Major Criteria Research Articles

P-47 Rare case of acromegaly due to plurihormonal pituitary adenoma and ACTH-independent Cushing syndrome

Abstract Introduction The concurrence of acromegaly and Cushing syndrome is infrequent. Pituitary adenomas are responsible for acromegaly and for Cushing syndrome in about 95% and 80% of cases respectively. Except adrenal adenoma, the other causes of Cushing syndrome remain rare. We here describe a case of a Tunisian patient with acromegaly due to plurihormonal pituitary adenoma and ACTH-independent Cushing syndrome with bilateral macronodules. Clinical Case A 35-year-old male patient was diagnosed with acromegaly by acrofacial dysmorphia. He had a family history of type 2 diabetes mellitus and hypertension but no endocrine diseases. He has diabetes mellitus for 15 years, hypertension and obstructive sleep apnea. Physical examination showed multiple blue nevi in the trunk. IGF-1 was elevated (1680ng/mL) and GH levels were not suppressed after an oral glucose load (nadir 78ng/mL). He had hypogonadotropic hypogonadism with normal prolactin (9,66ng/mL). Basal cortisol, FT4 and TSH levels were in the normal ranges. Pituitary MRI showed pituitary macroadenoma of 25×20.7 mm, invading both cavernous sinuses and compression of optic chiasma. He underwent transsphenoidal resection with histology confirming a prolactin, GH and LH co-secretory pituitary adenoma. He received postoperatively somatostatin analogue and cabergoline, in addition to external radiotherapy. Ultrasonography found infracentimetric EU-TIRADS 2 left nodule and multiple colloid cysts of the thyroid, testicles microlithiasis and no cardiac myxomas. Nine years after the diagnosis of acromegaly, bilateral adrenal adenomas (left:14 mm, right: 9 mm) were incidentally discovered by CT-scan done for abdominal pain. Low dose dexamethasone suppression test was carried out showing no suppression of cortisol and the low ACTH level confirmed ACTH-independent Cushing syndrome. Conclusion In our patient, at least two endocrine syndromes deserve to be mentioned. The first syndrome is Multiple Endocrine Neoplasia Type 1 but calcium and PTH levels were normal and there was no sign for neuroendocrine tumors. The second one is Carney's complex since our patient has acromegaly and multiple blue nevi which are two major criteria confirming the diagnosis. Cushing syndrome in Carney's complex is related to primary pigmented nodular adrenal disease characterized by micronodular hyperplasia. However, bilateral macronodules could be found in up to 30% of cases.

Economic analysis of hybrid solar-wind power system for application in Heipang community

Economic feasibility is one of the major criteria for selecting energy options for application in any location. One of the main drawbacks of renewable energy technology is its initial cost of investment which results in high energy tariffs making it unaffordable for low-income earners. The cost of renewable energy depends on many factors such as the potential of the renewable resources of the site and government policies on renewable energy technology. This paper aimed to determine the annualized cost of a designed hybrid solar-wind power system for the Heipang community to meet a load demand of 158.3kW and the sensitivity analysis of bank loan interest rate, inflation rate, day of autonomy, depth of battery discharge, and wind turbine rated velocity on the investment payback time. The cost of the components of the designed system was obtained from vendors and a techno-economic analysis was done using MATLAB software. Results show that the annualized cost of the hybrid solar-wind power system is ₦ 52,268,266.97, with battery, solar, and wind power systems taking 85%, 8%, and 7% of the total annualized cost respectively, and Levelized cost of energy ₦ 154.53/kWh. The analysis further shows that for ₦ 185.00, N 160.00, and ₦ 127.00 per kWh cost of energy at a 19% inflation rate and 20% bank interest rate, the investment payback times are 8.3, 9.5 and 11.9 years respectively, and 9.8, 11.4 and 14.3 years respectively. Information from this work may help policy-makers and would-be investors make informed decisions on renewable energy technology investment.

Comparison of Discriminative Ability of Bleeding Risk Criteria and Scores for Predicting Short- and Mid-Term Major Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention.

Background: This study aimed to compare the discriminative ability of the Japanese Version of High Bleeding Risk (J-HBR), Academic Research Consortium for High Bleeding Risk (ARC-HBR), and Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) scores for predicting major bleeding events. Methods and Results: Between January 2017 and December 2020, 646 consecutive patients who underwent successful percutaneous coronary intervention (PCI) were enrolled. We scored the ARC-HBR and J-HBR criteria by assigning 1 point to each major criterion and 0.5 point to each minor criterion. The primary outcome was major bleeding events, defined as Bleeding Academic Research Consortium type 3 or 5 bleeding events. According to the J-HBR, ARC-HBR, and PRECISE-DAPT scores, 428 (66.3%), 319 (49.4%), and 282 (43.7%) patients respectively had a high bleeding risk. During the follow-up period (median, 974 days), 44 patients experienced major bleeding events. The area under the curve (AUC) using the time-dependent receiver operating characteristic curve for major bleeding events was 0.84, 0.82, and 0.83 within 30 days and 0.86, 0.83, and 0.80 within 2 years for the J-HBR, ARC-HBR, and PRECISE-DAPT scores, respectively. The AUC values did not differ significantly among the 3 bleeding risk scores. Conclusions: The J-HBR score had a discriminative ability similar to the ARC-HBR and PRECISE-DAPT scores for predicting short- and mid-term major bleeding events.

The impact of concomitant infective endocarditis in patients with spondylodiscitis and isolated spinal epidural empyema and the diagnostic accuracy of the modified duke criteria.

The co-occurrence of infective endocarditis (IE) and primary spinal infections (PSI) like spondylodiscitis (SD) and isolated spinal epidural empyema (ISEE) has been reported in up to 30% of cases and represents a life-threatening infection that requires multidisciplinary management to be successful. Therefore, we aimed to characterize the clinical phenotypes of PSI patients with concomitant IE and furthermore to assess the accuracy of the modified Duke criteria in this specific population. We conducted a retrospective cohort study in consecutive SD and ISEE patients treated surgically at our University Spine Center between 2002 and 2022 who have undergone detailed phenotyping comprising demographic, clinical, imaging, laboratory, and microbiologic assessment. Comparisons were performed between PSI patients with IE (PSICIE) and without IE (PSIWIE) to identify essential differences. Methicillin-susceptible Staphylococcus aureus (MSSA) was the most common causative pathogen in PSICIE group (13 patients, 54.2%) and aortic valve IE was the most common type of IE (12 patients, 50%), followed by mitral valve IE (5 patients, 20.8%). Hepatic cirrhosis (p < 0.011; OR: 4.383; 95% CI: 1.405-13.671), septic embolism (p < 0.005; OR: 4.387; 95% CI: 1.555-12.380), and infection with Streptococcus spp. and Enterococcus spp. (p < 0.003; OR: 13.830; 95% CI: 2.454-77.929) were identified as significant independent risk factors for the co-occurrence of IE and PSI in our cohort. The modified Duke criteria demonstrated a sensitivity of 100% and a specificity of 66.7% for the detection of IE in PSI patients. Pathogens were detected more frequently via blood cultures in the PSICIE group than in the PSIWIE group (PSICIE: 23, 95.8% vs. PSIWIE: 88, 62.4%, p < 0.001). Hepatic cirrhosis (PSICIE: 10, 41.7% vs. PSIWIE: 33, 21.6%, p = 0.042), pleural abscess (PSICIE: 9, 37.5% vs. PSIWIE: 25, 16.3%, p = 0.024), sepsis (PSICIE: 20, 83.3% vs. PSIWIE: 67, 43.8%, p < 0.001), septic embolism (PSICIE: 16/23, 69.6% vs. PSIWIE: 37/134, 27. 6%, p < 0.001) and meningism (PSICIE: 8/23, 34.8% vs. PSIWIE: 21/152, 13.8%, p = 0.030) occurred more frequently in PSICIE than in PSIWIE patients. PSICIE patients received longer intravenous antibiotic therapy (PSICIE: 6 [4-7] w vs. PSIWIE: 4 [2.5-6] w, p < 0.001) and prolonged total antibiotic therapy overall (PSICIE: 11 [7.75-12] w vs. PSIWIE: 8 [6-12] w, p = 0.014). PSICIE patients spent more time in the hospital than PSIWIE (PSICIE: 43.5 [33.5-53.5] days vs. PSIWIE: 31 [22-44] days, p = 0.003). We report distinct clinical, radiological, and microbiological phenotypes in PSICIE and PSIWIE patients and further demonstrate the diagnostic accuracy of the modified Duke criteria in patients with PSI and concomitant IE. In the high-risk population of PSI patients, the modified Duke criteria might benefit from amending pleural abscess, meningism, and sepsis as minor criteria and hepatic cirrhosis as major criterion.

Effectiveness of Schema Therapy versus Cognitive Behavioral Therapy versus Supportive Therapy for Depression in Inpatient and Day Clinic Settings: A Randomized Clinical Trial

Introduction: Schema therapy (ST) reduces depressive symptoms, but clinical trials have not investigated its effectiveness for patients suffering from severe forms of depression and high rates of comorbidities. There is high demand for exploring and improving treatments for this patient group. The objective of the current study was to evaluate whether ST is more effective than individual supportive therapy (IST) and noninferior compared with cognitive behavioral therapy (CBT) in treating depression. Methods: For this clinical trial, medicated patients were recruited in inpatient and day clinic settings. The major inclusion criteria were age between 18 and 75 years and primary diagnosis of depression without psychotic symptoms. A total of 292 participants were randomized to ST, CBT, or IST and received 7 weeks of psychotherapy (up to 14 individual and 14 group sessions). The primary outcome was change in depression severity after treatment measured by Beck Depression Inventory-II. Primary test for efficacy was superiority of ST over IST. Secondary test was noninferiority of ST compared with CBT. Multilevel modeling was conducted. The results at 6-month follow-up were explored. Results: Across treatment, ST was not superior to IST. Secondary outcome analyses and completer analyses showed similar results. However, ST showed clinically relevant noninferiority compared with CBT. Conclusion: ST for depression as part of a psychiatric care program showed clinical noninferiority compared to CBT, without being superior to IST. ST represents a potentially useful addition to the therapeutic repertoire for the treatment of depression but its efficacy, including long-term efficacy, should be evaluated further.

Case series of infantile systemic hyalinosis: Suggested diagnostic criterion

Background: Infantile systemic hyalinosis (ISH) is a rare autosomal recessive disease which happens within the first weeks of life. It is present in Saudi Arabia due to positive parental consanguinity. A suggestive diagnostic criterion was proposed which would be helpful in determining ISH. Case Presentation: Seven children were diagnosed with infantile systemic hyalinosis based on clinical pictures and histopathological examination. A prospective consecutive and observational study was designed to determine the diagnostic criteria of ISH. On clinical examination, all patients had joints contractures which lead to frog like position, hyperpigmentation overlying the distal joints, in addition to failure to thrive. Only five patients of seven (71.42%) had erythematous papules coalesce to form plaque on the posterior neck. Out of seven, four patients (57.14%) had nodules (perianal &amp; subcutaneous), and gingival hypertrophy. Three patients of seven (42.85%) had intractable diarrhea. And just one patient (14.28%) had small pearly skin papules on the face. Hyaline deposits were evident in histopathological examination of the skin biopsies for all the patients. Although, severity index and genetic study was unavailable Conclusion: Infantile systemic hyalinosis is a congenital disease characterized by excessive hyaline deposits. Diagnostic criterion was evaluated for the seven patients as three major criteria and five minor criteria. It was suggested that the presence of all three major criteria or two major and two minor criteria is essential for the diagnosis of infantile systemic hyalinosis. The diagnostic criterion would help in the early evaluation of the disease prognosis and would enhance early intervention.

Preoperative joint line obliquity, a newly identified factor for overcorrection, can be incorporated into a novel preoperative planning method to optimise alignment in high tibial osteotomy.

The aim of this study was to analyse the factors associated with additional postoperative alignment changes after accurate bony correction by selecting only patients with well-performed bony correction as planned and developa method of incorporating significant factors into preoperative planning. Among 104 consecutive patients who underwent medial open wedge high tibial osteotomy (MOWHTO) between October 2019 and July 2022, 61 with well-performed bony corrections were retrospectively reviewed. The major criterion for well-performed bony correction was a difference of <1° between the simulated medial proximal tibial angle (MPTA) and the actual postoperative MPTA as measured in three dimensions. Radiographic parameters, such as the joint line convergence angle (JLCA) and joint line obliquity (JLO), were measured preoperatively and postoperatively, utilising standing and supine whole lower extremity anteroposterior, valgusand varus stress radiographs. Multiple linear regression analysis identified the factors affecting alignment changes, and a prediction model was developed. A method for applying this prediction model to preoperative planning was proposed. Preoperative JLCA on standing (preJLCAstd ), preoperative JLCA on 0° valgus stress radiograph (vgJLCA0 ), and preoperative JLO (preJLO) were significantly correlated with JLCA change (∆JLCA) (p < 0.001, p < 0.001, p = 0.006). The prediction model was estimated as ∆JLCA = 0.493 × (vgJLCA0 ) - 0.727 × (preJLCAstd ) + 0.189 × (preJLO) - 1.587 in. (R = 0.815, modified R2 = 0.646, p < 0.001). The proposed method resulted in a reduced overcorrection rate (p = 0.003) and an improved proportion of acceptable alignments (p = 0.013). PreJLCAstd , vgJLCA0 and preJLO can be used to estimate ∆JLCA. PreJLO was recently identified as a significant factor associated with additional alignment changes. Utilising the proposed preoperative planning and a prediction model with these factors shows promise in calibrating postoperative alignment after MOWHTO. Level III, retrospective cohort study.

Utilization of Triphala by Ayurvedic physicians for management of obesity: a cross-sectional study

Obesity is a metabolic condition observed due to multiple causes. The current treatment modalities necessitate the need of safe and effective pharmacotherapy. Ayurvedic texts have recommended various anti-obesity drugs and formulations for obesity, of which Triphala is a top cited formulation. In the present study, documentation of Triphala utilization by Ayurvedic physicians was carried out. A survey was carried out in 86 Ayurvedic physicians from Pune city. They were asked for frequency of Triphala usage, its dose, dosage form, beneficial and adverse effects using a pre-designed questionnaire. Of 86 respondents, data from only 70 physicians was analyzable. Triphala was used by 66 physicians for obesity. The commonly used form was churna in a dose of 3-7 gm. Ayurvedic signs and symptoms formed major criteria for dose selection followed by conventional anthropometry. Our study revealed that Ayurvedic physicians commonly prescribe Triphala to their obese patients owing to its efficacy and safety.

Seroprevalence of Toxoplasma gondii in wild boars (Sus scrofa) hunted in Ukraine

Toxoplasma gondii is an important zoonotic parasite worldwide, but it has received limited attention in Ukraine. A seroepidemiological study was conducted and samples from 452 wild boars that had been hunted in 2006–2011 in 23 of the 25 regions of Ukraine were tested to estimate T. gondii seroprevalence. A locally available commercial enzyme-linked immunosorbent assay (ELISA) was used for the investigation. Additionally, we tested 92 of the sera using a widely used commercial multi-species ELISA and an indirect immunofluorescence antibody test (IFAT). With the locally available ELISA, 35 of the 452 wild boars tested positive, yielding a seroprevalence estimate of 7.7% (95% confidence interval 5.5–10.5). The seropositive wild boars originated from eight of the regions. Using the majority criteria, 10/92 samples tested using both ELISAs and the IFAT were considered positive, yielding an estimated seroprevalence of 10.9% within the subset of samples. The highest seroprevalence was observed in wild boars hunted in Luhans'k (30.0%), Odesa (17.7%) and Kharkiv (12.7%). Seroprevalence was higher in older animals (13.3% for age group >12 months and 7.7% for age group ≤12 months). This is the first seroepidemiological study of T. gondii in wild boars in Ukraine. Assuming that seropositivity indicates presence of infectious parasites in the tissues, eating undercooked meat of wild boars hunted in Ukraine could be a potential source of infection to other hosts, including humans.

Incremental Diagnostic Value of Right Ventricular Strain Analysis in Arrhythmogenic Right Ventricular Cardiomyopathy.

Strain analysis is a sensitive method for the assessment of ventricular structural or functional alterations. The authors aimed to determine whether right ventricular (RV) strain parameters can discriminate patients with revised Task Force Criteria-diagnosed arrhythmogenic RV cardiomyopathy (ARVC) incremental to the existing cardiovascular magnetic resonance (CMR) criteria, thus improving the diagnostic yield of CMR in ARVC. A total of 74 patients with revised Task Force Criteria-diagnosed ARVC (37 borderline and 37 definite) and 37 controls were retrospectively enrolled for analysis. Using CMR feature tracking, RV global longitudinal (GLS), circumferential, and radial strain of all participants were evaluated. Compared with controls, the study patients demonstrated significantly impaired global biventricular strain in all 3 directions (all P<0.001). Receiver operating characteristic curve analysis indicated that RV GLS was the strongest discriminator among all RV strain parameters for the identification of patients with ARVC (area under the curve, 0.92). Using the Youden index, the authors determined RV GLS ≥-19.95% as the diagnostic criterion of ARVC. In patients diagnosed with borderline ARVC according to revised Task Force Criteria but with no or only minor CMR criteria, there were >50% presenting with impaired RV GLS. When both conventional criteria and RV GLS were considered together, this new diagnostic method demonstrated an overall diagnostic accuracy of 90%. The likelihood ratio test showed a significant incremental diagnostic value of RV GLS (P=0.02) over the existing CMR major criteria. The current study showed an improved diagnostic accuracy when both RV GLS and the existing CMR criteria were considered together, especially for patients with borderline diagnosis, suggesting the incremental value of strain analysis to the initial assessment of ARVC.

Adams-Oliver Syndrome (OSA)

Introduction: Adams-Oliver's syndrome (SAO) is a rare genetic condition characterized by the association of lumb anomalies and Aplasia cutis congenita in vertex, often accompanied by underlying ossification defect and vascular lesions. The objective through this new observation is to describe the clinical, radiological, therapeutic and evolutionary elements according to what was described up to there in the literature.&#x0D; Observation: Female newborn child, stemming from a pregnancy followed with normal obstetric ultrasounds. He presents a scalp agenesis, underlying cranial bone aplasia and toes hypoplasia with syndactyly. The association of these two major criteria allowed making the diagnosis of SAO. Moreover, she presents disjointed and large sagittal suture with left parietal bone borders hypoplasia. The notion of periventricular bleeding. The rest of the balance sheet deformation, namely the abdominal ultrasound and echocardiography was without anomalies. The newborn was sent in neurosurgery for restorative treatment, which will be planned at the age of 3 months.&#x0D; Discussion and Conclusion: This observation illustrates sporadic and not complicated SAO. The absence of complete gene mapping in SAO and therefore of any genetic counseling, prenatal morphological ultrasound, is making important in evolutionary terms of subsequent pregnancies.

Simple Multi-Attribute Rating Technique for Warehouse Location Selection (Case Study: PT. PPT)

Indonesia’s Manufacturing Industry, encompassing processing and non-oil and gas processing, grew in Q3 of 2022, contributing 17.88% and 16.10% to GDP. Transportation and storage played a significant part, with a 15.93% year-on-year growth in Q1 2023, highlighting the sector’s importance. PT. PPT is a sub-holding of one of Indonesia’s companies. The company manages to trade PP/PE significantly from more sources (import, local producer, or local trader). This research will determine and analyze the criteria for the selection of warehouse locations for PT. PPT analyzes the weight of each criterion at each location in the warehouse location selection process for PT. PPT and obtain the priority location for PT. PPT to build a new warehouse. This research aims to guide and help the decision makers to choose and find a suitable location based on the Centre of Gravity (CoG) analysis conducted by a third-party consultant. The five locations resulting from the Centre of Gravity (CoG) as alternatives will be analysed with Kepner-Tregoe Analysis in the decision-making process, using Situation Appraisal defined in Business Issues. The author then employs a Rich Picture and Fishbone Diagram to assess the scenario or the process of select the new warehouse. The decision analysis was carried out in eight stages using the one of Multi-Criteria Decision Making (MCDM) method, which is the Simple Multi-Attribute Rating Technique (SMART). Lastly, using the preceding analysis, undertake a Potential Problem Analysis. The major criterion is the distance to the customer, which aligns with the company’s emphasis on customer satisfaction. Demand growth affects warehouse capacity, with more growth necessitating a larger facility. Distance from suppliers reduces delivery lead time, and the size of the land must accommodate demand growth and product capacity for PT. PPT.

Fabry–Perot Antenna Based on an Electrically Tunable Slot Antenna and a Two-Layer Frequency-Selective Surface

Introduction. One of the directions in Fabry–Perot antenna design consists in increasing its operation frequency range. In the present work, we set out to develop a Fabry–Perot antenna with a smooth gain pattern across a wide frequency range. To that end, a tunable slot antenna based on a thin-film ferroelectric varactor was used. The major development criterion was a high uniformity of the gain pattern, not exceeding 1 dB in the given frequency band. Aim. To develop a Fabry–Perot antenna for the 4.9–5.5 GHz frequency range with a high gain uniformity within the operating frequency band.Materials and methods. The antenna under development was based on thin-film ferroelectric capacitors as tunable elements. Fluoroplastic plates metallized on both sides were used as a dielectric material for manufacturing a frequency selected surface and a slot antenna. The parameters of ferroelectric elements were measured using a resonance technique, while the parameters of the dielectric material were determined using the Nicholson–Ross–Weir method.Results. The developed antenna has an operating frequency band of 4.9–5.5 GHz. Samples of ferroelectric capacitors and foiled dielectric material were manufactured and experimentally investigated. A tunable slot antenna was fabricated, and its characteristics were measured. The simulation results show that the gain value of the developed Fabry–Perot antenna is not less than 10 dB in the operation frequency range. Variations in the gain value within the operating frequency band do not exceed 0.7 dB.Conclusion. A Fabry–Perot antenna based on an electrically tunable slot antenna and a two-layer frequency-selective surface was developed. The operating frequency band of the developed device ranges within 4.9–5.5 GHz, which corresponds to the frequency band of Wi-Fi networks. Optimization of the antenna design parameters made it possible to achieve higher gain values under their minor variations in the operation frequency band.

Current Clinical Profile of Acute Rheumatic Fever and Recurrent Acute Rheumatic Fever in Pakistan.

Inclusion of echocardiography as diagnostic tool and polyarthralgia and monoarthritis as major criteria for high-risk populations in the Revised Jones Criteria 2015 is likely to surface substantial variability in clinical manifestations among various populations. This study aimed to compare clinical profile of patients presenting with first and recurrent episodes of acute rheumatic fever (ARF) using most recent criteria. 130 consecutive patients with ARF were included in the study from August 2019 to March 2022. World Heart Federation standardized echocardiographic criteria were used for cardiac evaluation. The socio-demographic variables, clinical details and relevant investigations were recorded. Median age was 13(6-26) years. Male to female ratio was 1.6:1. Majority was of low socioeconomic status (90%) and with > 5 family members in a house (83.8%). 27 patients (20.8%) were with ARF while 103 (79.2%) with recurrent ARF. Carditis was the most common presenting feature (n = 122, 93.8%), followed by polyarthralgia (n = 46, 35.4%), polyarthritis (n = 32, 24.6%), subcutaneous nodules (n = 10, 7.7%), monoarthritis (n = 10, 7.7%), and chorea (n = 5, 3.8%). Monoarthralgia was more common in ARF than recurrence (29.4% vs. 3.2%, p = 0.004). Carditis (97.1% vs. 81.5%, p = 0.01) and congestive cardiac failure (18.5% vs. 5.9%, p = 0.001) were more common in recurrent ARF than ARF. Diagnostic categorization of Jones criteria for different populations has highlighted important variability in clinical presentation of ARF. Monoarthralgia is common in first episode of ARF. Carditis is the most common feature in recurrent ARF. Polyarthralgia is seen with higher frequency that polyarthritis. Subcutaneous nodules seem to be more common in our population.

Paradigms and Different Types of Research

The structure of the research processes is represented according to the paradigmatic nature of the researcher's knowledge and two major differentiation criteria: the DIACHRONIC Structure and the SYNCHRONOUS Structure. Every investigative process varies according to its evolution over time for the first structure and how it is considered an independent process over time, according to the second structure (Padrón, 1992). Researchers throughout the history of science have developed, shared, and worked under a worldview of reality that has led them to a system of beliefs around knowledge as ways of accessing and producing the knowledge that they come to be the different paradigms. This belief system has been very divergent from each other in different eras of science. Whether or not it coincides is determined by that paradigmatic vision, which in turn explains the techniques, procedures, types of samples, methods, and language used, among other things.

Assessing the e-commerce last-mile logistics’ hidden risk hurdles

Due to increasing last-mile logistics complexity, the e-commerce business's last-mile delivery has emerged as an imperative issue that impedes the advancement of contemporary last-mile logistics practices. The paper attempts to identify last-mile logistics associated risk hurdles from e-commerce literature and prioritize them on their significantly affecting logistics operations. The factors were identified by reflecting on the recent literature and internet resources coupled with in-depth brainstorming with experts in the field of Logistics Company including, practitioners, and employers. Two ranking methods namely TODIM (TOmada de Decisao Interativa Multicriterio in Portuguese “interactive and multicriteria decision making” in English) and ARAS (Additive Ratio ASsessment method) are used together to rank order the major risk hurdles and criteria. The results of this study present that lack of visibility (LV), low-efficiency levels (LEL), and unpredictable elements (UE) are ranked as the top three major risk hurdles whereas real-time information on a package’s location (LV1), putting a GPS tracking system to track last- mile journey (OT3) and users wants on time location of their package (LV2) are ranked as top three most significant criteria affecting the practices of modern last-mile logistics in e-commerce businesses. The findings can be used by logistics firms, organizations, and policymakers to better understand the issues and develop strategies to address them, making last-mile delivery a more efficient also better form of awareness for practitioners who are engaged in third-party logistics firms. The novelty of this study is to identify the primary risk hurdles affecting the practices of last-mile logistics and to prioritize them using ranking methods such as TODIM and ARAS. This offers advice for managers and researchers to consider how to handle the logistical uncertainty in e-commerce enterprises.

Characteristics and treatment options of glucagonomas: a national study from the French Group of Endocrine Tumors and ENDOCAN-RENATEN network.

Glucagonoma is a very rare functional pancreatic neuroendocrine tumor (PanNET). We aimed to provide data on the diagnosis, prognosis, and management of patients with glucagonoma. In this retrospective national cohort, we included all patients with glucagonoma, defined by at least one major criterion (necrolytic migratory erythema (NME) and/or recent-onset diabetes and/or weight loss ≥ 5 kg) associated with either glucagonemia >2xULN or positive glucagon immunostaining. Antisecretory efficacy was defined as partial/complete resolution of glucagonoma symptoms. Antitumor efficacy was assessed according to the time to next treatment (TTNT). Thirty-eight patients were included with median age 58.7 yo, primary PanNET located in the tail (68.4%), synchronous metastases (63.2%). Median Ki-67 index was 3%. Most frequent glucagonomas symptoms at diagnosis were NME (86.8%), weight loss (68.4%) and diabetes (50%). Surgery of the primary PanNET was performed in 76.3% of cases, mainly with curative intent (61.5%). After surgery, complete resolution of NME was seen in 93.8% (n = 15/16). The secretory response rates were 85.7%, 85.7%, 75% and 60% with surgery of metastases (n = 6/7), chemotherapy (n = 6/7), liver-directed therapy (n = 6/8) and somatostatin analogues (n = 6/10), respectively. All lines combined, longer TTNT was reported with chemotherapy (20.2 months). Median overall survival was 17.3 years. The Ki-67 index >3% was associated with shorter OS (HR 5.27, 95%CI [1.11-24.96], p = 0.036). Patients with glucagonoma had prolonged survival, even in the presence of metastases at diagnosis. Curative-intent surgery should always be considered. Chemotherapy, PRRT or liver-directed therapy seem to provide both substantial antitumor and antisecretory efficacy.

Effectiveness of Recruitment Sources in a Multicenter Clinical Trial for Dementia Prevention ‐ rrAD study

AbstractBackgroundExercise and Intensive Vascular Risk Reduction in Preventing Dementia (rrAD Study) was a NIH‐funded multisite, clinical trial. The rrAD Study assesses the effects of aerobic exercise training and intensive pharmacological reduction of vascular risk factors on cognitive performance in older adults at high risk for Alzheimer’s disease (AD). The enrollment goal was 640 participants across the span of two years. We report herein our recruitment and enrollment results of the rrAD Study.MethodThe major inclusion criteria were older adults, age 60‐85, who had family history (FH) of dementia or subjective memory complaints, hypertension, and a sedentary lifestyle. Individuals with dementia and other neurodegenerative diseases, or unstable medical conditions were excluded (NCT02913664). 3,291 potential participants were recruited and 2,747 were phone screened to participate in the rrAD Study. 513 cognitively normal older adults, aged 60 to 85 years with hypertension and increased risk for AD were randomized.ResultThe rrAD Study had a 15.5% recruitment yield of total phone screened individuals to randomization. E‐mail brought in the largest number of phone screen contacts and was the overall most cited recruitment source (20.9%, n = 574, Figure 1), followed by interviews/editorials (18.7%, n = 515), other/unknown source (17.9%, n = 492), and broadcast advertising (11.8%, n = 325). E‐mail and interview/editorials led to greatest number of consented and randomized participants. However, the recruitment sources that were more likely to lead to consent/participation were, professional referral (i.e. physician, 57.1% yield), social media (49.2% yield), and mail/phone from site (45.2% yield).ConclusionFrom this outreach, the utilization of multiple recruitment sources prove to be a dominant factor to meet recruitment and enrollment goals. E‐mail and interview/editorials demonstrate to be the most effective recruitment sources that led to the greatest number of phone screens, consents, and randomizations. In future studies, we might limit the broadcast advertisement effort since it did not lead to a high volume of consents and randomization; this could be due to the limited amount of study information stated on a 60‐second radio advertisement. Whereas, e‐mail and interview/editorials may produce more qualified participants since these sources can provide a wide scope and detailed information about the study.

Histological and biophysical changes of cassava roots during retting, a key step of fufu processing.

Retting is a key step of cassava processing into widely consumed foods (fufu, chikwangue, miondo and bobolo) in sub-Saharan Africa. For some populations, retting ability is a major quality criterion that drives the adoption of new cassava varieties. Despite this importance, the physiological basis associated with this process remains poorly understood, and should lead to improved screening tools for breeding. Eight cassava varieties contrasting in retting ability properties were used in the present study. Roots and soaking water were sampled during retting and characterized at both histological and biochemical levels. Histological data highlighted the degradation of root cell wall during retting. The average pH of soaking water decreased from 5.94 to 4.31 and the average simple sugars decreased from 0.18 to 0 g L-1, whereas the organic acids increased up to 5.61 g L-1. In roots tissue, simple sugars and organic acid contents decreased from 22.9 to 0 g kg-1 and from 80 to 0 g kg-1, respectively. The total pectin content of roots among varieties at harvest was similar, and decreased during the retting process. Overall, there was a negative correlation between total pectins content and root softening, although this did not reach statistical significance. Major histological and biochemical changes occurred during cassava root retting, with some of them associated with the process. Retting affected starch pasting properties more than starch content. Although this process is characterized by root softening and degradation of cell wall structure, the present study strongly suggested that pectin is not the only cell wall component involved in these changes. © 2023 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

The legal status of the class members during the group litigation

The study discusses certain rules of group litigation in the civil procedure in the context of the legal status of class members in procedural relations. Attention is paid to the rights and obligations of the person who applies to court with a request to protect the rights and legitimate interests of a group of members. Participants in a class action include the person conducting the case (plaintiff-representative) and group members who joined the collective claim. The comparative legal method and teleological interpretation allow to conclude that there are active procedural relations only between the court and the claimant-representative, which predetermines the possibility of performing administrative actions, proving and appealing judicial acts only by the plaintiff, but not by the other claimants. The extremely curtailed scope of powers of the group members is justified by their voluntary joining a class action lawsuit. Relations within a group of persons are substantive in nature; this allows to highlight the necessity of appropriate private material mechanisms to satisfy the interests of the majority of participants under the rules on decisions in meetings. In view of the possibility of consolidating in a class homogeneous but different in size substantive claims of the group members we believe it is essential to establish the majority criterion, regardless of the price of the claim of each member. The research also reveals the contradiction in legal regulation in the event of a refusal to certify a group of persons after the initiation of proceedings on a class action in civil, arbitration and administrative litigation, substantiates the inexpediency of leaving a class action without consideration, and the need to consider personal claims of group members and allocate relevant cases in a separate production, as provided for in the Arbitration (Commercial) Procedure Code of the Russian Federation. Attention is drawn to the gaps in the legal regulation of group proceedings in terms of establishing the amount and procedure for paying the state fee.