Major Changes In Management Research Articles

Impact of 18F-FDG PET/MRI on Therapeutic Management of Women with Newly Diagnosed Breast Cancer: Results from a Prospective Double-Center Trial.

Our rationale was to investigate whether 18F-FDG PET/MRI in addition to (guideline-recommended) conventional staging leads to changes in therapeutic management in patients with newly diagnosed breast cancer and compare the diagnostic accuracy of 18F-FDG PET/MRI with that of conventional staging for determining the Union for International Cancer Control (UICC) stage. Methods: In this prospective, double-center study, 208 women with newly diagnosed, therapy-naïve invasive breast cancer were enrolled in accordance with the inclusion criteria. All patients underwent guideline-recommended conventional staging and whole-body 18F-FDG PET/MRI with a dedicated breast examination. A multidisciplinary tumor board served to determine 2 different therapy recommendations for each patient, one based on conventional staging alone and another based on combined assessment of conventional staging and 18F-FDG PET/MRI examinations. Major changes in therapy recommendations and differences between the conventional staging algorithm and 18F-FDG PET/MRI for determining the correct UICC stage were reported and evaluated. Results: Major changes in therapeutic management based on combined assessment of conventional staging and 18F-FDG PET/MRI were detected in 5 of 208 patients, amounting to changes in therapeutic management in 2.4% (95% CI, 0.78%-5.2%) of the study population. In determining the UICC stage, the guideline-based staging algorithm and 18F-FDG PET/MRI were concordant in 135 of 208 (64.9%; 95% CI, 58%-71.4%) patients. The conventional guideline algorithm correctly determined the UICC stage in 130 of 208 (62.5%; 95% CI, 55.5%-69.1%) patients, and 18F-FDG PET/MRI correctly determined the UICC stage in 170 of 208 (81.9%; 95% CI, 75.8%-86.7%) patients. Conclusion: Despite the diagnostic superiority of 18F-FDG PET/MRI over conventional staging in determining the correct UICC stage, the current (guideline-recommended) conventional staging algorithm is sufficient for adequate therapeutic management of patients with newly diagnosed breast cancer, and 18F-FDG PET/MRI does not have an impact on patient management.

Implementation of streamlining measures in selecting and prioritising complex cases for the cancer multidisciplinary team meeting: a mini review of the recent developments.

In January 2020, NHS England and NHS Improvement, in the United Kingdom, issued a permissive framework for streamlining cancer multidisciplinary (MDT) meetings. Streamlining is defined as a process whereby complex cases are prioritized for full discussion by an MDT in an MDT meeting (MDM), while the management of straightforward cases is expedited using Standards of Care (SoC). SoC are points in the pathway of patient management where there are recognized guidelines and clear clinical consensus on the options for management and should be regionally agreed and uniformly applied by regional Cancer Alliances. While this report marks the first major change in cancer MDT management since the Calman-Hine report in 1995, its implementation, nationally, has been slow with now nearly four years since its publication. It is argued however that streamlining is a necessary step in ensuring the viability of MDT processes, and therefore maintaining patient care in the current socioeconomic context of rising workload and cancer incidence, financial pressures, and workforce shortages. In this mini review, we offer a succinct summary of the recent developments around the implementation of the 2020 streamlining framework, including challenges and barriers to its implementation, and the potential future directions in this field, which we propose should increase utilisation of implementation science. We conclude that ensuring successful implementation of the framework and the SOC requires securing a buy-in from key stakeholders, including MDTs and hospital management teams, with clearly defined (a) management approaches that include triage (e.g. through a mini MDT meeting), (b) assessment of case complexity (something that directly feeds into the SOC), and (c) roles of the MDT lead and the members, while acknowledging that the SOC cannot be universally applied without the consideration of individual variations across teams and hospital Trusts.

Multi-center implementation of rapid whole genome sequencing provides additional evidence of its utility in the pediatric inpatient setting.

Multi-center implementation of rapid whole genome sequencing with assessment of the clinical utility of rapid whole genome sequencing (rWGS), including positive, negative and uncertain results, in admitted infants with a suspected genetic disease. rWGS tests were ordered at eight hospitals between November 2017 and April 2020. Investigators completed a survey of demographic data, Human Phenotype Ontology (HPO) terms, test results and impacts of results on clinical care. A total of 188 patients, on general hospital floors and intensive care unit (ICU) settings, underwent rWGS testing. Racial and ethnic characteristics of the tested infants were broadly representative of births in the country at large. 35% of infants received a diagnostic result in a median of 6 days. The most common HPO terms for tested infants indicated an abnormality of the nervous system, followed by the cardiovascular system, the digestive system, the respiratory system and the head and neck. Providers indicated a major change in clinical management because of rWGS for 32% of infants tested overall and 70% of those with a diagnostic result. Also, 7% of infants with a negative rWGS result and 23% with a variant of unknown significance (VUS) had a major change in management due to testing. Our study demonstrates that the implementation of rWGS is feasible across diverse institutions, and provides additional evidence to support the clinical utility of rWGS in a demographically representative sample of admitted infants and includes assessment of the clinical impact of uncertain rWGS results in addition to both positive and negative results.

АВТОМАТИЗАЦИЯ ВСЕХ ПРОЦЕССОВ УПРАВЛЕНИЯ ЧЕЛОВЕЧЕСКИМИ РЕСУРСАМИ КАК ОСНОВНОЙ ТРЕНД 2023 ГОДА

As a result of global changes, traditional approaches to HR management have become obsolete and there is now a trend towards full automation of HR processes. Paper-based and purely human factors in management have lost their relevance. In their place has come digitalization. Its relevance arose because of the need for flexible and rapid response to emerging issues in the course of business processes. This paper examines the major changes in human resource management using digital tools, their impact on workflow, recruitment and on onboarding, employee monitoring and maintaining the corporate climate in companies. Statistical data, charts and graphs have been used to support the theoretical aspects outlined by the authors of this paper.

RURAL POLICY OF THE PEOPLE'S REPUBLIC OF CHINA

The report examines rural development of the People's Republic of China and agricultural policy of the Communist Party of China in the second half of the 20th and early 21st centuries. After the end of World War II, the Chinese Communist Party largely secured its victory over the Kuomintang in the Civil War (1946-1949) thanks to the rural population of China, a predominantly agrarian country at the time. The reforms in the village envisage the implementation of an agrarian reform, expressed in the confiscation of land and means of production from the large landowners and wealthier peasants using hired labor and their distribution among the landless peasants. The first stage of the agrarian reform was carried out until 1952 and was related to the land acquisition of poor peasants. The second stage took place during the First Five-Year Plan (1953-1957) and was related to the collectivization of agriculture. In practice, the agrarian reform ends with the complete cancellation of private ownership of land. At the beginning of the period of the so-called "Great Leap Forward" (1958-1961), cooperatives were transformed into people's communes - basic public organizations in which agricultural and industrial production, trade, education, etc. was developed. After a short period of calm between 1962 and 1965, in May 1966 Mao Zedong launched the "Great Proletarian Cultural Revolution", whose vanguard were the student-run "Red Guard Squads", the so-called "Hóng Wèibīng". Undoubtedly, the impact of the Cultural Revolution (May 16, 1966 – October 6, 1976) on the PRC in social, political, cultural and economic aspects was very negative. The economy was hit particularly hard in 1967-1968. The death of Mao Zedong on September 9, 1976, the elimination of the far-left Gang of Four, the complete seizure of power by Hua Guofeng on October 7, 1976, and the rehabilitation of Deng Xiaoping, set the stage for major changes in the country's economic management. The beginning of economic reform is associated with the 3rd Plenary Session after the 11th Congress of the Central Committee of the Communist Party of China, held from December 18 to 22, 1978 in Beijing. The reforms start in the rural areas where 80% of China's population lived at that time and marked the beginning of the new path of building socialism with Chinese characteristics, initially reviving the family form of land management, and then developing channels for the sale of agricultural products, reviving rural enterprises related to the processing of raw materials from the rural economy. First coined by Deng Xiaoping in 1982, the concept of socialism with Chinese characteristics aims to redefine the relations between planning and socialism, and market economy and capitalism. It has preserved institutions of socialism and public ownership while importing sophisticated management experience and advanced market mechanisms from developed countries. The term "socialist market economy" was introduced in 1992 by Jiang Zemin.

Impact of 68Ga-FAPI PET/CT on Staging and Oncologic Management in a Cohort of 226 Patients with Various Cancers.

Since the development of fibroblast activation protein-targeted radiopharmaceuticals, 68Ga-fibroblast activation protein inhibitor (FAPI) PET/CT has been found to be suitable for detecting primary and metastatic lesions in many types of tumors. However, there is currently a lack of reliable data regarding the clinical impact of this family of probes. To address this gap, the present study aimed to analyze the clinical impact of 68Ga-FAPI PET/CT by examining a large cohort of patients with various tumors. Methods: In total, 226 patients (137 male and 89 female) were included in this retrospective analysis. Pancreatic cancer and head and neck cancers were the most common tumor types in this cohort. TNM stage and oncologic management were initially determined with gold standard imaging, and these results were compared with 68Ga-FAPI PET/CT. Changes were classified as major and minor. Results: For 42% of all patients, TNM stage was changed by 68Ga-FAPI PET/CT results. Most of these changes resulted in upstaging. A change in clinical management occurred in 117 of 226 patients. Although a major change in management occurred in only 12% of patients, there was a significant improvement in the ability to accurately plan radiation therapy. In general, the highest clinical impact of 68Ga-FAPI PET/CT imaging was found in patients with lung cancer, pancreatic cancer, and head and neck tumors. Conclusion: 68Ga-FAPI PET/CT is a promising imaging probe that has a significant impact on TNM stage and clinical management. 68Ga-FAPI PET/CT promises to be a crucial new technology that will improve on conventional radiologic imaging methods such as contrast-enhanced CT and contrast-enhanced MRI typically acquired for cancer staging.

Is it all about the economy? To what extent did the Roman economy shape the morphology of livestock?

The main domesticated animals (pig, cattle, sheep and chicken) underwent some of the most prominent size increase and morphological changes in past husbandry practices during the Roman period. The phenomenon is now well described for many parts of the Roman Empire. Variability in the timing and intensity of changes have been highlighted between different regions. The purposes of rearing taller and more robust animals have also been extensively discussed with a strong bias in favour of economic explanations. This paper aims to further investigate the drivers of cattle morphological evolution by combining both bioarchaeological evidence and written sources. A comparative approach between several areas of the Roman Empire will be conducted to take into account the environmental, economic, cultural, and religious factors behind these major changes in animal management. In particular, this paper will address the question not yet investigated of the impact of the ritual practices on the dynamics of morphological changes in livestock. By adopting a similar holistic approach to this phenomenon in different regions of the Roman Empire, this paper also aims to clarify the respective roles of regional and supra-regional drivers in the animal economy.

Chest CT in COVID-19 patients: A clinical need.

The COVID-19 pandemic caused by the coronavirus SARS-CoV-2 has resulted in a global healthcare crisis. The provision of computed tomography (CT) imaging services by radiology departments for COVID-19 patients poses multiple challenges. Consequently, it is important to explore the clinical need and indications for thoracic CT and whether they subsequently alter patient management. We report our experience in this single-centre retrospective cohort study of all confirmed COVID-19 cases admitted during the peak of the 'Delta' variant wave in Australia, and who underwent a chest CT. Clinical indication and patient management plan pre- and post-CT were ascertained. A total of 92 out of 1403 patients who were admitted with COVID-19 underwent a thoracic CT (73 CT pulmonary angiogram (CTPA), 14 CT Chest and five high-resolution CT (HRCT) studies). 72.8% of studies were to evaluate for pulmonary emboli, 16.2% for assessment of COVID-19 pneumonia complications, 5.4% for tuberculosis and 6.5% for other indications. 21 (23%) of these studies resulted in a change in management with two patients having a major change in management (thrombolysis, CT-guided aspiration). Management was altered due to diagnosis of pulmonary embolism (PE), pneumonia, cryptogenic organising pneumonia and other reasons. Of 73 CTPA studies, 11 (15%) patients had evidence of PE. In our centre, thoracic CT in COVID-19 patients were predominantly for the evaluation of PE with other indications being for COVID-19 complications and other cardiopulmonary pathologies. 23% of studies subsequently altered patient management, suggesting there is good clinical need for CT chests for these indications.

Expert Opinion on Practice Patterns in Mild Asthma After the GINA 2019 Updates: A Major Shift in Treatment Paradigms from a Long-Standing SABA-Only Approach to a Risk Reduction-Based Strategy with the Use of Symptom-Driven (As-Needed) Low-Dose ICS/LABA.

This expert opinion, prepared by a panel of chest disease specialists, aims to review the current knowledge on practice patterns in real-life management of mild asthma and to address the relevant updates in asthma treatment by The Global Initiative for Asthma (GINA) to guide clinicians for the best clinical practice in applying these new treatment paradigms. On the basis of the emerging body of evidence suggesting the non-safety of short-acting β2-agonists (SABA)-only therapy and comparable efficacy of the as-needed inhaled corticosteroids (ICS)-formoterol combinations with maintenance ICS regimens, GINA recently released their updated Global Strategy for Asthma Management and Prevention Guide (2019). The new GINA 2019 recommendations no longer support the SABA-only therapy in mild asthma but instead includes new off-label recommendations such as symptom-driven (as-needed) low-dose ICS-formoterol and "low dose ICS taken whenever SABA is taken." The GINA 2019 asthma treatment recommendations include a major shift from long-standing approach of clinical practice regarding the use of symptom-driven SABA treatment alone in the management of mild asthma. This expert opinion supports the transition from a long-standing SABA-only approach to a risk reduction-based strategy, with the use of symptom-driven (as-needed) low-dose ICS/LABA in mild asthma patients, particularly in those with poor adherence to controller medications. The thoughtful and comprehensive approach of clinicians to these strategies is important, given that the exact far-reaching impact of this major change in management of mild asthma in the real-world settings will only be clarified over time.

Clinical impact of PSMA PET in patients with biochemically recurrent prostate cancer after locoregional definitive therapy.

e17009 Background: [68Ga]-PSMA-11 positron emission tomography (PSMA PET) detects sites of biochemically recurrent prostate cancer (BCR) at higher rates than conventional imaging. We hypothesized that PSMA PET would lead to high change in management (CIM) rates in this setting. Methods: We prospectively recruited patients (pts) with BCR, defined as confirmed PSA > 0.2 ng/mL > 6 weeks post-surgery or PSA ≥2 ng/mL above nadir post-radiation therapy, to undergo Ga-68 PSMA-11 PET. Some also had equivocal lesions on CT, MRI, bone scan, or fluciclovine PET obtained prior to PSMA PET. Pre-PET intended treatment, PSA (ng/mL), and PSA doubling time (PSAdt, months) from most recent 3 values were recorded prior to imaging. Post-PET treatment (intended or actual) was collected from medical record. CIM was categorized as major (change in or addition of treatment modality) vs minor (change within treatment modality, such as altered radiation field). Any lesion with uptake above blood pool was interpreted as positive for prostate cancer by an experienced PET reader (DLC). All values were represented as the median [interquartile range, IQR]. Kruskal Wallis analysis tested for significant differences among groups. Results: 44 pts with BCR age 71 [10] with Gleason scores (GS) at diagnosis of 6 (N = 2), 7 (N = 23), 8 (N = 5), and 9 (N = 13) enrolled, 14/44 with equivocal lesions on conventional imaging. 42 had post-PSMA PET treatment decisions available in medical records for CIM analysis. Time from PSA nadir to PSA at time of PSMA PET was 5 [7.25] months. PSMA PET was positive in 33 (8/33 with equivocal lesions on prior imaging; 7 local disease only; 11 regional nodal metastases, 2/11 also with local disease; and 15 with distant metastases, 4/15 also with local disease, 9/15 with regional nodal metastases), negative in 6, and equivocal in 5 pts. Of those with distant metastases, 8 had oligometastases, defined as 3 or fewer distinct sites (1 site = single nodal region or single bone lesion), 4 in bones and 4 in distant nodes. CIM rate was 71% (30/42) overall, 65.5% (16/29 major, 3/29 minor) in pts with BCR and negative conventional imaging; 84.6% (11/13, all major) in pts with equivocal lesions on conventional imaging. Of the patients with major CIM, a treatment modality was added in 21/27, modality switched in 3/27, and a modality removed in 3/27. PSA was significantly lower (p = 0.04) for those with negative or equivocal PSMA PET (0.5 [2.7]) than those with localized disease (4.1 [2.8]), regional nodal (1.1 [3.4]) or distant metastases (3.8 [5.3]), but not PSAdt (p = 0.2, negative/equivocal PET 5 [6.5], localized 15 [36], regional nodal metastases 11 [13], distant metastases 6 [6]). Conclusions: PSMA PET may impact decision making in pts with BCR after treatment of localized prostate cancer, particularly for those with equivocal findings on conventional imaging, regardless of clinical risk at diagnosis. Clinical trial information: NCT04777071.

Chronic Lymphocytic Leukemia Progression Diagnosis with Intrinsic Cellular Patterns via Unsupervised Clustering.

Simple SummaryDistinguishing between chronic lymphocytic leukemia (CLL), accelerated CLL (aCLL), and full-blown transformation to diffuse large B-cell lymphoma (Richter transformation; RT) has significant clinical implications. Identifying cellular phenotypes via unsupervised clustering provides the most robust analytic performance in analyzing digitized pathology slides. This study serves as a proof of concept that using an unsupervised machine learning scheme can enhance diagnostic accuracy. Identifying the progression of chronic lymphocytic leukemia (CLL) to accelerated CLL (aCLL) or transformation to diffuse large B-cell lymphoma (Richter transformation; RT) has significant clinical implications as it prompts a major change in patient management. However, the differentiation between these disease phases may be challenging in routine practice. Unsupervised learning has gained increased attention because of its substantial potential in data intrinsic pattern discovery. Here, we demonstrate that cellular feature engineering, identifying cellular phenotypes via unsupervised clustering, provides the most robust analytic performance in analyzing digitized pathology slides (accuracy = 0.925, AUC = 0.978) when compared to alternative approaches, such as mixed features, supervised features, unsupervised/mixed/supervised feature fusion and selection, as well as patch-based convolutional neural network (CNN) feature extraction. We further validate the reproducibility and robustness of unsupervised feature extraction via stability and repeated splitting analysis, supporting its utility as a diagnostic aid in identifying CLL patients with histologic evidence of disease progression. The outcome of this study serves as proof of principle using an unsupervised machine learning scheme to enhance the diagnostic accuracy of the heterogeneous histology patterns that pathologists might not easily see.

Role of 68Ga and 18F PSMA PET/CT and PET/MRI in biochemical recurrence of prostate cancer: a systematic review of prospective studies.

To systematically review the prospective literature on the role of 68Ga and 18F PSMA PET/CT and PET/MRI as a tool for functional imaging in prostate cancer biochemical recurrence (BCR), particularly with respect to detection efficacy and impact on management. We performed a systematic literature search using PubMed in July 2021, focusing on original prospective studies looking at PSMA PET/CT and PET/MRI in BCR. We included 20 prospective studies reporting on 68Ga and 18F PSMA PET/CT and PET/MRI. Pooled PSMA PET positivity was 66.6% out of 2110 patients. The only factor consistently reported as associated with PSMA PET positivity was PSA level at the time of the study. Analysis of PSMA PET positivity rates in differing PSA ranges confirmed increasing positivity with increasing PSA levels. No significant adverse reactions were reported in the 20 studies, but only 6 studies mentioned safety or adverse reactions. A major change of management occurred in 42.7% of all patients scanned with PSMA PET/CT and more specifically 63.2% of those patients positive on PSMA PET/CT. There are no long-term studies that prove a survival benefit from these changes in management. There is prospective evidence for efficacy of PSMA PET/CT and PET/MRI in localizing disease recurrence in BCR, which increases with increasing PSA level at the time of scanning. There are no reported significant adverse effects related to the PSMA PET ligands. There is evidence of major change in management but no evidence for whether this achieves any improvement in outcome.

Impact of COVID-19 on routine malaria indicators in rural Uganda: an interrupted time series analysis

BackgroundIn March 2020, the government of Uganda implemented a strict lockdown policy in response to the COVID-19 pandemic. Interrupted time series analysis (ITSA) was performed to assess whether major changes in outpatient attendance, malaria burden, and case management occurred after the onset of the COVID-19 epidemic in rural Uganda.MethodsIndividual level data from all outpatient visits collected from April 2017 to March 2021 at 17 facilities were analysed. Outcomes included total outpatient visits, malaria cases, non-malarial visits, proportion of patients with suspected malaria, proportion of patients tested using rapid diagnostic tests (RDTs), and proportion of malaria cases prescribed artemether-lumefantrine (AL). Poisson regression with generalized estimating equations and fractional regression was used to model count and proportion outcomes, respectively. Pre-COVID trends (April 2017-March 2020) were used to predict the’expected’ trend in the absence of COVID-19 introduction. Effects of COVID-19 were estimated over two six-month COVID-19 time periods (April 2020-September 2020 and October 2020–March 2021) by dividing observed values by expected values, and expressed as ratios.ResultsA total of 1,442,737 outpatient visits were recorded. Malaria was suspected in 55.3% of visits and 98.8% of these had a malaria diagnostic test performed. ITSA showed no differences between observed and expected total outpatient visits, malaria cases, non-malarial visits, or proportion of visits with suspected malaria after COVID-19 onset. However, in the second six months of the COVID-19 time period, there was a smaller mean proportion of patients tested with RDTs compared to expected (relative prevalence ratio (RPR) = 0.87, CI (0.78–0.97)) and a smaller mean proportion of malaria cases prescribed AL (RPR = 0.94, CI (0.90–0.99)).ConclusionsIn the first year after the COVID-19 pandemic arrived in Uganda, there were no major effects on malaria disease burden and indicators of case management at these 17 rural health facilities, except for a modest decrease in the proportion of RDTs used for malaria diagnosis and the mean proportion of malaria cases prescribed AL in the second half of the COVID-19 pandemic year. Continued surveillance will be essential to monitor for changes in trends in malaria indicators so that Uganda can quickly and flexibly respond to challenges imposed by COVID-19.

PATH-47. THE 2016 WHO CLASSIFICATION AND IT'S CLINICAL IMPACT: THE LEEDS TEACHING HOSPITALS NHS TRUST EXPERIENCE

Abstract INTRODUCTION In 2016 the WHO Classification of Tumours of the Central Nervous System was updated to include molecular testing, in addition to the previous standard histological methods; producing a final integrated diagnosis. Although molecular information can guide treatment and aid in prognostication, it adds a significant workload to pathology and genetic testing services. Delayed diagnosis can also add anxiety to patients, at an already traumatic time. AIMS: To determine if final integrated diagnoses, for patients undergoing neurosurgery for CNS tumours, is being provided in an appropriate time frame, and whether it changes clinical management. METHODS All patients >16 years at the time of surgery with a histopathologically-confirmed CNS tumour were identified from 2016-2020. A retrospective analysis of the time taken to produce an integrated histological diagnosis took place, using the date of surgery and date of verified final integrated report being the first and last data points respectively. Data were collected by accessing electronic and paper health records, and local databases. Changes in clinical management between the initial histology result and the final integrated diagnosis were classified as no change or a major change. RESULTS 1390 surgical procedures for CNS pathology were identified between 2016-2020, producing 361 final integrated diagnosis reports. 64 (18%) of these reports resulted in a major change in clinical management when compared to the initial histology report. The turn-around time for initial histology from date of surgery was a mean of 9 days and a mean of 34 days for the final integrated diagnosis. CONCLUSIONS The integrated diagnosis is essential for providing the gold standard of treatment for patients, although for the majority of patients it does not change their clinical management. Further study and discussion is required about the role of the final integrated diagnosis in the management of patients with CNS tumours.

ANALYSIS OF THE IVF LABORATORY KEY PERFORMANCE INDICATORS (KPIs) IN IVF PATIENTS WITH DIFFERENT OVULATION TRIGGER REGIMENS

There are few published studies that report on the practical application and utility of IVF laboratory KPIs in identifying performance shifts in response to changes in laboratory processes. There are even fewer reports on the potential effects of major changes in patient clinical management upon laboratory quality indicators.The aim of this study is to collect and analyze our IVF laboratory KPIs based on the two newly adopted ovulation trigger regimens during controlled ovarian hyper-stimulation treatment.

Sacrum magnetic resonance imaging for low back and tail bone pain: A quality initiative to evaluate and improve imaging utility.

As quality and cost effectiveness become essential in clinical practice, an evidence-based evaluation of the utility of imaging orders becomes an important consideration for radiology’s value in patient care. We report an institutional quality improvement project including a retrospective review of utility of sacrum magnetic resonance (MR) imaging for low back pain at our institution over a four-year period and follow-up results after physician education intervention. Sacral MR imaging for low back pain and tailbone pain were only positive for major findings in 2/98 (2%) cases, and no major changes in patient management related to imaging findings occurred over this period, resulting in almost $500000 cost without significant patient benefit. We distributed these results to the Family Medicine department and clinics that frequently placed this order. An approximately 83% drop in ordering rate occurred over the ensuing 3 mo follow-up period. Sacrum MR imaging for low back pain and tail bone pain has not been a cost-effective diagnostic tool at our institution. Physician education was a useful tool in reducing overutilization of this study, with a remarkable drop in such studies after sharing these findings with primary care physicians at the institution. In conclusion, sacrum MR imaging rarely elucidates the cause of low back/tail pain diagnosed in a primary care setting and is even less likely to result in major changes in management. The practice can be adopted in other institutions for the benefit of their patients and improve cost efficiency.

SQL Versus NoSQL Databases to Assess Their Appropriateness for Big Data Application

Background: Nowadays, the digital world is rising rapidly and becoming very difficult in nature's quantity, diversity, and speed. Recently, there have been two major changes in data management, which are NoSQL databases and Big Data Analytics. While evolving with the diverse reasons, their independent growths balance each other and their convergence would greatly benefit organization to make decisions on-time with the amount of multifaceted data sets that might be semi structured, structured, and unstructured. Though several software solutions have come out to support Big Data analytics on the one hand, on the other hand, there have been several packages of NoSQL database available in the market. Aim and Methods: The main goal of this article is to give comprehension of their perspective and a complete study to associate the future of the emerging several important NoSQL data models. Results: Evaluating NoSQL databases for Big Data analytics with traditional SQL performance shows that NoSQL database is a superior alternative for industry condition need high-performance analytics, adaptability, simplicity, and distributed large data scalability. Conclusion: In this article we conclude with the adoption of NoSQL in various markets.

Groundwater resource exploration & development – Focus on groundwater to support surface water supply in the Lower Olifants River, South Africa

Many South-African towns in the Western Cape Province are dependent on surface water resources to satisfy the ever-increasing water demand. In recent years, the effects of climate change on the environment has challenged these areas continually and recently led to calls for major changes in water management. The Lower Olifants River Water Management Area experienced an extreme drought that persisted from 2016 to 2018, which led to the need for development of groundwater resources. The local economy of the Lower Olifants River is dependent on water releases from the Clanwilliam and Bulshoek Dams, located within the Olifants River Syncline (ORS), where ‘megafault’ zones form preferred flowpaths for groundwater in the Table Mountain Group (TMG) aquifers. The Lower Olifants River Water User Association (LORWUA) was mandated to proceed with the exploration and development of these aquifers to supplement the existing water use of the LORWUA. This will be available during periods of less rainfall and therefore increase the security of the water supplied. The groundwater project aimed at exploring and developing the fractured rock aquifers of the Peninsula (Op) and Skurweberg (Ss) Formations contained within the TMG. Through a high-level desktop assessment, remote sensing investigations and geophysical ground surveys, several target areas and drilling priorities were identified to obtain high borehole yields that access the resource in proximity to existing surface infrastructure. The projected water need from the groundwater resource was 8.6 million cubic metres per annum (Mm3/a). Faults/structure zones were the main hydrogeological targets, with drill target depths of structures planned for intersection deeper than 100 m below ground level (mbgl). Down-hole camera work and initial aquifer testing concluded that deep geological contact zones are prone to collapse when flow is induced in water-bearing fractures. This indicated the need for production borehole construction, even prior to aquifer testing for yield estimates. A major concern still to be resolved is the availability of water in storage and the realistic expectations of the well field over time. Although individual borehole testing provided information on the properties of specific water-bearing structures, long-term monitoring will provide a better understanding of the aquifer in response to abstraction and recovery in times of rest. The operating rules for the conjunctive use of the well field developed, with the existing surface water scheme, is still to be defined and modelled for optimisation, pending long-term monitoring.

Traitement chirurgical et interventionnel de l’obstruction sous-vésicale liée à une hyperplasie bénigne de prostate : revue systématique de la littérature et recommandations de bonne pratique clinique du Comité des Troubles Mictionnels de l’Homme

The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO). All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions. Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm3, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm3. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm3. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm3 without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols. Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Philosophical analysis of theory x and y

Objective: The historical context management can be examined, such as the Pyramids of Egypt management, control and communication practices in the ancient Roman Empire and the legal framework of trade in the fourteenth century Venice followed. Methodology: Nevertheless, Iranians, Chinese, German and some other relatives insights and attitudes of the past have chosen in this area, but major changes in management during the Industrial Revolution came expecting. The world in the seventeenth century, the era of social upheaval when the thirteen American colonies broke away from Britain and the United States formed the crucial transformations spent. In this period of rapid population growth created fairs and supply of consumer goods. Results: The It was during this period that extends mass production methods Adam Smith (based on the division of labor and specialization in the pin factory) industry took a big turn in such a way that its effects are still seen in how often business organizations be. For example, Henry Ford in the early twentieth century by mass production in automotive manufacturing were achieved legendary success. Conclusion: Although this effect is limited to the amount of released McGregor at the time of his life, but he still is important. His classic study on the topic and motivated work, reflecting his main concern in the mid and late 1960s, when the one-dimensional organizations were at the peak. Public criticism of the theory of X and Y is that they are very exclusive.