Modification Of Plan Research Articles

Comparative Hox genes expression within the dimorphic annelid Streblospio benedicti reveals patterning variation during development

Hox genes are transcriptional regulators that elicit cell positional identity along the anterior–posterior region of the body plan across different lineages of Metazoan. Comparison of Hox gene expression across distinct species reveals their evolutionary conservation; however, their gains and losses in different lineages can correlate with body plan modifications and morphological novelty. We compare the expression of 11 Hox genes found within Streblospio benedicti, a marine annelid that produces two types of offspring with distinct developmental and morphological features. For these two distinct larval types, we compare Hox gene expression through ontogeny using hybridization chain reaction (HCR) probes for in situ hybridization and RNA-seq data. We find that Hox gene expression patterning for both types is typically similar at equivalent developmental stages. However, some Hox genes have spatial or temporal differences between the larval types that are associated with morphological and life-history differences. This is the first comparison of developmental divergence in Hox gene expression within a single species and these changes reveal how body plan differences may arise in larval evolution.

Enhancing Urban Sustainability: Developing an Open-Source AI Framework for Smart Cities

To address the growing need for advanced tools that enable urban policymakers to conduct comprehensive cost-benefit analyses of traffic management changes, the Urbanite H2020 project has developed innovative artificial intelligence methods. Among them is a robust decision support system that assists policymakers in evaluating and selecting optimal urban mobility planning modifications by combining objective and subjective criteria. Utilising open-source microscopic traffic simulation tools, accurate digital models (or “digital twins”) of four pilot cities—Bilbao, Amsterdam, Helsinki, and Messina—were created, each addressing unique mobility challenges. These challenges include reducing private vehicle access in Bilbao’s city center, analysing the impact of increased bicycle traffic and population growth in Amsterdam, constructing a mobility-enhancing tunnel in Helsinki, and improving public transport connectivity in Messina. The research introduces five key innovations: the application of a consistent open-source simulation platform across diverse urban environments, addressing integration and consistency challenges; the pioneering use of Dexi for advanced decision support in smart cities; the implementation of advanced visualisations; and the integration of the machine learning tool, Orange, with a user-friendly GUI interface. These innovations collectively make complex data analysis accessible to non-technical users. By applying multi-label machine learning techniques, the decision-making process is accelerated by three orders of magnitude, significantly enhancing urban planning efficiency. The Urbanite project’s findings offer valuable insights into both anticipated and unexpected outcomes of mobility interventions, presenting a scalable, open-source AI-based framework for urban decision-makers worldwide.

Factors Associated With the Initiation of Comfort-Focused Nutrition Care Orders for Long-Term Care Residents at End of Life.

Comfort-focused nutrition orders are recommended to manage eating changes among long-term care (LTC) residents nearing the end of life, though little is known about their current use. This investigation aims to describe current practices and identify resident-level and time-dependent factors associated with comfort-focused nutrition orders in this context. Data were retrospectively extracted from resident charts of decedents (≥65 years at death, admitted ≥6 months) in 18 LTC homes from two sampling frames across southern Ontario, Canada. Observations occurred at 6 months (baseline), 3 months, 1 month and 2 weeks prior to death. Extracted data included functional measures (e.g. cognitive performance, health instability) at baseline, formalised restorative and comfort-focused nutrition care interventions at each timepoint and eating changes reported in the progress notes in 2 weeks following each timepoint. Logistic regression and time-varying logistic regression models determined resident-level (e.g. functional characteristics) and time-dependent factors (e.g. eating changes) associated with receiving a comfort-focused nutrition order. Less than one-third (30.5%; n = 50) of 164 participants (61.0% female; mean age = 88.3 ± 7.5 years) received a comfort-focused nutrition order, whereas most (99%) received at least one restorative nutrition intervention to support oral food intake. Discontinuation of nutrition interventions was rare (8.5%). Comfort orders were more likely with health instability (OR [95% CI] = 4.35 [1.49, 13.76]), within 2 weeks of death (OR = 5.50 [1.70, 17.11]), when an end-of-life conversation had occurred since the previous timepoint (OR = 5.66 [2.83, 11.33]), with discontinued nutrition interventions (OR = 6.31 [1.75, 22.72]), with co-occurrence of other care plan modifications (OR = 1.48 [1.10, 1.98]) and with a greater number of eating changes (OR = 1.19 [1.02, 1.38]), especially dysphagia (OR = 2.59 [1.09, 6.17]), at the preceding timepoint. Comfort-focused nutrition orders were initiated for less than one-third of decedents and most often in the end stages of life, possibly representing missed opportunities to support the quality of life for this vulnerable population. An increase in eating changes, including new dysphagia, may signal a need for proactive end-of-life conversations involving comfort nutrition care options. Early and open conversations with residents and family about potential eating changes and comfort-focused nutrition care options should be encouraged and planned for among geriatric nursing teams working in LTC. These conversations may be beneficial even as early as resident admission to the home.

Preoperative Nonselective Chest Computed Tomography Prior to Primary Cardiac Surgery Results in Meaningful Change to Surgical Management: Systematic Review and Pooled Prevalence Meta-Analysis

Routine screening chest computed tomography (CT) prior to primary cardiac surgery is advocated by some surgeons due to the purported benefits of identifying significant aortic calcification that impacts ongoing management, such as performing anaortic off-pump surgery or adjusting cannulation strategy. Additionally, axial imaging can identify incidental findings that may require concomitant or staged procedures such as ascending aortic dilatation or pulmonary lesions. The objective of this study was to quantify the impact that nonselective chest CT prior to primary cardiac surgery had on subsequent management. A systematic review and pooled prevalence meta-analyses were performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Included studies performed non-selective chest CT prior to primary cardiac surgery. A total of eight studies, including 2,250 patients were included. The rate of mortality and stroke was low (1% and 2%, respectively). Calcification of the ascending aorta was identified in 15% of patients (95% confidence interval [CI] 5.0-26.0). A significant change to the surgical plan such as cannulation strategy, off-pump surgery, cancellation, or an additional procedure was required in 7% (95% CI 2.0-12.0). Clinically relevant incidental findings requiring in-patient management or follow-up were identified in 10% (95% CI 6.0-14.0). Nonselective CT chest prior to primary cardiac surgery identifies clinically relevant findings that result in a modification of the surgical plan in a significant population of patients to address the risk of stroke associated with aortic calcification as well as the identification of important incidental findings such as pulmonary lesions.

Can 'Script Elicitation' Methods Be Used to Promote Physical Activity? An Acceptability Study.

Sustaining physical activity may require incorporating activity into everyday routines. Yet, many such routines are executed habitually, so people may not recognise physical activity opportunities. 'Script Elicitation'-a novel intervention method whereby participants detail the content and structure of their routines and are supported to plan modifications to those routines-has not yet been applied to physical activity. This mixed-methods study assessed the acceptability of Script Elicitation for increasing physical activity among office workers. Eleven UK office workers completed the one-to-one Script Elicitation procedure, describing their typical before-, during-, or after-work routines and receiving guidance on incorporating activity into those routines. One week later, they rated the acceptability of the method and completed a semi-structured interview. Physical activity was self-reported at baseline and at the one-week follow-up. Acceptability was descriptively assessed on two quantitative criteria (no clear decrease in physical activity; above-midpoint acceptability scores) and qualitatively explored via Thematic Analysis. The acceptability criteria were met, and participants reported raised awareness of routines and physical activity increases. Script Elicitation appears potentially suitable for promoting activity within everyday routines. If effectiveness is shown in a more rigorous trial, future work will need to develop script-based methods for efficient delivery at scale as a public health intervention.

Impact of multidisciplinary tumor boards on clinical decision making in a genitourinary oncology clinic in Mexico city.

e23217 Background: Effective management of genitourinary neoplasms demands a comprehensive approach due to the diverse treatment options and the need for multiple specialists. Multidisciplinary tumor board (MDTB) meetings are a platform for experts to collectively assess and discuss the latest evidence and provide their expertise to tailor treatment plans for patients. Methods: Cases discussed during uro-oncology MDTB meetings at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán in Mexico City over a five-year period (01/2018 to 12/2022) were included. We analyzed the type of neoplasm, reason for case discussion, specialties involved and whether the final decision led to a modification of the original plan. Descriptive statistics were used for analysis. Chi-squared test was used to determinate differences and p value < 0.05 was considered statistically significant. A logistic regression analysis was performed for multivariate analysis. Results: Over the study period, 500 discussions involving 399 patients were included. 87% were men. Prostate, kidney, testicular, upper tract urothelial and bladder carcinoma, represented: 223 (44.6%), 117 (23.4%), 84 (16.8%), 37 (7.4%), 32 (6.4%) of cases, respectively. The majority were presented by urology (319 cases; 63.6%). The primary reason for presentation was surgical decisions in 54.6%. Regarding final conclusions, 55.8% underwent modifications in the treatment plan, 33.2% had no changes and 11% remained inconclusive, requiring further assessment. Individuals with metastatic disease had a higher likelihood of treatment plan changes in 61.6% vs 52.3% (OR 1.46 95%CI 1.01-2.12; p = 0.042). The 163 cases (32.6%) presented during the COVID-19 pandemic were more prone to have treatment modifications 62.6% vs 52.5% (OR 1.51 95%CI 1.03-2.22; p = 0.034); cases presented for surgical reasons during this period were more likely to have a change in treatment modality 74% vs 52.3% (OR 2.6 95%CI 1.34-5.04; p = 0.004). Implementation of results was successful in most cases (72%), with a median time of 3.6 weeks. Reasons for not implementing the plan included: patient decision, treating physician decision, comorbidities, death, and lack of resources. Factors associated with implementation in the multivariate analysis included: male gender (OR 2.81), cases presented during pandemic (OR 2.0), and by urology service (OR 1.92). Conclusions: Among patients presented in our uro-oncology MDTB meetings, more than half will have a change in the original treatment plan, and this agreed strategy is successfully implemented in most individuals. These sessions remained key for patient management during the COVID-19 pandemic.

Evaluation of FebriDx® for the management of children with acute febrile respiratory infection

IntroductionAcute respiratory infections (ARI) are a common cause of inappropriate antibiotic prescription (ATB) in pediatrics. FebriDx® is a rapid diagnostic test that differentiates between viral and bacterial infections. The objective is to analyse the impact of FebriDx® on ATB prescription when managing febrile ARI. MethodsProspective study carried out in patients aged 1–<18 years with febrile ARI in the emergency department. FebriDx® was performed and the impact on management was evaluated at follow-up. ResultsA total of 216 patients were included. Clinical assessment and FebriDx® result coincided coincided in 174 (80.5%) cases. A modification of the initial therapeutic plan was made in 22 (52.4%) of the 42 discordant ones (10.2% of the overall patients). In pneumonia the impact was 34.5%; in all cases it involved not prescribing ATB. ConclusionsFebriDx® could be a useful tool in the management of pediatric patients with febrile ARI to optimize ATB prescription.

Magnetic Resonance Imaging-Guided Frameless Stereotactic Injections of the Bilateral Cerebellar Dentate Nuclei in Nonhuman Primates: Technical Note.

Nonhuman primates (NHPs) are important preclinical models for evaluating therapeutics because of their anatomophysiological similarities to humans, and can be especially useful for testing new delivery targets. With the growing promise of cell and gene therapies for the treatment of neurological diseases, it is important to ensure the accurate and safe delivery of these agents to target structures in the brain. However, a standard guideline or method has not been developed for stereotactic targeting in NHPs. In this article, we describe the safe use of a magnetic resonance imaging-guided frameless stereotactic system to target bilateral cerebellar dentate nuclei for accurate, real-time delivery of viral vector in NHPs. Seventeen rhesus macaques (Macaca mulatta) underwent stereotactic surgery under real-time MRI guidance using the ClearPoint® system. Bilateral cerebellar dentate nuclei were targeted through a single parietal entry point with a transtentorial approach. Fifty microliters of contrast-impregnated infusate was delivered to each dentate nucleus, and adjustments were made as necessary according to real-time MRI monitoring of delivery. Perioperative clinical outcomes and postoperative volumes of distribution were recorded. All macaques underwent bilateral surgery successfully. Superficial pin site infection occurred in 4/17 (23.5%) subjects, which resolved with antibiotics. Two episodes of transient neurological deficit (anisocoria and unilateral weakness) were recorded, which did not require additional postoperative treatment and resolved over time. Volume of distribution of infusate achieved satisfactory coverage of target dentate nuclei, and only 1 incidence (2.9%) of cerebrospinal fluid penetration was recorded. Mean volume of distribution was 161.22 ± 39.61 mm3 (left, 173.65 ± 48.29; right, 148.80 ± 23.98). MRI-guided frameless stereotactic injection of bilateral cerebellar dentate nuclei in NHPs is safe and feasible. The use of this technique enables real-time modification of the surgical plan to achieve adequate target coverage and can be readily translated to clinical use.

Independent Monte Carlo dose calculation identifies single isocenter multi-target radiosurgery targets most likely to fail pre-treatment measurement.

For individual targets of single isocenter multi-target (SIMT) Stereotactic radiosurgery (SRS), we assess dose difference between the treatment planning system (TPS) and independent Monte Carlo (MC), and demonstrate persistence into the pre-treatment Quality Assurance (QA) measurement. Treatment plans from 31 SIMT SRS patients were recalculated in a series of scenarios designed to investigate sources of discrepancy between TPS and independent MC. Targets with>5% discrepancy in DMean[Gy] after progressing through all scenarios were measured with SRS MapCHECK. A matched pair analysis was performed comparing SRS MapCHECK results for these targets with matched targets having similar characteristics (volume & distance from isocenter) but no such MC dose discrepancy. Of 217 targets analyzed, individual target mean dose (DMean[Gy]) fell outside a 5% threshold for 28 and 24 targets before and after removing tissue heterogeneity effects, respectively, while only 5 exceeded the threshold after removing effect of patient geometry (via calculation on StereoPHAN geometry). Significant factors affecting agreement between the TPS and MC included target distance from isocenter (0.83% decrease in DMean[Gy] per 2cm), volume (0.15% increase per cc), and degree of plan modulation (0.37% increase per 0.01 increase in modulation complexity score). SRS MapCHECK measurement had better agreement with MC than with TPS (2%/1mm / 10% threshold gamma pass rate (GPR)=99.4±1.9%vs. 93.1±13.9%, respectively). In the matched pair analysis, targets exceeding 5% for MC versus TPS also had larger discrepancies between TPS and measurement with no GPR (2%/1mm / 10% threshold) exceeding 90% (71.5%±16.1%); whereas GPR was high for matched targets with no such MC versus TPS difference (96.5%±3.3%, p=0.01). Independent MC complements pre-treatment QA measurement for SIMT SRS by identifying problematic individual targets prior to pre-treatment measurement, thus enabling plan modifications earlier in the planning process and guiding selection of targets for pre-treatment QA measurement.

Twelve Years Success of Radiographical Assessment and Clinical Review of Post Periapical Surgery of a Tooth with Canal Calcificification (Case Study)

This case report deliberates on the modification of the treatment plan for a young female patient having a history of trauma to her anterior tooth for two years duration. The patient didn’t pay attention to the trauma at that time and she barely remember about it, until she gets in pain. In this case study we will highlight on the treatment options and how to save the tooth. Different modality of treatment has been raised to study the possibility of the survival of this tooth since the patient doesn’t want to lose it.

Tools and Strategies to Integrate Multi-Domain Information for Personalized Decision-Making in Oncological Care Pathways: A Scoping Review.

There is a growing interest in personalized decision-making in oncology. According to the Integrated Oncological Decision-Making Model (IODM), decisions should be based on information from three domains: (1) medical technical information, (2) patients' general health status and (3) patients' preferences and goals. Little is known about what kind of tool/strategy is used to collect the information, by whom this is collected (nurse, clinician) when this is collected (moment in the care pathway), and how this information should be collected and integrated within decision-making in oncological care pathways, and what its impact is. We searched PUBMED, Embase and Web of Science in October 2023 for studies looking at tools to collect and integrate information from the three domains of the IODM. We extracted data on the content and implementation of these tools, and on decision and patient outcomes. The search yielded 2576 publications, of which only seven studies described collection of information from all three domains (inclusion criteria). In the seven included studies, information on the three domains was collected through dialogue, questionnaires, and assessments (what) by a nurse (2 out of 7 studies) or by other members of the Multi-Disciplinary Team (by whom) (5 out of 7 studies). Members of the Multi-Disciplinary Team subsequently integrated the information (5 out 7 studies) during their meeting (when), with patients and family attending this meeting in 2 studies (how). In terms of decision outcomes, 5 out of 7 studies compared the treatment recommendations before and after implementation of the tools, showing a modification of the treatment plan in 3% to 53% of cases. The limited data on patient outcomes suggest positive effects on well-being and fewer complications (3 out of 7 studies). The seven studies identified that integrated information from the three IODM domains into treatment decision-making lacked comprehensive information regarding the strategies, process, timing and individuals involved in implementing the tools. Nevertheless, the few studies that looked at patient outcomes showed promising findings.

Multi-analytical approach for Risk identification and its management for successful Infrastructure projects

It has been determined that managing risks is a crucial management technique for achieving project goals in terms of time, money, quality, and degree. On the basis of a thorough analysis of agreement states, this article recognises dangers and categorises them into eight categories. It is viewed in a personal way. It is believed that social body opposition, risk assessment, plan modifications, and work suspension will all have the biggest effects on the project's objectives. This research has produced a few suggestions for reducing the hazards associated with development projects, or mitigation methods. The contract agreements are employed as a tool to track risk, and the client, contractors, and financial backers who are sponsoring the project must specify how they intend to threaten the executive's plan during the project's lifespan. It is intended that clients, contractors, project workers, and governmental organisations will work together to manage projected hazards as they arise, starting at the attainability stage.

Preoperative assessment of depressor anguli oris to prevent myectomy failure: An anatomical study using high-resolution ultrasound

Myectomies of the lower lip depressor muscles have unexplained high failure rates. This study aimed to examine the depressor anguli oris (DAO) muscle using high-resolution ultrasound to identify potential anatomical explanations for surgical failures and to determine the accuracy of utilizing preoperative ultrasound assessment to improve myectomies. Anatomical features of DAO and the surrounding anatomy were examined in 38 hemifaces of human body donors using high-resolution ultrasound and dissection. The ultrasound and dissection measurements showed the DAO muscle width to be 16.2±2.9 versus 14.5±2.5mm, respectively, and the location of the lateral muscle border 54.4±5.7 versus 52.3±5.4mm lateral to the midline. In 60% of the cases, the facial artery was either completely covered by lateral DAO muscle fibers or was found to be in direct contact with the lateral border. Significant muscle fiber continuity was present between the DAO and surrounding muscles in 5% of cases, whereas continuity between the depressor labii inferioris and surrounding muscles was considerably more common and pronounced. High-resolution ultrasound can accurately reveal important preoperative anatomical information in myectomies. Two potential explanations for the surgical failures were discovered: an overlap of lateral DAO muscle fibers over the facial artery could lead to inadequate resections and continuity with the surrounding muscles might lead to muscle function takeover despite adequate resections. Both can be uncovered preoperatively by the surgeon through a brief, directed ultrasound examination, which may allow for modification of the surgical plan to reduce surgical failure.

A Rare Axillary Lymph Node Metastasis on 18F-FDG PET/CT for Staging in a Patient with Common Bile Duct Cancer.

Distant metastasis of cholangiocarcinoma is most commonly diagnosed in the liver; however, it can also be found in the lungs, distant lymph nodes, bones, and brain. Distant lymph node metastasis outside the abdominal region without concurrent abdominal metastasis is exceedingly rare in extrahepatic cholangiocarcinoma. Herein, we present interesting 18F-FDG PET/CT images of a 49-year-old male patient with common bile duct cancer. In this case, the patient, who was scheduled for surgery, unexpectedly showed axillary lymph node metastasis on a preoperative 18F-FDG PET scan, which was subsequently confirmed via histological examination. Although such cases are exceptionally rare, this accurate diagnosis prompted a modification of the treatment plan, leading to a positive therapeutic response.

Changing trends in central midface fracture – A proposal for revised classification and holistic management

BackgroundMidface fractures are one of the common facial fractures encountered in the current era. High energy impact injuries that lead to gross comminution of the midface warranting modification of the standard treatment plan, often cannot be categorized by existing classification systems. The aim of the current paper is to describe the changing trends in midface fracture patterns and propose a modification for the current classification system and describe the holistic approach for management. Materials and methodsA retrospective study was conducted at our center to include all the patients who reported to us for the management of maxillofacial trauma between 2020 and 2022. The details of the cause of facial trauma and pattern of injury, clinical presentation, diagnosis were retrieved from the medical records and the radiographic details including computed tomography details of the fracture pattern were tabulated for evaluation. The Fractures which could not be classified based on the classical Le fort fracture lines were isolated and were classified based on the current classification system and the modifications in the treatment plan and management were recorded. ResultsA total of 673 trauma cases reported between the given time frame. Out of which 205 were midface fractures. 109 patients from the foresaid group had central mid face fracture. 62 fractures of these cases could not be classified based on conventional Le fort classification due to fragmentation, bone loss and combination with other Le fort level injury of the opposite side of the midface and involvement of orbit/ anterior cranial fossa. The modified Le fort classification (Table 1) was used to reclassify these fractures and according to the same 12 cases of Le fort IA, 9 cases of le fort IB, 4 cases of Le fort IIA, 20 cases of Le fort IIB, 4 cases of Le fort IIIA, 9 cases of Le fort IIIB and 4 cases of Le fort IV fracture.The details of the management strategy along with the timing of repair are discussed. ConclusionWith continual rise in the high impact injuries, the pattern of midface fracture presentation is changing. Advanced fixation modalities that are currently available can be applied only when a precise diagnosis and planning can be performed. The current modification of the midface fractures provides a better insight in defining the fracture patterns which will enable the surgeon to plan the midface reconstruction adequately.

Prediction of summer daytime land surface temperature in urban environments based on machine learning

Land Surface Temperature (LST) is an important indicator of urban heat environments and can be largely influenced by the morphology factors of cities. However, previous studies mainly focus on large-scale and coarse-grained forecast modeling, making it hard to inform architects and urban designers without the advantage of quick, fine-grained prediction and visualization. The paper uses Generative Adversarial Networks (GAN) to address this gap by proposing a prediction model of city plans and corresponding LST heat maps. Taking New York City as an example, we use the Light Detection and Ranging (LiDAR) data, Landsat Surface Temperature data, and other relevant data to build seven hundred image pairs as the training set to train the model of predicting LST distribution. Using untrained pairs as the test set, the model can generate LST maps relatively quickly and accurately with the input of city plans. Then after accuracy analysis, different scenarios are simulated to test the application of the model in predicting the environmental impacts of plan modifications on land surface temperature. Eventually, the principles proposed in this paper can be applied to the development of relevant interactive design and planning tools in the future.

Harnessing the power of collective intelligence in dentistry: a pilot study in Victoria, Australia

BackgroundIn many dental settings, diagnosis and treatment planning is the responsibility of a single clinician, and this process is inevitably influenced by the clinician’s own heuristics and biases. Our aim was to test whether collective intelligence increases the accuracy of individual diagnoses and treatment plans, and whether such systems have potential to improve patient outcomes in a dental setting.MethodsThis pilot project was carried out to assess the feasibility of the protocol and appropriateness of the study design. We used a questionnaire survey and pre-post study design in which dental practitioners were involved in the diagnosis and treatment planning of two simulated cases. Participants were provided the opportunity to amend their original diagnosis/treatment decisions after viewing a consensus report made to simulate a collaborative setting.ResultsAround half (55%, n = 17) of the respondents worked in group private practices, however most practitioners (74%, n = 23) did not collaborate when planning treatment. Overall, the average practitioners’ self-confidence score in managing different dental disciplines was 7.22 (s.d. 2.20) on a 1–10 scale. Practitioners tended to change their mind after viewing the consensus response, particularly for the complex case compared to the simple case (61.5% vs 38.5%, respectively). Practitioners' confidence ratings were also significantly higher (p < 0.05) after viewing the consensus for complex case.ConclusionOur pilot study shows that collective intelligence in the form of peers’ opinion can lead to modifications in diagnosis and treatment planning by dentists. Our results lay the foundations for larger scale investigations on whether peer collaboration can improve diagnostic accuracy, treatment planning and, ultimately, oral health outcomes.

Scoring system for predicting 90-day mortality of in-hospital liver cirrhosis patients at Cipto Mangunkusumo Hospital

BackgroundLiver cirrhosis is the final stage of chronic liver disease. Complications due to progression of liver disease may deteriorate the liver function and worsen prognosis. Previous studies have shown that patients with liver cirrhosis are at increased risk of death within 90-day after hospitalization. It is necessary to identify patients who are at higher risk of early mortality. This study aims to develop a scoring system to predict the 90-day mortality among hospitalized patients with liver cirrhosis that could be used for modification of treatment plan according to the scores that have been obtained. By using this scoring system, crucial care of plans can be taken to reduce the risk of mortality.MethodThis prospective cohort study was conducted on hospitalized cirrhotic patients at Cipto Mangunkusumo National General Hospital, Jakarta. Demographic, clinical, and laboratory data were recorded. Patients were monitored for up to 90-day after hospitalization to determine their condition. Cox regression analysis was performed to obtain predictor factors contributing to mortality in liver cirrhosis patients. The scoring system that resulted from this study categorized patients into low, moderate, and high-risk categories based on their predicted mortality rates. The sensitivity and specificity of the scoring system were evaluated using the AUC (area under the curve) metric.ResultThe study revealed that liver cirrhosis patients who were hospitalized had a 90-day mortality rate of 42.2%, with contributing factors including Child-Pugh, MELD, and leukocyte levels. The combination of these variables had a good discriminative value with an AUC of 0.921 (95% CI: 0.876–0.967). The scoring system resulted in three risk categories: low risk (score of 0–3) with a 4.1-18.4% probability of death, moderate risk (score of 5–6) with a 40.5-54.2% probability of death, and high risk (score of 8–11) with a 78.1-94.9% probability of death.ConclusionThe scoring system has shown great accuracy in predicting 90-day mortality in hospitalized cirrhosis patients, making it a valuable tool for identifying the necessary care and interventions needed for these patients upon admission.

The Procedure for Restructuring Budgetary Claims from Necessity to Reality

Abstract The present work approaches the legal institution of the restructuring of budgetary claims from the perspective of the procedure to be followed by the tax debtors interested in agreeing on the need to extinguish their budgetary claims with the desire to avoid the insolvency of the company. We bring up that the restructuring of budgetary claims was thought so as to offer a helping hand, especially to large companies in a situation of major financial difficulty. This present study aims to provide a synthetic picture of the steps to be followed in order to successfully complete this procedure. For this, the procedure is divided into three stages, namely the pre-stage, the procedure itself and the completion of the procedure. The acts to be performed at the pre-stage refer to the notification of the restructuring intention, the restructuring plan and the prudent private creditor test. The stage itself of the restructuring starts with the submission of the application to the tax authority, which will be settled by it either with a decision approving the restructuring or with a decision rejecting it, or with a decision approving a payment facility. Once the restructuring is approved, it will be carried out in accordance with the restructuring plan, under the supervision of the persons designated for this purpose. During its development, the restructuring process may undergo changes that will materialize either in the modification of the restructuring plan or in the modification of the payment facilitation decision, if such a facility has been approved. Whether there is a change in the restructuring process, or not, once it has started, it will have to be completed. If the restructuring plan is successfully implemented, the fiscal debtor’s budgetary claims will be extinguished and he will be able to go on with the economic activity for which he was established. If, however, the restructuring plan fails, the tax debtor risks being subject to forced execution by the tax authority, or even to request its insolvency, which could lead to the cessation of its existence.

Outcomes of Gynecologic Cancer Surgery During the COVID-19 Pandemic: An International, Multicenter, Prospective CovidSurg–Gynecologic Oncology Cancer Study

ABSTRACT The logistic strain on the health care system during the COVID-19 pandemic disproportionally affected women with gynecologic cancers and surgical care delivery. Surgeries were being delayed or replaced by systemic or palliative care options with less favorable outcomes. The true impact of pandemic-related modifications to clinical management of surgical gynecologic cancer patients remains unknown. This international prospective cohort study aimed to analyze the clinical and surgical outcomes of patients with gynecologic cancer who had or were planned to have first-line treatment during the COVID-19 pandemic. This study was part of an umbrella study exploring the impact of COVID-19 in surgical patients across all solid cancer types and multiple specialties (GlobalSurg-CovidSurg Consortium). All hospitals that included patients discussed for surgery regardless of whether they were operated on or not were included in this study. Patients who were planned for curative or life-prolonging surgery or underwent surgery for gynecologic cancer during the COVID-19 pandemic were included. Patients were followed up from the time of multidisciplinary team decision for surgery for the next 3 months, representing the first peak period of the pandemic. The primary outcome was the incidence in pandemic-related changes in care, whereas secondary outcomes included perioperative morbidity and mortality, wait time before surgery, postoperative hospital stay time, proportion of patients not operated on with progression to incurable disease or death, and a composite adverse outcome to measure the potential impact of any treatment delays or adjustment. A total of 3973 patients from 227 centers across 52 countries were included, of whom 3784 (95.2%) ultimately underwent surgery. The majority of patients had uterine or ovarian cancer (n = 3270 [82%]) and were from high-income countries (n = 2906 [73%]). A total of 189 operations (7.9%) were canceled. Although the median time from multidisciplinary team decision to surgery was 3 weeks, 11.2% (424/3784) of patients underwent surgery more than 8 weeks later. Among ovarian cancer patients with stage III/IV disease and a significant delay (&gt;8 weeks) of surgery, 83.6% had neoadjuvant chemotherapy compared with 21% for those who did not experience a delay (P &lt; 0.0001). The overall 30-day postoperative complication rate was 19.3%, and the postoperative COVID-19 infection rate was 0.6%. The length of stay was significantly longer for COVID-19–infected patients (median, 8.5 vs 4 days; P = 0.0001). When evaluating the entire cohort, a total of 20.7% (823/3973) had their standard of care adjusted because of the pandemic. Patients in low- and middle-income countries (P &lt; 0.0001), areas under full lockdown (P &lt; 0.0001), with worse performance status (P &lt; 0.0001), more comorbidities (P = 0.0242), higher American Society of Anesthesiologists grade (P = 0.010), ovarian cancer (P &lt; 0.001), and stage 3 or 4 diseases (P &lt; 0.0001) were more likely to have their operations more than 8 weeks after the MTD decision. There was no significant difference in 30-day mortality among those with delayed operations; however, a significant difference was observed for the adverse composite outcome owing to delay including unresectable disease or disease progression, emergency surgery, and death (95/424 [22.4%] vs 601/3360 [17.9%]; P = 0.024). The results of this study demonstrate that despite a very low risk of perioperative COVID-19 infection, a significant portion of gynecologic cancer surgical patients had treatment plan modifications associated with early negative impact.