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Introduction: Acute pancreatitis (AP) is a common disease, and several scores aim to assess its prognosis. Our study aims to automatically recognize mild AP from computed tomography (CT) images in patients with acute abdominal pain but uncertain diagnosis from clinical and serological data through Radiomic model based on formal methods (FMs). Methods: We retrospectively reviewed the CT scans acquired with Dual Source 256-slice CT scanner (Somatom Definition Flash; Siemens Healthineers, Erlangen, Germany) of 80 patients admitted to the radiology unit of Antonio Cardarelli hospital (Naples) with acute abdominal pain. Patients were divided into 2 groups: 40 underwent showed a healthy pancreatic gland, and 40 affected by four different grades (CTSI 0, 1, 2, 3) of mild pancreatitis at CT without clear clinical presentation or biochemical findings. Segmentation was manually performed. Radiologists identified 6 patients with a high expression of diseases (CTSI 3) to formulate a formal property (Rule) to detect AP in the testing set automatically. Once the rule was formulated, and Model Checker classified 70 patients into "healthy" or "unhealthy". Results: The model achieved: accuracy 81%, precision 78% and recall 81%. Combining FMs results with radiologists agreement, and applying the mode in clinical practice, the global accuracy would have been 100%. Conclusions: Our model was reliable to automatically detect mild AP at primary diagnosis even in uncertain presentation and it will be tested prospectively in clinical practice. [ABSTRACT FROM AUTHOR]

Purpose: Evaluate the agreement between bone age assessments conducted by two distinct machine learning system and standard Greulich and Pyle method. Materials and methods: Carpal radiographs of 225 patients (mean age 8 years and 10 months, SD = 3 years and 1 month) were retrospectively analysed at two separate institutions (October 2018 and May 2022) by both expert radiologists and radiologists in training as well as by two distinct AI software programmes, 16-bit AItm and BoneXpert® in a blinded manner. Results: The bone age range estimated by the 16-bit AItm system in our sample varied between 1 year and 1 month and 15 years and 8 months (mean bone age 9 years and 5 months SD = 3 years and 3 months). BoneXpert® estimated bone age ranged between 8 months and 15 years and 7 months (mean bone age 8 years and 11 months SD = 3 years and 3 months). The average bone age estimated by the Greulich and Pyle method was between 11 months and 14 years, 9 months (mean bone age 8 years and 4 months SD = 3 years and 3 months). Radiologists' assessments using the Greulich and Pyle method were significantly correlated (Pearson's r > 0.80, p < 0.001). There was no statistical difference between BoneXpert® and 16-bit AItm (mean difference = − 0.19, 95%CI = (− 0.45; 0.08)), and the agreement between two measurements varies between − 3.45 (95%CI = (− 3.95; − 3.03) and 3.07 (95%CI − 3.03; 3.57). Conclusions: Both AI methods and GP provide correlated results, although the measurements made by AI were closer to each other compared to the GP method. [ABSTRACT FROM AUTHOR]

The redundancy present within the musculoskeletal system may offer a non-invasive source of signals for movement augmentation, where the set of muscle activations that do not produce force/torque (muscle-to-force null-space) could be controlled simultaneously to the natural limbs. Here, we investigated the viability of extracting movement augmentation control signals from the muscles of the wrist complex. Our study assessed (i) if controlled variation of the muscle activation patterns in the wrist joint's null-space is possible; and (ii) whether force and null-space cursor targets could be reached concurrently. During the null-space target reaching condition, participants used muscle-to-force null-space muscle activation to move their cursor towards a displayed target while minimising the exerted force as visualised through the cursor's size. Initial targets were positioned to require natural co-contraction in the null-space and if participants showed a consistent ability to reach for their current target, they would rotate 5 ∘ incrementally to generate muscle activation patterns further away from their natural co-contraction. In contrast, during the concurrent target reaching condition participants were required to match a target position and size, where their cursor position was instead controlled by their exerted flexion–extension and radial-ulnar deviation, while its size was changed by their natural co-contraction magnitude. The results collected from 10 participants suggest that while there was variation in each participant's co-contraction behaviour, most did not possess the ability to control this variation for muscle-to-force null-space virtual reaching. In contrast, participants did show a direction and target size dependent ability to vary isometric force and co-contraction activity concurrently. Our results indicate the limitations of using the muscle-to-force null-space activity of joints with a low level of redundancy as a possible command signal for movement augmentation. [ABSTRACT FROM AUTHOR]

Iron titanate mixed metal oxides were synthesized by the sol–gel method through four different routes. The effect of (i) the solvent of iron precursor, (ii) the addition of the chelating agent to the titanium or iron solution and (iii) the molar ratio between the chelating agent and the titanium or iron precursor over the overall percentage of obtained iron titanates was evaluated. Fourier-transform infrared spectroscopy (FTIR) and UV–Vis spectroscopy (UV–Vis) performed on the reaction medium evidenced the formation of acetate complexes of titanium (IV) or iron (III) during the different routes. X-ray diffraction (XRD) patterns of the obtained materials showed the formation of ilmenite (FeTiO3), pseudorutile (Fe2Ti3O9) and pseudobrookite (Fe2TiO5) in different proportions, as well as hematite (Fe2O3), rutile [TiO2 (R)] and anatase [TiO2 (A)]. The materials with the highest content of iron titanates obtained in each route were characterized and evaluated in the photocatalytic degradation of cyanide using visible light irradiation. UV–Vis Diffuse Reflectance Spectroscopy (UV–Vis DRS) showed that the samples exhibited energy bandgap values between 2.31 and 2.90 eV, which agrees with the values reported for iron titanates and evidence the possible activation of the materials under visible light. Scanning electron microscopy (SEM) and nitrogen physisorption results showed that the synthesized materials exhibited nanometric particle size and lower surface area (36.7 ± 4.8 m2·g-1) than TiO2 Degussa P-25 (72–155 m2·g-1). The photocatalytic performance of the synthesized materials toward oxidation of CN− exceeded by 56% the activity of pure TiO2. The content of iron titanates in the synthesized materials was found to be the variable with the greatest influence on the photodegradation of cyanide. In addition, an inversely proportional relationship between the pseudorutile content of the materials and their photocatalytic activity was observed. [ABSTRACT FROM AUTHOR]

Muscle synergies are defined as coordinated recruitment of groups of muscles with specific activation balances and time profiles aimed at generating task-specific motor commands. While muscle synergies in postural control have been investigated primarily in reactive balance conditions, the neuromechanical contribution of muscle synergies during voluntary control of upright standing is still unclear. In this study, muscle synergies were investigated during the generation of isometric force at the trunk during the maintenance of standing posture. Participants were asked to maintain the steady-state upright standing posture while pulling forces of different magnitudes were applied at the level at the waist in eight horizontal directions. Muscle synergies were extracted by nonnegative matrix factorization from sixteen lower limb and trunk muscles. An average of 5-6 muscle synergies were sufficient to account for a wide variety of EMG waveforms associated with changes in the magnitude and direction of pulling forces. A cluster analysis partitioned the muscle synergies of the participants into a large group of clusters according to their similarity, indicating the use of a subjective combination of muscles to generate a multidirectional force vector in standing. Furthermore, we found a participant-specific distribution in the values of cosine directional tuning parameters of synergy amplitude coefficients, suggesting the existence of individual neuromechanical strategies to stabilize the whole-body posture. Our findings provide a starting point for the development of novel diagnostic tools to assess muscle coordination in postural control and lay the foundation for potential applications of muscle synergies in rehabilitation. [ABSTRACT FROM AUTHOR]

This study, through a systematic literature review spanning 1990 to 2023, interrogates how servitization, and nowadays digital servitization, enhances manufacturing competitiveness. It introduces the DASOBI (Drivers, Actors, Strategies, Obstacles, Benefits, and Impact) framework for navigating the digital servitization transition, emphasizing strategic adaptability and technological alignment. Analysis of 157 articles reveals a significant increase in research, highlighting digital servitization's role in competitive enhancement and customer engagement. The DASOBI framework offers manufacturers a novel approach for managing this transition, marking a unique contribution by distilling extensive literature into actionable insights for both theory and practice in the evolving field of digital servitization. [ABSTRACT FROM AUTHOR]

Liver steatosis is the most common chronic liver disease and affects 10–24% of the general population. As the grade of disease can range from fat infiltration to steatohepatitis and cirrhosis, an early diagnosis is needed to set the most appropriate therapy. Innovative noninvasive radiological techniques have been developed through MRI and US. MRI-PDFF is the reference standard, but it is not so widely diffused due to its cost. For this reason, ultrasound tools have been validated to study liver parenchyma. The qualitative assessment of the brightness of liver parenchyma has now been supported by quantitative values of attenuation and scattering to make the analysis objective and reproducible. We aim to demonstrate the reliability of quantitative ultrasound in assessing liver fat and to confirm the inter-operator reliability in different respiratory phases. We enrolled 45 patients examined during normal breathing at rest, peak inspiration, peak expiration, and semi-sitting position. The highest inter-operator agreement in both attenuation and scattering parameters was achieved at peak inspiration and peak expiration, followed by semi-sitting position. In conclusion, this technology also allows to monitor uncompliant patients, as it grants high reliability and reproducibility in different body position and respiratory phases. [ABSTRACT FROM AUTHOR]

The incorporation of biomacromolecules onto silicon waveguiding microstructures constitutes a growing trend that pushes towards compact and miniaturized biosensing systems. This paper presents the integration of one-dimensional periodic nanostructures of proteins on the surface of micrometric silicon waveguides for transducing binding events between biomacromolecules. The study demonstrates this new bioanalytical principle by experimental results and theoretical calculations, and proves that rib waveguides (1-–1.6-µm width) together with protein gratings (495-–515-nm period) display suitable spectral responses for this optical biosensing system. Protein assemblies of bovine serum albumin are fabricated on the surface of silicon nitride waveguides, characterized by electron microscopy, and their response is measured by optical frequency domain reflectometry along the fabrication process and the subsequent stages of the biorecognition assays. Detection and quantification limits of 0.3 and 3.7 µg·mL−1, respectively, of specific antibodies are inferred from experimental dose–response curves. Among other interesting features, the results of this study point towards new miniaturized and integrated sensors for label-free bioanalysis. [ABSTRACT FROM AUTHOR]

The possibility to excite and control charges in matter on ultrafast timescales is a key requisite to overcome the current limits of information transfer and data processing. The major route towards this milestone is based on the employment of short light pulses to manipulate the electro-optical properties of a solid. Nevertheless, the elusive physical mechanisms that unfold on extreme timescales are often complex and entangled, hindering their correct identification and possible exploitation. Here we investigate light-driven excitation in monocrystalline germanium by using attosecond transient reflection spectroscopy. We show that the complex regime established during light–matter interaction cannot be treated with simplified models but requires a detailed analysis in time and reciprocal space to address diverse phenomena such as tunnelling, band dressing, intra-band motion and multiphoton injection. Although single-photon absorption activates and develops earlier during excitation, two-photon processes, tunnelling and other field-driven phenomena reach their maximum effect soon after the peak of the pump pulse. Going against past observations, our results suggest that field-driven phenomena—namely intra-band transitions—can hinder charge injection, confirming that it is impossible to establish the next generation of petahertz information technology without a deep understanding of the diverse physical mechanism behind light–matter interaction. Attosecond transient reflectivity spectroscopy, in combination with extensive time-dependent density functional theory calculations, is used to study field-driven carrier injection in germanium in the time window of few femtoseconds around pulse overlap, paving a route towards achieving full optical control over charge carriers in semiconductors. [ABSTRACT FROM AUTHOR]

Celulose nanofibers are lightweight, recycable, biodegradable, and renewable. Hence, there is a great interest of using them instead of fossil-based components in new materials and biocomposites. In this study, we disclose an environmentally benign (green) one-step reaction approach to fabricate lactic acid ester functionalized cellulose nanofibrils from wood-derived pulp fibers in high yields. This was accomplished by converting wood-derived pulp fibers to nanofibrillated "cellulose lactate" under mild conditions using lactic acid as both the reaction media and catalyst. Thus, in parallel to the cellulose nanofibril production, concurrent lactic acid-catalyzed esterification of lactic acid to the cellulose nanofibers surface occurred. The direct lactic acid esterification, which is a surface selective functionalization and reversible (de-attaching the ester groups by cleavage of the ester bonds), of the cellulose nanofibrils was confirmed by low numbers of degree of substitution, and FT-IR analyses. Thus, autocatalytic esterification and cellulose hydrolysis occurred without the need of metal based or a harsh mineral acid catalysts, which has disadvantages such as acid corrosiveness and high recovery cost of acid. Moreover, adding a mineral acid as a co-catalyst significantly decreased the yield of the nanocellulose. The lactic acid media is successfully recycled in multiple reaction cycles producing the corresponding nanocellulose fibers in high yields. The disclosed green cellulose nanofibril production route is industrial relevant and gives direct access to nanocellulose for use in variety of applications such as sustainable filaments, composites, packaging and strengthening of recycled fibers. [ABSTRACT FROM AUTHOR]

The transitions between sitting and standing have a high physical and coordination demand, frequently causing falls in older individuals. Rollators, or four-wheeled walkers, are often prescribed to reduce lower-limb load and to improve balance but have been found a fall risk. This study investigated how rollator support affects sit-to-stand and stand-to-sit movements. Twenty young participants stood up and sat down under three handle support conditions (unassisted, light touch, and full support). As increasing task demands may affect coordination, a challenging floor condition (balance pads) was included. Full-body kinematics and ground reaction forces were recorded, reduced in dimensionality by principal component analyses, and clustered by k-means into movement strategies. Rollator support caused the participants to switch strategies, especially when their balance was challenged, but did not lead to support-specific strategies, i.e., clusters that only comprise light touch or full support trials. Three strategies for sit-to-stand were found: forward leaning, hybrid, and vertical rise; two in the challenging condition (exaggerated forward and forward leaning). For stand-to-sit, three strategies were found: backward lowering, hybrid, and vertical lowering; two in the challenging condition (exaggerated forward and forward leaning). Hence, young individuals adjust their strategy selection to different conditions. Future studies may apply this methodology to older individuals to recommend safe strategies and ultimately reduce falls. [ABSTRACT FROM AUTHOR]

Smart protective coatings and devices are currently of great interest. In particular, they can absorb or reflect harmful waves of electromagnetic interference (EMI). In this work, novel binary and ternary composites with highly amorphous poly(vinyl alcohol) (HAVOH) as a matrix and single-walled carbon nanotubes (SWCNTs) and MXenes as nanofillers were prepared. HAVOH is a recently patented kind of poly(vinyl alcohol) (PVOH) that was modified with diol monomers. MXenes are a new type of inorganic two-dimensional (2D) nanoparticle consisting of carbides, nitrides and carbonitrides. Three series of composites, HAVOH/SWCNTs, HAVOH/MXenes and HAVOH/SWCNTs/MXenes, were prepared using the solvent casting method. Samples were tested with various methods to study their structure, electrical properties, thermal behavior and EMI-shielding properties. HAVOH/3.0 wt.% SWCNTs/3.0 wt.% MXene specimens revealed a shielding effectiveness of 55 dB, which is 122 times better than that of the neat matrix. These results are promising for the fabrication of films with protective effects against EMI. [ABSTRACT FROM AUTHOR]

DBR1 encodes the only known human lariat debranching enzyme and its deficiency has been found to cause an autosomal recessive inborn error of immunity characterized by pediatric brainstem viral-induced encephalitis (MIM 619441). We describe a distinct allelic disorder caused by a founder recessive DBR1 variant in four families (DBR1(NM_016216.4):c.200A > G (p.Tyr67Cys)). Consistent features include prematurity, severe intrauterine growth deficiency, congenital ichthyosis-like presentation (collodion membrane, severe skin peeling and xerosis), and death before the first year of life. Patient-derived fibroblasts displayed the characteristic accumulation of intron lariats in their RNA as revealed by targeted and untargeted analysis, in addition to a marked reduction of DBR1 on immunoblot analysis. We propose a novel DBR1-related developmental disorder that is distinct from DBR1-related encephalitis susceptibility and highlight the apparent lack of correlation with the degree of DBR1 deficiency. [ABSTRACT FROM AUTHOR]

Most sex education programs for adults with intellectual disabilities are led by non-disabled sexual health experts. This approach may be less effective and appropriate for adult learners. Using community-based participatory research (CBPR), we explored a program that uses an inquiry-based learning process so that members can create reliable information about sex and disseminate it on Instagram. Through thematic analysis of interviews with group participants, we identified three themes about how the program brought everyone's different ideas about sex and sex ed together into content for Instagram: Blurring the Lines Between the Educated and Educating; Learning is Dependent on the Strengths and Weaknesses of Our Connections; and Committed to Inclusivity but Wrestling with Ableism. [ABSTRACT FROM AUTHOR]

This article reports the results of a novel perioperative treatment implementing the gut microbiota to prevent anastomotic fistula and leakage (AL) in patients undergoing laparoscopic colorectal resections for cancer and represents the continuation of our pilot study on 60 cases. A series of 131 patients underwent elective colorectal surgery at the S. Eugenio Hospital (Rome—Italy) between December 1, 2020, and November 30, 2022, and received a perioperative preparation following the Microbiota Implementation to Reduce Anastomotic Colorectal Leaks (MIRACLe) protocol comprising oral antibiotics, mechanical bowel preparation and perioperative probiotics. The results obtained in the MIRACLe group (MG) were compared to those registered in a Control group (CG) of 500 patients operated on between March 2015 and November 30, 2020, who received a standard ERAS protocol. Propensity score-matching (PSM) analysis was performed to overcome patients' selection bias. Patients were categorised according to perioperative preparation (MIRACLe protocol vs standard ERAS protocol) into two groups: 118 patients were in post-matched MIRACLe group (pmMG) and 356 were in post-matched Control group (pmCG). In the pmMG, only 2 anastomotic leaks were registered, and the incidence of AL was just 1.7% vs. 6.5% in the pmCG (p = 0.044). The incidence of surgical site infections (1.7% vs. 3.1%; p = 0.536), reoperations (0.8% vs. 4.2%; p = 0.136) and postoperative mortality (0% vs. 2.0%; p = 0.200) was lower in pmMG. Additionally, the postoperative outcomes were better: the times to first flatus, to first stool and to oral feeding were shorter (1 vs. 2, 2 vs. 3 and 2 vs. 3 days, respectively; p < 0.001). The postoperative recovery was faster, with a shorter time to discharge (5 vs. 6 days; p < 0.001). The MIRACLe protocol was confirmed to be safe and significantly able to reduce anastomotic leaks in patients receiving elective laparoscopic colorectal surgery for cancer. [ABSTRACT FROM AUTHOR]

Background: The gastroesophageal reflux disease (GERD) worldwide prevalence is increasing maybe due to population aging and the obesity epidemic. Nissen fundoplication is the most common surgical procedure for GERD with a failure rate of approximately 20% which might require a redo surgery. The aim of this study was to evaluate the short- and long-term outcomes of robotic redo procedures after anti-reflux surgery failure including a narrative review. Methods: We reviewed our 15-year experience from 2005 to 2020 including 317 procedures, 306 for primary, and 11 for revisional surgery. Results: Patients included in the redo series underwent primary Nissen fundoplication with a mean age of 57.6 years (range, 43–71). All procedures were minimally invasive and no conversion to open surgery was registered. The meshes were used in five (45.45%) patients. The mean operative time was 147 min (range, 110–225) and the mean hospital stay was 3.2 days (range, 2–7). At a mean follow-up of 78 months (range, 18–192), one patient suffered for persistent dysphagia and one for delayed gastric emptying. We had two (18.19%) Clavien–Dindo grade IIIa complications, consisting of postoperative pneumothoraxes treated with chest drainage. Conclusion: Redo anti-reflux surgery is indicated in selected patients and the robotic approach is safe when it is performed in specialized centers, considering its surgical technical difficulty. [ABSTRACT FROM AUTHOR]

The minichromosome maintenance (MCM) complex acts as a DNA helicase during DNA replication, and thereby regulates cell cycle progression and proliferation. In addition, MCM-complex components localize to centrosomes and play an independent role in ciliogenesis. Pathogenic variants in genes coding for MCM components and other DNA replication factors have been linked to growth and developmental disorders as Meier–Gorlin syndrome and Seckel syndrome. Trio exome/genome sequencing identified the same de novo MCM6 missense variant p.(Cys158Tyr) in two unrelated individuals that presented with overlapping phenotypes consisting of intra-uterine growth retardation, short stature, congenital microcephaly, endocrine features, developmental delay and urogenital anomalies. The identified variant affects a zinc binding cysteine in the MCM6 zinc finger signature. This domain, and specifically cysteine residues, are essential for MCM-complex dimerization and the induction of helicase activity, suggesting a deleterious effect of this variant on DNA replication. Fibroblasts derived from the two affected individuals showed defects both in ciliogenesis and cell proliferation. We additionally traced three unrelated individuals with de novo MCM6 variants in the oligonucleotide binding (OB)-fold domain, presenting with variable (neuro)developmental features including autism spectrum disorder, developmental delay, and epilepsy. Taken together, our findings implicate de novo MCM6 variants in neurodevelopmental disorders. The clinical features and functional defects related to the zinc binding residue resemble those observed in syndromes related to other MCM components and DNA replication factors, while de novo OB-fold domain missense variants may be associated with more variable neurodevelopmental phenotypes. These data encourage consideration of MCM6 variants in the diagnostic arsenal of NDD. [ABSTRACT FROM AUTHOR]

Background: Increased complication rates following laparoscopic cholecystectomies have been described, likely related to surgical difficulty, anatomical variations, and gallbladder inflammation severity. Parkland Grading Scale (PGS) stratifies the severity of intraoperative findings to predict operative difficulty and complications. This study aims to validate PGS as a postoperative-outcome predictive tool, comparing its performance with Tokyo Guidelines Grading System (TGGS). Methods: This is a single-center retrospective cohort study where PGS and TGGS performances were evaluated regarding intraoperative and postoperative outcomes. Both univariate and bivariate analyses were performed on each severity grading scale using STATA-SE 16.0 software. Additionally, we proposed a Logistic Regression Model for each scale. Their association with outcomes was compared between both scales by their Receiver Operating Characteristic Curve. Results: 400 Patients were included. Grade 1 predominance was observed for both PGS and TGGS (47.36% and 25.3%, respectively). A positive association was observed between higher PGS grades and inpatient postoperative care, length of stay, ICU care, and antibiotic requirement. Based on the area under the ROC curve, better performance was observed for PGS over TGGS in the evaluated outcomes. Conclusion: PGS performed better than TGGS as a predictive tool for inpatient postoperative care, length of stay, ICU, and antibiotic requirement, especially in severe cases. [ABSTRACT FROM AUTHOR]

In recent years, interest has grown in servitization strategies as business models for selling combined packages of goods and services to create competitive advantage to provide great customer value. Various studies have examined the benefits servitization offers to both businesses and their customers; however, there is very little research on the moderating role played by the digital enablers of Industry 4.0 on servitization. It is this research gap that the present study aims to fill. Using a framework developed from the extant literature, case studies, with an exploratory objective, were conducted to the aim of identifying and analyzing the challenges and opportunities that could be presented in those companies that decide to develop digital servitization. To achieve it, this study focuses on a deep analysis of the experience in five manufacturing companies, and, from that, we draw significant conclusions (both for further research and for business practice) about the strategy of servitization and the moderating role of Industry 4.0 on business competitiveness. We first carried out detailed interviews with key personnel from companies, complementing that with additional information from various sources before analyzing the results to identify emerging topics. The qualitative study allowed us to highlight how the different kinds of digital technologies supported servitization and product innovation. In addition, it provides empirical evidence about the different servitization strategies and Industry 4.0 digital enablers, which, in combination, allows companies achieving increased competitiveness, generate greater returns, find new customers, access new markets, and develop new business ideas. [ABSTRACT FROM AUTHOR]

The most common anesthetic approach in hepato-pancreatic-biliary (HPB) surgery is general anesthesia (GA), but it may result in increased morbidity and mortality and peri-operative risks especially in frail patients. The aim of this study was to assess the safety and effectiveness of neuraxial anesthesia (NA) in HPB in a pilot clinical series. This analysis was conducted on 46 consecutive patients undergoing HPB surgery in an Italian Tertial referral center. Data were prospectively collected and retrospectively analyzed. continuous spinal anesthesia (CSA), combined spino-epidural anesthesia (CSEA) and peridural anesthesia (PA) were used in major and minor hepatectomies and bilio-pancreatic surgery instead of GA. NA was evaluated by analyzing the surgical and anesthesiological short-term outcomes. 46 patients were considered eligible for the study between February 2018 and May 2020. The average age was 69.07 (± 9.95) years. 22 were males and 24 were females. According to the ASA score, 19 (41.30%) patients had ASA II, 22 (47.83%) had ASA III and 5 (10.87%) had ASA IV. 22 (47.83%) patients underwent CSA, 20 (43.48%) CSEA and 4 (8.69%) PA. We performed 8 major and 19 minor hepatectomies, 7 bilio-digestive derivations, 5 Whipple procedures, 4 iatrogenic biliary duct injuries, 2 splenopancreatectomies and 1 hepatic cyst fenestration. Clavien–Dindo ≥ 3 was observed in 3 patients. The conversion rate to endotracheal intubation occurring in 3 of 46 (6.52%) patients. After surgery, no local or pulmonary complications and delirium were reported in our series. The present study demonstrates that NA is a safe and feasible option in selected patients, if performed in referral centers by well-trained anaesthesiologists and surgeons. [ABSTRACT FROM AUTHOR]

CLEC16A is a membrane-associated C-type lectin protein that functions as a E3-ubiquitin ligase. CLEC16A regulates autophagy and mitophagy, and reportedly localizes to late endosomes. GWAS studies have associated CLEC16A SNPs to various auto-immune and neurological disorders, including multiple sclerosis and Parkinson disease. Studies in mouse models imply a role for CLEC16A in neurodegeneration. We identified bi-allelic CLEC16A truncating variants in siblings from unrelated families presenting with a severe neurodevelopmental disorder including microcephaly, brain atrophy, corpus callosum dysgenesis, and growth retardation. To understand the function of CLEC16A in neurodevelopment we used in vitro models and zebrafish embryos. We observed CLEC16A localization to early endosomes in HEK293T cells. Mass spectrometry of human CLEC16A showed interaction with endosomal retromer complex subunits and the endosomal ubiquitin ligase TRIM27. Expression of the human variant leading to C-terminal truncated CLEC16A, abolishes both its endosomal localization and interaction with TRIM27, suggesting a loss-of-function effect. CLEC16A knockdown increased TRIM27 adhesion to early endosomes and abnormal accumulation of endosomal F-actin, a sign of disrupted vesicle sorting. Mutagenesis of clec16a by CRISPR–Cas9 in zebrafish embryos resulted in accumulated acidic/phagolysosome compartments, in neurons and microglia, and dysregulated mitophagy. The autophagocytic phenotype was rescued by wild-type human CLEC16A but not the C-terminal truncated CLEC16A. Our results demonstrate that CLEC16A closely interacts with retromer components and regulates endosomal fate by fine-tuning levels of TRIM27 and polymerized F-actin on the endosome surface. Dysregulation of CLEC16A-mediated endosomal sorting is associated with neurodegeneration, but it also causes accumulation of autophagosomes and unhealthy mitochondria during brain development. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic cholecystectomy (LC) is one of the most commonly performed emergency procedures, with approximately 600,000 patients undergoing the procedure every year in the United States. Although LC is associated with fewer complications when compared with open cholecystectomy, the risk for infectious complications, including surgical site infection and intra-abdominal abscess, remains a significant source of postoperative morbidity. The goal of this study is to determine whether the gallbladder retrieval technique during LC affects risk of infectious complications. Methods and procedures: We conducted a retrospective comparative study in a minimally invasive surgery high-volume center in Bogota, Colombia. Patients who underwent LC in 2018 to 2020 were identified. The patients were divided into three groups. One group of LC performed using home-made gallbladder retrieval bag (HMGRB), and another group of LC performed using commercial gallbladder retrieval bag (CGRB). The primary outcomes were infectious complications of superficial site infection and intra-abdominal abscess. Results: A total of 68 (7.58%) patients underwent LC using an HMGRB, and 828 (92.41%) using a CGRB. There was no significant difference in preoperative sepsis, or sex distribution between patient groups. Using t test, we found differences on age distribution among groups (p < 0.01), surgical times (p < 0.01), and length of stay (p = 0.01). When using Chi square, we found differences in Tokyo and Parkland Grading Scale severity (p < 0.01), use of postoperative antibiotics (p < 0.01), and drain use (p < 0.01). Nonetheless, there was no difference in the rate of superficial surgical site infection (p = 0.92). Conclusion: HMGRB are not associated with increased risk of postoperative intra-abdominal abscess or superficial surgical site infection in comparison with CGRB but imply longer surgical times and length of stay. The use of HMGRB is safe, feasible, and has lower cost during LC. [ABSTRACT FROM AUTHOR]

Gliomas are amongst the most common primary brain tumours in adults and are often associated with poor prognosis. Understanding the extent of white matter (WM) which is affected outside the tumoral lesion may be of paramount importance to explain cognitive deficits and the clinical progression of the disease. To this end, we explored both direct (i.e., tractography based) and indirect (i.e., atlas-based) approaches to quantifying WM structural disconnections in a cohort of 44 high- and low-grade glioma patients. While these methodologies have recently gained popularity in the context of stroke and other pathologies, to our knowledge, this is the first time they are applied in patients with brain tumours. More specifically, in this work, we present a quantitative comparison of the disconnection maps provided by the two methodologies by applying well-known metrics of spatial similarity, extension, and correlation. Given the important role the oedematous tissue plays in the physiopathology of tumours, we performed these analyses both by including and excluding it in the definition of the tumoral lesion. This was done to investigate possible differences determined by this choice. We found that direct and indirect approaches offer two distinct pictures of structural disconnections in patients affected by brain gliomas, presenting key differences in several regions of the brain. Following the outcomes of our analysis, we eventually discuss the strengths and pitfalls of these two approaches when applied in this critical field. [ABSTRACT FROM AUTHOR]

The first objective of the paper is to implement a two stage Bayesian hierarchical nonlinear model for growth and learning curves, particular cases of longitudinal data with an underlying nonlinear time dependence. The aim is to model simultaneously individual trajectories over time, each with specific and potentially different characteristics, and a time-dependent behavior shared among individuals, including eventual effect of covariates. At the first stage inter-individual differences are taken into account, while, at the second stage, we search for an average model. The second objective is to partition individuals into homogeneous groups, when inter individual parameters present high level of heterogeneity. A new multivariate partitioning approach is proposed to cluster individuals according to the posterior distributions of the parameters describing the individual time-dependent behaviour. To assess the proposed methods, we present simulated data and two applications to real data, one related to growth curve modeling in agriculture and one related to learning curves for motor skills. Furthermore a comparison with finite mixture analysis is shown. [ABSTRACT FROM AUTHOR]

Pulmonary arterial hypertension (PAH), documented in a significant portion of hypertrophic cardiomyopathy (HCM) patients, has been shown to adversely impact prognosis. In most HCM patients congestive symptoms are consistently elicited by exercise, thus suggesting the need for a provocative test to assess cardiac hemodynamics during effort. Combining cardiopulmonary exercise test (CPET) with echocardiography, we aimed to evaluate the presence of exercise induced pulmonary arterial hypertension (EiPAH), its role in functional limitation and its prognostic significance in a cohort of patients with obstructive and non-obstructive HCM. Study population included 182 HCM patients evaluated combining CPET and stress echocardiography. Left-ventricular outflow tract (LVOT) velocities, trans-tricuspid gradient, and cardiopulmonary variables were continuously measured. Thirty-seven patients (20%) developed EiPAH, defined as systolic pulmonary arterial pressure (sPAP) > 40 mmHg during exercise. EiPAH was associated with lower exercise performance, larger left atrial volumes, higher LVOT gradient and higher VE/VCO2 slope. At multivariable analysis baseline sPAP (p < 0.0001) and baseline LVOT obstruction (p = 0.028) were significantly associated with EiPAH. Kaplan-Meier curve analysis showed EiPAH was a significant predictor of HCM-related morbidity (Hazard Ratio 6.21, 95% CI 1.47-26.19; p = 0.05; 4.21, 95% CI 1.94-9.12; p < 0.001 for the primary and the secondary endpoint respectively). EiPAH was present in about one fifth of HCM patients without evidence of elevated pulmonary pressures at rest and was associated with adverse clinical outcome. Diagnosing EiPAH by exercise echocardiography/CPET may help physicians to detect early stage of PAH thus allowing a closer clinical monitoring and individualized therapies. [ABSTRACT FROM AUTHOR]

Purpose: To describe our institutional experience in cochlear implantation after vestibular schwannoma (VS) resection, and compare the audiological outcomes between sporadic and neurofibromatosis type 2 (NF2) VS sub-cohorts of patients, and in relation to preoperative contralateral hearing. Methods: Seventeen patients (8 sporadic and 9 NF2-associated VSs) who had undergone VS resection and cochlear implant (CI) were analyzed retrospectively. Audiological outcomes at 24 months were correlated with preoperative clinical variables. The results according to VS type (sporadic vs. NF2-associated) and contralateral hearing (impaired vs. normal) were compared. Results: Fourteen CIs were actively used by the patients (77.8%). Twenty-four months after CI activation, the median postoperative PTA (pure tone average) was 45.6 dB nHL and a measurable WRS (Word Recognition Score) was achieved by 44.4% of patients (median WRS = 40%). The median postoperative PTA in the implanted ear resulted better in the group with an impaired contralateral hearing (36.3 dB nHL vs. 78.8 dB nHL, p = 0.019). Good preoperative contralateral hearing status (A–B classes of AAO-HNS) was a negative prognostic factor for CI performance on open-set discrimination (OR = 28.0, 95% CI 2.07–379.25, p = 0.012). Conclusions: CI is a viable rehabilitative option for patients with sporadic or NF2-associated VS. A good contralateral hearing adversely affects CI outcome and should be taken into consideration for patients' selection and rehabilitation programs. [ABSTRACT FROM AUTHOR]

Craniopharyngiomas (CP) ectopic localizations off the midline outside the sellar-suprasellar region are very rare and most often associated to secondary tumor dissemination, being primary ectopic CPs extremely unusual. We herein report the first case of a primary ectopic craniopharyngioma within the orbit. A 15-year-old patient presented with progressive right ptosis, proptosis, and retro ocular pain. Magnetic resonance imaging (MRI) showed a predominantly cystic lesion, occupying the superolateral right corner of the orbit, outside the intraconal space with no evidence of intracranial involvement. An endoscopic transorbital eyelid approach was adopted. Pathology report disclosed a primary ectopic craniopharyngioma. [ABSTRACT FROM AUTHOR]

The Fourth Industrial Revolution, or Industry 4.0, aims at automating traditional manufacturing and industrial practices using modern smart technology. Autonomous mobile robots equipped with different sensors and employing different techniques have been proposed in the literature in the logistics and inventory warehouse management contexts. Efficient robot motion and planning depend on precise localization, mapping, and awareness of the environment. To properly localize items, recent attempts have been made employing radio frequency identification (RFID) in a 3D environment. This manuscript introduces four least mean squares methods to estimate the 3D positions of tags employing synthetic apertures and phase unwrapping. The proposed methods approach the localization problem solving a system of equations typical of multilateration methods to find the intersections of multiple hyperboloids. The novelty introduced here is the use of unwrapped phase distances to compute pseudo ranges for the multilateration problem. The use of such a technique is feasible thanks to precise mobile robot localization and custom navigation policies. All the analyzed methods are suitable for online localization due to reduced computation timings and have been tested on three different datasets. Two of them contain virtual data that has been generated by simulation, while the other one comes from an indoor experimental setup. Simulated tests show that combined antenna motions in 3D space (including Z-axis) improve the localization obtaining errors under the centimeter for 3D localization. Experimental tests obtained results as low as 13 cm of mean accuracy for 3D localization and 0.21 cm for 2D localization. [ABSTRACT FROM AUTHOR]

The washing process of synthetic fabrics represents the main source of primary microplastics in sea and oceans as large amounts of microfibers are released during washing. Recent researches have been focused on the development of effective approaches to mitigate the effects of microfiber release. Relevant approaches are aimed to design capturing devices and filters. In this work, the development, testing, and demonstration of the effectiveness of a new filtration system for washing machines are reported. This system is designed to retain microfibers avoiding their entrance into the wastewater system. Washing tests were performed using two different prototypes of the proposed filtration system, in order to optimize its design and efficiency. The obtained results demonstrate that, after its optimized, the proposed filtration system shows a capture efficiency of 64% toward microfibers released from commercial polyester t-shirts, comparable or even better than the efficiency shown by other commercial or prototype microfiber capturing systems. [ABSTRACT FROM AUTHOR]

The potential etiological role of early acetaminophen exposure on Autism Spectrum Conditions (ASC) and Attention-Deficit/Hyperactivity Disorder (ADHD) is inconclusive. We aimed to study this association in a collaborative study of six European population-based birth/child cohorts. A total of 73,881 mother–child pairs were included in the study. Prenatal and postnatal (up to 18 months) acetaminophen exposure was assessed through maternal questionnaires or interviews. ASC and ADHD symptoms were assessed at 4–12 years of age using validated instruments. Children were classified as having borderline/clinical symptoms using recommended cutoffs for each instrument. Hospital diagnoses were also available in one cohort. Analyses were adjusted for child and maternal characteristics along with indications for acetaminophen use. Adjusted cohort-specific effect estimates were combined using random-effects meta-analysis. The proportion of children having borderline/clinical symptoms ranged between 0.9 and 12.9% for ASC and between 1.2 and 12.2% for ADHD. Results indicated that children prenatally exposed to acetaminophen were 19% and 21% more likely to subsequently have borderline or clinical ASC (OR = 1.19, 95% CI 1.07–1.33) and ADHD symptoms (OR = 1.21, 95% CI 1.07–1.36) compared to non-exposed children. Boys and girls showed higher odds for ASC and ADHD symptoms after prenatal exposure, though these associations were slightly stronger among boys. Postnatal exposure to acetaminophen was not associated with ASC or ADHD symptoms. These results replicate previous work and support providing clear information to pregnant women and their partners about potential long-term risks of acetaminophen use. [ABSTRACT FROM AUTHOR]

Ilmenite (FeTiO3) concentrates were modified by high energy ball milling (HEBM) at different times (1, 2, and 3 h) and in the presence of MgO or metallic Mg at different contents (0.5, 1.0, and 3.0 wt%), with the aim of obtaining a low-cost and highly available photocatalyst with enhanced performance towards H2 production. FeTiO3 concentrates were obtained from ilmenite-rich black sand by gravimetric concentration followed by wet electromagnetic and dry magnetic separation. HEBM was performed to insert Mg into FeTiO3 structure and to simultaneously reduce the particle size. The insertion of Mg intended to shift the conduction band of the materials to more negative potentials, in spite of the band-gap widening. XRD patterns of the milled samples showed a decrease in the intensity of ilmenite peaks without any displacement, indicating slight amorphization without significant changes in the crystalline structure. However, the increase in the intensity of hematite peaks suggests substitutional doping according to the proposed solid-state reactions. Although thermodynamic analyses showed that doping with metallic Mg should be more favorable, doping with MgO appears to be kinetically favored due to the physical characteristics of the precursor, as it was revealed by XRD, XPS, Raman spectroscopy, SEM–EDS, and UV–Vis DRS results. Deconvolution of high-resolution XPS spectra corresponding to Mg1s exhibited the presence of an additional component peak for the sample milled with metallic Mg, in comparison to that with MgO. This result evidenced the formation of a new phase, suggesting that part of the metallic Mg was not inserted into FeTiO3, as it was confirmed by Raman spectroscopy. UV–Vis DRS analyses showed an increase in the band-gap of the samples milled in the presence of Mg precursors (from 2.51 to 2.55–2.59 eV) which were attributed to slight modifications of the conduction band due to the insertion of Mg. The performance towards hydrogen production under UV irradiation was improved from 240.5 µmol g−1 h−1 (unmilled sample) to 255.3 µmol g−1 h−1 (2 h milled in the absence of Mg precursor), 296.0 µmol g−1 h−1 (2 h milled with 1.0 wt% MgO), and 265.2 µmol g−1 h−1 (2 h milled with 1.0 wt% metallic Mg). This improvement was attributed mainly to the insertion of Mg, and the consequent modification of the band structure, rather than the modification in the surface area. [ABSTRACT FROM AUTHOR]

The photoelectrocatalytic oxidation of an anionic surfactant (internal olefin sulfonate C20-C24, IOS) in synthetic oilfield wastewater was investigated by photocurrent measurements using a sulfur and nitrogen co-doped titanium dioxide electrode (S,N-TiO2/Ti). For the electrode preparation, S,N-TiO2 films were supported on Ti expanded meshes by sol–gel dip-coating, followed by thermal treatment at 400 °C. Photocurrent measurements were performed by linear sweep voltammetry (LSV) under UV–Vis irradiation using different IOS concentrations (20–200 ppm). The photocurrent values obtained at 0.5 V vs Ag/AgCl (iph) for each IOS concentration (CIOS) were used to plot the 1/iph vs 1/CIOS graph, in which two trends were identified. For high IOS concentrations (70–200 ppm), the values fitted well to the unimolecular Langmuir–Hinshelwood (LH1) kinetic model (R2 = 0.973), which can be associated with the direct oxidation mechanism. For low IOS concentrations (20–70 ppm), the values fitted better to a linear combination of both unimolecular and bimolecular Langmuir–Hinshelwood (LH1 and LH2) kinetic models (R2 = 0.854), which can be associated with direct and indirect oxidation mechanisms, respectively. These results suggest that at high IOS concentrations the IOS adsorption plays the main role on the photoelectrocatalytic oxidation, while at low IOS concentrations both IOS adsorption and H2O adsorption (surface hydrophilicity) play important roles on the photoelectrocatalytic oxidation. [ABSTRACT FROM AUTHOR]

Visual quality inspection for defect detection is one of the main processes in modern industrial production facilities. In the last decades, artificial intelligence solutions took the place of classic computer vision techniques in the production lines and specifically in tasks that, for their complexity, were usually demanded to human workers yet obtaining similar or greater performance of their counterparts. This work exploits a Deep Neural Network for a smart monitoring system capable of performing accurate quality checks to detect welding defects in fuel injectors during the production stage. The contribution focuses on a novel approach to cope with unforeseen changes in production quality introduced by the alteration of a particular machine or process. Results suggest that pre-filtering could avoid the retraining of custom-designed networks. Moreover, the introduction of a weighting strategy on the confusion matrix allows obtaining good performance estimations even in the case of small and unbalanced datasets. Concerning a specific demanding case of an imbalanced dataset with very few positive examples, the system displayed a 96.30% accuracy on defect classification. [ABSTRACT FROM AUTHOR]

Modern industrial processes aim for the continuous production of small volumes tailored to the customer's needs. Machines and robotic platforms have to be more and more adaptable, flexible, and able to cope with complex scenarios where sensing and manipulation capabilities are the key technology to succeed. The literature has plenty of capacitive, resistive, piezoelectric, and piezoresistive sensors used as tactile or force sensors. All of them present some drawbacks like non-linear behavior, sensitivity to temperature or electromagnetic noise, and hysteresis, among others. Other sensing systems are bulky and hard to integrate, sometimes jeopardizing the dexterity and manipulability of the gripper. In this context, the manuscript proposes fiber Bragg grating (FBG) optical fiber as a tactile sensing element to capture the interaction forces during material handling and object manipulation since it has numerous advantages compared with the other sensing devices. The work also offers a methodology to easily integrate the fiber in industrial grippers and introduces a set of tests useful to characterize the sensors. Custom gripper fingers have been realized in rapid prototyping to present a pictorial example of such an integration. Finally, the essay presents some experiments that assess the capability of a tactile sensor based on FBG optical fiber showing as it can correctly perceive the contact forces (NRMSE = 0.75%) and can recognize the material of the object that is being manipulated. The authors believe that the application of optical fiber sensor as tactile feedback can be useful in industrial scenarios to enable complex manipulation activities. [ABSTRACT FROM AUTHOR]

Perioperative management of patients with sellar lesion submitted to endoscopic transsphenoidal neurosurgery (TSS) lacks standardization and therefore it is committed to each center clinical practice. Although neurosurgical procedure remains the same for all sellar lesions, perioperative approach can require different measures depending on the underlying disease. With the aim of standardizing our perioperative procedures and sharing our experience with other centers involved in the management of pituitary disease, we developed a clinical care path for patients with sellar lesions candidate to endoscopic TSS. For the drafting of the following protocol, the national and international guidelines published in the last 5 years have been evaluated and integrated with our center experience accumulated in decades of clinical practice. A steering committee including medical doctors involved in management of patients with pituitary masses at the Padua Hospital reviewed current knowledge on this topic. The committee developed a first draft which was shared with a broader group of medical doctors to reach a preliminary consensus; when it was reached, the clinical care assistance pathway was confirmed, validated, and published in the local web-based health service. We want to present and share our experience with colleagues involved in the perioperative management of pituitary diseases in other centers. [ABSTRACT FROM AUTHOR]

Purpose: Recently, the Zurich Pituitary Score (ZPS) has been proposed as a new quantitative preoperative classification scheme for predicting gross total resection (GTR), extent of resection (EOR), and residual tumor volume (RV) in endoscopic pituitary surgery. We evaluated the external validity of the ZPS. Methods: In three reference centers for pituitary surgery, the ZPS was applied and correlated to GTR, EOR, and RV. Furthermore, its inter-rater agreement was assessed. Results: A total of 485 patients (53% male; age, 53.8 ± 15.7) were included. ZPS grades I, II, III, and IV were observed in 110 (23%), 270 (56%), 64 (13%), and 41 (8%) patients, respectively. GTR was achieved in 358 (74%) cases, with mean EOR of 87.6% ± 20.3% and RV of 1.42 ± 2.80 cm3. With increasing ZPS grade, strongly significant decreasing trends for GTR (I, 92%; II, 77%; III, 67%; IV, 15%; p < 0.001) and EOR (I, 93.8%; II, 89.9%; III, 88.1%; IV, 75.4%; p < 0.001) were found. Similarly, RV increased steadily ([cm3] I, 0.16; II, 0.61; III, 2.01; IV, 3.84; p < 0.001). We observed intraclass correlation coefficients of 0.837 (95% CI, 0.804–0.865) for intercarotid distance and 0.964 (95% CI, 0.956–0.970) for adenoma diameter, and Cohen's kappa of 0.972 (95% CI, 0.952–0.992) for the ZPS grades. Conclusions: Application of the ZPS in three external cohorts was successful. The ZPS generalized well in terms of GTR, EOR, and RV; demonstrated excellent inter-rater agreement; and can safely and effectively be applied as a quantitative classification of adenomas with relevance to surgical outcome. [ABSTRACT FROM AUTHOR]

The frequency of premature atrial complexes (PACs) has been related with atrial fibrillation (AF) occurrence and adverse prognosis. Research objective was to evaluate whether temporal patterns of PACs are directly associated with AF onset in pacemaker patients with continuous monitoring of the atrial rhythm. Overall, 193 pacemaker patients (49% female, 72 ± 9 years old), enrolled in a national registry, were analyzed. Frequency of daily PACs was measured in a 14-day initial observation period, during which patients were in sinus rhythm. In the following period, temporal occurrence and frequency of daily PACs and eventual onset of AF were derived by pacemaker diagnostics. In the run-in period, median PACs frequency was 614 PACs/day (interquartile range 70-3056). Subsequently, in a median follow-up of 6 months, AF occurred in 109 patients, in particular in 37/96 (38.5%) patients with a PAC rate < 614 PACs/day and in 72/97 (74.2%) patients with PAC rate ≥ 614 PACs/day (p < 0.001). In patients with AF occurrence, the number of daily PACs, normalized by dividing for the average of PACs in ten preceding days, progressively increased in the 5 days preceding AF. Cox model predictive analysis showed that the risk of AF was significantly higher in patients with a relative increase of the daily PACs higher than 30% compared with PACs average number in ten preceding days [hazard ratio (95% confidence interval) 3.67 (2.40-5.59), p < 0.001]. PACs frequency increases in the 5 days preceding AF onset. A relative increase of the daily PACs is significantly associated with the risk of AF occurrence. [ABSTRACT FROM AUTHOR]

Several intracellular proteins are involved in mediating vesicular transport of protein and lipid cargo from the endoplasmic reticulum (ER) to the Golgi apparatus (GA) in eukaryotic cells. An important protein in these processes is YIF1B, an intracellular 314-residue transmembrane protein. Computational protein modelling of YIF1B predicted that the first ~ 68 residues form a cytosolic disordered region and indicated the presence of transmembrane helices in the remaining ~ 250 residues (Fig. [Extracted from the article]

Background: As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems.Methods: We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes.Results: Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently.Discussion: Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis. [ABSTRACT FROM AUTHOR]