The impact of chemotherapy-naïve open radical cystectomy delay and perioperative transfusion on the recurrence-free survival: A perioperative parameters-based nomogram.

Objective: To develop and internally validate a nomogram to predict recurrence-free survival (RFS) including the time to radical cystectomy (RC) and perioperative blood transfusion (PBT) as potential predictors. Methods: Patients who underwent open RC and ileal conduit between January 1996 to December 2016 were split into developing (n=948) and validating (n=237) cohorts. The time to radical cystectomy (TTC) was defined as the interval between the onset of symptoms and RC. The regression coefficients of the independent predictors obtained by Cox regression were used to construct the nomogram. Discrimination, validation, and clinical usefulness in the validation cohort were assessed by the area under the curve, the calibration plot, and decision curve analysis. Results: In the developing dataset, the 1-, 5-, and 10-year RFS were 83.0%, 47.2%, and 44.4%, respectively. On multivariate analysis, independent predictors were TTC (hazards ratio [HR] 1.07, 95% confidence interval [CI] 1.05-1.08, p<0.001), PBT (one unit: HR 1.40, 95% CI 1.03-1.90, p=0.03; two or more units: HR 1.72, 95% CI 1.29-2.29, p<0.001), bilateral hydronephrosis (HR 1.54, 95% CI 1.21-1.97, p<0.001), squamous cell carcinoma (HR 0.60, 95% CI 0.45-0.81, p=0.001), pT3-T4 (HR 1.77, 95% CI 1.41-2.22, p<0.001), lymph node status (HR 1.53, 95% CI 1.21-1.95, p<0.001), and lymphovascular invasion (HR 1.28, 95% CI 1.01-1.62, p=0.044). The areas under the curve in the validation dataset were 79.3%, 69.6%, and 76.2%, for 1-, 5-, and 10-year RFS, respectively. Calibration plots showed considerable correspondence between predicted and actual survival probabilities. The decision curve analysis revealed a better net benefit of the nomogram. Conclusion: A nomogram with good discrimination, validation, and clinical utility was constructed utilizing TTC and PBT in addition to standard pathological criteria.

Voiding and renal function 10 years after radical cystectomy and orthotopic neobladder in women.

OBJECTIVES: To assess long-term voiding and renal function (RF) changes after radical cystectomy (RC) and orthotopic neobladder (ONB) surgery in women without disease recurrence. MATERIAL AND METHODS: Women who underwent RC and ONB reconstruction between 1995 and 2011 were included in this study. Patients who developed disease failure or were lost to follow-up were excluded. The study outcomes were long-term voiding function and the incidence and predictors of RF deterioration (defined as >20% decline of baseline). Analysis was performed using the log-rank test and Cox regression analysis. RESULTS: The study included 195 patients with a median (interquartile range) follow-up of 98 (53-151) months, of whom 95 had >10 years of follow-up. Daytime continence, night-time continence and chronic urine retention (CUR) were identified in 170 (87%), 134 (69%) and 52 patients (27%), respectively. Among patients with >10 years of follow-up, 82 (86%), 66 (70%) and 31 (33%) had daytime continence, night-time continence and CUR at the last follow-up visit, respectively. RF deterioration events occurred in 74 patients throughout the follow-up and chronic kidney disease (CKD) stage III-V developed in 80 patients. Patients' age (hazard ratio [HR] 1.41, 95% confidence interval [CI]1.06-1.89; P = 0.02) and serous-lined extramural tunnel diversion (HR 0.43, 95% CI 0.19-0.86; P = 0.02) were the independent predictors of RF deterioration. Among patients with >10 years of follow-up, RF deteriorated in 46 patients (49%) and CKD stage III-V developed in 40 (42%). CONCLUSION: Women surviving more than 10 years after RC and ONB maintained acceptable continence status, apart from having a higher CUR rate, compared to those followed for <10 years. However, RF deterioration developed in nearly half of them.

Bioprospecting for Novel Probiotic Strains from Human Milk and Infants: Molecular, Biochemical, and Ultrastructural Evidence.

Human milk comprises a diverse array of microbial communities with health-promoting effects, including colonization and development of the infant's gut. In this study, we characterized the bacterial communities in the Egyptian mother-infant pairs during the first year of life under normal breastfeeding conditions. Out of one hundred isolates, forty-one were chosen for their potential probiotic properties. The selected isolates were profiled in terms of morphological and biochemical properties. The taxonomic evidence of these isolates was investigated based on 16S rRNA gene sequence and phylogenetic trees between the isolates' sequence and the nearest sequences in the database. The taxonomic and biochemical evidence displayed that the isolates were encompassed in three genera: Lactobacillus, Enterococcus, and Lactococcus. The Lactobacillus was the most common genus in human milk and feces samples with a high incidence of its different species (Lacticaseibacillus paracasei, Lactobacillus delbrueckii, Lactiplantibacillus plantarum, Lactobacillus gasseri, and Lacticaseibacillus casei). Interestingly, BlastN and Jalview alignment results evidenced a low identity ratio of six isolates (less than 95%) with database sequences. This divergence was supported by the unique physiological, biochemical, and probiotic features of these isolates. The isolate L. delbrueckii, ASO 100 exhibited the lowest identity ratio with brilliant probiotic and antibacterial features suggesting the high probability of being a new species. Nine isolates were chosen and subjected to probiotic tests and ultrastructural analysis; these isolates exhibited antibiotic resistance and antibacterial activity with high probiotic characteristics, and high potentiality to be used as prophylactic and therapeutic agents in controlling intestinal pathogens.

Physicochemical, Microbiological and Microstructural Characteristics of Sucrose-Free Probiotic-Frozen Yogurt during Storage.

Frozen yogurt is known as ice cream with some properties of yogurt. Frozen yogurts are a rich source of sucrose levels between 15% and 28% of total ingredients. Consumers suffering from lactose intolerance and metabolic syndrome are looking for sugar-free products. The current study investigates the sugar replacements by using sweeteners (stevia, sucralose and sorbitol) on physicochemical, microbiological, microstructural and sensory characteristics of probiotic-frozen yogurt. Four different treatments of probiotic-frozen yogurts were studied (control probiotic-frozen yogurt with sucrose (F1), probiotic-frozen yogurt with stevia (F2), probiotic-frozen yogurt with sucralose (F3) and probiotic-frozen yogurt with sorbitol (F4)). The chemical properties were not significantly present p > 0.05) during storage in all treatments. In the F1 treatment, sucrose value was higher (14.87%) and not detected in the F2, F3 and F4 treatments. The highest values of overrun, hardness and viscosity (p < 0.05) were detected in the F2, F3 and F3 samples, but the lowest value was detected in the F1 treatment. Total Str. thermophilus and Lb. delbrueckii ssp. bulgaricus counts were gradually decreased (p < 0.05) during storage periods. At 1 day, the Bifidobacteria counts ranged from 7.56 to 7.60 log10 CFU g−1 in all groups and gradually decreased during storage, but these bacterial counts remained viable (>6.00 log10 CFU g−1) during storage periods up to 60 d. During storage periods, the highest scores of total acceptability were detected in the F3, F4 and F2 treatments. Scanning electron microscopy (SEM) micrographs of all probiotic-frozen yogurt treatments illustrated that the microstructures showed a difference with a fine network, size pores and structure between the frozen yogurt with sweeteners (F2, F3 and F3) and control frozen yogurt (F1).

Microstructural, Physicochemical, Microbiological, and Organoleptic Characteristics of Sugar- and Fat-Free Ice Cream from Buffalo Milk.

Ice cream is a popular dessert product across the world. Structure, body, taste, and odor properties are created by adding non-milk ingredients and milk ingredients. The main aim of the study is to decrease the caloric value of ice cream by using sugar and fat replacements. Ice cream treatments were investigated based on microstructural, chemical, physical, microbiological, sensory, and calorific values. Four different ice creams were used (control ice cream (SC1), ice cream with stevia (SC2), ice cream with sucralose (SC3), and ice cream with sorbitol (SC4)). The chemical properties in all treatments of ice cream were significantly recorded (p < 0.05). The highest sucrose and fat levels were detected in the SC1 treatment compared with the other treatments (p < 0.05). The lowest fat and sugar amounts were observed in the SC2, SC3, and SC4 treatments (p < 0.05). The highest viscosity, overrun, and hardness values (p < 0.05) were detected in the control ice cream. Total aerobic mesophilic bacterial counts were not significantly recorded between different ice cream treatments (p < 0.05). The sensory scores were not significantly affected by sweeteners and bulk agents in the different treatments. The highest calorific value was calculated in the SC1 samples (p < 0.05). On the other hand, the lowest calorific value was calculated in SC2, followed by the SC3 and SC4 treatments. In scanning electron microscopy (SEM), the gel exhibited a homogeneous structure with a fine network within the SC2, SC3, and SC4 treatments, as it contained a cohesive structure with small-sized pores.

Predictors and survival benefit of achieving pentafecta in a contemporary series of open radical cystectomy.

BACKGROUND: Pentafecta provides a comprehensive approach for standardized reporting of surgical and oncologic outcomes after radical cystectomy and urinary diversion. We aimed to report the rate, predictors of achieving pentafecta and its impact on long-term survival in a contemporary series of open radical cystectomy (ORC). METHODS: A retrospective analysis of a computerized database of patients treated with ORC between 2004 till 2014 was performed. Pentafecta criteria included negative soft tissue surgical margin (STSM), retrieval of ≥16 lymph nodes, absence of clinical recurrence within 12 months after surgery, absence of high-grade complication (GIII-V) within 90 days after surgery, and absence of urinary diversion related complications at 12 months follow-up. Multivariate analysis was used to identify predictors of achieving pentafecta. RESULTS: Pentafecta was achieved in 545 (33.6%) patients out of 1624 included in the study. Absence of ≥16 LN yield was the first cause of missing pentafecta (49.5%). Multivariate analysis identified: ASA Score grades ≥III (OR=0.7, 95%CI 0.6-0.9, P=0.04), BMI≥35 (OR=0.5, 95%CI 0.3-0.8, P=0.007), perioperative blood transfusion (≥4 units) (OR=0.5, 95%CI 0.3-0.7, P=0.001), and ileal conduit (OR=0.7, 95%CI 0.5-0.9, P= 0.01) as independent predictors of missing pentafecta. Patients who achieved pentafecta had higher estimated 5-year RFS than their counterparts (81.7% vs. 62.5%; P<0.0001). CONCLUSIONS: Pentafecta was achieved in nearly one third of patients after ORC. Achievement of pentafecta was associated with better long-term recurrence-free survival. Obesity (class II, III), perioperative blood transfusion (>4 units), associated comorbidities, and ileal conduit were independent predictors of missing pentafecta.

Physiological Performance of Rabbits Administered Buffalo Milk Yogurts Enriched with Whey Protein Concentrate, Calcium Caseinate or Spirulina platensis.

The present study examines the impacts of supplementing yogurt with 1% whey protein concentrate (WPC), Ca-caseinate (Ca-CN) and Spirulina platensis on the physiological performance of V-line rabbits receiving diets containing yogurt (at a dose of 5 g/kg body weight/day) and the different meat quality aspects. The results show that fat content was highest (p < 0.05) in yogurt fortified with Spirulina powder, but protein (%) was highest in yogurt enriched with WPC. Yogurt containing Spirulina powder showed a significant (p < 0.05) increase in total antioxidant activity. The final live body weight for G1 was higher than the other groups. However, additives affected the saddle, hind legs, liver and neck percentages significantly (p < 0.05). There were not significant differences for all groups in the forelegs, lung and heart percentages. LDL-cholesterol, total protein, globulin, albumin, creatinine and immunoglobulin M values were lowest (p < 0.05) in the WPC group. Significant improvements appeared in the small intestinal wall, microbiology, growth performance, serum biochemistry, organ histology and meat quality of the group receiving enriched yogurt. Yogurts enriched with WPC, Ca-CN and Spirulina platensis can be used as functional foods.

Shelf-life of Domiati cheese under modified atmosphere packaging.

The present study describes the effects of modified atmosphere packaging (MAP) on shelf-life extension, chemical, microbiological, and sensory properties of Domiati cheese. Five different MAP were studied [10% CO2/90% N2 (G1), 15% CO2/85% N2 (G2), 25% CO2/75% N2 (G3), 100% CO2 (G4), and 100% N2 (G5)]. Control samples were packaged in air (CA) and under vacuum. In both groups of cheeses, chemical analysis was significantly affected by MAP during cold storage. Ripening indexes were significantly affected by MAP during cold storage. Microbiological data showed that G4, followed by G5, were the most effective groups inhibiting the growth of total aerobic mesophilic and psychrotrophic bacteria, and yeasts and molds until the end of storage. Sensory evaluation was significantly affected by MAP and storage period, at 45 d CA cheese samples were judged as unacceptable. The best sensory properties were obtained in G5, G4, and G3 treatments, and recorded a relatively higher sensory evaluation scores. The best shelf-life extension was obtained in G5, G4, and G3 treatments.

[Impact of the healthcare pathway on the rate of obstetrical interventions in small for gestational age fetuses (IATROPAG Study)]. / Impact du parcours de soins sur le taux d'interventions obstétricales dans la prise en charge des fœtus petit pour l'âge gestationnel (Étude IATROPAG).

BACKGROUND: While previous studies have demonstrated an improvement in implementation of clinical practices and an improved neonatal prognosis when growth restricted fetuses were followed within a standardized healthcare pathway, the objective of this study was to assess the prevalence of obstetric interventions in small-for-gestational-age (SGA) fetuses followed within a standardized care pathway compared to a traditional care pathway. METHODS: We conducted a retrospective study between 2015 and 2017, in a type III maternity hospital in Lyon, in a population of SGA fetuses, considered as such in case of antenatal diagnosis of fetal weight<10th percentile but>3rd centile without umbilical Doppler abnormality during antenatal surveillance and without ultrasound argument suggesting intrauterine growth retardation (IUGR). We collected the gestational age at diagnosis, obstetrical events and prevention of preterm delivery (antenatal corticosteroids), gestation age at birth, the method of delivery (spontaneous or induced), indication of induction, the method of birth (spontaneous, instrumental extraction or caesarean section), and the immediate neonatal outcome including cord pH, Apgar score at 5minutes, birth weight and fetal sex. After diagnosis, the choice of the pathway was left to the practitioner depending on their habit, their ability to manage the follow-up and their organizational constraints. RESULTS: Over the study period, and after exclusion of IUGR, 96 SGA were followed up in the traditional pathway and 106 SGA were followed up in the standardized pathway P=0.75. The traditional pathway showed in multivariate analysis a higher prevalence of antenatal corticosteroid therapy for SGA (16,6%) between 2015 and 2017 with OR 7.3 95% CI [1.41-38.43] when compared to the standardized pathway (3,7%). Similarly, the traditional pathway proposes a higher prevalence of induction of labor (54,1%) than the standardized pathway (33,9%) between 2015 and 2017 with OR 3.19 95% CI [1.70-7.80]. The "a posteriori" post-hoc power of the study is 82.9%. CONCLUSION: This study confirms the absence of excessive obstetrical intervention in the SGA population when followed in a standardized healthcare pathway. The latter would reduce unnecessary obstetrical interventions while respecting the intrinsic neonatal prognosis of small for gestational age fetuses.

Quality and microstructure of freeze-dried yoghurt fortified with additives as protective agents.

The effect of freeze drying of yoghurt and addition of some additives on the physico-chemical, microbiological, texture, microstructure, and sensory quality of yoghurt was studied. Freeze drying of yoghurt had light effects on the viability of Streptococcus thermophilus and no effect on viability of Lactobacillus delbreuckii subsp. bulgaricus and rehydrated yoghurt. Addition of modified starch had a considerable protection effect on Streptococcus thermophilus during freeze drying process. Addition of whey protein concentrate produced different surface structures and caused porous and loos structure. The microstructure of the freeze-dried yoghurt fortified with spirulina powder showed a coarse and a compact less porous structure in comparison with the freeze-dried yoghurt samples fortified with whey protein concentrate. All Additives significantly decreased adhesiveness and significantly increased cohesiveness, springiness, gumminess, and chewiness in both fresh and rehydrated yoghurts.

Parastomal hernia after ileal conduit urinary diversion: re-visiting the predictors radiologically and according to patient-reported outcome measures.

PURPOSE: To evaluate the predictors of post-ileal conduit (IC) parastomal hernia (PSH) based on a standard grading methodology and according to the patients reported outcome measures (PROM). METHODS: A prospective evaluation for patients with IC attending their scheduled follow-up was conducted between December 2013 and October 2015. The hernia stage was determined according to the European Hernia Society (EHS) classification as types I and II included defect size < 5 cm without and with a concomitant incisional hernia, respectively. Types III and IV included defect size > 5 cm without and with a concomitant incisional hernia (high-grade hernia). The evaluation was performed by a non-contrast CT scan. PROM were defined as symptomatic if there were hernia-related abdominal discomfort, appliance problems, and/or bowel complications. Perioperative parameters were modeled for prediction of high-grade and PROM outcomes. RESULTS: PSH was diagnosed in 138 (39.9%) patients, symptomatic in 119 (34.4%) and high-grade in 59 (17%). Independent predictors of radiologically diagnosed PSH were hypoalbuminemia (odds ratio [OR]: 1.7; 95% Confidence interval [CI]: 1.1-2.7; p = 0.02), localised disease (OR: 0.6; 95% CI: 0.3-0.9; p = 0.04) and negative lymphadenopathy (OR: 0.4; 95%CI: 0.2-0.8; p = 0.004). Predictors of symptomatic PSH were hypoalbuminemia (OR: 2; 95%CI: 1.2-2.3: p = 0.003) and previous hernia surgery (OR: 2.1; 95%CI: 1.1-4.2; p = 0.024). CONCLUSIONS: Only a small proportion of patients with PSH were asymptomatic. Preoperative hypoalbuminemia was the most significant factor contributing to the development and symptomatizing of PSH. Previous hernia surgery further contributed to the patient complaint.

Easy mesh fixation to the promontory during sacrocolpopexy procedure.

We propose a simplified technique to approach the promontory and to fix the mesh on the anterior longitudinal ligament during the sacrocolpopexy procedure by using an instrument initially designed for the vaginal approach of the sacrospinous ligament. Using this easy technique in case of anatomic variations on the sacral promontory may avoid complications.

Effect of an educational programme on the attitudes towards patient safety of operation room nurses.

BACKGROUND: A culture of patient safety is one of the cornerstones of good-quality healthcare, and its provision is one of the significant challenges in healthcare environments. AIM: The purpose of this study was to evaluate the effect of a surgical safety educational programme on the attitudes of nurses to patient safety in operating rooms (OR). DESIGN: An interventional one-group pre-/post-test design, which sought to measure changes in OR nurses' attitudes toward patient safety culture. METHODS: A simple random sampling technique was used to recruit 66 OR nurses working at six Royal Medical Service hospitals in Amman, Jordan. All participants took part in a 4-hour educational workshop. Pre-tests and post-tests were done. RESULTS: The results of this study showed that OR nurses' attitudes towards a culture of patient safety was originally negative; significant improvement after attending the programme was found (3.3 ± 0.20 versus 3.8 ± 0.30). There was a negative correlation between years of experience and nurses' attitudes towards patient safety. CONCLUSIONS: Incorporating courses about safety culture into continuing education programmes may improve nurses' attitudes towards patient safety. Nurses should be qualified to play an important role in creating a culture of patient safety.

Study protocol to investigate biomolecular muscle profile as predictors of long-term urinary incontinence in women with gestational diabetes mellitus.

BACKGROUND: Pelvic floor muscles (PFM) and rectus abdominis muscles (RAM) of pregnant diabetic rats exhibit atrophy, co-localization of fast and slow fibers and an increased collagen type I/III ratio. However, the role of similar PFM or RAM hyperglycemic-related myopathy in women with gestational diabetes mellitus (GDM) remains poorly investigated. This study aims to assess the frequency of pelvic floor muscle disorders and pregnancy-specific urinary incontinence (PS-UI) 12 months after the Cesarean (C) section in women with GDM. Specifically, differences in PFM/RAM hyperglycemic myopathy will be evaluated. METHODS: The Diamater is an ongoing cohort study of four groups of 59 pregnant women each from the Perinatal Diabetes Research Centre (PDRC), Botucatu Medical School (FMB)-UNESP (São Paulo State University), Brazil. Diagnosis of GDM and PS-UI will be made at 24-26 weeks, with a follow-up at 34-38 weeks of gestation. Inclusion in the study will occur at the time of C-section, and patients will be followed at 24-48 h, 6 weeks and 6 and 12 months postpartum. Study groups will be classified as (1) GDM plus PS-UI; (2) GDM without PS-UI; (3) Non-GDM plus PS-UI; and (4) Non-GDM without PS-UI. We will analyze relationships between GDM, PS-UI and hyperglycemic myopathy at 12 months after C-section. The mediator variables to be evaluated include digital palpation, vaginal squeeze pressure, 3D pelvic floor ultrasound, and 3D RAM ultrasound. RAM samples obtained during C-section will be analyzed for ex-vivo contractility, morphological, molecular and OMICS profiles to further characterize the hyperglycemic myopathy. Additional variables to be evaluated include maternal age, socioeconomic status, educational level, ethnicity, body mass index, weight gain during pregnancy, quality of glycemic control and insulin therapy. DISCUSSION: To our knowledge, this will be the first study to provide data on the prevalence of PS-UI and RAM and PFM physical and biomolecular muscle profiles after C-section in mothers with GDM. The longitudinal design allows for the assessment of cause-effect relationships between GDM, PS-UI, and PFMs and RAMs myopathy. The findings may reveal previously undetermined consequences of GDM.

[Differences between hypertension in Metropolitan France compared to Overseas France Departments and Regions (DOM-ROM)]. / Différences de prise en charge de l'HTA entre la métropole et les DOM-ROM.

BACKGROUND: High blood pressure (HBP) is the most common chronic disease worldwide. In France, its prevalence varies by region. It is high in most Overseas Departments and Regions (DOM-ROM), at 38.2% in Réunion (1), 44% in Mayotte (2), 28% in the French Antilles, 18% in French Guiana, 25% in French Polynesia (3) and 28% in Saint-Martin (4). PURPOSE: To determinate the differences within the same healthcare system between hypertension in Metropolitan France compared to Overseas France Departments and Regions (DOM-ROM). RESULTS: Sex-based differences. In contrast to Metropolitan France, in Overseas France the prevalence of HBP is higher in women, although women show better rates of care (screening and rates of patients "normalised" under medical treatment). The main explanation for this is the higher prevalence of obesity in women. Obesity multiplies the risk of developing hypertension by 2.5 Obesity in Guadeloupe affects 14% of men compared to 31% of women. Socio-economic particularities of hypertension in Overseas France. The numerous epidemiological surveys carried out in the French Antilles have demonstrated the major role of socio-economic conditions in the occurrence of hypertension, alongside the usual risk factors such as sedentary lifestyle, salt consumption and obesity (7). In the absence of socio-economic disparity, there is no significant disparity in the prevalence of hypertension specially in men. CONCLUSIONS: There are differences between France Overseas Regions and Territories (DOM-ROMs) and Metropolitan France in terms of the prevalence, knowledge, treatment and control of hypertension, and these vary according to sex. For men, the prevalence and treatment of hypertension differ very little when considering a population of workers or employees in both regions. On the other hand, for women, the prevalence of hypertension is higher in the French Antilles-Guiana. This difference is not fully explained by the higher prevalence of obesity observed among female employees in the French Antilles-Guiana. For these patients, we also observe better knowledge and better control of hypertension. Care for men in socio-economically disadvantaged situations of precarity must be improved in terms of screening and adherence to treatment.

Minoxidil for patchy alopecia areata: systematic review and meta-analysis.

BACKGROUND: Alopecia areata (AA) is a complex immune and polygenic inflammatory disease that causes hair loss on some or all areas of the body; extent, severity and progression vary widely among individuals. Alopecia areata, considered one of the most frequently occurring immune diseases, affects 0.2% of the world population at any given time. Uncertainty prevails about the most appropriate intervention for AA. The aim is to evaluate the effectiveness and safety of over 80 interventions for AA, including minoxidil - one of the most promising interventions for patchy AA in children and adults of both sexes. MATERIAL AND METHODS: An extensive search was conducted of international medical literature involving randomized clinical trials (RCTs) of AA interventions. RCTs were evaluated qualitatively and quantitatively according to the previously published protocol and for seven specific outcomes. RESULTS: The meta-analysis involving 5% minoxidil vs. placebo presented a significant difference in favor of 5% minoxidil with the moderate quality of evidence in children and adults with patchy AA (RR 8.37 [3.16-22.14], 95% CI). No severe adverse event was reported. CONCLUSIONS: Treatment of patchy AA with 5% minoxidil proved effective, and clinically and statistically safe in studies with limited sample size; quality of evidence was moderate. Further studies with sound methodological quality, more participants and outcome observations lasting longer than 6 months are needed to address remaining uncertainties.