Optimal Management Strategy Research Articles

Dynamical and optimal control analysis of lymphatic filariasis and buruli ulcer co-infection

This study delves into the dynamics of lymphatic filariasis and buruli ulcer coinfection, two overlooked yet impactful tropical diseases. With lymphatic filariasis, commonly referred to as elephantiasis, and buruli ulcer, a chronic affliction caused by mycobacterium ulcerans, both posing significant health challenges, understanding their interaction is crucial. Utilizing a mathematical model, this research aims to analyze the dynamics of this coinfection, elucidating its complexities. The study establishes the local asymptotic stability of the disease-free equilibrium and calculates the basic reproduction number using the next generation matrix. It uncovers transcritical and backward bifurcation phenomena within the model. Additionally, the integration of time-dependent controls enables the exploration of optimal disease management strategies. Numerical simulations highlight the efficacy of employing a comprehensive approach, utilizing all available controls simultaneously, as the most effective strategy for disease control. These findings underscore the importance of integrated interventions in combating lymphatic filariasis and buruli ulcer coinfection, offering valuable insights for public health policymakers and practitioners.

Third ventricle teratoma with malignant transformation

Intracranial germ cell tumors(GCTs) are rare and heterogeneous group of primary brain tumors, mainly affecting pediatric population and young adults. The current understanding of the etiology of intracranial GCTs and their optimal management strategies remain controversial. Treatment plans differ depending on the subtype GCT and may vary among physicians and institutions. Central nervous system non-germinomatous germ cell tumor (NGGCT) usually requires surgical resection with histological verification, chemotherapy, and radiation. The extent of surgical resection is an important prognostic factor alongside the etiology and genetics of NGGCT. This article presents a rare clinical case of a rapidly growing teratoma located in the posterior part of third ventricle of a 17-year-old male presenting with symptoms of intracranial hypertension. Surgical total resection was preceded by endoscopic third ventriculostomy. Immunohistochemistry revealed the presence of embryonal carcinoma and immature teratoma cells turning the tumor into mixed type NGGCT with unfavorable prognosis. Despite the complete resection of the tumor and the timely initiation of adjuvant therapy, a rapid progression of the disease with subsequent unfavorable outcome was observed 3.6 months after the surgical treatment.

Optimum management strategy for improving maize water productivity and partial factor productivity for nitrogen in China: A meta-analysis

China’s agricultural production suffers significant constraints due to low water productivity (WP) and partial factor productivity for nitrogen (PFPN). The pivotal solution to enhance maize yield, WP, and PFPN is through optimizing field management practices. However, previous studies primarily focused on the effects of individual or coupled field management practices on maize yield, WP, or PFPN in an area or land mass, so it is necessary to conduct a comprehensive quantitative analysis of various field management practices on maize yield, WP, and PFPN at the national scale. In this study, we compiled 286 studies encompassing 6959 pairs of experimental data spanning from 1990 to 2023. Meta-analysis was conducted to observe the variations in maize yield, WP, and PFPN across diverse field management practices (straw returning, nitrogen fertilizer application, irrigation practice, and tillage practice) on a national scale. The results showed that nitrogen fertilizer application (215 kg N ha−1) was the most effective in enhancing maize yield and WP by 68.1 % and 54.8 %, respectively. Additionally, irrigation had the most substantial impact on PFPN, enhancing 16.8 %. Straw mulching, application of slow and controlled release fertilizers, drip irrigation, and subsoiling were identified as the most effective practices in increasing maize yield, WP, and PFPN by Random forest model. Maize straw returning could reduce nitrogen fertilizer application by 20 kg ha−1, while increasing WP and PFPN by 4.2 % and 11.6 %, respectively. Moreover, straw returning could reduce water consumption by 23–60 mm, while increasing WP and PFPN by 2.9 % and 6.8 %, respectively. These findings can provide a reference for the formulation of comprehensive management strategies for sustainable maize production in China and globally.

Cardiovascular and all-cause mortality outcomes of adrenalectomy versus medical treatment in primary aldosteronism: an umbrella review.

Primary aldosteronism (PA) is now recognized as the most prevalent form of secondary hypertension globally, contributing significantly to cardiovascular morbidity and mortality. This umbrella review aims to systematically compare cardiovascular outcomes and all-cause mortality in PA patients undergoing adrenalectomy versus mineralocorticoid receptor antagonist (MRA) treatment, aiming to inform optimal management strategies. Following PRISMA guidelines, Supplemental Digital Content 1, http://links.lww.com/JS9/D386, Supplemental Digital Content 2, http://links.lww.com/JS9/D387, a comprehensive search strategy was employed across multiple databases. Meta-analyses focusing on cardiovascular outcomes or all-cause mortality, comparing adrenalectomy and MRAs treatment in PA patients, were included. Studies were independently screened and assessed for quality using AMSTAR 2, Supplemental Digital Content 3, http://links.lww.com/JS9/D388 and GRADE checklists. A total of 8 studies met the inclusion criteria. Adrenalectomy showed potential benefits over MRAs in reducing the risk of arrhythmias (OR=2.17; 95% CI: 1.25-3.76) and major adverse cardiovascular events (OR=1.81; 95% CI: 1.33-2.46). Patients treated with MRAs exhibited a higher risk of cardiovascular events (OR=1.23; 95% CI: 1.05-1.44), hypertension (OR=3.22; 95% CI: 1.15-8.97), and all-cause mortality (OR=3.03; 95% CI: 1.36-6.70) compared to adrenalectomy. Adrenalectomy appears to offer favorable outcomes compared to MRAs treatment in PA patients, particularly in reducing the risk of major adverse cardiovascular events and all-cause mortality. These findings suggest the importance of considering surgical intervention as a primary treatment modality for PA.

Elizabethkingia bloodstream infections in severely immunocompromised patients: persistent, relapsing and associated with high mortality.

Elizabethkingia species are uncommon causes of bloodstream infections, representing a true opportunistic and multi-drug-resistant pathogen to immunocompromised or vulnerable hosts. Despite this, data are lacking regarding optimal management strategy for infections with this organism, which is associated with significant mortality and morbidity. We describe patient characteristics, management and outcomes in this case series. All inpatients at the Royal Brisbane and Women's Hospital with a positive blood culture for Elizabethkingia spp. were identified by database query. Clinical information including medical history, source of infection, attempts at source control and outcome were collected. Laboratory data including duration of bacteraemia and antimicrobial susceptibility testing were also collected. All patients had severe defects of innate and adaptive immunity. Targeted therapy was started promptly and efforts at source identification and control were appropriately pursued. Despite this, outcomes were generally poor. A previously unrecognized presentation of relapsing infection was described in one case, requiring long-term suppressive antimicrobials to control. One case died as a result of infection and one case was cured, but died soon after due to complications of immunosuppression. Treatment of these organisms is challenging due to limited effective therapy, development of on treatment resistance and profound host immunocompromise. Up-front use of multiple, optimally dosed antimicrobials, attempting source control and attempting to restore host immune function all appear to be key to achieving good outcomes.

Optimal management of breast cancer with physical exam negative/radiological abnormal axilla

For breast cancer patients with physical exam node negative but radiological finding node abnormal (cN0/rNa), the NCCN and ASCO guidelines recommend sentinel lymph node biopsy (SLNB) as the first-line axillary staging. However, patients who undergo surgery firstly may be upstaged to pathological II–III status, and these patients happen to be the adaptive population of neoadjuvant therapy (NAT). There is no consensus on the optimal management of cN0/rNa patients. The aim is to explore the optimal management strategy of these patients. We performed a retrospective real-world study of 1414 cN0/rNa patients from June 2014 to October 2022. There were 1003 patients underwent surgery first and 411 patients underwent surgery after NAT. We analyzed the real-world conditions of these patients, compared axilla tumor burden between these two groups. In addition, we compared benefit ratio of axillary surgery and regional nodal irradiation (RNI) de-escalation under the two strategies. Among 1003 patients underwent surgery first, the positive and negative rates of fine needle aspiration (FNA) were 18.5% and 81.5%, respectively. There were 66.1% had ≤ 2 lymph nodes+. There were 40.8% of FNA+ patients could be exempted from ALND underwent surgery first. In 411 patients underwent surgery after NAT, the FNA positive and negative rates were 60.8% and 49.2%, respectively. There were 54.4% of FNA+ patients achieved axilla pathologic complete response (apCR) and could omit ALND after NAT. The apCR was 67.3% in HER2+/TNBC subtypes. According to the NSABP-B51 trial, there were 0 and 54.4% of FNA+ patients could omit RNI among surgery first and after NAT, respectively. Among 1–2 sentinel lymph node (SLN)-positive patients underwent surgery first, with a median follow-up 49 months, there was no difference of survival benefit between SLNB-only and SLNB-ALND. Compared with 1–2 SLN+ patients without RNI, RNI could bring better invasive disease-free survival (97.38% vs. 89.36%, P = 0.046) and breast cancer special survival (100% vs. 94.68%, P = 0.020). It is safe to perform SLNB omitting ALND when detected 1–2 positive SLNs in cN0/rNa patients. Patients with HER2+/TNBC subtypes underwent surgery after NAT had more chance to benefit from dual de-escalation, including axillary surgery and RNI de-escalation.

Long-Term Management of Post-Stroke Spasticity with Botulinum Toxin: A Retrospective Study.

Stroke-induced spasticity is a prevalent condition affecting stroke survivors, significantly impacting their quality of life. Botulinum Toxin A injections are widely used for its management, yet the long-term effects and optimal management strategies remain uncertain. This retrospective study analyzed medical records of 95 chronic stroke patients undergoing long-term BoNT-A treatment for spasticity. Demographic data, treatment duration, dosage variability, and dropout rates were assessed over a period ranging from 2 to 14 years. The study revealed a notable extension of the interval between BoNT-A injections throughout the treatment duration. Dropout rates peaked during the initial 5 years of treatment, perhaps due to perceived treatment ineffectiveness. Additionally, a trend of escalating dosage was observed across all groups, indicating a potential rise in the severity of spasticity or changes in treatment response over time. BoNT-A injections emerged as the predominant treatment choice for managing post-stroke spasticity. The delayed initiation of BoNT-A treatment underscores the need for heightened awareness among healthcare providers to recognize and manage spasticity promptly post-stroke. Patients' expectations and treatment goals should be clearly defined to optimize treatment adherence, while the observed escalation in dosage and treatment intervals emphasizes the dynamic nature of spasticity and underscores the importance of monitoring long-term treatment outcomes.

Dual-layer multi-mode energy management optimization strategy for electric vehicle hybrid energy storage systems

Dual-layer multi-mode energy management optimization strategy for electric vehicle hybrid energy storage systems

Data-driven energy utilization for plug-in hybrid electric bus with driving patten application and battery health considerations

The efficient utilization of energy is a crucial consideration for plug-in hybrid electric buses (PHEB). However, achieving the optimal energy management strategy (EMS) for PHEB necessitates the harmonious optimization of both driving conditions and battery status. Consequently, an innovative EMS that integrates the data-driven prediction of the driving cycles and battery health status. Explicitly, the bi-directional long short-term memory algorithm is employed to reconstruct and train the health status data of power batteries, enabling the accurate estimation of their State of Health (SOH) values. Moreover, a database of historical driving behavior is meticulously collected through a real-world PHEB platform, and the driving cycles for a certain while are predicted with the clustering algorithm. Then, this invaluable information on the battery status and driving cycles is seamlessly introduced into an adaptive-network-based fuzzy inference system (ANFIS) to regulate of the energy conversion factor in the following equivalent consumption minimization strategy (ECMS). Besides, the offline global optimization of equivalent fuel consumption with the Pontryagin's minimum principle (PMP) is preliminarily conducted to generate the pre-established energy conversion factors, facilitating convenient access to the engine and motor's reasonable power distribution range. Finally, simulations and experiments have validated the effectiveness of the proposed EMS, demonstrating a 23.57 % reduction in battery SOC depletion and a 10.53 % decrease in fuel consumption compared to traditional ECMS methods. More importantly, the proposed method has been validated for its executability in embedded devices through real-world bench experiments. This research holds significant reference value for energy utilization and practical implementation in the PHEB, thereby contributing to the advancement of knowledge in this field.

An interdisciplinary consensus approach to pulmonary hypertension in developmental lung disease.

It is increasingly recognised that diverse genetic respiratory disorders present as severe pulmonary hypertension (PH) in the neonate and young infant, but many controversies and uncertainties persist regarding optimal strategies for diagnosis and management to maximise long-term outcomes. To better define the nature of PH in the setting of developmental lung disease (DEVLD), in addition to the common diagnoses of bronchopulmonary dysplasia and congenital diaphragmatic hernia, we established a multidisciplinary group of expert clinicians from stakeholder paediatric specialties to highlight current challenges and recommendations for clinical approaches, as well as counselling and support of families. In this review, we characterise clinical features of infants with DEVLD/DEVLD-PH and identify decision-making challenges including genetic evaluations, the role of lung biopsies, the use of imaging modalities and treatment approaches. The importance of working with team members from multiple disciplines, enhancing communication and providing sufficient counselling services for families is emphasised to create an interdisciplinary consensus.

Infusion of 20% Human Albumin Reduces the Requirement of Intraoperative Intravenous Fluids in Patients Undergoing Open Gastrointestinal Oncosurgeries – A Randomised Controlled Study

Background and Aims: The optimal strategy for intraoperative fluid management in patients undergoing major abdominal oncosurgery remains undecided. The present study was undertaken to determine the effect of 20% intravenous (IV) albumin on the requirement of IV fluids (IVFs) during open gastrointestinal (GI) cancer surgeries. Methods: This randomised, double-blinded, controlled trial was conducted in a tertiary care centre from August to October 2022 after obtaining approval from the institutional ethics committee and informed written consent from the study subjects. Forty patients were randomised to either Group A (n = 20), receiving an IV infusion of 25 mL/h of 20% albumin, or Group C (n = 20), receiving an IV infusion of 25 mL/h of plasmalyte for 4 h (total 100 mL). Fluid and vasopressor administration was guided by systemic and pulse pressure variations. The primary outcome was the intraoperative requirement for IVF in the two study groups. The secondary outcomes included intraoperative IV vasopressor requirement, serum lactate levels, incidence of post-operative complications and length of hospital stay. Results: After the exclusion of three patients due to intraoperative bleeding, 37 patients were included in the final analysis. Patients in Group A (n = 19) required less IVF (3.92 ± 0.54 mL/kg/h) as compared to Group C (n = 18) (5.03 ± 1.20 mL/kg/h) (P < 0.001). Four patients (22%) in Group C required intraoperative noradrenaline IV infusion (P = 0.040). There was no significant difference between the two groups, regarding the mean intraoperative serum lactate values, incidence of post-operative complications and mean length of hospital stay (P > 0.05). Conclusions: A 100 mL of 20% human albumin as an IV infusion over 4 h reduced the requirement of IV fluid and vasopressor intraoperatively in patients undergoing open GI cancer surgery.

The current landscape of in situ and ex situ machine perfusion utilization for liver grafts from cardiac donation after circulatory death donors in the US

Donation after circulatory death (DCD) is driving the increase in deceased organ donors in the United States. Normothermic regional perfusion (NRP) and ex situ machine perfusion (es-MP) have been instrumental in improving liver transplant outcomes and graft utilization. This study examines the current landscape of liver utilization from cardiac DCD donors in the United States. Using the United Network for Organ Sharing Standard Transplant Analysis and Research file, all adult (≥18 years old) DCD donors in the United States from which the heart was used for transplantation from October 1, 2020, to September 30, 2023, were compared by procurement technique (NRP versus super rapid recovery [SRR]) and storage strategy (es-MP versus static cold storage). One hundred eighty-eight livers were transplanted from 309 thoracoabdominal NRP donors (61% utilization) versus 305 (56%) liver transplants from 544 SRR donors. es-MP was used in 20% (n = 38) of NRP cases versus 32% (98) of SRR cases. Of the liver grafts, 281 (59%) were exposed to NRP, es-MP, or both. While there is widespread utilization of machine perfusion, more research is needed to determine optimal graft management strategies, particularly concerning the use of multiple technologies in complementary ways. More complete data collection is necessary at a national level to address these important research questions.

A management algorithm for idiopathic intracranial hypertension in skull base meningoencephaloceles.

In this study, the authors assessed an algorithm for the diagnosis and management of idiopathic intracranial hypertension (IIH) in patients who had undergone surgical repair of skull base meningoencephaloceles presenting with spontaneous cerebrospinal fluid (sCSF) leakage. The authors conducted an institutional retrospective review of patients surgically treated for skull base sCSF leaks between 2014 and 2021. Opening pressure (OP) measurements were taken intraoperatively. The algorithm recommended a ventriculoperitoneal shunt (VPS) for high-risk patients (OP ≥ 30 cm H2O), 4 weeks of acetazolamide plus a 2-week washout and repeat lumbar puncture (LP) at 6 weeks for intermediate-risk patients (OP = 20-29 cm H2O), and repeat LP at 4-6 weeks for low-risk patients (OP < 20 cm H2O). Demographics, radiographic characteristics, management adherence, and outcomes were analyzed. Eighty patients with sCSF leakage were identified. The mean age was 51.9 years, and the mean body mass index was 36.3 kg/m2. The median follow-up was 8.3 months (IQR 3.3-19.7 months). The overall VPS rate was 15.0%. Three patients (3.8%) experienced acute recurrent leakage, and 3 (3.8%) developed remote recurrent leaks (mean time of 48.1 months). For the 50 patients with both intra- and postoperative OPs, the mean OPs were not significantly different (23.3 vs 23.0 cm H2O, respectively, p = 0.82). The mean variability between the two measurements was an absolute difference of 6.6 cm H2O. While 13 patients (26.0%) moved to a higher-risk category based on postoperative OP, 18 patients (36.0%) moved to a lower-risk category. Utilizing an algorithm of direct meningoencephalocele repair and selective shunting, acute and remote CSF leak recurrence rates were each 3.8%, and the VPS rate was 15.0%. These data provide further insight into CSF dynamics in this population and argue against the theoretical concern that CSF pressure will increase postrepair. Significant intraindividual variability suggests multiple LPs may be necessary before committing to invasive IIH treatment. Further work is necessary to determine the optimal IIH management strategy.

Surgical outcomes of patients with locally advanced thymic epithelial tumor undergoing induction therapy followed by surgery: a narrative review.

Thymic epithelial tumors (TETs), including thymomas and thymic cancers, are relatively rare malignancies originating from the thymus. Although complete surgical resection is the cornerstone of treatment for these tumors, the optimal management strategy for locally advanced cases remains uncertain. Neoadjuvant therapies, with their potential to improve the likelihood of complete resection, are promising, particularly in marginally operable cases. However, the current evidence supporting this approach is lacking. This review of the existing literature on the efficacy of induction therapy followed by surgical resection for stage III or IV locally advanced TETs aimed to provide an up-to-date perspective and highlighting directions for future clinical research. PubMed was searched using the keywords "surgery," "survival", "thymoma", "thymic cancer", and "induction therapy". Relevant articles including case series, retrospective studies, prospective studies, and review articles were reviewed and selected for this comprehensive narrative review. This review included primarily revealed retrospective studies and a limited number of prospective phase II trials on induction therapy followed by surgery for stage III or IV locally advanced TETs. No randomized phase III studies were identified, indicating that a comprehensive evaluation of the benefits of induction therapy on overall survival (OS) has not yet been conducted. Induction therapies for both invasive thymoma and thymic cancer included chemotherapy, radiotherapy, and chemoradiotherapy, with anthracycline-based combination chemotherapies being the primary option. For exclusively invasive thymomas, the median rate of complete surgical resection and the 5-year OS rate were reported as 76% and 85%, respectively. Literature focusing on induction therapy for TETs, which includes both thymoma and thymic cancers, indicates that the rates of complete resection and 5-year OS are 76% and 70%, respectively. Our narrative review of retrospective and prospective studies highlighted promising long-term OS rates in patients with advanced TETs who underwent induction therapy followed by surgical resection. These findings support this multimodal treatment strategy in selected patients with stage III and IV TETs.

Top-Down or Bottom-Up? Choosing the Best Path of Management for Waqf-Takaful Death Compensation Product in Malaysia

In Malaysia, the integration of waqf and takaful for death compensation products aims to enhance financial protection within the Islamic finance framework. However, the effectiveness of this integration is influenced by the management approach adopted, either top-down or bottom-up. The top-down approach, driven by high-level government entities such as Bank Negara Malaysia (BNM) and the Ministry of Finance (MOF), promises streamlined processes and uniformity. Conversely, the bottom-up approach involves grassroots-level engagement through individual takaful agents, which emphasizes personalized interactions and alignment with local needs. Despite these theoretical benefits, there is a lack of empirical evidence assessing the practical impact of these approaches on key dimensions such as participant engagement, compliance with Islamic law, implementation speed, and institutional support. This study seeks to address this gap by applying a qualitative research design, including in-depth interviews with experts and comparative analysis methods, to evaluate the advantages and limitations of each approach. The goal is to provide actionable insights for policymakers and practitioners to optimize management strategies and improve the effectiveness and relevance of waqf-takaful death compensation products in Malaysia.

198. IDENTIFYING THE OPTIMAL MANAGEMENT OF ESOPHAGEAL ANASTOMOTIC LEAKS. A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Abstract Background There is currently no consensus as to how best to manage esophageal anastomotic leaks. Intervention with Endoscopic Vacuum Assisted Closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. Consequently, we aimed to conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. Methods A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. Results In total, 12 retrospective studies were included which included 511 patients. Of the 449 patients for whom data was available 371 (82.6%) were male, and 78 (17.4%) were female. The average age of patients was 62.6 years (Standard deviation (SD) 10.2). Overall, 94.5% of patients underwent initial esophagectomy for an underlying malignancy. The average Body Mass Index (BMI) reported was 25.9 kg/m2. The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The re-operation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (Odds ratio (OR) 0.23 95% confidence interval (CI) 0.09-0.58). EVAC had a significantly lower mortality rate than stenting (OR: 0.43, 95% CI 0.21; 0.87). Re-operation was used in significantly larger leaks than stenting (mean difference (MD) 14.66; 95%CI 4.61 24.70). Re-operation was also associated with a significantly increased mortality rate (OR: 2.66, 95% CI: 1.01-6.99.). Using stenting as a comparator, NMA failed to demonstrate a significant difference between interventions in terms of success rate. However, EVAC had the greatest difference in success rate (OR: 2.23, 95% CI 0.78-6.34). Conclusion The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. One aspect of EVT that was not examined in this study was the number of endoscopic interventions required. Sponge exchanges every 48 to 72 hours are necessary during EVT whereas stents may be left in place for 4-8 weeks. This may have significant implications for treatment choice in resource-limited settings and may have a profound impact on patient quality of life. Surgical management is often necessary for significantly larger leaks. Reoperation in the case of anastomotic leak is often the intervention of choice in systemically unwell patients and those with uncontained leaks. It therefore stands to reason that mortality rates are elevated among this patient cohort and differences in outcome are unlikely to be attributable to the modality of intervention alone.

Evolution of Medical and Surgical Management of Carotid Disease from Carotid Endarterectomy to Transfemoral Carotid Stenting to TCAR

Patients with carotid stenosis can be broadly classified into two categories: symptomatic and asymptomatic. While there is little disagreement about surgical management of symptomatic carotid stenosis, the optimal management strategy for the patients with asymptomatic carotid disease has undergone significant evolution over past five decades. With increasing focus on role of plaque morphology on the etiology of symptoms, there has been an increased focus on optimizing the medical management targeted at plaque stabilization, especially for the patients with asymptomatic carotid disease, while reserving the most aggressive surgical treatment options for the patients with symptomatic carotid stenosis. This review summarizes the scientific evidence based on multiple large clinical studies showing how the modern-day management of carotid stenosis has evolved. Multiple, large randomized clinical trials have established carotid endarterectomy (CEA) as the treatment of choice for symptomatic patients with symptomatic, >50% stenosis of carotid artery or those who have asymptomatic high grade carotid stenosis. With the advancements in endovascular techniques, the technique of Trans Femoral Carotid Artery Stenting (TF-CAS) was popularized, but after multiple, large randomized controlled trials demonstrated superiority of CEA, the indications for TF-CAS as the initial operation of choice for carotid disease for all patients have been reduced. In the past five years, the introduction of the newer technique of Trans Carotid Artery Revascularization (TCAR) has shown promising results with significant reduction in the incidence of perioperative complications as compared to CEA and TF-CAS, however, there have been no randomized controlled trials comparing TCAR to either CEA or TF-CAS. Moreover, with the developments in the medical field with introduction of several new medications which have been demonstrated to successfully change the plaque morphology, there has been a renewed interest in exploring if the indications for surgical management for the asymptomatic carotid disease should be revisited.

Prevalence, Clinical Features, and Management of Cervical Polyps: A One-Year Study at Rabia Balkhi Hospital in Afghanistan.

Background Cervical polyps are benign growths from the cervical epithelium, found in 2% to 5% of the population. They usually appear as small, stalk-attached lesions ranging from pea to cherry size. Contributing factors include cervical infections, congestion, and elevated estrogen levels. During pregnancy, these polyps may increase the risk of late abortion and preterm birth. While malignancy is rare, histopathological examination after removal is advised to rule out cancer. Materials and methods This current study, the first of its kind in Afghanistan, aimed to assess the scope of cervical polyps among Afghan women presenting to Rabia Balkhi National Hospital in 2018. We conducted a descriptive study of cervical polyps, exploring the prevalence, symptoms, complications, and procedures used to remove them. Data were collected from 3730 cases admitted to the hospital. Results Out of 3730 cases, 50 patients (1.34%) were diagnosed with cervical polyps. The polyps varied in size and were typically attached to the cervix by a slender stalk. Symptoms reported included inter-menstrual, post-coital, and post-menopausal bleeding. Histopathological examinations were performed following polyp removal to rule out malignancy. Conclusion This study provides a comprehensive overview of the prevalence and clinical presentation of cervical polyps among Afghan women. The findings highlight the importance of recognizing and managing cervical polyps to prevent potential complications, especially during pregnancy. Further research is needed to understand this population's epidemiology, pathogenesis, and optimal management strategies for cervical polyps.

Epidemiologic pattern and factors associated with adverse outcomes of diabetic ketoacidosis in medical intensive care units of a tertiary care centre in India

AimDiabetic ketoacidosis (DKA) is a dreadful complication of diabetes mellitus characterized by a biochemical triad of hyperglycemia, ketosis, and metabolic acidosis. The clinic-epidemiologic pattern and outcomes of DKA in the Indian subcontinent are largely unexplored, yet understanding them is crucial for optimizing management strategies. MethodsA total of 138 patients admitted with a DKA diagnosis were reviewed retrospectively over two years. Patient demographics, clinical history, laboratory findings, precipitating factors, and intensive care management were extracted from case files. Clinical outcomes were classified as either discharge or death. Data analysis was performed using SPSSv29. ResultsThe mean age of the patients was 41.54 (16) years; 77 (55.79 %) were female, 56.52 % had type 1, 23.19 % had type 2, and 20.29 % had pancreatic diabetes. Non-compliance with infection (21.02 %), and pancreatitis (21.01 %) were common DKA triggers. Severity was assessed by pH, anion gap, and bicarbonate levels. The overall mortality rate was 11.59 %. Factors significantly associated with mortality included age >60 years, >3 previous DKA episodes, hypokalaemia, elevated serum creatinine, and altered sensorium. ConclusionThese findings emphasize the importance of demographics and risk factors in assessing DKA mortality risk, aiding early identification and targeted interventions for high-risk patients.

Optimal management of citrus disease and extreme climatic factors

This study develops a dynamic bioeconomic model using the Bellman equation to derive the optimal management strategy for Witches’ Broom Disease of Lime (WBDL) and the optimal replanting age of citrus trees after the first attack under multiple scenarios of disease management options and climate conditions. In addition, the study investigates different scenarios of disease presence and spread given different climatic conditions of arid, semi-arid and tropical zones in Oman. Factors such as disease incidence, severity, spread, and specific climatic conditions of three growing regions are considered. The farmers' optimal disease mitigation decision is determined by the disease density and insect vector level on the farm, and adverse climate conditions have a significant negative impact on the economic value of citrus cultivation. Results indicate that management measures by citrus growers and policymakers should be based on the climatic conditions of the growing region with a high level of treatment frequency and intensity in the arid region, and lime production should be concentrated in the tropical and semi-arid regions of the country.