Wait and See

Will a Donald Trump presidency mean business as usual for U.S.-Africanrelations？ONCE,the United States would have been considered too far from Cameroon.But in today＇s Internet era,better and faster communication links have shrunk the world into a global village and made the far near.So when Cameroonian Raoul Keddy wanted a better life, he did not think of moving to capital Yaounde from Douala. where his family lived, or even to more devel- oped economies on the continent like South Africa. Instead he went to Atlanta.

Neoadjuvant treatment of rectal cancer: Where we are and where we are going

Locally advanced rectal cancer requires a multidisciplinary approach based on total neoadjuvant treatment with radiotherapy(RT)and chemotherapy(ChT),followed by deferred surgery.Currently,alternatives to the standard total neoadjuvant therapy(TNT)are being explored,such as new ChT regimens or the introduction of immunotherapy.With standard TNT,up to a third of patients may achieve a complete pathological response(CPR),potentially avoiding surgery.However,as of now,we lack predictive markers of response that would allow us to define criteria for a conservative organ strategy.The presence of muta-tions,genes,or new imaging tests is helping to define these criteria.An example of this is the diffusion coefficient in the diffusion-weighted sequence of magnetic resonance imaging and the integration of this imaging technique into RT treatment.This allows for the monitoring of the evolution of this coefficient over successive RT sessions,helping to determine which patients will achieve CPR or those who may require intensification of neoadjuvant therapy.

Effect of Extending Voluntary Waiting Period on Health of Holstein Friesian Dairy Cows

The aim of this of this experimental study to investigate the effect of 3 voluntary waiting periods (VWP) on health of dairy cows. A total of 100 lactations of 100 Holstein Friesian cows with high milk production (average 9.442 ± 620 kg) were randomly (based on the ear tags digits of cows) distributed to 1 to 3 experimental groups with VWP of 50 (VWPG50;n = 32), 100 (VWPG100;n = 34) or 150 days (VWPG150;n = 34). Observations relating to diseases of the cows were made by the farm veterinarian and research personnel. Were defined eight disease: puerperal fever, retained fetal membranes, displaced abomasum, metritis, clinical ketosis, clinical mastitis, ovarian cysts, and claw diseases. The experimental days (ED) were from 4 days in milk (DIM) to 100 days after the next calving. The experiment was managed at Dairy Research Farm ?imnic-Craiova January 2018 to December 2022. A clear set of clinical signs were used to define a case at the diseases without the need for laboratory confirmation. Values of Lactational incidence risk (LIR) median postpartum days at diagnosis and pairwise comparison of proportion between VWPs were calculated. LIR for puerperal fiver, retained fetal membranes, displaced abomasum, clinical ketosis, clinical mastitis, ovarian cysts and claw disease were 4;5;2;8;8;and 4% respectively. Numerically, cows with VWP of 100 and150 days had more disease cases compared with VWP of 50 days. The differences between experimental groups of cows regarding proportions of cows with disease cases were not statistically significant. Any of the eight disorders reported in this study was analyzed independently to other health problems. For all enrolled cows (n = 100) VWP was extended until 100 or 150 days postpartum with no effect on the lactational incidence risk for the eight disorders analyzed.

Reexamining Positivity of Thinking in Waiting for Godot Through Camus’s Absurdism

Absurdity originated from French existentialism,and Martin Esslin,in categorizing Waiting for Godot as a theater of the absurd,ignores the positive aspects of Camus’s absurdism and regards that as an existential tragedy of mankind.However,the author Samuel Beckett himself did not approve of such a definition,believing that Esslin’s definition of theater of the absurd was too judgmental and pessimistic.Through the imagery of boots,ropes,hats and baggage in Waiting for Godot,Beckett reveals the rootlessness,constraint and agony of the minds of people born into absurdity in the early 20th century.The luck of Lucky is Beckett’s use of irony:people who have lost the ability to think for themselves escape the absurdity and dystopia of life and descend to slaves.Gogo and Didi,who are waiting and expecting,and thinking in the midst of absurdity,represent“Godot”,the symbol of hope.Their endurance in waiting,akin to Camus’s Sisyphus,underscores a form of existential defiance that challenges the notion of absolute pessimism in absurdist literature.

Bridging and downstaging treatments for hepatocellular carcinoma in patients on the waiting list for liver transplantation

Several therapeutic procedures have been proposed as bridging treatments for patients with hepatocellular carcinoma(HCC)awaiting liver transplantation(LT).The most used treatments include transarterial chemoembolization and radiofrequency ablation.Surgical resection has also been successfully used as a bridging procedure,and LT should be considered a rescue treatment in patients with previous HCC resection who experience tumor recurrence or post-treatment severe decompensation of liver function.The aims of bridging treatments include decreasing the waiting list dropout rate before transplantation,reducing HCC recurrence after transplantation,and improving post-transplant overall survival.To date,no data from prospective randomized studies are available;however,for HCC patients listed for LT within the Milan criteria,prolonging the waiting time over 6-12 mo is a risk factor for tumor spread.Bridging treatments are useful in containing tumor progression and decreasing dropout.Furthermore,the response to pre-LT treatments may represent a surrogate marker of tumor biological aggressiveness and could therefore be evaluated to prioritize HCC candidates for LT.Lastly,although a definitive conclusion can not be reached,the experiences reported to date suggest a positive impact of these treatments on both tumor recurrence and post-transplant patient survival.Advanced HCC may be downstaged to achieve and maintain the current conventional criteria for inclusion in the waiting list for LT.Recent studies have demonstrated that successfully downstaged patients can achieve a 5-year survival rate comparable to that of patients meeting the conventional criteria without requiring downstaging.

Watch and wait approach in rectal cancer:Current controversies and future directions

According to the main international clinical guidelines,the recommended treatment for locally-advanced rectal cancer is neoadjuvant chemoradiotherapy followed by surgery.However,doubts have been raised about the appropriate definition of clinical complete response(cCR)after neoadjuvant therapy and the role of surgery in patients who achieve a cCR.Surgical resection is associated with significant morbidity and decreased quality of life(QoL),which is especially relevant given the favourable prognosis in this patient subset. Accordingly, therehas been a growing interest in alternative approaches with less morbidity,including the organ-preserving watch and wait strategy, in which surgery isomitted in patients who have achieved a cCR. These patients are managed with aspecific follow-up protocol to ensure adequate cancer control, including the earlyidentification of recurrent disease. However, there are several open questionsabout this strategy, including patient selection, the clinical and radiologicalcriteria to accurately determine cCR, the duration of neoadjuvant treatment, therole of dose intensification (chemotherapy and/or radiotherapy), optimal followupprotocols, and the future perspectives of this approach. In the present review,we summarize the available evidence on the watch and wait strategy in thisclinical scenario, including ongoing clinical trials, QoL in these patients, and thecontroversies surrounding this treatment approach.

Watch and wait approach to rectal cancer: A review

In 2014, there were an estimated 136800 new cases of colorectal cancer, making it the most common gastrointestinal malignancy. It is the second leadingcause of cancer death in both men and women in the United States and over one-third of newly diagnosed patients have stage Ⅲ(node-positive) disease. For stage Ⅱ and Ⅲ colorectal cancer patients, the mainstay of curative therapy is neoadjuvant therapy, followed by radical surgical resection of the rectum. However, the consequences of a proctectomy, either by low anterior resection or abdominoperineal resection, can lead to very extensive comorbidities, such as the need for a permanent colostomy, fecal incontinence, sexual and urinary dysfunction, and even mortality. Recently, trends of complete regression of the rectal cancer after neoadjuvant chemoradiation therapy have been confirmed by clinical and radiographic evaluationthis is known as complete clinical response(cC R). The "watch and wait" approach was first proposed by Dr. Angelita Habr-Gama in Brazil in 2009. Those patients with c CR are followed with close surveillance physical examinations, endoscopy, and imaging. Here, we review management of rectal cancer, the development of the "watch and wait" approach and its outcomes.

Using Poisson Modeling and Queuing Theory to Optimize Staffing and Decrease Patient Wait Time in the Emergency Department

Introduction: Studies have shown Emergency Department (ED) crowding contributes to reduced quality of patient care, delays in starting treatments, and increased number of patients leaving without being seen. This analysis shows how to theoretically and optimally align staffing to demand. Methods: The ED value stream was identified and mapped. Patients were stratified into three resource-driven care flow cells based on the severity indices. Time observations were conducted for each of the key care team members and the manual cycle times and service rate were calculated and stratified by severity indices. Using X32 Healthcare’s Online Staffing Optimization (OSO) tool, staffing inefficiencies were identified and an optimal schedule was created for each provider group. Results: Lower Severity Indices (higher acuity patient) led to longer times for providers, nurses, patient care assistants, and clerks. The patient length of stay varied from under one hour to over five hours. The flow of patients varied considerably over the 24 hours’ period but was similar by day of the week. Using flow data, we showed that we needed more nurses, more care team members during peak times of patient flow. Eight hour shifts would allow better flexibility. We showed that the additional salary hours added to the budget would be made up for by increased revenue recognized by decreasing the number of patients who leave without being seen. Conclusion: If implemented, these changes will improve ED flow by using lean tools and principles, ultimately leading to timeliness of care, reduced waits, and improved patient experience.

SOME NEW RESULTS ON WAITING TIME AND BUSY TIME IN M/G/1 QUEUE

This paper considers an M/G/1 queue with Poisson rate lambda > 0 and service time distribution G(t) which is supposed to have finite mean 1/mu. The following questions are first studied: (a) The closed bounds of the probability that waiting time is more than a fixed value; (b)The total busy time of the server, which including the distribution, probability that are more than a fixed value during a given time interval (0, t], and the expected value. Some new and important results are obtained by theories of the classes of life distributions and renewal process.

Exact Distributions of Waiting Time Problems of Mixed Frequencies and Runs in Markov Dependent Trials

We study waiting time problems for first-order Markov dependent trials via conditional probability generating functions. Our models involve α frequency cells and β run cells with prescribed quotas and an additional γ slack cells without quotas. For any given and , in our Model I we determine the waiting time until at least frequency cells and at least run cells reach their quotas. For any given τ ≤ α + β, in our Model II we determine the waiting time until τ cells reach their quotas. Computer algorithms are developed to calculate the distributions, expectations and standard deviations of the waiting time random variables of the two models. Numerical results demonstrate the efficiency of the algorithms.

Emergency Department Waiting Times and Determinants of Prolonged Length of Stay in a Botswana Referral Hospital

Introduction: Emergency medicine is a critical component of quality public health service. In fact length of stay and waiting times in the Emergency department are key indicators of quality. The aim of this study was to determine waiting times and determinants of prolonged length of stay (LOS) in the Princess Marina Hospital Emergency Department. Methods: This was a retrospective observational study. It was done at Princess Marina, a referral hospital in Gaborone, Botswana. Triage forms of patients who presented between 19/11/ 2018 and 18/12/2018 were reviewed. Data from patient files was used to determine time duration from triage to being reviewed by a doctor, time duration from review by emergency doctor to patients’ disposition and the time duration from patient’s triage to disposition (length of stay). Prolonged length of stay was defined as duration > 6 hours. Results: A total of 1052 files repre- senting patients seen over a 1-month period were reviewed. 72.5% of the patients had a prolonged length of stay. The median emergency doctor waiting time was 4.5 hours (IQR 1.6 - 8.3 hours) and the maximum was 27.1 hours. The median length of stay in the emergency department was 9.6 hours (IQR 5.8 - 14.6 hours) and the maximum was 45.9 hours. Patient’s age (AOR 1.01), mental status (AOR 0.61), admission to internal medicine service (AOR 5.12) and pediatrics admissions (AOR 0.11) were significant predictors of prolonged length of stay in the emergency department. Conclusion: Princess Marina Hospital emergency department waiting times and length of stay are long. Age, normal mental status and internal medicine admission were independent predictors of prolonged stay (>6 hours). Admission to the pediatrics service was associated with shorter length of stay. There is a need for interventions to address the long waiting times and length of stay. Interventions should particularly focus on the identified predictors.

Waiting Times and Length of Stay of Trauma Patients in a Botswana Referral Hospital Emergency Department

Background: Mortality and morbidity due to trauma are a significant public health challenge. There is paucity of data on the waiting times and length of stay (LOS) of trauma patients in emergency departments in Botswana. The aim of this study was to determine the Emergency Department (ED) waiting times and LOS of trauma patients at Princess Marina Hospital in Gaborone, Botswana. Methods: This was a retrospective medical records review of waiting times (time from triage to review by ED medical officer) and LOS (time from triage to disposition from the emergency department). The waiting times for the different assigned acuities were assessed against the South African Triage System (SATS) standards. All trauma patients seen from 19/11/2018 to 18/12/2018 were included in the study. Prolonged length of stay was defined as duration > 6 hours. Categorical data was summarized with frequencies while numeric data was summarized with medians and interquartile ranges. Results: A total of 187 trauma patients’ files were analyzed. Of these, 72 (38.5%) were females. The median waiting time was 3.8 hours and the maximum was 19.2 hours. The median length of stay (LOS) was 8.8 hours with a maximum of 37.2 hours. Only 53 (28.3%) of the participants had a LOS of less than 6 hours. None of the emergent patients were seen immediately. Only 5 (4.0%) of the very urgent patients were seen within the target of 10 minutes. Finally, only 10 (20.4%) of urgent patients were seen within the target time of 1 hour. Conclusion: The waiting times and length of stay in Princess Marina Hospital were mostly above the recommended standards. Urgent interventions are needed to reduce waiting times and length of stay for trauma patients. More studies are needed to explore the sources of delay and investigate possible solutions to this public health challenge.

Watch and wait policy in advanced neuroendocrine tumors: What does it mean?

Neuroendocrine neoplasms(NENs) are a group of rare and heterogeneous malignancies, which can develop in various organs. The clinical course of NENs is quite heterogeneous, with different spontaneous growth rates after diagnosis, and different degrees of sensitivity to the same therapy even when they have similar characteristics. Watch and wait(W and W), is a term coined to indicate observation being conducted to assess the evolution of the tumor without administering any anti-tumor therapy. It has been applied to NENs since in extremely rare cases they tend to remain stable for a long time. Although W and W has been reported in several guidelines and recommendations it has never been validated, nor has it been specifically investigated. Furthermore it is not standardized. Therefore its application in clinical practice can differ in terms of tumor status assessment, type and timing of imaging or other exams utilized. In conclusion, while undertaking W and W to delay the first-line therapy by some weeks may be justified in good performance asymptomatic patients with low-grade NENs in order to usefully characterize the disease and patient and thereby choose the best therapy and therapeutic strategy, it seems to be far more difficult to justify W and W with the intent of avoiding an anti-tumor treatment. It should be considered that not only do NENs tend to grow even when they have very favorable biological characteristics but also that the alternative to W and W is most commonly a low toxic and effective treatment with somatostatin analogs.

Waiting times and stopping probabilities for patterns in Markov chains

Suppose that C is a finite collection of patterns. Observe a Markov chain until one of the patterns in C occurs as a run. This time is denoted by τ. In this paper, we aim to give an easy way to calculate the mean waiting time E(τ) and the stopping probabilities P(τ = τA)with A ∈ C, where τA is the waiting time until the pattern A appears as a run.

Reaction Subdiffusion with Random Waiting Time Depending on the Preceding Jump Length

To describe the energy-dependent characteristics of the reaction-subdiffusion process, we analyze the simple reaction A--→B under subdiffsion with waiting time depending on the preceding jump length, and derive the corresponding master equations in the Fourier Laplace space for the distribution of A and B particles in a continuous time random walk scheme. Moreover, the generalizations of the reaction-diffusion equation for the Gaussian jump length with the probability density function of waiting time being quadratically dependent on the preceding jump length are obtained by applying the derived master equations.

Pain and function deteriorate in patients awaiting total joint arthroplasty that has been postponed due to the COVID-19 pandemic

BACKGROUND Elective total joint arthroplasty(TJA)procedures have been postponed as part of the coronavirus disease 2019(COVID-19)response to avert healthcare system collapse.Total hip arthroplasty(THA)and total knee arthroplasty(TKA)procedures comprise the highest volume of elective procedures performed at health care facilities worldwide.AIM To determine the demand for TJA despite the pandemic and the impact of surgery postponement on physical and mental health.METHODS We conducted a prospective cross-sectional telephonic interview-based study on patients awaiting THA and TKA at an academic institution in South Africa.The questionnaire consisted of four sections.The first section recorded baseline demographic data and medical co-morbidities,the length of time spent awaiting TJA,and the patients’desire to undergo elective surgery despite the COVID-19 pandemic.Section 2 and Section 3 assessed the patients’current physical and mental health,respectively,as a consequence of deferred surgical intervention.The last section established the patients’perception of the healthcare system’s response to the COVID-19 pandemic and necessity to postpone elective surgery.Patients received counseling and education on the current state of surgery during the COVID-19 pandemic and associated risks.Thereafter,patients were once again asked about their desire to undergo TJA during the COVID-19 pandemic.RESULTS We included 185 patients(65.95%female;mean age:50.28 years)awaiting TJA for a mean of 26.42±30.1 mo.Overall,88.65%of patients wanted TJA despite the COVID-19 pandemic.Patients awaiting TJA for 1-3 years were 3.3-fold more likely to want surgery than those waiting<1 year(P<0.000).Patients with comorbidities were 8.4-fold less likely to want TJA than those with no comorbidities(P=0.013).After receiving education,the patients wanting TJA decreased to 54.05%.Patients who changed their opinion after education had less insight on the increased morbidity(P=0.046)and mortality(P=0.001)associated with COVID-19.Despite awaiting TJA for shorter period(24.7±20.38 mo),patients who continued to demand TJA had greater pain(P<0.000)and decreased function(P=0.043)since TJA postponement.CONCLUSION There is deterioration in health for patients,who have had elective procedures postponed during the COVID-19 pandemic.Waiting lists should be prioritized for urgency with the re-initiation of elective surgery.

Factors Determining Wait-Time and Patient Satisfaction at Post-Operative Orthopaedic Follow-Up

Introduction: There has been increasing attention on the evaluation of the efficiency and delivery of healthcare while trying to maintain the quality of service patients expect. A variety of studies have looked at various, non-orthopaedic surgical outpatient clinics and the factors involved in patient satisfaction and wait-time. The purpose of this study was to identify if such a relationship exist between the environmental, patient, and social-demographic factors to patient wait-time and satisfaction at an orthopaedic follow-up clinic. Methods: Patients were tracked through the clinic at various time points: appointment time, registration time, time to diagnostic imaging, time to being called into an exam room, time to being seen by a trainee, time to being seen by the staff surgeon, and time of leaving the clinic were collected. Overall satisfaction scores were calculated as per the VSQ-9. Patients who presented for their two or six week follow-up appointment were compared to those presenting for their three, six, or 12 month follow-up appointment. Result: A total of 80 patients were enrolled in this study. There was a good distribution of age and level of education. Ethnicity was heavily weighted towards the white population (76.6%) with the next largest ethnic group being East/Southeast Asian (7.8%). The mean total wait-time in clinic was 126.7 ± 46.5 minutes and the mean total VSQ-9 score was 78.5 ± 14.6. The longest time interval experienced by the patients in clinic was waiting for a consultation room after completion of imaging investigations (46.3 ± 33.3 min). The shortest time interval occurred once patients were in the consultation room and waited to be seen by the trainee or surgeon (15.0 ± 9.7 min. There were no statistically significant differences between the total wait-time in clinic, total VSQ-9 scores and age, gender, ethnicity, education, location of injury and overall health. Environmental variables were analyzed and it was found that patients reported greater satisfaction when seen only by the surgeon and not the trainee. Conclusion: Measurement variables have focused on patient satisfaction and wait-time as markers for improving healthcare. Although our study showed that there appears to be no association between any of the variables studied and wait-time or patient satisfaction, interventions at the patient level like using a custom designed clinic traffic flow board to track the position of each patient throughout their follow-up providing patients with a visual estimate of their position relative to other patients in queue may improve patient satisfaction and wait-time.

Watch and wait in locally advance rectal cancer:Past,present and future

In rectal cancer,a complete pathological response after neoadjuvant therapy means better rates survival and better rates of local recurrence.Nevertheless,these patients suffer from complications following surgery such as low anterior resection syndrome,sexual dysfunction or colostomy for the rest of their lives.Due to this,several groups are working in an organ preservation strategy when a clinical response is diagnosed.This strategy is known as watch and wait.In this editorial,we review the past,present and future perspectives for this conservative management.

Anomalous transport in fluid fleld with random waiting time depending on the preceding jump length

Anomalous（or non-Fickian） transport behaviors of particles have been widely observed in complex porous media.To capture the energy-dependent characteristics of non-Fickian transport of a particle in flow fields,in the present paper a generalized continuous time random walk model whose waiting time probability distribution depends on the preceding jump length is introduced,and the corresponding master equation in Fourier-Laplace space for the distribution of particles is derived.As examples,two generalized advection-dispersion equations for Gaussian distribution and levy flight with the probability density function of waiting time being quadratic dependent on the preceding jump length are obtained by applying the derived master equation.

Regional variation in routes to diagnosis of cholangiocarcinoma in England from 2006 to 2017

BACKGROUND Incidence of cholangiocarcinoma(CCA)is rising,with overall prognosis remaining very poor.Reasons for the high mortality of CCA include its late presentation in most patients,when curative options are no longer feasible,and poor response to systemic therapies for advanced disease.Late presentation presents a large barrier to improving outcomes and is often associated with diagnosis via mergency presentation(EP).Earlier diagnoses may be made by Two Week Wait(TWW)referrals through General practitioner(GP).We hypothesise that TWW referrals and EP routes to diagnosis differ across regions in England.AIM To investigate routes to diagnosis of CCA over time,regional variation and influencing factors.METHODS We linked patient records from the National Cancer Registration Dataset to Hospital Episode Statistics,Cancer Waiting Times and Cancer Screening Programme datasets to define routes to diagnosis and certain patient characteristics for patients diagnosed 2006-2017 in England.We used linear probability models to investigate geographic variation by assessing the proportions of patients diagnosed via TWW referral or EP across Cancer Alliances in England,adjusting for potential confounders.Correlation between the proportion of people diagnosed by TWW referral and EP was investigated with Spearman’s correlation coefficient.RESULTS Of 23632 patients diagnosed between 2006-2017 in England,the most common route to diagnosis was EP(49.6%).Non-TWW GP referrals accounted for 20.5%of diagnosis routes,13.8%were diagnosed by TWW referral,and the remainder 16.2%were diagnosed via an‘other’or Unknown route.The proportion diagnosed via a TWW referral doubled between 2006-2017 rising from 9.9%to 19.8%,conversely EP diagnosis route declined,falling from 51.3%to 46.0%.Statistically significant variation in both the TWW referral and EP proportions was found across Cancer Alliances.Age,presence of comorbidity and underlying liver disease were independently associated with both a lower proportion of patients diagnosed via TWW referral,and a higher proportion diagnosed by EP after adjusting for other potential confounders.CONCLUSION There is significant geographic and socio-demographic variation in routes to diagnosis of CCA in England.Knowledge sharing of best practice may improve diagnostic pathways and reduce unwarranted variation.