, a swift and accurate diagnosis is crucial to initiate timely treatment. Cases suggestive of anaplastic thyroid cancer (ATC) or poorly differentiated cancer present unique challenges in obtaining satisfactory diagnostic material through FNAB, due to advanced necrosis or extensive inflammatory components. In these instances, core needle biopsy (CNB) emerges as a complementary diagnostic tool when FNAB results are ambiguous. This study aimed to evaluate the effectiveness of CNB in diagnosing rapidly growing thyroid tumours with clinical indication of ATC. Between 2019-2023, 31 CNBs were performed on large, rapidly expanding thyroid tumours. All cases exhibited clinical signs of malignancy, with previous FNAB outcomes being either equivocal or inconclusive. The subsequent CNBs demonstrated accurate results with minimal complications among the patients. While reservations about CNB for thyroid nodules persist, it offers a valuable diagnostic alternative, potentially preventing unwarranted surgical biopsy or removal of the thyroid. Core needle biopsy deployment should be judicious, reserved for select cases, and carried out in a hospital environment to ensure diagnostic precision with the least risk of complications.

The Inflammatory Characteristics of Symptomatic Glioma Associated With Poor Prognosis and Chemoresistance via Tumor Necrosis Factor Signaling Pathway.

Among gliomas, the most common primary malignant brain tumor, incidental gliomas account for 2.5%-5% of cases. The controversy over whether to pursue immediate treatment or adopt a wait-and-see approach remains, and more molecular and immunological evidence is needed for definitive treatment decisions. Total RNA sequencing (RNA-seq) data and single cell RNA sequencing (scRNA-seq) data were retrospectively analyzed to compare the molecular and immunological tumor microenvironment differences between incidental glioma and symptomatic glioma samples. These were classified using symptom data from The Cancer Genome Atlas (TCGA) and public dataset. RNA-seq analysis of the GBMLGG dataset identified 343 genes upregulated in symptomatic glioma and 118 in incidental glioma, with 104 common genes upregulated in symptomatic glioma across both the TCGA and Chinese Glioma Genome Atlas (CGGA) datasets. Enrichment analysis revealed that these 104 genes in symptomatic glioma were significantly associated with immunological pathways. scRNA-seq analysis of glioma revealed 11 cell types, including T cells, myeloid cells, and oligodendrocytes, with the tumor necrosis factor (TNF) signaling pathway strongly influencing other cell types, particularly myeloid cells. Enrichment and survival analyses showed that TNF signaling is associated with temozolomide resistance and poorer prognosis in glioma patients. The findings suggest that symptomatic glioma enhances inflammatory responses linked to poor prognosis and chemoresistance. This supports the hypothesis that immediate treatment of incidental glioma may improve patient outcomes over a wait-and-see approach.

Почему прошлое ирреально и что ирреального в прошлом: когнитивный аспект типологической взаимосвязи категорий ирреалиса и прошедшего времени глагола

The article deals with cross-linguistic patterns of past tense verb forms functioning under the category of irrealis. Approaching language as a means and process of understanding and organizing the world, we examine ways in which the irreal meaning of the past tense is grounded in human experience. Theory of language does not seem to offer a consistent explanation as to why the past is irreal or why irreality is construed in past tense verbs. With this in mind, the investigation of the preterit as an irrealis marker across languages builds on a cognitive interpretation of the contrastive analysis. In other words, typological regularities of the irreal past are explained in terms of embodied reasoning in which a human engages when interacting with the world and others. It is hypothesized that the meaning of past tense is rooted in the subject’s experience with perspectival alternatives arising with her abstractions from and reflections on interactions with things that are no longer in a perceptual field, which requires coordinations (interpretations) of varied perceptual vantage points and temporal perspectives under uncertainty. It follows that the past as a domain of mediated, secondary observations (“hindsight observations”) is conceptualized as a domain of hypothetical entities and actions on which the meaning of irreality builds. Research data is mainly represented by corpus-based examples from literary and spoken discourse of Russian, English, and Bulgarian. The cognitive analysis reveals that past-tense marking of irrealis is accounted for by the prevalently relational, inter-subjective semantics through which a discourse of the past is constructed and made sense of relative to displaced and displaceable reference points, aka other subjects’ perspectives. This semantic distinction helps understand the difference between grammatical forms and meanings that underlie such categories as subjunctive, palliative, desiderative, dubitative, apprehensive, and other irreal moods across languages. In particular, non-preterit markers of irrealis in English and Russian subjunctives are apparently linked to a more linear and/or egocentric reasoning about temporal changes, whereby reality is identified with the “inner moving force” or the subject’s interests and desires that she can hardly control (as in imperative mood, for example), that is why such grammatical expressions of irreality are usually more emotional, colloquial and logically basic. Preterit markers, by contrast, are embedded in a more participatory, dialogical discourse that involves engagement in open-ended meaning-making wherein no definitive answer, decision, or choice is required, but rather options for acting are left open (as in counterfactuals and optatives, for example). Therefore, such expressions of irreality are usually more polite and logically challenging.

Management of Grade IV Renal Graft Trauma Secondary to Oncological Surgery: A Case Report

Renal graft injury is a challenging condition that can endanger function or become a life-threatening event. Although the most common cause of renal graft injury is trauma, some cases of injuries associated with surgical procedures have been described. Here, we present a case of a transplant patient who experienced a grade IV renal graft injury after an open oophorectomy. A 31-year-old woman received a renal transplant from a cadaveric donor. During her follow-up, a multilocular cyst with a solid mural nodule tumor of the left ovary was documented, with an 84% risk for malignancy as determined by the International Ovarian Tumour Analysis score. Therefore, an open unilateral (left) oophorectomy was scheduled. The patient was readmitted 2 days after surgery and was hemodynamically stable despite intense pain in the right iliac fossa, sudden creatinine elevation, and hematuria. Tomography revealed a peri-graft hematoma with a mass effect. An exploratory laparotomy was performed, and 2 lacerations with an exposed collecting system and without urinary leakage were identified. These were repaired with absorbable barbed sutures reinforced with Teflon patches on the edges, with cellulose hemostatic mesh and fibrin adhesive on top of these patches. In the postoperative period, creatinine decreased to its baseline levels, but a urinary leak was noted, which was corrected by ureteral stent placement. The management of renal graft trauma requires closer monitoring and stricter criteria for reaching a definitive therapeutic decision to prevent the deterioration of the graft and the patient.

Intrinsic Factors Influencing Career Development among College Music Teachers in Establishment Stage from Fujian, China

In the career development, individuals show a stronger need on the professional advancement and are expected to make more definite career decisions in the establishment career stage. This study used semi-structure interview of qualitative study to investigate the intrinsic motivation influencing career development among three music teachers who were in the career stage of establishment from higher educational institutions in Fujian, China. The interview was modelled and the interview transcriptions were analysed and coded based on the theory of Maslow’s Hierarchy of Needs. The results indicated that higher education music teachers who sought for professional upgrading in the music industry in their establishment career stage will be intrinsically influenced by the needs of love and belonging in terms of the salient life roles (for example, son/daughter, spouse, and parent); the needs on esteem that boosting the career expectation toward receiving recognition from students, students’ parents, and music professionals; and the needs on self-actualization on music professionalism by enhancing music playing skills, mastering new music skills, and lifelong learning. The study offered a valuable knowledge to the field of music education, inform policy and practice, and ultimately empower music teachers to realize their full potential in nurturing the next generation of musicians and scholars.