Preferred Management Strategy Research Articles

Estimating stream sediment loads to assess management options for a Southern Appalachian mountain lake

Enka Lake is a 25-ha reservoir in the Southern Appalachian mountains surrounded by the Biltmore Lake residential neighborhood. The aesthetic and recreational value of Enka Lake can be negatively affected by turbid water and sediment buildup, resulting from stormwater originating upstream in its 15.38 km2 watershed. In this study, we monitored streamflow and sediment loads for nearly 2 years to better understand sedimentation dynamics and evaluate management options. We collected nearly 500 water samples throughout the watershed, focusing on two tributaries that provide the majority of streamflow into Enka Lake. During baseflow conditions, those tributaries are very clear (turbidity ranging from 1 to 20 NTU), but sediment-laden stormflow (turbidity > 1000 NTU) from dirt roads, gravel driveways, and poorly vegetated yards is common and, during extreme storm events, causes lake discoloration. Discharge-sediment data pairs were used to construct sediment rating curves and estimate sediment fluxes through these tributaries. The predicted sediment fluxes were tested with high-frequency sampling during and after three storms in different seasons; predicted values underestimated the peak sediment fluxes (0–400%) but generally matched total measured sediment loads. Estimates of annual sediment load from the two tributaries (540–900 tonnes/year) suggest that a dredging effort commissioned by the neighborhood association in 2016 may have removed only about 1–3 years’ worth of sediment. Installing sediment forebays or other retention structures is likely the preferred sediment management strategy moving forward (over a regular dredging schedule) since they can be maintained more easily without affecting lake levels. Designing these retention structures will benefit from the estimates of stormflow and sediment fluxes, and the study design presented here—including the help of community-based volunteer samplers—provides a model that could be used at other sites in the Southern Appalachians and elsewhere.

Risk factors of video urodynamics and bladder management for long-term complications in patients with chronic spinal cord injury

This study explores 15-year urological complications in chronic spinal cord injury (SCI) patients and investigates the predictive factors from video-urodynamic study (VUDS) and bladder management. Analyzing 864 SCI patients with a mean 15.6-year follow-up, we assessed complications and utilized multivariate logistic regression for risk evaluation. VUDS factors such as autonomic dysreflexia, detrusor sphincter dyssynergia, vesicourethral reflux (VUR), contracted bladder, and high voiding detrusor pressure significantly increased the likelihood of recurrent urinary tract infections (rUTI). Low bladder compliance, VUR, and contracted bladder notably raised the risk of hydronephrosis, while contracted bladder and detrusor overactivity with detrusor underactivity heightened chronic kidney disease risk. Volitional voiding reduced rUTI and VUR risk, whereas Valsalva maneuver-assisted voiding increased hydronephrosis risk. In conclusion, a contracted bladder identified in VUDS is associated with long-term urological complications in SCI, we propose that patients already experiencing a contracted bladder should prioritize volitional voiding as their preferred bladder management strategy to minimize the risk of additional complications such as rUTI and VUR. These findings unveil previously unexplored aspects in research, emphasizing the need for proactive management strategies in this patient population.

Management Approaches in WHO Grade III Meningioma: A National Oncology Trainees' Collaborative for Healthcare Research (NOTCH) UK Multi-Centre Retrospective Study

AimsWHO Grade 3 (G3) meningiomas are rare tumours with limited data to guide management. This retrospective study documents UK management approaches across 14 centres over 11 years. Materials and methodsPatients with WHO G3 meningioma between 01/01/2008 and 31/12/2018 were identified. Data were collected on demographics, management strategy, adjuvant radiotherapy, approach in recurrence setting and survival. Results84 patients were identified. 21.4% transformed from lower-grade disease. 96.4% underwent primary surgical resection, with 20.8% having evidence of residual disease on their post-op MRI. 59.3% of patients underwent adjuvant radiotherapy (RT) following surgical resection.Overall median PFS and OS were 12.6 months and 28.2 months, respectively. Median OS in the group who underwent complete surgical resection was 34.9 months, compared to 27.5 months for those who had incomplete resection (HR 0.58, 95% CI 0.27–1.23, p = 0.15). Median OS was 33.1 months for those who underwent adjuvant RT and 14.0 months for those who did not (HR 0.48, 95% CI 0.27–0.84, p = 0.004). Median adjuvant RT dose delivered was 60Gy (range 12Gy–60Gy), 45.8% of adjuvant RT was delivered using IMRT.At disease relapse, 31% underwent salvage surgery and 29.3% underwent salvage RT. Of those treated with salvage RT, 64.7% were re-treats and all were treated with hypofractionated RT. ConclusionSurgery continues to be the preferred primary management strategy. Post-operative MRI within 48 hours is indicated to assess presence of residual disease and guide further surgical options. Adjuvant radiotherapy plays an important part of the management paradigm in these patients with the data supporting an attached survival advantage. Further surgery and re-irradiation is an option in the disease recurrence setting with radiosurgery frequently utilised in this context.

Management of intraoperatively identified small bile duct stones in patients undergoing cholecystectomy

IntroductionThe management of CBDS (common bile duct stones) in patients with co-existing gallbladder stones has been debated. Guidelines recommend patients with CBDS identified on imaging should be offered duct clearance; however, this is based on low-quality evidence. This study aimed to investigate the natural history of small CBDS identified using IOUS (intraoperative ultrasound) in patients undergoing cholecystectomy. This may provide evidence to support a short-term expectant management approach in such patients.MethodsPatients with CBDS diagnosed on IOUS during cholecystectomy were identified from a database of consecutive patients undergoing surgery. Patients with CBDS identified were divided into small stone (SS, ≤5 mm) and large stone (LS, >5 mm) groups. Intraoperative CBDS management, postoperative investigations, postoperative bile duct clearance, re-admissions, complications, length of stay (LOS) and follow-up are described.ResultsFifty-nine of 427 patients had CBDS identified on IOUS. In the SS group (n=51), 46 patients underwent short-term expectant management rather than immediate/planned bile duct clearance. Following short-term expectant management, 41/46 patients (89.1%) did not require postoperative endoscopic retrograde cholangiopancreatography and at >3 year follow-up, none has since presented with residual CBDS. Median LOS was 0 days in the short-term expectant management group and 2 days in the immediate/planned bile duct clearance group, P=0.039.ConclusionsThis study reports the natural history of small CBDS identified on IOUS in patients undergoing cholecystectomy. Such patients were safely treated with short-term expectant management associated with a reduced hospital LOS. This provides rationale for undertaking further research to establish this as a preferred management strategy.

Effect of water and nitrogen coupling on energy balance and production efficiency in rice production

This study evaluated the effects of water-nitrogen coupling on the energy balance and production efficiency of rice production in Hainan Province, a region of China with tropical climatic. Results showed that the effects of water and nitrogen fertilizer on the total energy output (Eo), net energy (NE), and energy production efficiency (EPE) of rice were coupled. The total energy input (Ei) for rice production increased with irrigation water and nitrogen fertilizer application. Rice production currently depends heavily on indirect and nonrenewable Eis. Diesel, machinery, and nitrogen fertilizer Eis accounted for more than 75 % of the total Eis for rice production. The highest total Eo and NE were observed in rice treated with F-N100 and AWD-N150, respectively. Except for the F-N150 treatment, the total Eo and NE of rice increased with nitrogen fertilizer application. Higher EPE was observed for rice treated with R-N100. In conclusion, the AWD-N150 treatment is suitable for rice production areas with good irrigation conditions, while the R-N100 treatment should be adopted as the preferred water and nitrogen management strategy in rice production areas with high rainfall. Furthermore, research on reducing Eis for irrigation, tillage, and nitrogen fertilizer application for rice production should be strengthened in the future.

Increasing Use of Conservative Management of Low-Risk Prostate Cancer in the Veterans Affairs System from 2012 to 2021

Conservative management (CM), including either active surveillance or watchful waiting, is the preferred management strategy for men with low-risk prostate cancer. We sought to describe contemporary trends in CM among men with localized prostate cancer across the equal-access Veterans Affairs (VA) system. Using VA tumor registry data, we identified all men with a new diagnosis of biopsy-proven, clinically node-negative, non-metastatic prostatic adenocarcinoma from 2012 to 2021, excluding men with missing National Comprehensive Cancer Network risk group. We quantified the yearly proportion of patients with low and favorable intermediate-risk (FIR) prostate cancer undergoing conservative management and examined age-specific rates. Multivariable logistic regression was used to identify independent clinical predictors of CM among men with low-risk and FIR disease. The cohort included 86,415 patients with localized prostate cancer, of whom 20,290 (23.5%) had low risk and 25,447 (29.5%) had FIR disease. The proportion of men diagnosed with low-risk disease decreased from 27.7% in 2012 to 20.1% in 2021. The proportion of men with localized prostate cancer who were 70 years or older at diagnosis increased from 19.5% in 2012 to 46.4% in 2021, with similar increases seen across risk groups. The proportion of men with low-risk disease undergoing CM increased from 63.1% in 2012 to 86.6% in 2021. CM rates in 2021 among low-risk patients were largely consistent across age groups (50-59: 85.1%; 60-69: 87.4%; 70+: 86.3%). For FIR patients, CM rates increased among the subset with Gleason 6 disease (49.5% in 2012 to 80.7% in 2021). In multivariable models, independent predictors of CM in low-risk patients included older age, more recent year, lower PSA at diagnosis, North Atlantic or Pacific region, and presence of another cancer at diagnosis; similar predictors were found in FIR patients. Self-reported race (Black, White, or Other) was not associated with CM. While there was wide geographic variation in CM rates among low-risk patients early in the study period (2012-2014: 56.1% in Southeast region vs 74.1% in Pacific), these disparities resolved in recent years (2019-2021: 83.2% in Southeast vs 83.8% in Pacific). Rates of conservative management for localized prostate cancer increased dramatically over time in the VA, with over 85% of low-risk patients managed conservatively in 2021. Recent years showed no differences in CM rates by self-reported race, geographic region, or age group. Despite this progress, we observed a concomitant increase in the proportion of men 70 years or older diagnosed with localized prostate cancer, including low risk disease. This raises a need to consider strategies to reduce the diagnosis of low-risk disease in elderly Veterans.

Management of the mitral valve in thoracoscopic trans-mitral myectomy for hypertrophic obstructive cardiomyopathy

ObjectiveThis study aimed to compare clinical outcomes of different mitral valve (MV) management methods in thoracoscopic transmitral myectomy (TTM) and guide surgeons' decision making for hypertrophic obstructive cardiomyopathy (HOCM). MethodsSeventy-three consecutive patients (41 females; mean age, 53.7 ± 13.6 years) with HOCM who underwent TTM between January 2019 and October 2022 were enrolled and divided into 3 groups according to MV surgical strategy. Clinical outcomes were analyzed and compared among the groups. ResultsNone of the patients experienced postoperative residual left ventricular outflow tract obstruction. Percentages of patients with mitral regurgitation (MR) grade ≥3+ (57.5% vs 1.4%) and systolic anterior motion (95.9% vs 2.7%) were significantly decreased postoperatively (P < .001 for both). The preoperative anterior mitral leaflet length was longer in patients in the anterior mitral leaflet direct reattachment group (median, 2.9 cm [interquartile range (IQR), 2.7-3.3 cm] vs 2.7 [IQR, 2.4-2.9 cm]; P = .018), but the postoperative coaptation length was shorter (mean, 8.3 ± 2.1 mm vs 11.1 ± 3.8 mm; P = .038). After a median echocardiography follow-up of 11.8 months, the left ventricular outflow tract gradient (LVOTG) and mitral regurgitation grades remained significantly improved in all 3 groups (P < .05 for all). ConclusionsTotal TTM in selected patients is safe and effective, and all 3 MV management strategies can significantly reduce the LVOTG while improving MR. Mitral valvuloplasty is the preferred initial management strategy over valve replacement except in the scenario of irreparable intrinsic MV disease and valvuloplasty failure.

Post-Fire Restoration and Deadwood Management: Microsite Dynamics and Their Impact on Natural Regeneration

After large and severe wildfires, the establishment of tree regeneration, particularly for species without specific fire-adaptive traits, can be challenging. Within harsh environments, the presence of favorable microsites, as those provided by deadwood, enhancing microclimatic conditions, is crucial to the re-establishment of forest cover and thus to foster recovery dynamics. Active restoration strategies can have an impact on these dynamics, altering or hindering them. The main hypothesis of this study is that manipulating deadwood in terms of quantity and spatial arrangement can result in differences in natural regeneration density and composition. Post-disturbance regeneration dynamics and the role played by deadwood over time in the creation of safe sites for seedling establishment were investigated in an area affected by a high-severity wildfire that underwent different post-fire restoration treatments along a gradient of increasing deadwood manipulation, spanning from salvage logging to non-intervention. Two inventories were performed 5 and 11 years after the fire. Ground cover proportion was significantly different among treatments, with lower values of lying deadwood in salvaged sites. A higher probability of regeneration establishment close to deadwood was found in both surveys, confirming the facilitating role of deadwood on post-fire forest regeneration. Microsite dynamics resulting from deadwood facilitation were highlighted, with establishment probability and anisotropic relationships between deadwood elements and seedlings changing over time, as recovery processes slowly improved environmental conditions. In dry mountain areas affected by stand-replacing wildfires, by removing deadwood, salvage logging reduces the number of safe sites for regeneration, further impairing the ecosystem recovery. Passive management should be the ecologically preferred management strategy in these conditions, although intermediate interventions (e.g., felling without delimbing, leaving deadwood on the ground) could be effective alternatives, accelerating snag fall dynamics and immediately increasing favorable microsite availability.

Endoscopic dilation with bougies versus balloons in caustic esophageal strictures: 17-year experience from a tertiary care center.

Endoscopic dilation is the preferred management strategy for caustic esophageal strictures (CES). However, the differences in outcome for different dilators are not clear. We compared the outcome of CES using bougie and balloon dilators. Between January 2000 and December 2016, the following data of all the patients with CES were collected: demographic parameters, substance ingestion, number of strictures, number of dilations required to achieve ≥ 14mm dilation, post-dilation recurrence, and total dilations. Patients were divided into two groups for the type of dilator, i.e., bougie or balloon. The two groups were compared for baseline parameter, technical success, short- and long-term clinical success, refractory strictures, recurrence rates, and major complications. Of the 189 patients (mean age 32.17 ± 12.12years) studied, 119 (62.9%) were males. 122 (64.5%) patients underwent bougie dilation and 67 (35.5%) received balloon dilation. Technical success (90.1% vs. 68.7%, p < 0.001), short-term clinical success (65.6% vs. 46.3%, p value 0.01), and long-term clinical success (86.9% vs. 64.2%, p < 0.01) were higher for bougie dilators compared to balloon dilators. Twenty-four (12.7%) patients developed adverse events which were similar for two groups. On multivariate analysis, use of bougie dilators (aOR 4.868, 95% CI 1.027-23.079), short-term clinical success (aOR 5.785, 95% CI 1.203-27.825), and refractory strictures (aOR 0.151, 95% CI 0.033-0.690) were independent predictors of long-term clinical success. Use of bougie dilators is associated with better clinical success in patients with CES compared to balloon dilators with similar rates of adverse events.

Novel approaches to redesign surveillance strategies following orchiectomy for localized testicular cancer: a narrative review.

Surveillance is the preferred management strategy for most men with clinical stage I testicular cancer after orchiectomy. However, frequent office visits, imaging tests, and laboratory studies place a significant burden on patients, which may contribute to poor compliance with guideline-recommended surveillance regimens. Identifying strategies to overcome these barriers may help improve quality of life, reduce costs, and improve adherence for patients. We reviewed evidence for three strategies that may help with surveillance redesign: telemedicine, implementing microRNA (miRNA) as a biomarker, and novel imaging protocols. A web-based literature search for novel imaging strategies, diagnostic utility of miRNA, and telehealth as they relate to early-stage testicular germ cell cancer was completed during the month of August 2022. We focused our search on contemporary PubMed-indexed and Google Scholar-registered manuscripts written in English. Supportive data sourced from current guideline statements were also included. Evidence was compiled for narrative review. Telemedicine is a safe and acceptable platform for urologic cancer follow-up care, but it requires further study specifically among men with testicular cancer. Access to care may either be improved or reduced depending on system- and patient-level characteristics and should be implemented with this in mind. miRNA may potentially be a helpful biomarker for men with localized disease, but further research on diagnostic accuracy and marker kinetics are needed before implementing it into routine surveillance strategies or using it to deviate from long-standing surveillance regiments. Novel imaging strategies with less frequent imaging and the use of magnetic resonance imaging (MRI) instead of computed tomography (CT) appear to be non-inferior in clinical trials. However, use of MRI requires expert radiologist availability and may be more costly with a lower ability to detect small, early recurrences when used in routine practice. Using telemedicine, integrating miRNA as a tumor marker, and adopting less intensive imaging strategies may improve guideline-concordant surveillance for men with localized testicular cancer. Future studies are needed to assess the risks and benefits of using these novel approaches separately or together.

Structured decision making to navigate trade‐offs between multiple conservation values in threatened grasslands

AbstractManaging biodiversity often requires making difficult trade‐offs, especially when threatened species and ecosystems overlap in their distributions, and management actions to promote their persistence varies between them. Trade‐offs reflect preferences and how much decision makers are willing to give up in benefits for one objective in exchange for gains in other objectives. Despite the increase of tools for exploring trade‐offs, decisions are often made without clear specification of preferences among objectives, reducing transparency and limiting clear communication of the rationale behind decisions. We used structured decision making to navigate trade‐offs between ecological objectives and management costs across three conservation reserves of protected grasslands in Victoria, Australia. The objectives included four nationally listed threatened species, two nationally listed threatened ecosystems, a group of locally threatened and rare non‐listed species and management costs. Alternative management strategies included various combinations of fire management and weed control. The consequences of alternatives were estimated using stochastic models, empirical data and expert judgment. Context dependent preferences were elicited using swing weighting from nine decision makers and stakeholders. While all species and ecosystems are valued, how they are weighted, and the resulting preferred management strategy is context dependent. Weights were variable across participants for all objectives. There was stronger alignment of weights for one of the ecosystems, Natural Temperate Grasslands, than other objectives. One of the threatened species, striped legless lizard, tended to be weighted higher than other ecological objectives, while management costs had the lowest weights. Stakeholder's weightings for objectives varied, however the influence on the rank order of management strategies was minimal. The structured approach to navigate trade‐offs identified management strategies that best address stakeholder preferences across multiple objectives. This approach offers improvements in evidence‐based decision making and provides a transparent and defensible rationale for selecting management interventions that considers all relevant objectives.

Time Trends and Variation in the Use of Active Surveillance for Management of Low-risk Prostate Cancer in the US

Active surveillance (AS) is endorsed by clinical guidelines as the preferred management strategy for low-risk prostate cancer, but its use in contemporary clinical practice remains incompletely defined. To characterize trends over time and practice- and practitioner-level variation in the use of AS in a large, national disease registry. This retrospective analysis of a prospective cohort study included men with low-risk prostate cancer, defined as prostate-specific antigen (PSA) less than 10 ng/mL, Gleason grade group 1, and clinical stage T1c or T2a, newly diagnosed between January 1, 2014, and June 1, 2021. Patients were identified in the American Urological Association (AUA) Quality (AQUA) Registry, a large quality reporting registry including data from 1945 urology practitioners at 349 practices across 48 US states and territories, comprising more than 8.5 million unique patients. Data are collected automatically from electronic health record systems at participating practices. Exposures of interest included patient age, race, and PSA level, as well as urology practice and individual urology practitioners. The outcome of interest was the use of AS as primary treatment. Treatment was determined through analysis of electronic health record structured and unstructured clinical data and determination of surveillance based on follow-up testing with at least 1 PSA level remaining greater than 1.0 ng/mL. A total of 20 809 patients in AQUA were diagnosed with low-risk prostate cancer and had known primary treatment. The median age was 65 (IQR, 59-70) years; 31 (0.1%) were American Indian or Alaska Native; 148 (0.7%) were Asian or Pacific Islander; 1855 (8.9%) were Black; 8351 (40.1%) were White; 169 (0.8%) were of other race or ethnicity; and 10 255 (49.3%) were missing information on race or ethnicity. Rates of AS increased sharply and consistently from 26.5% in 2014 to 59.6% in 2021. However, use of AS varied from 4.0% to 78.0% at the urology practice level and from 0% to 100% at the practitioner level. On multivariable analysis, year of diagnosis was the variable most strongly associated with AS; age, race, and PSA value at diagnosis were all also associated with odds of surveillance. This cohort study of AS rates in the AQUA Registry found that national, community-based rates of AS have increased but remain suboptimal, and wide variation persists across practices and practitioners. Continued progress on this critical quality indicator is essential to minimize overtreatment of low-risk prostate cancer and by extension to improve the benefit-to-harm ratio of national prostate cancer early detection efforts.

Early mortality and neurologic outcomes following mitral valve surgery in the very elderly.

Valve repair is the gold standard for treatment of degenerative mitral valve disease. As the population ages, patients undergoing valve degeneration and therefore considered for mitral valve surgery will naturally be getting older. We sought to evaluate whether mitral repair retained a survival advantage over replacement in patients ≥80 years old. A retrospective cohort study was performed using data acquired from the United Kingdom National Adult Cardiac Surgery Audit for the outcomes of in-hospital mortality and postoperative cerebrovascular event (CVA). Individual multivariable logistic regression models were created to investigate adjusted associations between these outcomes and type of mitral valve operation, repair or replacement. Additionally, associations between the individual model parameters and in-hospital mortality and CVA were investigated. A total of 1140 patients underwent mitral repair (66.4%, median age 82.3), and 577 patients underwent mitral replacement (33.6%, median age 82.1). The overall age range was 80-92. The incidence of in-hospital mortality favored the repair group (4.4% vs. 8.3%, p = .001). Multivariable logistic regression modeling demonstrated an increased adjusted odds of in-hospital mortality for mitral valve replacement (MVR) (odd ratio [OR]: 2.01, 1.15-3.50, p = .01). The only other parameter associated with an increased adjusted odds of in-hospital mortality was postoperative dialysis (OR: 14.2, 7.67-26.5, p < .001). There was not a demonstrated association between MVR and perioperative CVA (OR: 1.11, 0.49-2.4, p = .8). In patients ≥80 years old, mitral valve repair (MVr) was shown to be associated with a decreased adjusted odds of mortality, with a null association with CVA. These results suggest that, if feasible, MVr should remain the preferred management strategy, even in the very elderly.

Current Practice Patterns among Radiation Oncologists at High-Volume Pancreatic Cancer Centers Participating in the Canopy Cancer Collective Learning Health Network

<h3>Purpose/Objective(s)</h3> Radiation therapy (RT) for localized pancreatic ductal adenocarcinoma (PDAC) remains controversial, with conflicting data likely resulting in variable practice patterns. The Canopy Cancer Collective (CCC) is a learning health network of 14 institutions with high-volume multidisciplinary PDAC teams. To characterize the current state of RT for PDAC at high-volume, academic centers, radiation oncology faculty at CCC member institutions were surveyed. <h3>Materials/Methods</h3> A survey focusing on RT practice patterns for localized PDAC was distributed to 18 faculty with expertise in gastrointestinal RT at CCC sites. Survey results are descriptively reported. <h3>Results</h3> The survey was completed by 17/18 (94%) faculty. Among respondents, the number of localized PDAC patients treated per year with RT included >50 (n=5, 29%), 26-50 (n=8, 47%), 10-25 (n=3, 18%), and <10 (n=1, 6%). Two (12%) respondents reported that they routinely offer pre-operative RT for resectable PDAC. Majority of respondents (n=15, 88%) indicated that pre-operative RT is offered to certain patients with borderline resectable pancreatic cancer (BPRC), but the specific proportion of BRPC patients receiving pre-operative RT was variable across respondents (median 70%, range: 10-100%). Similarly, majority of respondents (n=16, 94%) indicated that RT is offered as definitive treatment for certain patients with locally advanced pancreatic cancer (LAPC), but the specific proportion of LAPC patients receiving RT was also variable (median 80%, range: 20-100%), as was the estimated proportion of LAPC patients who eventually undergo resection (median 25%, range 2-50%). Table 1 summarizes the distribution of preferred planning techniques and target volumes used by respondents in both the pre-operative and definitive settings. Variation was also seen in use of fiducials (n=12, 71%), preferred motion management strategy (breath-hold: n=12, 71%; gating: n=5, 29%), systematic use of adjunctive imaging beyond CT for target delineation (MRI: n=6, 35%; PET: n=3, 18%), and use of prophylactic anti-emetics (n=5, 29%) and proton pump inhibitors (n=11, 65%). <h3>Conclusion</h3> RT practice patterns for the treatment of localized PDAC remain disparate, with significant variation in institutional standards across stage of disease as well as in basic treatment parameters such as prescription dose and target volume design. A better understanding of the basis for such variation may help guide future avenues of study.

Elective induction of labour and expectant management in late-term pregnancy: A prospective cohort study alongside the INDEX randomised controlled trial.

ObjectiveTo assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy.DesignMulticentre prospective cohort study alongside RCT.Setting90 midwifery practices and 12 hospitals in the Netherlands.Population3642 low-risk women with uncomplicated singleton late-term pregnancy.Main outcome measuresComposite adverse outcome (perinatal death, Apgar score 5′ < 7, NICU admission, meconium aspiration syndrome), composite severe adverse perinatal outcome (all above with Apgar score 5′ < 4 instead of < 7) and caesarean section.ResultsFrom 2012–2016, 3642 women out of 6088 eligible women for the INDEX RCT, participated in the cohort study for observational data collection (induction of labour n = 372; expectant management n = 2174; unknown preference/management strategy n = 1096).Adverse perinatal outcome occurred in 1.1 % (4/372) in the induction group versus 1.9 % (42/2174) in the expectant group (adjRR 0.56; 95 %CI: 0.17–1.79), with severe adverse perinatal outcome occurring in 0.3 % (1/372) versus 1.0 % (22/2174), respectively (adjRR 0.39; 95 % CI: 0.05–2.88). There were no stillbirths among all 3642 women; one neonatal death occurred in the unknown preference/management group. Caesarean section rates were 10.5 % (39/372) after induction and 8.9 % (193/2174) after expectant management (adjRR 1.32; 95 % CI: 0.95–1.84).A higher incidence of adverse perinatal outcome was observed in nulliparous compared to multiparous women. Nulliparous 1.8 % (3/170) in the induction group versus 2.6 % (30/1134) in the expectant management group (adjRR 0.58; 95 % CI 0.14–2.41), multiparous 0.5 % (1/201) versus 1.1 % (11/1039) (adjRR 0.54; 95 % CI 0.07–24.19). One maternal death due to amniotic fluid embolism occurred after elective induction at 41 weeks + 6 days.ConclusionIn this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1 % versus 1.9 %) and severe adverse (0.3 % versus 1.0 %) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3642 women. Caesarean section rates were comparable.

Periprosthetic humerus fractures after shoulder arthroplasty: an evaluation of available classification systems

Periprosthetic proximal humerus fractures (PPHFs) are a detrimental complication of shoulder arthroplasty, yet their characterization and management have been poorly studied. We aimed to determine the intra- and interobserver reliability of 4 previously described PPHF classification systems to evaluate which classifications are the most consistent. We retrospectively reviewed 32 patients (34 fractures) that were diagnosed with a PPHF between 1990 and 2017. Patient electronic medical records and research electronic data capture (REDCap) were used for data collection. Post-PPHF radiographs in multiple views for all 34 cases were organized into an encrypted, randomized Qualtrics survey. Four blinded fellowship-trained shoulder and elbow surgeons graded each fracture using previously reported classification systems by (1) Wright and Cofield (1995), (2) Campbell etal (1998), (3) Worland etal (1999), and (4) Groh etal (2008), along with selecting a preferred management strategy for each fracture. Grading was performed twice with at least 2 weeks between each randomized attempt. Intraobserver reliability was calculated as an unweighted Cohen kappa coefficient between attempt 1 and attempt 2 for each surgeon. Interobserver reliability and agreeability between surgeons' preferred management strategies were calculated for each classification system using Fleiss kappa coefficient. The kappa coefficients were interpreted using the Landis and Koch criteria. The average intraobserver kappa coefficient for each classification was as follows: Wright and Cofield=0.703, Campbell=0.527, Worland=0.637, Groh=0.699. The overall Fleiss kappa coefficient for interobserver reliability for each classification was as follows: Wright and Cofield=0.583, Campbell=0.488, Worland=0.496, Groh=0.483. Interobserver reliability was significantly greater with the Wright and Cofield classification. Using Landis and Koch criteria, all the classification systems assessed demonstrated only moderate interobserver agreement. Additionally, the mean interobserver agreeability kappa coefficient for preferred management strategy was 0.490, indicating only moderate interobserver agreement. There is only moderate interobserver reliability among the 4 PPHF classification systems and the preferred management strategy for the fractures assessed. Of the 4 PPHF classification systems, Wright and Cofield demonstrated the greatest mean intraobserver reliability and overall interobserver reliability. Our study highlights a need for the development of a PPHF classification system that can achieve high intra- and interobserver reliability and that can allow for a standardized treatment algorithm in the management of PPHFs.

Outcomes of treatment for deep left ventricular assist device infection

ObjectiveAmong left ventricular assist device patients, the most commonly infected component is the drive line, which can be managed with antibiotics and local debridement. Infection of intrathoracic device components is less common but more difficult to manage. Herein we describe the incidence of deep device infection (DDI) at our center as well as management and outcomes. MethodsWe retrospectively reviewed 658 patients who underwent implantable left ventricular assist device insertion with HeartMate 2 (Abbott) or HeartMate 3 (Abbott) devices between January 2004 and June 2021. DDI was defined according to radiographic and clinical criteria. Cumulative incidence was calculated using a Fine-Gray subdistribution model; survival analysis was performed using the method of Kaplan and Meier. ResultsThere were 32 (4.8%) DDIs during this study period. Drive line infection and re-exploration for bleeding were associated with development of DDI. Cumulative incidence of DDI increased over time, affecting 11% (7%-18%) at 5 years. The dominant microbes involved in DDI were Pseudomonas aeruginosa (19%) and methicillin-resistant Staphylococcus aureus (13%). Nineteen patients (59%) with device infection underwent device exchange, 6 (19%) underwent initial transplant, and 7 (22%) were treated solely with debridement and antibiotics. Of those who underwent device exchange, 12 (63%) developed reinfection of their new device and 6 underwent subsequent heart transplant. Patients who underwent transplantation for management of device infection had improved 5-year survival (80% vs 11%; P = .01) but 3 patients (25%) developed deep sternal wound infection after transplant. ConclusionsDDI is a rare but challenging complication in this destination era. Heart transplantation is the preferred management strategy for eligible patients but infectious complication is common.

Let Us Give Voice to Local Farmers: Preferences for Farm-Based Strategies to Enhance Human-Elephant Coexistence in Africa.

Simple SummaryLocal communities living on the edge of protected areas often experience negative impacts on their livelihoods due to wildlife. These situations threaten support for long-term conservation of wildlife and wild habitats so a key for conservation sustainability should be based on implementing socially accepted and economically sustainable mitigation practices. For successful design and implementation of mitigation strategies, it is vital to engage local communities and understand their preferences and previous experiences. In this study, we present a choice experiment as a tool to analyze local farmer preferences for the most common farm-based solutions to reduce African elephant crop damage. Results show that there are significant differences among responses triggered by farmers’ previous experience with elephants and socioeconomic situation, with a marked spatial distribution among respondents. This methodology, based on a choice modeling approach considering the differential availability of resources and previous experience with elephants or other wildlife, is highly applicable, with small changes in other areas where wildlife competes with local communities for resources. This approach also represents a suitable instrument for identifying stakeholders’ preferences in each specific context.Local communities surrounding wildlife corridors and natural reserves often face challenges related to human–wildlife coexistence. To mitigate the challenges and ensure the long-term conservation of wildlife, it is important to engage local communities in the design of conservation strategies. By conducting 480 face-to-face interviews in 30 villages along and adjacent to the Selous-Niassa Wildlife Corridor (Tanzania), we quantified farmers’ preferences for farm-based measures to mitigate African elephant damage using choice experiments. Results show that farmers considered no action the least preferred option, revealing that they are open to trying different measures. The most preferred management strategy matched with the preferences of wildlife rangers in the area, suggesting low concern about the potential conflicts between stakeholders. However, a latent class model suggests that there are significant differences among responses triggered by farmers’ previous experience with elephants, the intensity of the elephant damage, and the socioeconomic situation of the farmer. Results show a marked spatial distribution among respondents, highlighting the benefits of zone management as conflicts were found to be highly context dependent. Understanding the human dimension of conservation is essential for the successful planification and implementation of conservation strategies. Therefore, the development and broad utilization of methodologies to gather specific context information should be encouraged.

Society for Vascular Surgery appropriate use criteria for management of intermittent claudication

The Society for Vascular Surgery appropriate use criteria (AUC) for the management of intermittent claudication were created using the RAND appropriateness method, a validated and standardized method that combines the best available evidence from medical literature with expert opinion, using a modified Delphi process. These criteria serve as a framework on which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition of treatments rated as inappropriate (risk outweighs benefit). Clinical situations will occur in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC requires a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with the best available evidence should determine the treatment strategy. These scenarios require mechanisms to track the treatment decisions and outcomes. AUC should be revisited periodically to ensure that they remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral, and femoropopliteal segments in the round 2 rating. Of these, only nine (0.4%) showed a disagreement using the interpercentile range adjusted for symmetry formula, indicating an exceptionally high degree of consensus among the panelists. Post hoc, the term “inappropriate” was replaced with the phrase “risk outweighs benefit.” The term “appropriate” was also replaced with “benefit outweighs risk.” The key principles for the management of IC reflected within these AUC are as follows. First, exercise therapy is the preferred initial management strategy for all patients with IC. Second, for patients who have not completed exercise therapy, invasive therapy might provide net a benefit for selected patients with IC who are nonsmokers, are taking optimal medical therapy, are considered to have a low physiologic and technical risk, and who are experiencing severe lifestyle limitations and/or a short walking distance. Third, considering the long-term durability of the currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitations and a short walking distance. Fourth, in the common femoral segment, open common femoral endarterectomy will provide greater net benefit than endovascular intervention for the treatment of IC. Finally, in the infrapopliteal segment, invasive intervention for the treatment of IC is of unclear benefit and could be harmful.

Active surveillance in favorable intermediate risk prostate cancer: outstanding questions and controversies.

Active surveillance has become the preferred management strategy for patients with low risk prostate cancer, but it is unclear if active surveillance can be safely extended to favorable intermediate risk (FIR) prostate cancer patients. Furthermore, defining a favorable intermediate risk prostate cancer population safe for active surveillance remains elusive due to paucity of high-level data in this population. This article serves to review relevant data, particularly the safety of active surveillance in grade group 2 patients, and what tools are available to aid in selecting a favorable subset of intermediate risk patients. Active surveillance studies with long-term data appear to report worsened survival outcomes in intermediate risk patients when compared to those undergoing definitive treatment, but there exists a subset of intermediate risk patients with nearly equivalent outcomes to low risk patients on active surveillance. Tools such as percentage and total length of Gleason pattern 4, tumor volume, prostate specific antigen density, magnetic resonance imaging, and genomic modifiers may help to select a favorable subset of intermediate risk prostate cancer appropriate for active surveillance. Active surveillance is a viable strategy in select patients with low volume group grade 2 (GG2) prostate cancer. Prospective and retrospective data in the FIR population appear to be mostly favorable in regards to survival outcomes, but there exists some heterogeneity with respect to long-term outcomes in this patient population.