Definitive Plan Research Articles

The interplay between crystallinity and the levels of Zn and carbonate in synthetic microcalcifications directs thyroid cell malignancy.

One of the key challenges in diagnosing thyroid cancer lies in the substantial percentage of indeterminate diagnoses of thyroid nodules that have undergone ultrasound-guided fine-needle aspiration (FNA) biopsy for cytological evaluation. This delays the definitive diagnosis and treatment plans. We recently demonstrated that hydroxyapatite microcalcifications (MCs) aspirated from thyroid nodules may aid nodule diagnosis based on their composition. In particular, Zn-enriched MCs have emerged as potential cancer biomarkers. However, a pertinent question remains: is the elevated Zn content within MCs a consequence of cancer, or do the Zn-enriched MCs encourage tumorigenesis? To address this, we treated the human thyroid cancer cell line MDA-T32 with synthetic MC analogs comprising hydroxyapatite crystals with varied pathologically relevant Zn fractions and assessed the cellular response. The MC analogs exhibited an irregular surface morphology similar to FNA MCs observed in cancerous thyroid nodules. These MC analogs displayed an inverse relationship between Zn fraction and crystallinity, as shown by X-ray diffractometry. The zeta potential of the non-Zn-bearing hydroxyapatite crystals was negative, which decreased once Zn was incorporated into the crystal. The MC analogs were not cytotoxic. The cellular response to exposure to these crystals was evaluated in terms of cell migration, proliferation, the tendency of the cells to form multicellular spheroids, and the expression of cancer markers. Our findings suggest that, if thyroid MCs play a role in promoting cancerous behavior in vivo, it is likely a result of the interplay of crystallinity with Zn and carbonate fractions in MCs.

Orthodontic treatment of an open bite after splint therapy for a patient with idiopathic condylar resorption

In the treatment of orthodontic patients with idiopathic condylar resorption, symptoms of temporomandibular joint disorders and constantly changing occlusions caused by an instability of mandibular position make it difficult for orthodontists to confirm definitive orthodontic diagnosis and treatment plans. Therefore, these patients' temporomandibular joint (TMJ) structures need to be stabilized with splint therapy before active tooth movement to identify and maintain the true mandibular position. For some idiopathic condylar resorption patients, orthognathic surgery can cause further resorption on the vulnerable condyles of the mandible; thus, effective orthodontic camouflage treatment after joint stabilization should be considered. During the orthodontic camouflage treatment, adverse loads on the TMJ structures, which could change the position of condyles, should be avoided, and TMJ-friendly mechanics must be applied.

α-Fetoprotein, α-Fetoprotein-L3, and Des-γ-Carboxy Prothrombin Stratify Hepatocellular Carcinoma Treatment Response and Progression Risk

Background & AimsAssessing aggressive biology at early-stage HCC diagnosis remains challenging. Alpha-fetoprotein (AFP) is the only clinical biomarker of aggressive HCC. In this study, AFP, Lens culinaris agglutinin-reactive AFP (AFP-L3), and des-γ-carboxy prothrombin (DCP) were measured at diagnosis prior to transplant evaluation and first cycle liver-directed therapy (LDT). MethodsThe prospective cohort included 207 patients who received LDT as a bridge/downstage to transplant or definitive treatment plan between 2016 and 2022. Plasma AFP, AFP-L3, and DCP levels were measured at diagnosis and analyzed with other factors associated with treatment response and time-to-progression (TTP). ResultsBiomarker phenotyping revealed 41% were triple negative, 30% expressed multiple biomarkers, and 12% express all three biomarkers. The biomarker profile was associated with target/overall response rate and TTP (P < 0.001). Profiling stratified 1-year progression risk in non-transplant candidates, driven by co-expression of AFP and DCP in multivariate analysis controlling for tumor burden and staging. ConclusionThe biomarker panel at diagnosis established prognosis for LDT response and stratified 1-year HCC progression risk. AFP, AFP-L3, and DCP profiling isolated aggressive HCC biology at diagnosis and may have important implications in post-LDT surveillance and transplant wait time.

Standardization of Artistic Gymnastic SkillTest on Salto Backward Stretched Dismount for Sub Junior Girls

The purpose of this study was to standardization of artistic gymnastic skill test on salto backward stretched dismount for sub junior girls. A sample size or design is a definite plan for determining before any data is actually collected for obtaining a sample from a given population. The subjects of this study was girls Gymnastic players who represented minimum state level or 3 year game age (as per certified by coach) with the help of purposive sampling. The age group of the subjects were below 14 years only. To construct the gymnastic skills test battery’s face validity was formulated by the researcher. A researcher taken different kinds of gymnastic skills from the FIG rulebook. After that we sent the skills to 13 experts for rating through likert scale. Then the experts rated &amp; gave suggestions. When we finalized the skill by looking at the ratings. Highly rated skill had been considered for skill test battery. It is concluded that the gymnastic skill test ultimately could retain better skill item among the various skill items, which can successfully measure the gymnastic skill ability of the sub-junior gymnastic players with acceptable face validity, highly reliability and objectivity.

FRI226 Ectopic Cushing’s Syndrome Of Unknown Primary Origin With Etomidate Use

Abstract Disclosure: C. Ohammah: None. J. Lloyd: None. T. Abdulwahid: None. R. Tangri: None. C. Musgrove: None. K. Selk: None. Background: Ectopic Cushing's syndrome (ECS) is rare and requires adrenolytic agents to control hypercortisolism until a definitive plan can be made to treat the underlying cause. We present a case of ECS of unknown primary origin causing immunosuppression due to the hypercortisolism that responded with etomidate infusion. Case: A 61-year-old male who presented to the hospital after a few weeks of increasing weakness, dyspnea, and hemoptysis. In the months prior to his admission, he was found to have persistent hypokalemia, COVID pneumonia, and new onset diabetes mellitus. On admission, his examination was remarkable for proximal hip flexor weakness. Labs were significant for metabolic alkalosis, hyperglycemia (A1c 7.7%) and persistent hypokalemia requiring about 300 mEq of potassium daily. CT chest, abdomen and pelvis was remarkable for aspiration pneumonia, vertebral compression fracture, and bilateral adrenal enlargement. Blood cultures grew Staphylococcus Aureus (MSSA) (suspected lung source) and Candida albicans. Treatment with vancomycin and caspofungin was initiated and narrowed to cefazolin after speciation. His MSSA cleared rapidly however, fungemia was persistent after 1.5 weeks of treatment. MRI brain was unremarkable for causative lesion. Further testing revealed elevated morning cortisol (136.2ug/dL) confirmed on repeated testing and elevated ACTH (653pg/mL). Serum metanephrines were normal. A high-dose dexamethasone suppression was unremarkable. In the following days, he developed respiratory failure secondary to a spontaneous hemothorax requiring intubation and ICU admission. He was started on an etomidate infusion given abnormal liver enzymes and unavailability of metyrapone. The infusion was titrated every 6 hours based on cortisol levels. His liver enzymes improved and ketoconazole was added but later discontinued due to development of thrombocytopenia. His cortisol level decreased (21.5ug/dL) and fungemia cleared. Arrangement for bilateral adrenalectomy was made but the patient decompensated and developed shock requiring pressors. After a goals of care discussion, he was transitioned to comfort measures and eventually passed. Conclusion: ECS is rare, and the diagnosis is challenging and often delayed. Ectopic ACTH can result from various malignancies. Medical management with adrenolytic agents should be considered early in the management of ECS until a definitive plan is made. Etomidate, ketoconazole, metyrapone, and mitotane can be used to treat hypercortisolism to achieve medical adrenalectomy. Bilateral adrenalectomy should be considered in patients without adequate response to adrenolytic agents. This case describes the severity of hypercortisolism from an ectopic ACTH production causing refractory hypokalemia and immunosuppression resulting in fatal infections. We highlight the use of etomidate to control hypercortisolism. Presentation: Friday, June 16, 2023

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.

Farmer card as an instrument for fertilizer direct subsidy on Lombok Island, Indonesia

Like other direct subsidies using subsidy cards, direct fertilizer subsidies using farmer cards are believed to be a mechanism for providing subsidies that are more appropriate for target farmers. However, before this policy is widely implemented, it is necessary to carry out a trial phase for its implementation. The trial was carried out in Sekarbela District, Mataram City with the consideration of the availability of relatively complete data on subsidy recipient farmers accompanied by a National Identity Number (NIK). The trial results indicated that the farmers receiving the subsidy were generally young (48-50 years old), had more than 20 years of farming experience, and most of them controlled land of less than 0.5 hectares with ownership, lease or cultivation status. However, most of the farmers (88%) have only elementary school education but are active in preparing the Group Needs Definitive Plan (RDKK). The results of the analysis conclude that the probability of using a Farmer’s Card to obtain subsidized fertilizer is smaller for tenant farmers compared to owning or cultivating farmers. In addition, farmers with a higher level of education have a greater probability of using the farmer’s card as a means of obtaining subsidized fertilizer.

Segmental Stabilization of Multilevel Noncontiguous Spinal Fracture

Abstract A multilevel noncontiguous spinal fracture (MNSF) is defined as a spinal injury at two or more levels separated by single or multiple normal vertebrae. We report a case of MNSF having D6, D11, and D12 fractures with AIS-ASIA B. The patient underwent segmented posterior stabilization from D5 to L1 along with decompression at D11. Secondary or tertiary lesions are always overlooked during preliminary physical examination and investigations. Early diagnosis of these lesions and definitive planning before surgery will prevent complication-related lesions or hardware.

Quantifying Value in an Iterative Disease-Site Specific Peer Review System

To assess the greatest impact of peer review on treatment planning and plan modification in two disease-site specific peer review groups to improve quality assurance workflow. We implemented an iterative peer review checklist tool and treatment planning registry to document recommendations and time spent in breast and thoracic disease-site specific peer review. Plan review included discussion of the clinical scenario, radiation dose/fractionation, prescription, organs at risk and target volumes, planning metrics including dose volume histogram and patient setup. Pre-treatment (Pre-tx) review of volumes and plans occurred prior to treatment start for definitive plans of ≤five fractions or using protons, and cases were re-reviewed in subsequent sessions to complete checklist items as needed. Reviews were graded as follows: discussion (no required changes), minor recommendations (changes recommended at attending discretion) and major recommendations (changes required). Students t-test and chi-squared analysis were used to identify statistical significance. We identified 723 peer reviews over a 3-month period: 275 thoracic reviews of 195 unique patients (32% reviewed ≥twice), and 448 breast reviews of 273 unique patients (48% reviewed ≥twice, most commonly for a boost plan). On average, pre-tx review doubled the amount of time spent per case, (4:47min versus 2:03min, p<0.01) and resulted in significantly more discussion (29.3% vs 9.3%, p<0.01), minor changes recommended (13.2% versus 4.8%, p<0.01) and plan revision (19.2% versus 2.4%, p<0.01). Thoracic pre-tx reviews were twice as long as breast (5:43min versus 3:00min, p<0.01), and had a greater proportion of cases prompting discussion (26.7% vs 13.2%, p<0.01) and minor changes recommended (12.8% vs 6.3%, p<0.01). No time difference was found in regular review (2:19min vs 1:58 min, p = 0.09). The most frequent discussion/recommendation topics also varied by group with planning metrics in thoracic cases (14.9%) and setup imaging including PORT films and electron setup (5.1%) in breast (Table). Iterative plan review with pre-review for selected cases encouraged educational discussion and plan revision, with notable variability by disease site. Thoracic cases required longer review time and had more frequent plan change recommendations likely reflecting differences in case complexity. In contrast, setup imaging in breast cases, which are more commonly 3D or electron-based, more frequently warranted discussion/revision and should be considered within the peer review paradigm.

Nutritional Management in the Compromised Gut: Short Bowel Syndrome, Enterocutaneous Fistula, and Stoma

Nutrition in patients with a compromised gut is a challenge requiring a multidisciplinary management and necessitates individualized nutritional planning. Intestinal failure is defined as significant deficit in gut absorption of micro and macronutrients such that intravenous supplementation is necessary to sustain life. If absorption is inadequate, however intravenous supplementation is not required, it is called intestinal insufficiency. Short bowel syndrome and entero cutaneous fistula are the most common conditions leading to intestinal insufficiency and failure. These conditions in the initial phase may lead to significant loss of fluids and electrolytes and require multidisciplinary team management. Definite plan for restoration of adequately functioning bowel after stabilization of patient is important. Based on evidences, recommendations for nutritional management in such patients were thoroughly discussed and approved by the Gastrointestinal nutrition core committee of the Indian Association of Parenteral and enteral nutrition (IAPEN). Keywords: Short bowel syndrome, Enterocutaneous fistula, Nutrition

Improvements in networking processes for hip or knee revision arthroplasty: a silver lining of the COVID-19 pandemic.

Improvements in outcomes following hip and knee revision arthroplasties have been demonstrated following the introduction of specialised orthopaedic services in the form of 'hub and spoke' networking models. In light of the COVID-19 pandemic, these networks have undergone some inevitable adaptations. We investigated the impact of recent adaptations on the performance of our regional revision arthroplasty network. A retrospective review of all referrals that were discussed at our regional revision arthroplasty meeting, over 2 separate phases, was undertaken. Phase 1 included data between March 2018 and April 2019, representing an interval prior to COVID-19 pandemic. Phase-2 included data between September 2020 and March 2021 (during COVID-19 pandemic). Data were collected from East Midland South Orthopaedic Network (EMSSON) database and included data relating to indication and time to revision surgery, surgeon's proposal plan, network proposal plan, and executed definitive plan. We compared and analysed network performance between 2 phases. In phase 1, 99 cases were discussed in EMSSON meetings, equating to 35.7% of the region's revision arthroplasty volume, according to the National Joint Registry (NJR) records. Plan alterations were recommended in 48/99 cases (48.5%), of which 41/48 (85.4%) were adhered to. Phase 2 included 98 discussed cases, equating to 81.6% of the region's revision arthroplasty volume. Plan alterations were recommended in 20/98 cases (20.4%), all of which were adhered to (100%). Adherence to recommended adaptations showed significant improvement (p < 0.03). Based upon our observations, a greater volume and proportion of revision arthroplasty cases are now being discussed. Adherence to MDT recommendations has significantly improved following the described adaptations. The number of recommended adaptations to management plans have decreased, indicating an educational value of the network.Overall, these findings demonstrate a trend towards NHS England's target of 100% of revision arthroplasty cases undergoing MDT discussion.

The Influence of Field Agricultural Extension (PPL) Development on The Dynamics of Farmer Groups

The role of agricultural extension workers is needed to improve the abilities, knowledge and skills of each member of the farmer group so that the goals of the farmer group can be achieved properly. An extension worker in fostering farmer groups in an effort to increase production and productivity by helping to develop definitive group plans (RDK) and (RDKK). In addition, in terms of fostering farmer groups, extension workers implement the Training and Visit (LAKU) work system. The purpose of this study is to determine the influence of agricultural extension workers in assisting the preparation of DRC and RDKK; knowing the development of agricultural extension workers in the Training and Visit Work System (LAKU); knowing the influence of agricultural extension worker development in assisting the preparation of RDK RDKK and agricultural extension worker development in the Training and Visit Work System (LAKU) on the Dynamics of Farmer Groups in the Farmer Fortune Association, Sukagumiwang Village, Sukagumiwang District, Indramayu Regency. This research was conducted in Sukagumiwang Village, Sukagumiwang District, Indramayu Regency. The research was carried out in October-December 2022. The respondents in this study were Farmer Groups in the Farmer Fortune Association (GAPOKTAN) as many as 89 people. The design used in this study was quantitative descriptive. Data analysis techniques in this study use descriptive analysis and multiple linear regression analysis, f-Test, t-Test and coefficient of determination. The results showed that the development of agricultural extension workers in assisting the preparation of RDK RDKK and the training and visit work system (LAKU) had a real effect on the Dynamics of Farmer Groups in the Farmer Fortune Association. The development of agricultural extension workers in assisting the preparation of RDK RDKK with the development of agricultural extension workers in the Training and Visit Work System has a real effect together on the Dynamics of Farmer Groups in the Farmer Fortune Association.

Molecular testing raises thyroid nodule fine needle aspiration diagnostic value.

Thyroid fine needle aspiration biopsy (FNAB) remains indeterminate in 16%-24% of the cases. Molecular testing could improve the diagnostic accuracy of FNAB. This study examined the gene mutation profile of patients with thyroid nodules and analyzed the diagnostic ability of molecular testing for thyroid nodules using a self-developed 18-gene test. Between January 2019 and August 2021, 513 samples (414 FNABs and 99 formalin-fixed paraffin-embedded (FFPE) specimens) underwent molecular testing at Ruijin Hospital. Sensitivity (Sen), specificity (Spe), positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated. There were 457 mutations in 428 samples. The rates of BRAF, RAS, TERT promoter, RET/PTC, and NTRK3 fusion mutations were 73.3% (n=335), 9.6% (n=44), 2.8% (n=13), 4.8% (n=22), and 0.4% (n=2), respectively. The diagnostic ability of cytology and molecular testing were evaluated in Bethesda II and V-VI samples. For cytology alone, Sen, Spe, PPV, NPV, and accuracy were 100%, 25.0%, 97.4%, 100%, and 97.4%; these numbers were 87.5%, 50.0%, 98.0%, 12.5%, and 86.2% when considering positive mutation, and 87.5%, 75.0%, 99.0%, 17.6%, and 87.1% when considering positive cytology or and positive mutation. In Bethesda III-IV nodules, when relying solely on the presence of pathogenic mutations for diagnosis, Sen, Spe, PPV, NPV, and AC were 76.2%, 66.7%, 94.1%, 26.8%, and 75.0%, respectively. It might be necessary to analyze the molecular mechanisms of disease development at the genetic level to predict patients with malignant nodules more accurately in different risk strata and develop rational treatment strategies and definite management plans.

The Added Diagnostic Value of Transcatheter CT Hepatic Arteriography for Intraprocedural Detection of Previously Unknown Colorectal Liver Metastases During Percutaneous Ablation and Impact on the Definitive Treatment Plan

PurposeThis study assessed the diagnostic value of CT hepatic arteriography (CTHA) for the intraprocedural detection of previously unknown colorectal liver metastases (CRLM) and the impact on the definitive treatment plan.Materials and MethodsAll patients treated with CTHA-guided percutaneous ablation for CRLM between January 2012 and March 2022 were identified from the Amsterdam Colorectal Liver Met Registry (AmCORE). Radiology reports of the ablative procedure and follow-up imaging were reviewed to see if (a) previously unknown CRLM were detected intra-procedurally and if (b) new CRLM, potentially missed on CTHA, appeared within 6 months following the procedure; three abdominal radiologists re-reviewed the baseline CTHA scans of these patients with early recurrence. To ratify immediate ablations of concomitantly detected CRLM, the upper limit of false positives was predefined at 10%.ResultsOne hundred and fifty-two patients were included. With CTHA, a total of 17 additional tumours in 15 patients were diagnosed and treated immediately, two representing disappeared tumours following systemic chemotherapy. Compared to the conventional contrast-enhanced (ce)CT, ceMRI and 18F-FDG PET-CT, adding CTHA was superior for the detection of CRLM (P < .001). Within 12 months of follow-up 121, new CRLM appeared in 49/152 patients (32.2%); retrospective blinded assessment revealed 56 to already be visible on the baseline CTHA scan (46%); four lesions without substrate on follow-up scans were considered false positives (n = 4/60; 7%). Arterial ring enhancement was the most frequently reported imaging characteristic (n = 45/60; 75%).ConclusionThe subsequent use of CTHA has added value for the detection of previously unknown and vanished CRLM. Taking into account the low number of false positives (7%) and the favourable safety profile of percutaneous ablation, we believe that immediate ablation of typical ring-enhancing supplementary tumours is justified and sufficiently validated.Level of EvidenceLevel 3; individual cross-sectional study with consistently applied reference standard and blinding.

Indian data on response of positive pelvic lymph nodes in carcinoma cervix patients treated with simultaneous integrated boost using volumetric modulated arc radiation therapy

Objectives The percentage of pelvic lymph node positivity in cervical cancer patients varies from 19% in early stages to 68% in advanced cases. Thirty three percent of patients will develop recurrence within 2 years following therapy and 5-year relative survival for patients with affected regional lymph nodes is 57%. Hence, pelvic lymph nodes need to be included in the definitive plan of radiation treatment for better disease control and longer survival. With conventional radiation therapy, dose escalation was not possible because of small bowel constraints. With higher conformity of intensity modulated radiotherapy technique (IMRT), doses to pelvic and abdominal organs can be minimized. The added advantage of simultaneous integrated boost (SIB) is that high dose per fraction is delivered to the gross disease and low dose to the microscopic disease, thereby reducing the total treatment time and improving the therapeutic ratio. Material and Methods Forty one patients presenting to the Department of Radiation Oncology, between January 2016 and June 2017, with newly biopsy proven carcinoma cervix Stage IB to IVA were enrolled in the study and all the investigations were performed. The radiation dose was delivered using volumetric modulated arc therapy plan to a dose of 5000 cGy in 25 fractions to the whole pelvis and 5500 cGy in 25 fractions at 220 cGy per fraction to the involved nodes using SIB along with weekly cisplatin at 40 mg/m2. After completion of external beam radiation, all the patients received three fractions of brachytherapy to a total dose of 21 Gy. Acute toxicities were assessed using RTOG criteria. At 3 months after completion of treatment, all the patients had been followed up with DW MRI of abdomen and pelvis to assess the response. Results Of the 41 carcinoma cervix patients with significantly positive lymph nodes treated with SIB VMAT, 9.8% of the patients (4 patients) had residual nodal disease, 87.8% of the patients (36 patients) had complete response, 19.5% (8 patients) had residual disease of primary disease, and 78% (32 patients) had complete response at 3 months after completion of treatment with only Grade – I and Grade – II toxicities. Conclusion Treatment with SIB VMAT in carcinoma cervix patients with significant pelvic lymph nodes shows very good response with acceptable acute toxicities. But longer follow-up period is required to see if this response translates into better DFS and OS.

Kinerja Kelembagaan Terhadap Distribusi Pupuk Bersubsidi (Studi Kasus pada Gapoktan Sepakat di Desa Pattinoang Kecamatan Galesong Kabupaten Takalar)

Gapoktan as a socio-economic organization aims to increase economies of scale and business efficiency. The Gapoktan institution in Pattinoang Village is one of the most important parts in managing the formulation of the distribution of subsidized fertilizers. However, the process of distributing subsidized fertilizers must be initiated by the proposed fertilizer needs of the farmers as outlined in the RDKK (Definitive Plan for Group Needs). The sampling technique used is purposive sampling. The results showed that (1) The institutional performance of the Association of Farmer Groups (Gapoktan) agreed on the distribution of subsidized fertilizers in Pattinoang Village, Galesong District, Takalar Regency, in the high category with an average of 81.8. of 3 variables based on the quantity of subsidized fertilizer, service quality and timeliness of distribution. (2) The distribution pattern of subsidized fertilizer in Pattinoang village on time according to the concept of the Definitive Plan for Group Needs (RDKK) is not implemented properly and its implementation has not been implemented in accordance with the guidelines for implementing subsidized fertilizer subsidies from the government.

Outcomes of Transarterial Embolisation (TAE) vs. Transarterial Chemoembolisation (TACE) for Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis.

Although hepatocellular carcinoma is increasingly common, debate exists surrounding the management of patients with unresectable disease comparing transarterial embolisation (TAE) or transarterial chemoembolisation (TACE). This study aimed to compare the outcomes of patients receiving TAE and TACE. A systematic review was performed using PubMed, Medline, Embase, and Cochrane databases to identify randomised controlled trials (RCTs) until August 2021. The primary outcome was overall survival (OS) and the secondary outcomes were progression-free survival (PFS) and adverse events. Five studies with 609 patients were included in the analysis. There was no statistically significant difference in the OS (p = 0.36) and PFS (p = 0.81). There was no difference in OS among patients treated with a single TACE/TAE versus repeat treatments. Post-procedural adverse effects were higher in the TACE group but were not statistically significant. TACE has comparable long-term survival and complications profile to TAE for patients with HCC. However, the low-to-moderate quality of current RCTs warrants high-quality RCTs are necessary to provide enough evidence to give a definitive answer and inform treatment plans for the future.

Influence Of Relationship Marketing On Customers’ Loyalty Among Solar Power Consumers In Ekiti State, Nigeria

The study investigated the effect of Customers Relationship Marketing on Customers’ Loyalty among Solar Power Consumers in Ekiti State, Nigeria. The study employed simple linear regression. The research findings revealed that customer loyalty is being explained by customer relationship marketing dimensions (commitment, trust and Customers’ complaint handling) to the tune of 60%, 68% and 91% respectively. The null hypotheses that relationship marketing components do not significantly affect customers’ loyalty were tested and rejected, their P-Values having been found significant at 0.05 level of significance. Thus, the alternative hypotheses were upheld. The study therefore recommends that solar power firms need to maintain a definite strategic plan to maintain customers’ trust, commitment and company’s customers’ complaint handling system as well as to show more care and concern when relating to their customers as all these give the consumers a sense of assurance and honor as revealed by the study.

Against All Odds

Against All Odds

Critical care nurses’ experiences of caring for patients with iatrogenic opioid withdrawal in the intensive care unit: A qualitative study

ObjectivesTo explore critical care nurses’ experiences of caring for adult patients experiencing iatrogenic opioid withdrawal in the intensive care unit. Research methodology/designA qualitative study with an explorative and descriptive design was conducted. Data were collected through semi-structured interviews and systematic text condensation was used to analyse the data. The study was reported according to the consolidated criteria for reporting qualitative research checklist. Setting and participantsTen critical care nurses, working at three different intensive care units in two university hospitals in Norway. FindingsThree categories were identified in the data analysis. “Subtle signs and symptoms of opioid withdrawal”, lack of a systematic approach to opioid withdrawal, and the prerequisites for appropriate management of opioid withdrawal. Critical care nurses experienced challenges in identifying opioid withdrawal due to subtle and vague signs and symptoms, especially when not knowing their patient or when difficulties were encountered with patient communication. A systematic approach to opioid withdrawal and increased knowledge, definitive plans for weaning, as well as interdisciplinary unity and collaboration, could improve the management of opioid withdrawal. ConclusionValidated assessment tools, systematic strategies, and guidelines are essential for the management of opioid withdrawal in opioid naïve patients in intensive care units. The prerequisites for an appropriate management of opioid withdrawal are an accurate and effective communication among critical care nurses and other healthcare professionals involved in patient care. Implications for clinical practiceThere is a need for a validated assessment tool, systematic strategies, and guidelines for the management of opioid withdrawal in opioid naïve patients in intensive care units. Increased emphasis needs to be placed on the process of identifying iatrogenic opioid withdrawal and improving opioid withdrawal management in the education system and clinical practice.