Scheduling Procedure Research Articles

Response of health-related quality of life following pediatric/congenital cardiac catheterization procedures

BackgroundHealth related quality of life (HRQOL) is a patient-reported metric (PRM) that provides a holistic measure of health that is not addressed in traditional outcome measures. The acute responsiveness of HRQOL after pediatric/congenital cardiac catheterization procedures has not, to our knowledge, been studied. MethodsA single-center prospective cohort study was performed, longitudinally evaluating HRQOL and other PRM in school-age children and adolescents (ages 8-18) undergoing diagnostic and interventional cardiac catheterization procedures prior to their scheduled procedure, and then 1 day, ∼1 month, and ∼3 months after the procedure. Differences between HRQOL at baseline and at 1- and 3-month follow-up were evaluated using paired Student's t-tests. ResultsA total of 70 patient-parent/guardian dyads were studied. The participating patients were 13±3 years old, 51% female, and 74% non-Hispanic white, with 54% undergoing a diagnostic procedure. The trajectory of cardiac-specific HRQOL as measured through Pediatric Cardiac Quality of Life Inventory differed for patients undergoing diagnostic and interventional procedures. Following diagnostic procedures, there was no significant change in cardiac-specific HRQOL (p>0.05). After interventional procedures, patient-reported cardiac-specific HRQOL increased at both 1-month (4.3±11, p=0.04) and 3-months (5.9±11.4, p=0.02), though the same changes were not seen in parent/guardian-reported cardiac-specific HRQOL (p>0.05). PROMIS measures of physical function, psychological symptoms, and social function were associated with baseline cardiac-specific HRQOL (all p<0.05), but no associations were seen between other patient-reported outcomes and baseline HRQOL or change from baseline to 3-month follow-up. ConclusionAcross a range of transcatheter interventional procedures, patient-reported cardiac-specific HRQOL improved in short term follow up, though these changes were not seen in parent/guardian reported measures. Incorporating these patient-centered metrics into evaluation of transcatheter therapies may provide more accurate measures of comparative effectiveness.

Resiliency-informed optimal scheduling of smart distribution network with urban distributed photovoltaic: A stochastic P-robust optimization

An increased worldwide emphasis on resilience has resulted in a greater concentration on the distribution networks' resiliency. Therefore, the conventional approach to advance scheduling for power distribution networks is no longer sufficient, thereby requiring the creation of resilient scheduling approaches. This paper examines a proactive day-ahead scheduling method for distribution networks that are linked with significant renewable energy sources. The suggested approach employs a probabilistic scenario-generating strategy to quantify the uncertainties related to wind speed, solar irradiation, catastrophe duration, and load fluctuations. This study utilizes a hybrid stochastic p-robust optimization technique to enhance the analysis and provide robust strategies against risks. The present methodology employs a regret-based metric to quantify the adverse impacts of uncertainty inside the proactive scheduling procedure. The suggested methodology is verified using an IEEE 33-bus test system that includes significant distributed photovoltaic sources. The findings indicate a significant decrease of 43% in the highest level of regret, accompanied by a relatively limited rise of 1.22% in the operational expenses of the distribution network. This framework efficiently manages natural occurrences in the day-ahead scheduling process, making it a very promising method for improving the robustness of power distribution networks.

Orthopedic Surgery in Osteogenesis Imperfecta in Adults.

Osteogenesis imperfecta is a genetic disorder, mainly characterized by bone fragility. In adult with osteogenesis imperfecta, surgical treatment may be indicated as an emergency procedure in the event of a fracture, or as a scheduled procedure in case of patient functional impairment due to many causes, such as persistent pain, complex bone deformities, and degenerative arthropathies. In all cases, a multidisciplinary approach is recommended. It is essential to consider the patient's characteristics and expectations regarding treatment, as well as the local conditions, which may be complex due to the poor bone quality, bone deformity, and the presence of hardware implanted during childhood. The procedure can be very complex and challenging and each patient is a unique case. An accurate preoperative planning is mandatory to select the appropriate surgical technique, which can be either conservative or prosthetic, and to evaluate its feasibility and the risk-benefit ratio. The aim is to improve the patient's quality of life and autonomy as long as possible.

QLTI-12. COST ANALYSIS OF EMERGENCY PROCEDURES FOR BRAIN TUMORS – WHEN YOU CAN WAIT

Abstract BACKGROUND Neurosurgery is expensive and requires advanced technology to achieve the best outcomes, especially for brain tumors. Generally patients are prepared during consultations for a brain tumor surgery, with anesthesiology, cardiology, neuropsychology and other specialties evaluations. Ideally, the hospitalization is planned before and patient is admitted only when is in good conditions. However some patients with brain tumors are evaluated in emergency department and sometimes require urgent procedures. OBJECTIVE This study aimed to estimate the direct cost of specialized care for adult neuro-oncological patients considering previous scheduled procedures versus urgent surgeries and another factors that may impact decision about nonelective procedures. METHODS This observational economic analysis describes the direct cost of care of neuro-oncological patients in Santa Casa de São Paulo, Brazil. Only adult patients with a common primary brain tumor were included. RESULTS The global mortality rate considering all patients were 12.7% and 92.3% of them occurred in nonelective procedures. Also these patients had a greater infection rate and period of hospitalization. Because of this we reviewed when a patient with brain tumor really need an urgent procedure. Despite several patients are initially diagnosed through ER investigation, probably the majority could be compensated through ambulatory consultations and after admitted with better conditions. Situations in which emergency surgery are required include acute hydrocephalus and non-compensated intracranial hypertension. CONCLUSIONS These patients usually have difficulty access to neurosurgical evaluation and so, only look for health assistance when the disease cause severe disability. Emergency surgeries were associated with an increased rate of infections and mortality. The findings of this study could be used by policymakers for resource allocation and to perform economic analyses to establish the value of neurosurgery in achieving global health goals. severe disability. KEY WORDS: costs; brain tumor; emergency; infections

TeleHelp Ukraine: A distributed international telemedicine response to the ongoing war.

Humanitarian crises frequently garner solidarity and robust volunteer recruitment among health care communities. However, a common obstacle is matching providers to those in need across geographic and other barriers. We examined the application of a decentralised governance strategy in establishing an emergency telemedicine response, TeleHelp Ukraine (THU). Using a case study approach, we explored how global networking and technological advancements empower organisations to generate, access, disseminate, and utilise knowledge for sustainable health care delivery. Preliminary results suggest that a non-profit, decentralised model strengthened by robust team dynamics may optimise the distribution of clinical workload and scheduling procedures. Institutional and cultural diversity among health care providers and volunteers fosters the mobilisation of knowledge resources, synergistic collaboration, and tailored care standards that align with both provider and patient expectations. By integrating these diverse, distributed networks, a synergistic effect is achieved, combining effective learning mechanisms with intellectual capital. Our study provides insights into the structure, implementation strategies, dissemination methodologies, and initial results of THU's operation. These findings may inform future emergency telemedicine responses in humanitarian scenarios, thereby reinforcing the practical implementation of health as a human right.

Scheduling of e-commerce packaging machines: blocking machines and their impact on the performance–waste tradeoff

AbstractTo streamline their fulfillment processes, many e-commerce retailers today use automated packaging machines for their outbound parcels. An important performance–waste tradeoff is associated with these machines: To reduce packaging waste when handling different sized goods, packaging machines should be able to handle different carton sizes. However, more carton sizes lead to a more involved scheduling process, so that the throughput performance deteriorates (and vice versa). To investigate this tradeoff, this paper develops scheduling procedures for a specific type of packaging machine, called blocking machines. These packaging machines provide multiple back-to-back packaging devices, each continuously processing a dedicated carton size, but blocking each other whenever incoming goods are not properly ordered according to carton sizes on the infeed conveyor. To reduce the resulting throughput loss, we derive various scheduling problems for optimizing the inflow of goods, provide a thorough analysis of the computational complexity, and derive an exact dynamic programming approach that is polynomial in the number of orders to be packed. This allows us to solve even large real-world instances to proven optimality with which we can analyze the performance–waste tradeoff of blocking machines.

Long-term Outcomes Following Non-operative Management of Acute Appendicitis: A Population-based Analysis.

To describe long-term re-presentations and interventions following non-operative management (NOM) of acute appendicitis (AA). Trial data suggest NOM of AA carries a substantial risk of subsequent appendectomy, although NOM is increasingly offered to patients. Population-based data is required to understand the real-world long-term course of patients undergoing NOM of AA. This population-based cohort study included all adult patients in Ontario, Canada who presented to any emergency department (ED) with AA between 2004-2019. Patients who did not undergo a procedure on index ED presentation or hospital admission were defined as NOM and followed for five years. The cumulative incidence of composite re-presentation or intervention (ED re-presentation, re-admission, emergency, or scheduled appendicitis procedure) was calculated accounting for competing risk of death. Of 156,362 patients identified with AA, 13,200 underwent NOM. The cumulative incidence of composite re-presentation or intervention was 33% at 1-year (95%CI 32-33%) and 36% at 5-years (95%CI 36-37%). At 5-years, the incidence of appendicitis-specific ED re-presentation or hospital re-admission was 16% (95%CI 15-16%), the incidence of an emergency procedure for AA was 12% (95%CI 12-13%), and the incidence of scheduled surgery was 21% (95%CI 20-21%). In a subgroup of patients with uncomplicated AA, composite re-presentation or intervention was 28% at 1-year (95%CI 27-29%) and 32% at 5-years (95%CI 32-33%). Real-world estimates of emergency re-presentation with or without urgent surgery following NOM of AA were lower than previously described. Scheduled appendectomy made up an important proportion of long-term interventions following NOM.

Urogenital schistosomiasis, a leading cause of bladder squamous cell carcinoma

Abstract Introduction/Objective Schistosoma, genus of trematodes, commonly known as blood flukes are parasitic flatworms responsible for a group of infections in humans termed schistosomiasis and hundreds of millions of people are infected worldwide. In areas where Shistosoma is not endemic to the region most cases of bladder malignancy are of urothelial origin. In areas where Shistosoma is endemic bladder malignancy is more commonly squamous cell carcinoma. However, with increased travel, migration and tourism it is important to potentially consider Shistosoma infection in areas that are not typically considered endemic regions. Methods/Case Report A 62-year-old male presented to our hospital and revealed through an interpreter he has had 1.5 years hematuria with “pieces of meat or brown dirt”. Cystoscopy was performed and showed a large necrotic mass. CT scan showed an 8.2 cm exophytic bladder dome mass. TURBT was performed and a diagnosis of invasive high-grade urothelial carcinoma with squamous differentiation and with multiple Schistosoma organisms identified.The patient received Schistosoma treatment and was scheduled for radical cystectomy and ileal conduct. A few days before the scheduled procedure the patient presented to our emergency department with acute abdominal pain. He was subsequently diagnosed with progressive bladder cancer with new left malignant ureteral obstruction, which lead to hydronephrosis, DVT, abdominopelvic ascites and intraperitoneal bladder perforation. Abdominal fluid cytology showed atypical keratinizing squamous cells suspicous for malignancy and marked acute inflammation. Patient underwent cystectomy with ileal conduit and the specimen was sent to pathology for examination. Results (if a Case Study enter NA) NA Conclusion Gross examination showed an irregular perforated bladder. Microscopic examination showed a high grade urothelial carcinoma with squamous and sarcomatoid differentiation with detrusor muscle invasion. Additionally, Schistosoma organisms with a terminal spine and calcified eggs were identified. Some of the calcified egg material was engulfed by giant cells. The organisms are surrounded by a prominent eosinophilic infiltrate. Lymphovascular invasion is also noted. Schistosomiasis is associated with the development of squamous cell carcinoma of the bladder. It is important to maintain high oncological alertness for squamous cell carcinoma, particularly for patients arriving from endemic areas. Such as in our case, a patient from Somalia living in Kansas City.

Enhancing Cloud Task Scheduling with Multi-Objective Optimization Using K-Means Clustering and Dynamic Resource Allocation

The scheduling and resource allocation procedure is an essential component of cloud resource management. Effective resource allocation is severely hampered by the task arrival rates' erratic and unclear behavior. To prevent under or overusing resources, an effective scheduling strategy is necessary. To improve scheduling and allocation performance, a multi-objective optimization technique is presented for the best resource allocation and task scheduling inside scientific workflow datasets in a heterogeneous environment. In the first stage, the system calculates four key metrics: Communication Cost, Computation Cost, Earliest Finished Time on a particular VM, and Total Task Length for a specific scientific workflow dataset. These metrics provide a comprehensive understanding of the resource requirements and help make informed scheduling decisions. In the second stage, tasks are clustered using the K-Means clustering algorithm. This clustering groups similar tasks together, making managing and scheduling them easier. In the third stage, the proposed resource allocation algorithm allocates the clustered tasks to the appropriate VMs. This step ensures that the tasks are assigned to the best-suited resources, optimizing the overall system performance and resource utilization. By following this multi-stage process, the system aims to achieve optimal resource allocation and task scheduling, thereby improving the efficiency and effectiveness of cloud resource management. The proposed method significantly outperforms PSO, CSO, and GWO by consistently achieving lower Makespan—under 400 units at 50 tasks—while maintaining high resource utilization rates above 0.75, demonstrating superior efficiency in task execution and resource management.

Acoustic emission during the freezing of water or the melting of ice in aircraft

It is a frequently overlooked phenomenon that matter can produce sound emissions when undergoing a phase transition. The exact cause of this sound is until now not modeled and understood in depth, but it appears certain that sudden volume changes, cracks, friction, and other sources that occur during e.g. crystal decay/growth in melting/freezing processes must be considered. However, a generally accepted theory of the "sound of phase transitions" is lacking. In this paper we present a general introduction in this field. Besides the more fundamental aspects, the AE generation during the melting of ice can be used to detect the presence of this respective substance in technical structures. An interesting application is to detect the melting ice in aircraft. Adverse water accumulation, resulting from contamination and condensation, is regularly found in fuel tanks, and scheduled drainage procedures of this water after the melting of the ice are important to ensure the safety of systems and structures. A practical problem for drainage after flight is determining the right time to start the process. Beginning too early would mean that the remaining ice cannot be removed, and waiting too long presents an economic problem as it increases the aircraft's downtime. There is currently no technology that reports when all water has melted. To realize this goal acoustic sensors were attached to the skin of the tank walls, and the acoustic signals were intense enough to propagate through the aluminum sheets and coating and further analyzed. In this way, the completion of the melting of ice was determined by the time at which the acoustic emission stopped. We present measurements on a laboratory scale, the results from a climate chamber on relevant replica’s, and the outcome of a first campaign on an operational aircraft (Airbus A330).

Governing new technologies that stop biological time: Preparing for prolonged biopreservation of human organs in transplantation

Time limits on organ viability from retrieval to implantation shape the US system for human organ transplantation. Preclinical research has demonstrated that emerging biopreservation technologies can prolong organ viability, perhaps indefinitely. These technologies could transform transplantation into a scheduled procedure without geographic or time constraints, permitting organ assessment and potential preconditioning of the recipients. However, the safety and efficacy of advanced biopreservation with prolonged storage of vascularized organs followed by reanimation will require new regulatory oversight, as clinicians and transplant centers are not trained in the engineering techniques involved or equipped to assess the manipulated organs. Although the Food and Drug Administration is best situated to provide that process oversight, the agency has until now declined to oversee organ quality and has excluded vascularized organs from the oversight framework of human cells, tissues, and cellular-based and tissue-based products. Integration of advanced biopreservation technologies will require new facilities for organ preservation, storage, and reanimation plus ethical guidance on immediate organ use versus preservation, national allocation, and governance of centralized organ banks. Realization of the long-term benefit of advanced biopreservation requires anticipation of the necessary legal and ethical oversight tools and that process should begin now.

Efficacy and Safety of Thrombopoietin Receptor Agonist (TPO-RA) in Patients with Chronic Liver Disease: A Systematic Review and Meta-Analysis

Context: The TPO-receptor agonist (TPO-RA) has been extensively studied for its use in thrombocytopenia. Objectives: We aimed to systematically analyze the efficacy and safety of TPO-RA in chronic liver disease patients. Methods: The study population consisted of adults with chronic liver disease. The intervention was TPO-RA. The primary outcome was the efficacy of TPO-RA (increase in thrombocyte levels and likelihood of avoiding thrombocyte transfusion pre-operatively), while the secondary outcome was the safety of TPO-RA. The demographics of the study and the usage of TPO-RA medications were used to classify the research. Results: This review consisted of 1529 chronic liver disease patients who received TPO-RA and 911 who received a comparator (placebo or thrombocyte transfusion). The TPO-RA significantly increased thrombocyte levels by 34.59 × 109/L (P &lt; 0.00001). The use of TPO-RA pre-procedure reduced the likelihood of pre-operative platelet transfusion and up to seven days following the scheduled procedure by 88% (P &lt; 0.00001). TPO-receptor agonist was not associated with all-cause mortality (P = 0.77) or an increase in thrombosis events, with a pooled OR of 1.36 (P = 0.43). According to a meta-regression analysis, the population may explain the heterogeneity. Subsequent leave-one-out sensitivity analysis of the thrombocyte level change after TPO-RA revealed that no single study was accountable for the heterogeneity of thrombocyte level changes. Conclusions: The use of TPO-RA increases the thrombocyte levels of chronic liver disease patients and reduces the odds of needing thrombocyte transfusion pre-operatively. TPO-receptor agonist is also safe to use, with no increase in mortality risk or thrombosis risk.

Interior-point policy optimization based multi-agent deep reinforcement learning method for secure home energy management under various uncertainties

Improving the efficiency of home energy management (HEM) is of great significance in reducing resource waste and prompting renewable energy consumption. With the development of advanced HEM systems and internet-of-things technology, more residents are willing to participate in the electricity market through a demand response mechanism, which can not only reduce the electricity bill but also stabilize the operation of the main grid through peak shaving and valley filling. However, the uncertainties from household appliance parameters, user behaviors, penetrated renewable energy, and electricity prices render the HEM problem a non-trivial task. Although previous deep reinforcement learning (DRL) methods have no requirement for system dynamics due to their model-free and data-driven merits, the unrestricted action space may violate the physical constraints of various devices, and few works have concentrated on this area before. To solve the above challenges, this paper proposes a novel interior-point policy optimization-based multi-agent DRL algorithm to optimize the home energy scheduling procedure while guaranteeing safety during its operation. Besides, a time-series prediction model based on a non-stationary Transformer neural network is proposed to predict the future trend of solar generation and electricity price, which can provide the agents with abundant information to make better decisions. The superior performance of our proposed predictive-control coupled method is demonstrated through extensive numerical experiments, which achieves more precise prediction results, near-zero constraint violations, and better trade-offs between cost and safety than several benchmark methods.

Development of a Practical Procedure for Data-Driven Weigh-in-Motion Equipment Calibration Scheduling to Assure Data Accuracy and Consistency over Time

Weigh-in-motion (WIM) technology is a traffic monitoring technology that highway agencies use to obtain information about the weight, axle loading, and configuration of heavy vehicles moving at operational speed. To ensure high-quality WIM data, the Federal Highway Administration (FHWA) recommends regular calibration of WIM equipment. This study addresses the need to optimize the allocation of the limited resources that agencies have for WIM equipment calibration by developing a procedure for data-driven calibration scheduling. This was accomplished through an analysis of WIM measurement errors from test truck data collected during field performance validation and calibration events and an analysis of monthly changes in truck weight and axle loading characteristics, based on WIM data collected between calibration events. The analysis results were used to draw conclusions on the functional performance of different WIM sites. The study also demonstrates how the newly developed National Cooperative Highway Research Program (NCHRP) WIM Data Quality Assurance Analysis Tool can be used to compute truck weight and axle loading parameters and visualize data analysis results using four case studies: two WIM sites with piezo quartz sensors in asphalt pavements and two WIM sites with bending plate sensors in concrete pavements. This paper provides a practical procedure and recommendations that highway agencies can use to develop data-driven WIM calibration schedules that will ensure consistent high-quality WIM data for sites managed by an agency with the aid of the NCHRP WIM Data Quality Assurance Analysis Tool.

Staphylococcus aureus screening and preoperative decolonisation with Mupirocin and Chlorhexidine to reduce the risk of surgical site infections in orthopaedic surgery: a pre-post study

BackgroundNasal carriage of Staphylococcus aureus is a risk factor for surgical site infections (SSI) in orthopaedic surgery. The efficacy of decolonisation for S. aureus on reducing the risk of SSI is uncertain in this speciality. The objective was to evaluate the impact of a nasal screening strategy of S. aureus and targeted decolonisation on the risk of S. aureus SSI.MethodsA retrospective pre-post and here-elsewhere study was conducted between January 2014 and June 2020 in 2 adult orthopaedic surgical sites (North and South) of a French university hospital. Decolonisation with Mupirocin and Chlorhexidine was conducted in S. aureus carriers starting February 2017 in the South site (intervention group). Scheduled surgical procedures for hip, knee arthroplasties, and osteosyntheses were included and monitored for one year. The rates of S. aureus SSI in the intervention group were compared to a historical control group (South site) and a North control group. The risk factors for S. aureus SSI were analysed by logistic regression.ResultsA total of 5,348 surgical procedures was included, 100 SSI of which 30 monomicrobial S. aureus SSI were identified. The preoperative screening result was available for 60% (1,382/2,305) of the intervention group patients. Among these screenings, 25.3% (349/1,382) were positive for S. aureus and the efficacy of the decolonisation was 91.6% (98/107). The rate of S. aureus SSI in the intervention group (0.3%, 7/2,305) was not significantly different from the historical control group (0.5%, 9/1926) but differed significantly from the North control group (1.3%, 14/1,117). After adjustment, the risk factors of S. aureus SSI occurrence were the body mass index (ORaper unit, 1.05; 95%CI, 1.0-1.1), the Charlson comorbidity index (ORaper point, 1.34; 95%CI, 1.0–1.8) and operative time (ORaper minute, 1.01; 95%CI, 1.00–1.02). Having benefited from S. aureus screening/decolonisation was a protective factor (ORa, 0.24; 95%CI, 0.08–0.73).ConclusionsDespite the low number of SSI, nasal screening and targeted decolonisation of S. aureus were associated with a reduction in S. aureus SSI.

Predictive Validity of Anesthesiologists' Quality of Clinical Supervision and Nurse Anesthetists' Work Habits Assessed by Their Associations With Operating Room Times.

At all Joint Commission-accredited hospitals, the anesthesia department chair must report quantitative assessments of anesthesiologists' and nurse anesthetists' (CRNAs') clinical performance at least annually. Most metrics lack evidence of usefulness, cost-effectiveness, reliability, or validity. Earlier studies showed that anesthesiologists' clinical supervision quality and CRNAs' work habits have content, convergent, discriminant, and construct validity. We evaluated predictive validity by testing for (expected) small but statistically significant associations between higher quality of supervision (work habits) and reduced probabilities of cases taking longer than estimated. Supervision quality of each anesthesiologist was evaluated daily by assigned trainees using the 9-item de Oliveira Filho scale. The work habits of each CRNA were evaluated daily by assigned anesthesiologists using a 6-item scale. Both are scored binary, 1 if all items are rated the maximum, 0 otherwise. From 40,718 supervision evaluations and 53,722 work habit evaluations over 8 fiscal years, 16 mixed-effects logistic regression models were estimated, with raters as fixed effects and ratees (anesthesiologists or CRNAs) as random effects. Empirical Bayes means in the logit scale were obtained for 561 anesthesiologist-years and 605 CRNA-years. The binary-dependent variable was whether the case took longer than estimated from the historical mean time for combinations of scheduled procedures and surgeons. From 264,060 cases, 8 mixed-effects logistic regression models were fitted, 1 per fiscal year, using ratees as random effects. Predictive validity was tested by pairing the 8 one-year analyses of clinical supervision, and the 8 one-year analyses of work habits, by ratee, with the 8 one-year analyses of whether OR time was longer than estimated. Bivariate errors in variable linear least squares linear regressions minimized total variances. Among anesthesiologists, 8.2% (46/561) had below-average supervision quality, and 17.7% (99/561), above-average. Among CRNAs, 6.3% (38/605) had below-average work habits, and 10.9% (66/605) above-average. Increases in the logits of the quality of clinical supervision were associated with decreases in the logits of the probabilities of cases taking longer than estimated, unitless slope = -0.0361 (SE, 0.0053), P < .00001. Increases in the logits of CRNAs' work habits were associated with decreases in the logits of probabilities of cases taking longer than estimated, slope = -0.0238 (SE, 0.0054), P < .00001. Predictive validity was confirmed, providing further evidence for using supervision and work habits scales for ongoing professional practice evaluations. Specifically, OR times were briefer when anesthesiologists supervised residents more closely, and when CRNAs had better work habits.

A novel score to predict left atrial appendage thrombus and sludge in patients with persistent atrial fibrillation on chronic anticoagulants

Abstract Introduction Left atrium (LA) and left atrial appendage (LAA) thrombus may occur during atrial fibrillation (AF) and atrial flutter (AFl), and potentially cause main embolic events. Sludge is a pre-thrombotic condition, associated with long term adverse outcomes. Current guidelines do not recommend to perform transesophageal echocardiography (TEE) before cardioversion (CV) of patients with persistent AF/AFl when at least 3 weeks of anticoagulation are administered with appropriate compliance. Instead, they suggest TEE before atrial ablations (Abl), even in anticoagulated patients. Evidence to support these approaches are weak and conflicting, due to not infrequent occurrence of peri-procedural stroke and several reports of not negligible prevalence of LAA thrombus finding. Purpose Aim of the study was to evaluate the real prevalence of LAA thrombus and sludge in a retrospective cohort of consecutive anticoagulated patients with persistent AF and AFl, who underwent TEE before a scheduled cardioversion or catheter ablation. Moreover, clinical and echocardiographic characteristics were analyzed to develop a score that could predict the individual risk of combined thrombus/sludge. Methods We conducted a retrospective, monocentric, observational study, recruiting 1037 consecutive patients with persistent AF/AFl referred to our center for CV or Abl. TEE had been always performed to rule out thrombus and sludge before procedures. We collected data about patients characteristics, medication and compliance, electrographic and echocardiographic findings and type of scheduled procedure. Data was compared in univariate and multivariate analysis to identify possible predictors of LAA thrombus and sludge, and we used the last significant results to create a predictive score with logistic regression analysis. We identified best cutoff value with ROC curve. Results 767 patients were included in final dataset. Mean CHA2DS2-VASc was 3.2. LA/LAA thrombus and sludge were identified in 63 subjects (8.21%), 17 thrombi (2.21%) and 45 sludge (5.86%). Presence of valvular AF (+1), previous stroke or TIA (+1.5), heart failure history (+1), ventricular systolic (LVEF &amp;lt; 45%)(+0.5) and diastolic (Lateral E/e’ &amp;gt; 9) dysfunctions (+1) were significantly associated to higher risk of thrombus/sludge occurrence, meanwhile AFl (-1) was associated to lower risk. A novel score, called HEELP score, was developed based on these variables, and a threshold of 1 point showed high sensitivity (89%) and remarkable negative predictive value (98%). Conclusion Thrombus and sludge prevalence is not infrequent in anticoagulated patients with persistent AF/AFl. A strategy to perform TEE before procedures in patients with high risk features according to our score could be effective in preventing main embolic events, but it has to be validated in further studies.LAA empty (1), sludge (2), thrombus (3)HEELP score

How Preoperative Investigations Affect the Management of Bariatric Patients - Results of a Cohort Study of 897 Patients

Abstract Background Poorly defined preoperative diagnostic protocols worldwide vary in their emphasis on comprehensive investigations, with some prioritizing patient safety while others question routine procedures. Aims This study explores how diverse preoperative findings, from inflammatory processes to structural abnormalities, significantly influence patients’ management and the choice of bariatric procedures, underscoring the complexity in decision-making for individualized surgical interventions based on a cohort study's findings. Methods In a retrospective analysis of prospective data of over 1000 bariatric surgery patients from January 2017 to December 2022, we specifically included those who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG). In all patients, preoperative upper endoscopy was performed, with selected candidates also undergoing additional procedures like upper GI series and esophageal manometry, especially when LSG was planned. The study primarily analyzed the impact of preoperative examinations on therapeutic approaches. Results In this study, 897 patients were included, with 741 undergoing laparoscopic LRYGB and 156 LSG. All patients underwent upper endoscopy, revealing common findings such as type C gastritis, gastroesophageal reflux disease, and detection of Helicobacter pylori. Upper endoscopy prompted a therapeutic change in 216 patients (24.3%), resulting in a number needed to screen (NNS) of 4.1, with no significant differences based on the initially scheduled procedure. Preoperatively, upper GI series were more frequently conducted before planned LSG, uncovering hiatal hernias and motility disorders. However, no change in the surgical procedure resulted from upper GI series findings. Esophageal manometry, primarily performed for LSG, indicated normal findings in 84.6%, with a procedural change in 3 patients (2.0%). Overall, 14 (1.6%) patients experienced a change in the planned procedure, with 12 changes prompted by preoperative findings and two by technical difficulties. Conclusion We recommend routine upper endoscopy for all bariatric surgery patients, with additional manometry for planned LSG. Upper GI series should be reserved for selected cases and specific clinical indications.

Minimizing Flight Hours Losses by Utilizing Deep-Q Learning Techniques in Scheduling Aircraft Maintenance

Currently, there are insufficiently good or efficient tools or procedures for long-term scheduling of aviation maintenance activities in the world, and Vietnam specifically. Airlines are impacted by a variety of elements, including the quantity of aircraft they operate, their capacity, their personnel resources, their maintenance resources, and unforeseen and urgent occurrences that cause schedule disruptions. There are no fast, automatic solutions to the above-described problems existing in aviation today. The reinforcement learning method as described here could potentially be one answer to these problems. The idea is to plan in years running across a specified period such that the aircraft is brought as close as possible to the inspection deadline. From there, the airworthiness of the aircraft increases while the maintenance inspection decreases, reducing the cost of maintenance. Application optimization of the scheduling plan is done using the Deep Q-learning method. The results achieved by the Q-learning and Deep Q-learning algorithms are better in terms of computation times as compared to the other current techniques. The research results of the checks showed reinforcement learning potential in dealing with this problem, where the fly hours loss of planned inspections was reduced by using data from Vietnam Airlines. Computational experiments show that our methods adapt for different purposes and settings of reality. After teaching the model with these simulated conditions, they show how well a reinforcement learning application quickly arrives at lean repair plans.

Peformance Analysis of Fishery Extensions in Banyuwangi, East Java, Indonesia

This research aims to analyze the performance of fisheries instructors in improving the class of fish cultivator groups in East Java and analyze factors that can influence the performance of fisheries instructors in improving the class of fish cultivator groups in East Java. This research was conducted in East Java at BPPP Banyuwangi. Location determination was carried out using purposive sampling, where BPPP Banyuwangi had complete and accurate data that the author needed during the research. This research was conducted for 2 (two) months, namely December 2022 to January 2023. This type of research uses quantitative analysis with linear regression analysis. To obtain an overview of the implementation of counseling in East Java at BPPP Banyuwangi, it will be described descriptively. ResultsThe performance of instructors is very good, both in terms of quality, quantity, timeliness, effectiveness, relationships between individuals supported by quality human resources, availability of supporting facilities and infrastructure, trustworthy media and extension materials, systematic and scheduled work procedures according to time and analysis of four factors that are thought to influence the performance of fisheries instructors, it turns out that only one factor has a very real meaningful correlation, namely media and extension materials