Sparing Strategies Research Articles

P0242 Improving quality in IBD – evaluation of corticosteroid excess prescription trends and its predictive role in disease-related outcomes

Abstract Background Corticosteroids (CS) are effective in induction of remission in inflammatory bowel disease (IBD), but should be used sparingly, given their unfavourable safety profile. In fact, CS excess has been incorporated in quality of care standards in IBD, highlighting the importance of auditing CS use. A CS sparing strategy is frequently recommended due to risk of side effects, but its consequences in IBD outcomes have been less studied. Our primary aim was to evaluate current CS use and excess in IBD patients, and compare them with a historic cohort. Our secondary aims were to identify predictors of CS excess prescription and compare prognostic outcomes (surgery, hospitalisation, new CS cycle, structural damage and a composite outcome) at 12 months between three prescription groups (no CS use, CS use with no excess, and CS excess). Methods Adult outpatients with IBD were included from one trimester in 2014 and one in 2023. CS prescription trends were compared between groups. The latter group was then used to identify predictors of excess CS prescription and to compare outcomes between prescription groups. Results A total of 1131 outpatients with IBD were included, 374 in 2014 and 757 in 2023. CS use was significantly lower in 2023, compared to 2014 (6.4% vs 20.6%, p<0.001), as was CS excess (12.0% vs 2.2%, p<0.001). C reactive protein (CRP) (OR = 1.055, IC 95% 1.024-1.087, p<0.001) and number of previous biologics (OR = 1.703, IC 95% 1.054-2.753, p=0.030) were independent predictors of CS excess prescription. The rates of hospitalisation, new CS cycle and composite outcome were significantly different between the 3 prescription groups (p<0.001). In multivariable Cox regression, CS excess prescription was an independent predictor of hospitalisation, new CS cycle and the composite outcome. CRP and clinical activity were also independent predictors of the latter outcomes. Conclusion CS prescription rate has significantly decreased, possibly due to different monitoring and treatment strategies. CS excess was associated with negative outcomes, namely hospitalisation and new CS cycles. Improving quality of care in IBD should target measures to avoid excess CS prescription.

Optimizing Spare Parts Inventory Management of Truck Dealer Services using Forecasting Methods and Continuous Review System Approach

A truck dealership company, specializing in maintenance, repair, and spare parts sales, faces stockout challenges that hinder its ability to meet demand for moving code 1 spare parts. The absence of effective forecasting methods and safety stock policies exacerbates these issues. This study aims to optimize inventory management by identifying suitable forecasting methods and implementing the Continuous Review System (CRS) to establish safety stock and reorder points as the parameter for procurement planning. The results indicate that the Double Exponential Smoothing (DES) method effectively predicts demand, while the Monte Carlo simulation method performs better for spare part 493051110L. The CRS approach improves the fill rate and reduces stockout risks, ensuring better inventory management for the company. These findings provide a framework for the company to enhance its spare parts inventory strategy, contributing to improved service reliability and operational efficiency.

Oncologic safety and technical feasibility of completion transanal total mesorectal excision after local excision; a cohort study from the International TaTME Registry.

As part of an organ sparing strategy, a surgical local excision may be performed in patients with early-stage rectal cancer or following neoadjuvant (chemo)radiotherapy. In selected cases, a completion total mesorectal excision may be recommended which can be more complex because of the preceding local excision. A transanal approach to perform completion total mesorectal excision may offer an advantage through the better visualization of the surgical field in the distal rectum and less forceful retraction for exposure. However, the oncologic safety and technical feasibility of this approach have yet to be demonstrated in these patients. Therefore, the aim of this study was to evaluate the oncological and technical safety of completion transanal total mesorectal excision following a local excision in patients with rectal cancer. Patients from the prospective International Transanal Total Mesorectal Excision Registry who underwent a surgical local excision prior to completion transanal total mesorectal excision were retrospectively analyzed. In total, 189 patients were included of which 22% received neoadjuvant radiotherapy. In 94% of the patients, a low anterior resection was performed. A primary anastomosis was constructed in 91% (n = 171/189) of the patients, with the majority also receiving a defunctioning stoma (84%, n = 144/171), of which 69% (n = 100/144) were reversed. Within 30 days, 7% developed an anastomotic leakage. The two-year local recurrence rate was 5% (n = 5/104) with an estimated rate of 3% (95% CI 0-7%). Two-year disease-free survival was 85% (n = 88/104) and overall survival was 95% (n = 99/104). Transanal completion total mesorectal excision following local excision for rectal cancer is oncologically safe, with low complication rates and high restorative rates.

Spare Parts Management Strategy of High-Speed Railway Running Department Based on Performance Prediction

Spare parts management is a critical aspect of high-speed train health management, playing a vital role in maximizing in-service time and minimizing maintenance costs. However, traditional spare parts management methods, which rely solely on historical experience and suggest spare parts quantities or ratios in equipment manuals, often lack practicality and fail to meet real-world demands. To address these limitations, this paper proposes a performance prediction-based spare parts management strategy for high-speed trains. The strategy comprises three main components. First, a performance degradation model is developed using performance evaluation results to define a performance degradation envelope. Next, the required quantity or ratio of spare parts for multiple devices in different performance states is determined using the expected performance score method. Finally, the timing of spare parts orders is scientifically optimized by accounting for production and transportation lead times. To demonstrate the effectiveness of the proposed strategy, we conducted experiments using the spare parts management of a specific high-speed train running gear as a case study and compared it with existing spare parts management methods.

Opioid free versus opioid sparing strategies for multimodal antinociception during laparoscopic colectomy: a randomised controlled trial

It remains unclear whether opioid-free anesthesia (OFA), when compared to opioid-sparing anesthesia (OSA), reduces postoperative opioid consumption while still providing adequate pain control. We thus tested the hypothesis that patients having an OFA strategy during laparoscopic colectomy would require less postoperative opioids when compared to an OSA strategy. This single-center, prospective randomized controlled superiority trial, randomly allocated consecutive patients undergoing laparoscopic colectomy to receive either sevoflurane-dexmedetomidine anesthesia with a continuous infusion of lidocaine and ketamine (OFA group) or sevoflurane-sufentanil boluses anesthesia with a continuous infusion of lidocaine (OSA group). Both groups received multimodal antinociception with boluses of dexamethasone, lidocaine, and ketamine during anesthesia induction, as well as acetaminophen, ketoprofen, and nefopam before the end of the surgery. OFA patients also received a dose of magnesium sulfate during induction. The primary outcome was cumulative opioid consumption at 48 h after surgery, expressed in oral morphine equivalents (OME). Secondary exploratory outcomes were pain scores, opioid-related adverse events, and patient quality of life (WHODAS score). Of the 160 randomized patients, 155 were included in a modified intention-to-treat analysis. Median [Q1-Q3] OME consumption at 48 h after surgery did not differ between groups (9 [0-30] mg for OFA vs. 14 [0-30] mg for OSA; p = 0.861). Key secondary outcomes were not different between groups except a three time higher incidence of bradycardia in the OFA group. In patients undergoing laparoscopic colectomy with a multimodal antinociception protocol, OFA, when compared to OSA, did not decrease postoperative opioid consumption. NCT05031234.

Calculating optic nerve planning organ at risk volume margins for stereotactic radiosurgery using optic nerve motion determined using MRI.

The combination of sharp dose gradients in stereotactic radiosurgery (SRS) and minute optic nerve motion may significantly increase dose to the optic nerves when treating perioptic lesions. The aim of this study was to calculate optic nerve planning organ at risk volume (PRV) margins for CyberKnife SRS treatment planning. MRI scans were taken of 10 healthy volunteers looking left, right, up, down, and straight ahead to measure optic nerve motion. The measured optic nerve motion and the uncertainties in the technical accuracy of CyberKnife were used to calculate optic nerve PRV margins. Two optic nerve PRV margins were calculated: a non-isotropic margin of mL/R,PRV=3mm, mSup/Inf,PRV=2mm, and mAnt/Post,PRV=1mm which considers the full range of motion measured in a worst case scenario; and an isotropic margin of mPRV=1mm which considers a scenario where patients are asked to look neutrally during imaging and treatment. Applying these PRVs to 8 historical sphenoid wing meningioma CyberKnife plans showed tolerance levels may be exceeded due to optic nerve motion. Optic nerve PRV margins may be needed in CyberKnife planning to reduce risk to the optic nerves. The use of a mPRV=1mm PRV to account for organ motion, along with instructing patients to hold their gaze neutrally during imaging and treatment, may be a suitable organ sparing strategy. Measured optic nerve motion and the technical accuracy of the CyberKnife system have been used to calculate optic nerve PRV margins.

Combined strategy of device-based contrast minimization and urine flow rate-guided hydration to prevent acute kidney injury in high-risk patients undergoing coronary interventional procedures.

Contrast-associated acute kidney injury (CA-AKI) is a major complication following coronary procedures. We aimed to evaluate the effectiveness of a combination of urine flow rate-(UFR) guided hydration (RenalGuardTM) and device-based contrast media (CM) reduction (DyeVertTM) in CA-AKI prevention. Stable high-risk patients undergoing coronary procedures with the use of DyeVertTM and RenalGuardTM were prospectively included (Combined group) and matched with a similar cohort of patients treated only with RenalGuardTM in whom CM volume was controlled by operator-dependent strategies (Control group). CA-AKI was defined as a serum creatinine increase ≥0.3 mg/dL at 48 h. Overall, 55 patients were enrolled and matched with comparable controls. Patients in the Combined group were exposed to a lower CM dose (Control: 55 [30-90] mL vs. Combined: 42.1 [24.9-59.4] mL; p = 0.024). A significant interaction was found between treatment allocation and serum creatinine changes (p = 0.048). CA-AKI occurred in five (9.1%) patients in the Combined group and in 14 (25.4%) patients in the Control group (OR 0.29, 95% CI [0.09-0.88]). A combined strategy of device-based CM reduction plus UFR-guided hydration is superior to operator-dependent CM sparing strategies plus UFR-guided hydration in preventing CA-AKI in high-risk patient.

295. SAFETY OF SURVEILLANCE GASTROSCOPY AND ENDOSCOPIC ULTRASONOGRAPHY IN THE OESOPHAGUS AFTER NEOADJUVANT CHEMORADIOTHERAPY: RESULTS FROM THE SANO COHORT

Abstract Background An organ sparing strategy has been proposed for patients with oesophageal cancer and a clinically complete response after neoadjuvant chemoradiotherapy (nCRT). This active surveillance strategy involves (repeated) oesophagogastroduodenoscopy (OGD) with bite-on-bite biopsies and endoscopic ultrasonography (EUS). The preSANO trial and preliminary results of the SANO trial concluded that these procedures are safe to identify those with a clinically complete response. However, the safety of these procedures beyond that timeframe remains unknown. The aim of this study is to assess the safety of endoscopic procedures after nCRT, extending beyond three months. Methods This is a retrospective multicentre cohort study. All patients who participated in the pre-SANO and SANO studies were included. All were treated with CROSS nCRT for oesophageal cancer and underwent (repeated) endoscopic response evaluations (OGD with bite-on-bite biopsies and/or EUS with fine needle aspiration, as indicated). Primary outcome was serious adverse events (SAE) as defined by Central Committee on Research Involving Human Subjects (CCMO) associated with endoscopic procedures which include (but are not limited to) bleeding, infection and perforation. Secondary outcome included mechanical injury. Results A total of 919 patients underwent at least one endoscopic response evaluation. Some 2355 endoscopic procedures (61% OGD with EUS combined, 33% OGD and 6% EUS) were performed. Of these, 819 (35%) were performed more than three months after nCRT. SAEs were reported for five endoscopic procedures (0.2%) and included three cases of gastrointestinal bleeding after OGD with biopsies and two cases with infection secondary to the endoscopic procedures. No significant difference in SAEs was found between the procedures conducted before and more than three months after nCRT (2 vs. 3, OR 2.8, 95% CI, 0.3 – 33.7, P = 0.35). Conclusion OGD with biopsies and EUS are both procedures which can be safely performed after nCRT during an active surveillance strategy.

Coupled optimization of task sequence and hoist scheduling for electroplating production lines based on an improved salp swarm algorithm

Coupled optimization of task sequence and hoist scheduling for electroplating production lines based on an improved salp swarm algorithm

Enhancing bird conservation in tropical urban parks through land sparing and sharing strategies: Evidence from occupancy data

Enhancing bird conservation in tropical urban parks through land sparing and sharing strategies: Evidence from occupancy data

The NEO-RT trial: A phase 3 randomized trial of neoadjuvant chemotherapy, excision and observation versus chemoradiotherapy for early rectal cancer, CCTG CO.32.

TPS3646 Background: There is significant interest in organ-sparing management of rectal cancer. Data from the National Cancer Database suggest that in 2020 only 20% of US patients with stage I rectal cancer are managed non-operatively. The phase II CCTG CO.28/NEO trial previously reported high rates of tumor downstaging, organ preservation and excellent rectal function among patients with T1-T3abN0 rectal adenocarcinoma treated with 3 months of FOLFOX/CAPOX followed by Transanal Endoscopic Surgery (TES). The phase III CO.32/NEO-RT trial (NCT06205485) will compare two organ sparing strategies for patients with stage I rectal cancer. Methods: Eligible patients with clinical stage T1/2 N0 adenocarcinoma with preserved mismatch repair (MMR) will be randomized 1:1 to ARM A, 3 months of FOLFOX or CAPOX versus ARM B, chemoradiation (54 Gy) followed by tumor restaging within 16 weeks of start of therapy. Patients with histological high grade, mucinous or deficient MMR and those that can be treated with tumor excision alone are excluded. The primary endpoint is tumor downstaging to clinical Complete Response (cCR) by pelvic MRI, endoscopy and digital rectal exam. Subsequent TES is recommended for all patients with tumor response and may be done within 24 weeks of treatment begin, followed by 5 years (y) of observation with serial MRI (q6m x 2y then annually) and endoscopy (q4m x 2y, then q6m during year 3, then annually). The co-primary endpoint is Quality Of Life (QOL) measured by the Low Anterior Resection Score (LARS). In a non-inferiority comparison between treatment arms, if the cCR is assumed to be 45% in ARM B and if there is no true difference between ARMS A and B, then 250 patients are required to be 80% sure that the upper limit of a one-sided 90% confidence interval will exclude a difference in favor of chemoradiation of more than 14%. Results: The approved CCTG CO.32 trial is expected to open February, 2024 at Canadian CCTG and US Alliance, ECOG-ACRIN, NRG, and SWOG NCTN sites with an estimated accrual duration of 4 years. Conclusions: The results of this study will have a major impact on the treatment of patients with stage I rectal cancer. Both arms offer the potential of organ preservation and results will inform whether induction chemotherapy is non-inferior to ChemoRT and compare patient QOL and functional outcomes. Clinical trial information: NCT06205485 .

A bundle of opioid-sparing strategies to eliminate routine opioid prescribing in a urogynecology practice

Current evidence supports that many patients do not use prescribed opioids following reconstructive pelvic surgery, yet it remains unclear if it is feasible to eliminate routine opioid prescriptions without a negative impact on patients or providers. To determine if there is a difference in the proportion of patients discharged without opioids after implementing a bundle of opioid-sparing strategies and tiered prescribing protocol compared to usual care after minimally invasive pelvic reconstructive surgery (transvaginal, laparoscopic, or robotic). Secondary objectives include measures of patient-perceived pain control and provider workload. The bundle of opioid-sparing strategies and tiered prescribing protocol intervention was implemented as a division-wide evidence-based practice change on August 1, 2022. This retrospective cohort compares a 6-month postintervention (bundle of opioid-sparing strategies and tiered prescribing protocol) cohort to 6-month preintervention (usual care) of patients undergoing minimally invasive pelvic reconstructive surgery. A 3-month washout period was observed after bundle of opioid-sparing strategies and tiered prescribing protocol initiation. We excluded patients <18years, failure to consent to research, combined surgery with other specialties, urge urinary incontinence or urinary retention procedures alone, and minor procedures not typically requiring opioids. Primary outcome was measured by proportion discharged without opioids and total oral morphine equivalents prescribed. Pain control was measured by pain scores, postdischarge prescriptions and refills, phone calls and visits related to pain, and satisfaction with pain control. Provider workload was demonstrated by phone calls and postdischarge prescription refills. Data were obtained through chart review on all patients who met inclusion criteria. Primary analysis only included patients prescribed opioids according to the bundle of opioid-sparing strategies and tiered prescribing protocol protocol. Two sample t tests compared continuous variables and chi-square tests compared categorical variables. Four hundred sixteen patients were included in the primary analysis (207 bundle of opioid-sparing strategies and tiered prescribing protocol, 209 usual care). Baseline demographics were similar between groups, except a lower proportion of irritable bowel syndrome (13% vs 23%; P<.01) and pelvic pain (15% vs 24.9%; P=.01), and higher history of prior gynecologic surgery (69.1% vs 58.4%; P=.02) in the bundle of opioid-sparing strategies and tiered prescribing protocol cohort. The bundle of opioid-sparing strategies and tiered prescribing protocol cohort was more likely to be discharged without opioids (68.1% vs 10.0%; P<.01). In those prescribed opioids, total oral morphine equivalents on discharge was significantly lower in the bundle of opioid-sparing strategies and tiered prescribing protocol cohort (48.1 vs 81.8; P<.01). The bundle of opioid-sparing strategies and tiered prescribing protocol cohort had a 20.6 greater odds (confidence interval 11.4, 37.1) of being discharged without opioids after adjusting for surgery type, arthritis/joint pain, IBS, pelvic pain, and contraindication to nonsteroidal anti-inflammatory drugs. The bundle of opioid-sparing strategies and tiered prescribing protocol cohort was also less likely to receive a rescue opioid prescription after discharge (1.4% vs 9.5%; P=.03). There were no differences in opioid prescription refills (19.7% vs 18.1%; P=.77), emergency room visits for pain (3.4% vs 2.9%; P=.76), postoperative pain scores (mean 4.7 vs 4.0; P=.07), or patient satisfaction with pain control (81.5% vs 85.6%; P=.21). After bundle of opioid-sparing strategies and tiered prescribing protocol implementation, the proportion of postoperative phone calls for pain also decreased (12.6% vs 21.5%; P=.02). Similar results were identified when nonadherent prescribing was included in the analysis. A bundle of evidence-based opioid sparing strategies and tiered prescribing based on inpatient use increases the proportion of patients discharged without opioids after minimally invasive pelvic reconstructive surgery without evidence of uncontrolled pain or increased provider workload.

Site occupancy of native terrestrial mammals in oil palm landscapes is driven by the synergy of land sparing and sharing strategies

Site occupancy of native terrestrial mammals in oil palm landscapes is driven by the synergy of land sparing and sharing strategies

Preserving large blocks of primary forest is critical to conserve forest‐dependent bird species in the Amazon

AbstractResearch Highlight: Birch, B. D. J., Mills, S. C., Socolar, J. B., Martínez‐Revelo, D. E., Haugaasen, T., &amp; Edwards, D. P. (2024). Land sparing outperforms land sharing for Amazonian bird communities regardless of surrounding landscape context. Journal of Applied Ecology, https://doi.org/10.1111/1365‐2664.14596.Tropical forests are globally threatened by agricultural activities, including cattle farming. The land sharing versus land sparing debate has often been used as a means of addressing the trade‐off between agricultural production and biodiversity conservation, without finding a consensus within the scientific community. Moving forward, recent studies suggest combining both land allocation strategies, where wildlife‐friendly habitats within farmlands could allow movements of species within the agricultural matrix and connect natural habitats such as forest blocks, though this has rarely been demonstrated with empirical studies. In their study, Birch et al. tested how wildlife‐friendly habitats within and around cattle pastures could rescue the negative effects of converting forest to farmland on Amazon bird communities. To do so, they modelled bird species occupancies and simulated different land sharing versus land sparing scenarios with varying amount of landscape‐scale wildlife‐friendly habitat and levels of production. They found that the land sparing strategy outperformed land sharing in all scenarios, with limited benefits of landscape‐scale wildlife‐friendly habitat. This result was mostly driven by forest‐dependent species that cannot persist in farmlands. As these species are highly sensitive, preserving large blocks of primary forest is critical for their conservation.

Optimizing nano/micro satellite constellation lifecycle cost based on reliability after acceptance testing

Optimizing nano/micro satellite constellation lifecycle cost based on reliability after acceptance testing

The Importance of Spare Strategy in a Research Facility

This document shows the importance of spare part strategy in a research facility at one of the most important medical schools in the world. It presents technical concepts related to equipment criticality analysis and spare part management integrated with computerized maintenance management systems (CMMS). A case study utilizing VFDs on campus will be produced to reveals gaps, benefits, and opportunities to improve the current spare part management system. Challenges in the spare part process will also be addressed in this document, such as storage and external vendor support.

An algorithm based on immunotherapy discontinuation and liver biopsy spares corticosteroids in two thirds of cases of severe checkpoint inhibitor-induced liver injury.

There are few data on corticosteroids (CS)-sparing strategies for checkpoint inhibitor (ICI)-induced liver injury (ChILI). We aimed to assess the performance of a 2-step algorithm for severe ChILI, based on ICI temporary discontinuation (step-1) and, if lack of biochemical improvement, CS based on the degree of necroinflammation at biopsy (step-2). Prospective study that included all subjects with grade 3/4 ChILI. Peripheral extended immunophenotyping was performed. Indication for CS: severe necroinflammation; mild or moderate necroinflammation with later biochemical worsening. From 111 subjects with increased transaminases (January 2020 to August 2023), 44 were diagnosed with grade 3 (N = 35) or grade 4 (N = 9) ChILI. Main reason for exclusion was alternative diagnosis. Lung cancer (13) and melanoma (12) were the most common malignancies. ICI: 23(52.3%) anti-PD1, 8(18.2%) anti-PD-L1, 3(6.8%) anti-CTLA-4, 10(22.7%) combined ICI. Liver injury pattern: hepatocellular (23,52.3%) mixed (12,27.3%) and cholestatic (9,20.5%). 14(32%) presented bilirubin >1.2 mg/dL. Overall, 30(68.2%) patients did not require CS: 22(50.0%) due to ICI discontinuation (step-1) and 8/22 (36.4%) based on the degree of necroinflammation (step-2). Biopsy mainly impacted on grade 3 ChILI, sparing CS in 8 out of 15 (53.3%) non-improvement patients after ICI discontinuation. CD8+ HLA-DR expression (p = 0.028), central memory (p = 0.046) were lower in CS-free managed subjects, but effector-memory cells (p = 0.002) were higher. Time to transaminases normalisation was shorter in those CS-free managed (overall: p < 0.001, grade 3: p < 0.001). Considering our results, a strategy based on ICI discontinuation and biopsy for grade 3 ChILI is proposed. An algorithm based on temporary immunotherapy discontinuation and biopsy allows CS avoidance in two thirds of cases of severe ChILI.

Integration of the Molecular Classification of Endometrial Carcinoma to Select Patients for Fertility Sparing Strategies.

Fertility-sparing treatment (FST) for endometrial carcinoma (EC) is an option for a subgroup of young women with low-risk disease. The low-risk group comprises patients with endometrioid EC stage IA, grade 1, with or without focal lymphovascular invasion. In the era of molecular subtyping, treatment de-escalation for some EC subtypes is recommended. Recommendations for fertility-preserving treatments were developed regardless of the molecular classification of EC. However, few studies have focused on this topic. In this review, we summarize the actual data available in the literature and discuss the impact of some molecular subtypes of FST.

Rheumatology: what's new in 2023

In rheumatology, this year has been characterized by a broader knowledge of the pathogenesis of rheumatoid arthritis and mechanisms involved in the onset and persistence of low back pain. Studies relevant to the management of of gout, axial spondyloarthritis, autoinflammatory diseases and systemic vasculitides were published. New data on the safety of JAK inhibitors have been published. The ASAS-EULAR recommendations for the treatment of axial spondyloarthritis were updated, and the 2023 EULAR/PReS guidelines for the diagnosis and treatment of systemic juvenile idiopathic arthritis and adult-onset Still's disease are now available. New molecules and different glucocorticoid sparing strategies were introduced for giant cell arteritis.

Modelling the effectivity of a land sparing strategy to preserve an endangered steppe-land bird population in cereal farmland: Scopes and limits

Modelling the effectivity of a land sparing strategy to preserve an endangered steppe-land bird population in cereal farmland: Scopes and limits