Subsequent Management Research Articles

Care Nursing in Immune Disorder Assessment among Adult Oncology Patients: A Scoping Review.

International guidelines recommend a pathway for preferable nursing handling in a specific cancer topic, like chemotherapy toxicity, low adhesion in toxicity reported with a consequential increase in adverse events (AEs) frequency, poorer QoL outcomes, and increased use of healthcare service until death. Unpredictability, postponed reports, and incapability to access healthcare services can compromise toxicity-related effects by including patients' safety. In this scenario, a more attentive nursing intervention can improve patients' outcomes and decrease costs for healthcare services, respectively. The present scoping review aims to describe and synthesize scientific care nursing evidence assessment in oncology patients. PubMed, Embase, Nursing & Allied Health Database, and British Nursing were the databases examined. Keywords used and associated with Boolean operators were assessment, care, nursing, immune disorder, oncology, and patient. Research articles considered were published between 2013-2023. All systematic processes were performed according to the PRISMA procedure in order to reach all manuscripts considered in the present scoping review. The Embase database showed a total of 25 articles, PubMed displayed 77, the Nursing & Allied Health Database evidenced a total of 74, and the British Nursing database showed 252 records. Then, after a first revision in each database by considering the inclusion criteria, the abovementioned titles and abstracts were selected and, 336 records were removed, and 92 studies remained. Of these, 65 manuscripts were excluded after verifying abstracts. Finally, a total of 7 articles were carefully analysed and selected for this scoping review. Specifically, 2 articles belonged to the British Nursing Database, 3 articles belonged to Embase, 1 to the Nursing & Allied Health Database and one related to PubMed. Oncology nursing should consider several aspects, such as therapy-related toxicity and its related morbidity and mortality, worsening levels of quality of life, and increasing duty by the healthcare organization or endorsements for the principal symptoms and signs which may anticipate few diseases and worst clinical conditions, too. Therefore, careful monitoring may allow prompt recognition and subsequent earlier management in the treatment efficacy.

Prenatal diagnosis of genital anomalies with MRI: A case series

Introduction: Fetal magnetic resonance imaging (MRI) is commonly used as an adjunct to prenatal ultrasound (US) in identifying genitourinary abnormalities, but there is no data regarding its accuracy when identifying genital anomalies. To address this gap, this study reviewed our experience with identification of genital anomalies on fetal MRI and the correlation between fetal MRI findings and postnatal diagnosis. Case Series: An Institutional Review Board (IRB) approved retrospective review was conducted for patients with genital abnormalities noted on fetal MRI. Patients were excluded if the anomaly required no perinatal management steps, such as an isolated foreshortened phallus or due to an unrelated anomaly such as bladder exstrophy. The data collected included patient and maternal demographics, gravida status, prenatal ultrasound and fetal MRI findings, postnatal diagnosis, early postnatal course, and subsequent management. In this series of five patients with clinically significant genital findings on fetal MRI, two patients’ fetal MRI findings were confirmed by postnatal physical exam and/or imaging. Among the two patients with hypospadias in this series, only one was correctly diagnosed on fetal MRI and received postnatal follow-up by urology. Ambiguous genitalia were read in three patients’ fetal MRI with one of those confirmed postnatally. Two of these three patients underwent early rule-out congenital adrenal hyperplasia based on fetal MRI. Conclusion: A low percentage of patients with genital abnormalities received accurate prenatal diagnosis by fetal MRI. Fetal MRI may not provide an accurate diagnosis for prenatally detected genital findings but may serve as an additional data point to inform early postnatal diagnostics and level of care for patients with syndromic findings, such as ambiguous genitalia associated with congenital adrenal hyperplasia.

Late-onset asystole associated with vagal nerve stimulation.

Vagal nerve stimulation (VNS) is a form of neuromodulation that is an established adjunct in the management of drug-resistant epilepsy. The common side effects of VNS are cough, dysphonia, or shortness of breath, which are often mild and do not require discontinuation of therapy. However, serious adverse effects such as bradyarrhythmia and asystole can occur rarely in patients who have had VNS implanted several years ago due to certain technical issues, patient-related risk factors, and unknown causes that necessitate the deactivation of VNS. We describe the late onset of bradyarrhythmia in a 32-year-old patient with drug-resistant epilepsy 2 years after the implantation of VNS and the subsequent management. We also review similar cases in the literature to understand their mechanism of asystole and the antecedent risk factors. In conclusion, when selecting a patient for VNS, all the possible risk factors for adverse cardiac events should be considered. Initial EKG Holter prior to implantation and periodic monitoring is recommended for patients on VNS. PLAIN LANGUAGE SUMMARY: Vagal nerve stimulation (VNS) is a treatment used alongside medication for people with epilepsy who do not respond to drugs. It usually causes mild side effects such as cough or voice changes. Rarely, it can lead to serious heart problems such as slow heartbeat or heart stoppage, even years after the device is implanted. This report describes such a case in a 32-year-old patient and reviews similar cases to understand the risks. The authors recommend checking heart health with tests like an electrocardiogram before starting VNS and doing regular follow-up checks to help prevent serious complications.

Evaluation and processing of physical properties of anti-calcified glutaraldehyde-treated three-dimensional cultured cartilage tissues

Reconstruction using cartilage tissue is necessary to address deformities of the nose, ears, and maxillofacial region in several cases. However, autologous cartilage tissue transplantation is limited in the amount that can be harvested owing to invasiveness to the human body. Moreover, artificial materials such as implants cannot be used in many situations, given their potential to induce reactions to foreign bodies. Therefore, there is a growing demand for biomaterials that are less likely to cause foreign body reactions. Given that a tissue with a functionally superior three-dimensional (3D) structure can replace autologous tissue and artificial materials, we have developed a 3D cultured cartilage tissue without scaffolding material and are working toward its practical application. To achieve an off-the-shelf product that allows prolonged storage, the tissue was fixed with glutaraldehyde to maintain high strength for subsequent processing and management. Although tissue fixation with glutaraldehyde may cause calcification due to the deposition of calcium phosphate, calcification can be prevented by washing with high-concentration ethanol. We generated 3D cultured cartilage tissues using induced pluripotent stem cell-derived limb bud mesenchymal cells and an original cell self-culture aggregation method. The generated tissues were subjected to an anti-calcification treatment with glutaraldehyde and 80% ethanol. The treated tissue had improved stability and strength with minimal calcification. The tissue retained its physical properties that were effectively processable and could be processed into an ear-like shape.

Ferritin-guided management of blood donors with a marginally low pre-donation haemoglobin and its effect on the number of donations in the following 3 years.

The handling of donors with a marginally low haemoglobin is difficult and problematic and various methodologies have been applied to address this issue. The aim of this study was to assess whether measurement of serum ferritin and subsequent management of donors with a marginally low haemoglobin had any impact on the number of subsequent donations. Such donors were prospectively randomised into an intervention group whereby their serum ferritin was measured and those in the control group where routine assessments were done as per current SOPs. In the intervention group, action was taken depending on how low the serum ferritin was. The comparator in both study arms was the number of donations that were given during the follow-up period of 3 years. We could not find any significant consequence due to this intervention. The potential reasons are discussed, and we are proposing further studies on subsets of donors who are more prone to iron deficiency.

Total Intestinal Aganglionosis- A Deadly Masquerader!

Background: Total Intestinal Aganglionosis is an extremely rare variant of Hirschsprung’s disease (HD). Studies based on this malady are limited in literature, due to its rarity and its ability to masquerade as other surgical pathologies, thereby delaying and often preventing its correct diagnosis. This is a case series that describes its three varied presentations and subsequent management of it. Method: Retrospective observational study in a tertiary care centre in India. Clinical and operative data was retrospectively assessed from records from 2016 till 2023. Results: All three cases caused initial diagnostic dilemma- First case was diagnosed as meconium ileus and underwent Bishop Koop ileostomy. Second case was diagnosed as type I jejunal atresia and underwent resection anastomosis. Third case was suspected to be small bowel HD and underwent leveling jejunostomy. Multiple laparotomies were needed for all three cases, as there was no clinical improvement with first laparotomy. Histopathology proved to be crucial in clinching the final diagnosis of total intestinal aganglionosis. Ziegler’s myotomies were found to be effective for the first case, albeit for a brief period. Conclusion: Total Intestinal Aganglionosis is a rare entity that can masquerade as other surgical conditions in neonates leading to delayed or missed diagnosis. Routine biopsy can be taken in suspicious cases to rule out this ominous pathology. Autologous intestinal reconstructive procedures along with intestinal rehabilitation may become the ideal solution to this deadly masquerader, in the long run. Keywords: total intestinal aganglionosis, Hirschsprung's disease, Ziegler's myotomy, autologous intestinal reconstruction, total parenteral nutrition.

GIS-based Spatial-temporal Analysis of Castle-based Military Settlements in the Ming Great Wall Defense System of Yulin Zhen, Shaanxi Province, China

As a critical component of the Ming Great Wall Military Defense System (M-GWMDS) of Yulin Zhen in Shaanxi Province, China, castle-based military settlements have a horizontal distribution composed of three military routes and a vertical distribution consisting of two defense lines. These settlements played a key role in supervising the defense area and deploying troops. Exploring the spatial and temporal distribution of castle-based military settlements is a key link to revealing the in-depth distribution pattern of the M-GWMDS, but most studies have focused on their macroscopic distribution from a qualitative perspective. In this study, castle-based military settlements were selected as the research objects and were combined with architectural, archaeological, geographic, and military information. Their spatial and temporal analysis, including kernel density, slope/aspect conditions, and river systems, was explored based on GIS tools. By illustrating the military distribution nephogram and introducing the reachable spatial-temporal domains and viewshed, the deployment of military troops in this system was interpreted in depth. Taking both geographical and military factors into consideration, the XTENT model was comprehensively established to quantify the sphere of influence of castle-based military settlements, and the ranking and weights of factors influencing their distribution were eventually determined to illustrate the site catchment of these settlements, revealing the layout characteristics of the Ming Great Wall in the spatial and temporal dimensions to further reflect the military wisdom of the ancients. This research presents a new approach to thoroughly reveal the layout characteristics of the Ming Great Wall from a quantitative perspective, which will be beneficial to their subsequent protection and management.

Research on Vegetation Removal Strategies for the Ming Guangwu Great Wall Based on Clearance Resistance Assessment

The Great Wall of China, one of the nation’s most remarkable military defense structures, possesses a history spanning several millennia and is associated with numerous heritage sites. Today, it stands as a world-renowned cultural heritage asset. Vegetation growing on the ruins of the Great Wall can exert both detrimental and protective effects on the structure. Indiscriminate removal of such vegetation may lead to unintended damage to the heritage site. Drawing on the theory of “evaluative conservation”, this study integrates the analytic hierarchy process (AHP) and the Delphi method to develop a resistance assessment system for vegetation removal. A case study was conducted on 40 plant species or categories located along the Ming-era Guangwu section of the Great Wall, with spatial zoning analysis applied to inform removal strategies. The results reveal the structure, key factors, and classification criteria of the resistance evaluation system. Corresponding management recommendations are proposed, including strategies such as “preservation”, “partial preservation”, “removal”, and “subsequent removal and management”. This research provides a foundational reference for the conservation and restoration of the Great Wall heritage, and for the management of associated vegetation.

How soil fungal communities respond to invasive plant species treatments in soil from Banksia woodland, south-western Australia

Context Invasive plants are one of the most significant threats to woodlands globally. Methods of invasive plant control include manual removal and herbicide application. While the impacts of control methods on invasive and off-target native plant species are often explored, the impacts on below-ground organisms, such as fungi, are less well understood. Aims We conducted a glasshouse trial to investigate the responses of soil fungal communities to herbicides and manual removal that are used to control common invasive plant species in Banksia woodland in south-western Australia. Methods Broad spectrum (glyphosate and pelargonic acid) and grass-specific (fluazifop-p-butyl) herbicides were separately applied to pots containing either Ehrharta calycina, a key invasive grass species or Eucalyptus todtiana, a native woodland tree at the recommended woodland rate. After six weeks, samples of treated soils were subjected to high throughput sequencing to determine fungal community diversity, richness, relative abundance, composition and putative ecosystem function. Key results Pelargonic acid induced the widest range of changes including decreased fungal richness and Shannon diversity but all herbicides affected community composition. Within functional groups, fluazifop-p-butyl led to a significant decrease of symbiotrophs in the mycorrhizal species. Conclusions We show that invasive species management, in the manner applied, can lead to immediate changes in fungal community composition. Implications Observed patterns require further exploration, particularly repeat testing under different environmental conditions, to better determine the impact and mode of action of herbicides on below-ground organisms. The functional changes in the soil fungal community could further disturb the soil fungal community and complicate subsequent management considerations.

Transforming Water Research Through Human Rights-Based Approaches: A Framework for Implementation

The integration of human rights-based approaches (HRBAs) into water resource governance has gained significant momentum, particularly in regions facing complex water security challenges. It is now recognized that to address water security, we must address the human side of insecurity, and the HRBA endeavors to do this. Importantly, research projects are primary drivers of water management innovation. As research methodologies directly influence subsequent water management practices, the integration of HRBA in research becomes crucial for ensuring human rights considerations in future water governance. This study examines HRBA implementation in water research programs within the Mekong sub-region, where water insecurity significantly impacts local communities dependent on the Mekong River basin. Through an analysis of six research projects under the Sustainable Mekong Research Network, we assessed HRBA implementation using five dimensions: accountability, transparency, policy engagement, participation, and empowerment. Our mixed methods approach combined document analysis with semi-structured interviews. Projects revealed a spectrum of HRBA implementations from ‘thick’ to ‘thin’ applications, with political sensitivities and varying institutional capacities influencing implementation depth. This study introduces a novel framework for evaluating HRBA in water research, offering practical guidance for researchers and policymakers working in regions with complex socio-political dynamics. The resulting frameworks provide actionable tools that can be immediately applied in research design, stakeholder engagement processes, and policy development, enabling more equitable and effective water governance practices across diverse institutional contexts.

Peripartum fetal Doppler sonography and perinatal outcome: a systematic review and meta-analysis

ObjectiveSystematically review and critically appraise the literature on the association between peripartum fetal Doppler sonography findings, i.e., acquired upon admission for spontaneous or induced labor, and perinatal outcome in term (37-42w) pregnancies.MethodsMedline, Embase, Web of Science, Cochrane Library, and clinicaltrials.gov databases were systematically searched from inception to 05/2024. Studies conducted in unselected populations of term (37-42w) pregnancies, admitted for spontaneous or induced labor, reporting the association between fetal Doppler findings and perinatal outcome, were eligible for inclusion. Study eligibility was assessed independently by two reviewers. Methodological quality was assessed using the Quality In Prognosis Studies (QUIPS)-tool. Effect estimates were pooled using random-effects meta-analyses. Summary Odds Ratios (ORs) and Mean Differences (MDs) are reported with 95% confidence intervals.ResultsThirty-seven studies, reporting on 11.505 women and neonates, were included. Fourteen studies reported on findings from the umbilical artery (UA), four on the middle cerebral artery (MCA), five on the umbilical vein (UV), and nine on the cerebroplacental ratio (CPR). An abnormal UA Doppler and CPR increased the odds of fetal distress (FD) during labor (UA: OR 3.67 [1.14, 11.78], I2 = 72% – CPR: OR 3.19 [2.68, 3.80], I2 = 0%) and subsequent operative delivery (ODFD) (UA: OR 3.65 [1.66, 8.04], I2 = 81% – CPR: OR 2.48 [1.66, 3.70], I2 = 57%). Likewise, the presence of UV pulsations was strongly associated with both outcomes (FD: OR 28.78 [11.21, 73.87], I2 = 0% – ODFD: OR 303.36 [11.11, 8279.82], I2 = 0%). Regarding neonatal outcome, an Apgar-score < 7 at 5 min and NICU admission occurred more frequently if Doppler findings were abnormal in the UA (Apgar: OR 3.65 [1.82, 7.34], I2 = 0% – NICU: OR 3.92 [2.36, 6.51], I2 = 0%), or in case of an abnormal CPR (Apgar: OR 3.64 [2.03, 6.54], I2 = 0% – NICU: OR 2.71 [1.15, 6.38], I2 = 0%). Neonatal birthweight was also lower in the presence of an abnormal UA or CPR result, with a MD of -630.61g ([-1234.29, -26.93], I2 = 80%) and -146.52g ([-285.03, -8.01], I2 = 0%) respectively. Most studies (70.3%) were at high risk of bias on one or more domains; only 11 studies had an overall low risk of bias score.ConclusionDoppler sonography in the peripartum period allows for the identification of fetuses at risk of adverse birth outcomes. Further research on optimal thresholds to define at-risk cases and subsequent management strategies is needed.PROSPERO registration numberCRD42023413264.

The analysis of marketing performance in E-commerce live broadcast platform based on big data and deep learning

This study aims to conduct a comprehensive and in-depth analysis of the marketing performance of e-commerce live broadcast platforms based on big data management technology and deep learning. Firstly, by synthesizing large-scale datasets and surveys, the study constructs a series of performance evaluation indicators including user participation, content quality, commodity sales effect, user satisfaction, and platform promotion effect. Secondly, the weight of each indicator is finally determined through the indicator screening of the expert scoring method. Finally, the experimental design and implementation steps such as data collection, experimental environment setting, parameter setting, and performance evaluation are introduced in detail. Through the training and evaluation of the Back Propagation Neural Network (BPNN), each secondary indicator’s adjusted weight value and global ranking are obtained, providing a scientific basis for subsequent management opinions. The research results emphasize the importance of comments and ratings, purchase conversion rate, advertising click-through rate, and other indicators in improving user satisfaction, promoting sales, and effective promotion. Overall, this study provides a clear direction for an e-commerce live broadcast platform to optimize user experience, improve sales performance, and strengthen brand promotion.

Missed golden hours of stroke patients at Zweditu Memorial Hospital in Addis Ababa, Ethiopia

BackgroundSeeking medical attention promptly after an acute stroke is essential for effective treatment and improved patient outcomes. However, delayed medical intervention after acute stroke contributes to increased mortality and morbidity. This study explored factors that contribute to the delayed appearance of stroke patients at the emergency department.MethodsA prospective cross-sectional study was conducted for 9 months at a referral hospital in Addis Ababa. Data was collected using questionnaires administered to stroke patients or their caregivers upon their arrival at the emergency department. Electronic medical records were further reviewed, and the treating physicians described the subsequent management of the patient after their arrival at the emergency department. Data was analyzed using descriptive and analytic parameters.ResultsOnly 33.3% (n = 30) arrived at the emergency department within 4.5 h. Hemorrhagic stroke was a statistically significant predictor of early presentation to the emergency department (OR = 3.182; 95% CI (1.258–8.046); p = 0.036). The absence of any substance was another marginally significant predictor for early appearance (OR = 2.555; 95% (0.936–6.970); p = 0.067). One of the marginally significant predictors for late presentation was low drug adherence (OR = 0.224; 95% CI (0.48–1.044); p = 0.057). The other factors attributed to the time of arrival, though not statistically significant, were level of education, perception of stroke as a serious illness, and prior number of health visits before arrival to the emergency department.ConclusionThe study found that many of the factors that cause delays in getting to the hospital can be changed, except for the type of stroke. Time spent in the hospital could also be positively impacted by the intervention from the appropriate authorities.

Distinguishing epileptic seizures from imitators: A video-based evaluation of non-epileptologist physicians.

Distinguishing epileptic seizures from imitators: A video-based evaluation of non-epileptologist physicians.

Identifying dysphagia in the intensive care unit: Validation of the Swedish version of the Gugging swallowing screen-Intensive care unit.

Dysphagia is independently associated with adverse outcomes in intensive care units (ICU). Early identification through dysphagia screening does not occur routinely, negatively impacting optimal patient management. This study aimed to validate the Swedish version of the Gugging Swallowing Screen-Intensive Care Unit (GUSS-IVA). This is a prospective multicentre study of 56 adult ICU patients with endotracheal intubation exceeding 48 h at three hospitals in Sweden. The GUSS-ICU was translated into Swedish (GUSS-IVA) and used to screen all prolonged intubated patients (>48 h) once extubated. The GUSS-IVA screen was conducted by ICU nursing staff and then compared with a gold standard Flexible Endoscopic Evaluation of Swallowing (FEES) within 2 h of the GUSS-IVA screen. Fifty-one of 56 patients underwent FEES (where assessors were blinded to the GUSS-IVA screen results). Sensitivity and specificity were calculated, as was the area under the receiver operating characteristic curves (AUC) with 95% confidence intervals (CI). For inter-rater reliability, within 2 h of the initial screen, 29/56 patients were GUSS-IVA screened a second time by a nursing staff blinded to the first GUSS-IVA results. Among the 56 patients, 38 (67.9%) were identified as dysphagic using the GUSS-IVA screen. With FEES, 42 of 51 patients (82.4%) were diagnosed with dysphagia; of these, 16 (31.4%) were classified as aspirating. Compared to FEES, GUSS-IVA showed high sensitivity and specificity values (81% and 89%, respectively) with an AUC of 0.85 (95% CI: 0.71-0.95) and a positive predictive value of 97%. High convergent validity was obtained for GUSS-IVA compared with the Dysphagia Outcome Severity Scale (ɸ = 0.57, p < .001) and the Functional Oral Intake Scale (ɸ = 0.52, p < .001) and moderate validity with the Penetration-Aspiration Scale (ɸ = 0.30, p = .033). The inter-rater reliability showed moderate agreement (Cohen's kappa κ = 0.501, p = .006). This study indicates that the Swedish GUSS-IVA is a valid and reliable screen to identify dysphagic ICU patients. Given the negative impact of dysphagia on short and long-term patient outcomes, the Swedish GUSS-IVA is recommended as an essential first step by nursing staff for early identification of dysphagia for further diagnostics and subsequent patient management.

Analysis of the interaction between sleep quantity and sex in neurocognitive performance testing for sports-related concussion.

Cognitive testing for sports-related concussion (SRC) has become a critical component in ensuring the health of adolescent athletes. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is a validated tool for assessing SRC and guiding subsequent medical management; thus the effect of different variables on ImPACT scoring is of clinical relevance. The aim of this study was to evaluate the influence of sleep quantity and patient sex on the ImPACT performance of athletes at baseline and time points after SRC. A database containing ImPACT assessments from 11,563 high school athletes gathered from July 2009 to June 2019 in Florida and Colorado was queried. A retrospective analysis that included univariable and multivariable linear regression modeling was performed to evaluate sex and sleep effects on performance, both at baseline and after SRC injury. Patients self-reported the number of hours they slept the night before ImPACT assessment. Multivariable analysis revealed that at baseline, sex and the number of hours of sleep the night before testing had a significant interaction effect with both the symptom score (p < 0.0001) and reaction time (p = 0.0145) ImPACT categories. At postinjury testing, only the symptom score (p = 0.0374) was significantly associated with sex and sleep quantity. Sleep quantity and sex were found to be significantly associated with specific neurocognitive ImPACT composite scores. The results of this study underscore the need for further investigation into these variables in the context of SRC management to provide optimal and personalized treatment for young athletes.

Imaging in Hyperthermic Intraperitoneal Chemotherapy.

Hyperthermic intraperitoneal chemotherapy (HIPEC) combined with cytoreductive surgery (CRS) (CRS-HIPEC) has revolutionized the management of peritoneal malignancies, pivoting from a palliative care approach to a treatment strategy tailored to improve overall survival. This procedure is based on the principle that local instillation of heated chemotherapeutic agents augments their cytotoxic effects, which target and eradicate microscopic disease. Imaging is integral to the management of patients undergoing HIPEC, having multiple roles that range from patient selection, preoperative assessment, and determining treatment effectiveness to postprocedural surveillance. Various imaging modalities can be used for radiologic assessment and include CT, dual-energy CT, MRI, fluorine 18-fluorodeoxyglucose PET/CT, and PET/MRI. A crucial step in assessing the feasibility of CRS-HIPEC is estimation of the peritoneal carcinomatosis index, which enables one to determine the total peritoneal disease burden and is essential for effective multidisciplinary management. Following HIPEC, the completeness of cytoreduction score and residual disease score provide a robust framework for assessing treatment efficacy and strategically guiding subsequent management and surveillance protocols. Imaging facilitates accurate evaluation of complications, as well as early recognition of residual or recurrent peritoneal disease. The authors provide a comprehensive overview of HIPEC therapy, focusing on the role of imaging in the management of patients with peritoneal malignancies, delving into the nuances of this procedure, and discussing crucial aspects related to patient selection, surgical complexity, and prediction of outcomes. ©RSNA, 2025 See the invited commentary by Wasif in this issue.

Management of Bungarus sp. Envenomation Presenting as Rapidly Progressing Respiratory Failure: An Intensive Care Case Report

Introduction: Envenomation by snakes of the Bungarus genus (kraits) represents a critical medical emergency, particularly prevalent in South and Southeast Asia, including Indonesia. Krait venom is primarily neurotoxic, often containing potent presynaptic toxins (β-bungarotoxins) that disrupt neuromuscular transmission, leading to rapidly progressive descending paralysis. Respiratory failure due to diaphragmatic and intercostal muscle paralysis is the most life-threatening complication, necessitating immediate and expert intensive care management. Case presentation: We report the case of a 55-year-old Indonesian male who presented to the emergency department approximately five hours after being bitten on his right hand by a snake suspected to be a Weling (Bungarus sp.). He exhibited rapidly deteriorating neurological function, including dysarthria and decreased consciousness, progressing swiftly to acute respiratory failure with paradoxical breathing and hypoxia. Emergent endotracheal intubation and mechanical ventilation were instituted. Subsequent management in the Intensive Care Unit (ICU) involved continued ventilatory support, administration of polyvalent snake antivenom (SABU), sedation, broad-spectrum antibiotics for complicating pneumonia, and comprehensive supportive care. Nerve conduction studies later confirmed bilateral phrenic nerve palsy and severe sensorimotor axonal polyneuropathy. Conclusion: This case highlights the fulminant respiratory failure characteristic of severe Bungarus envenomation. Prompt recognition, aggressive airway management, and mechanical ventilation are paramount lifesaving interventions. While antivenom administration is a standard therapy, its efficacy in reversing established presynaptic neuromuscular blockade remains debated, underscoring the critical role of prolonged ventilatory support and meticulous ICU care until neuromuscular function recovers, which can be significantly delayed due to the nature of presynaptic toxins. This case reinforces the need for high vigilance and resource preparedness in managing neurotoxic snakebites in endemic regions.

Multi-objective value of information assessment using stochastic programming: addressing uncertainty in site index determination

Abstract Assessing the value of information (VoI) plays a critical role in determining the usefulness of data for informed decision-making. The evaluation of VoI should reflect the specific forest planning goals and allow for the inclusion of multiple objectives. We present a method that quantifies multi-objective VoI using stochastic programming optimization, enabling the integration of data uncertainty into the planning process. The developed optimization model includes economic and ecological criteria and integrates the decision-maker’s targets through the use of an achievement-scalarizing function. The VoI reflects how well data will help to meet the defined targets by comparing the outcomes of using the data of varying quality. We demonstrate the VoI assessment method through a case study that incorporates the uncertainty in forest productivity, represented by the site index (SI). Erroneous estimates of SI will lead to cumulative errors when forecasting forest development and subsequent sub-optimal management decisions. We compared the VoI of the direct and height differential approaches for SI determination using either bi-temporal airborne laser scanning (ALS) data or ALS and subsequent digital aerial photogrammetry (DAP) data. To compute the VoI, we used field-measured SI as the reference SI. The results demonstrated that the height differential approach outperformed the direct approach and indicated that a combination of ALS and subsequent DAP data could be a good alternative to bi-temporal ALS data for SI determination. However, the results are case-specific and depend on the decision-maker’s individual preferences and objectives. The proposed VoI assessment method is easily adaptable to various preference information and can be applied to different data acquisition approaches.

Cellulitis in Pediatric Patients: Recognition and Management in the Era of Evolving Resistance.

Cellulitis, a bacterial skin infection most frequently caused by group A streptococci (Streptococcus pyogenes) and less so by Staphylococcus aureus, commonly occurs in pediatric patients. The non-specific clinical presentation of poorly demarcated, expanding erythema, and warmth is common to a multitude of similarly presenting conditions, contributing to challenges in accurate diagnosis. There is also no gold standard diagnostic test for cellulitis, as laboratory assessments, tissue and blood cultures, and imaging studies have not been helpful. These adjunctive studies may be useful, however, for ruling out mimickers or more serious or complicating conditions, such as osteomyelitis, necrotizing fasciitis, or abscess. Diagnosis remains largely clinical and evaluation by a dermatologist and/or infectious disease specialist continues to be the clinical gold standard. As a result, access to specialty care and further research into helpful adjunctive measures, such as thermal imaging, are imperative for accurate diagnosis and management to prevent inappropriate antibiosis. Multidrug resistance has continued to evolve since the initial emergence of community-associated methicillin-resistant Staphylococcus aureus, with more recent studies showing an overall decline of methicillin-resistant S. aureus in the community and highest rates remaining in the Southern region of the USA. Despite changing resistance patterns, inappropriate prescribing patterns have persisted and contribute to rising rates of resistance to antibiotics such as trimethoprim-sulfamethoxazole and clindamycin. Therefore, accurate diagnosis and subsequent management with the narrowest possible antimicrobial therapy is ideal both for individual patient outcomes and for public health.