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Outcomes after Strasberg grade E bile duct injury have been widely reported. However, there are comparatively few reports of outcomes after Strasberg A to D bile duct injury. Therefore, the aim of this study was to comprehensively evaluate the long-term clinical and economic impact of Strasberg A to D bile duct injury.Patients with Strasberg A to D bile duct injury were identified from a prospectively collected and maintained database. Long-term biliary complication rates, as well as treatment costs were then estimated, and compared across Strasberg injury grades.A total of N = 120 patients were identified, of whom N = 49, 13, 20, and 38 had Strasberg grade A, B, C, and D bile duct injury, respectively. Surgical repair was most commonly performed in Strasberg grade D injuries (74% vs 8%-20% in lower grades, P.001). By 5 years post bile duct injury, the estimated long-term biliary complication rate was 40% in Strasberg grade D injuries, compared with 15% in Strasberg grade A (P = .022). A significant difference in total treatment and follow-up costs was also detected (P.001), being highest in Strasberg grade D injuries (mean £11,048/US$14,252 per patient) followed by the Strasberg grade B group (mean £10,612/US$13,689 per patient).Strasberg grade A to D injuries lead to considerable long-term morbidity and cost. Strasberg grade D injuries are typically managed surgically and result in the highest complication rate and treatment costs. Strasberg grade B injuries lead to a similar complication rate and treatment cost but are often managed without surgery.

Background Several studies have reported the effect of bile duct injury (BDI) on health-related quality of life (HRQOL) with conflicting results. This systematic review aims to study the impact of patient and treatment factors on HRQOL after BDI. Methods A search of the PubMed database was performed and studies were reviewed as per the PRISMA guidelines. Selected studies (n = 11) were then divided into two subgroups depending on whether they found HRQOL to be similar or worse between BDI and control groups. Pooled rates of surgical repair and major BDI were calculated for each of these subgroups. Results Surgical repair rates were 99% (95% CI: 96%–99%) in studies where the BDI patients had similar outcomes to controls, compared to 78% (40%–100%) where their outcomes were significantly worse (p = 0.091). The major BDI rate was 51% (95% CI: 42%–61%) in studies where the BDI patients had similar outcomes to controls, compared to 72% (41%–94%) where their outcomes were significantly worse (p = 0.322). Considerable heterogeneity was present within the two subgroups (I2: 68–99%). Discussion HRQOL may be adversely affected amongst patients with BDI who do not undergo surgical repair. Significant heterogeneity of data suggests the need for standardised HRQOL tools and injury severity systems when assessing outcomes after BDI.

Experimental data collection methods and a corresponding numerical model are presented to investigate the quality of waveguide fabrication in nonlinear optics. The method utilises white light interferometry and standard image recognition techniques to calculate a waveguide propagation constant function. This enables comparison of a numerical second harmonic spectrum in quasi-phasematched materials, such as periodically poled lithium niobate, with the waveguide’s experimental phase-matching spectrum. Using the presented method, a 3rd order polynomial fit to waveguide ridge width is demonstrated to be in good agreement with experimental phasematching spectra. The presented technique provides a nondestructive route to discriminate between issues in fabrication steps in nonlinear waveguide design.

OBJECTIVES To measure variation in spending and inpatient prices associated with the primary care physician (PCP) practice to which patients are attributed. STUDY DESIGN Cross-sectional analysis of claims data. METHODS We used random effect models to estimate case mix-adjusted spending across large PCP practices within 3-digit zip codes. We compare inpatient prices for patients in high-spending practices with those in low-spending practices. RESULTS The physician practice to which a patient was attributed is associated with significant differences in spending after controlling for patient comorbidities and geography. Patients attributed to practices in the top quartile of total medical expenses have about 30% higher spending than patients attributed to practices in the bottom quartile of adjusted spending in their 3-digit zip code. If patients attributed to practices in the top 2 quartiles had spending equivalent to those in the median practice, total spending would drop by 8%. Price variation accounts for a meaningful amount of the variation, with inpatient prices 17% higher in top-quartile vs bottom-quartile practices. We cannot disaggregate the large variation in utilization into practice patterns and unmeasured case mix (including unmeasured differences in patients' socioeconomic status) vs random health shocks, but correlation in spending patterns across years suggests that some persistent differences in spending patterns exist. CONCLUSIONS There are meaningful opportunities to reduce spending by changing patient PCP selection, encouraging patients to use lower-priced specialists and hospitals, and eliminating wasteful care. Attention must be paid to the best ways to reap these savings.

Objectives The incidence of hip fracture is high and increasing globally due to an aging population. Morbidity and mortality from these injuries are high at baseline and worse without prompt surgical treatment to facilitate early mobilization. Due to resource constraints, surgeons in low-income countries often must adapt available materials to meet these surgical needs. The objective of this study is to assess functional outcomes after surgical fixation of intertrochanteric femur fractures with the Surgical Implant Generation Network (SIGN) intramedullary nail augmented by a lateral SIGN plate. Design Prospective case series. Setting Juba Teaching Hospital, Tertiary Referral Hospital for South Sudan. Participants Adult patients with intertrochanteric hip fractures. Intervention SIGN nail augmented by a lateral plate. Main outcome measurements Primary outcome was hip function as measured by a modified Harris Hip Score (mHHS) at 1-year after surgery. Secondary endpoints were the occurrence of reoperation or infection at 1-year after surgery. Results Thirty patients were included, 16 (53%) men and 14 (47%) women, with a mean age of 62 years. Fractures were classified as AO/OTA Type 31A1 in 12 (40%) patients, 31A2 in 15 (50%) patients, and 31A3 in 3 (10%) patients. Mean mHHS at 1-year was 75.10 ± 21.2 with 76% categorized as excellent or good scores. There was 1 (3%) infection and 2 (7%) reoperations. Conclusions The SIGN nail augmented by a lateral plate achieved good or excellent hip function in the majority of patients with intertrochanteric hip fractures. This may be a suitable alternative to conventional implants for hip fracture patients in low-resource settings to allow mobilization.

Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI.Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes.Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p 0.001). Repair by a non-specialist surgeon (HR: 4.00, p 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates.Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.

OBJECTIVES (1) To determine the infection rate after fixation of open tibial shaft fractures using the Surgical Implant Generation Network (SIGN) intramedullary nail in low- and middle-income countries (LMICs) and (2) to identify risk factors for infection. DESIGN Prospective cohort study using an international online database. SETTING Multiple hospitals in LMICs worldwide. PATIENTS/PARTICIPANTS A total of 1061 open tibia fractures treated with the SIGN nail in LMICs between March 2000 and February 2013. INTERVENTION Intravenous antibiotic administration, surgical debridement, and definitive intramedullary nailing within 14 days of injury. MAIN OUTCOME MEASUREMENTS Deep or superficial infection at follow-up, implant breakage/loosening, angular deformity >10 degrees, repeat surgery, radiographic union, weight bearing, and ability to kneel. RESULTS The overall infection rate was 11.9%. Infection rates by the Gustilo and Anderson classification were type 1: 5.1%, type II: 12.6%, type IIIa: 12.5%, type IIIb: 29.1%, and type IIIc: 16.7% (P = 0.001 between groups). Patients who developed infection had a longer mean time from injury to definitive surgery (4.7 vs. 3.9 days, P = 0.03) and from injury to wound closure (13.7 vs. 3.6 days, P < 0.001). Distal fractures had a higher infection rate than midshaft fractures (13.3% vs. 8.2%, P = 0.03). Infection rates were not associated with time from injury to initial debridement, time from injury to initial antibiotic administration, or total duration of antibiotics. CONCLUSIONS Open tibia fractures can be managed effectively using the SIGN intramedullary nail in LMICs with an overall infection rate of 11.9%. Risk factors for infection identified include more severe soft-tissue injury, delayed nailing, delayed wound closure, and distal fracture location. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND There are few validated instruments that serve as a proxy for fracture-healing after lower-extremity trauma in low-resource settings. The squat-and-smile test (S&S) has been under development by SIGN (Surgical Implant Generation Network) Fracture Care International to monitor outcomes of lower-extremity long-bone fractures after intramedullary nailing in resource-limited settings. The goals of this study were to develop and identify domains of the S&S test. METHODS The S&S domains were developed through an iterative process, and consensus was achieved regarding 3: squat depth, support needed to squat, and facial expression. Adult patients with an OTA/AO type-32 femoral shaft fracture were included in this retrospective study and had the S&S administered at 6 weeks and 3, 6, and 12 months postoperatively. Two authors independently assessed photographs of the patients performing the S&S. S&S domains were correlated with the EuroQol 5-Dimensions (EQ-5D) index score, and comparisons were made between S&S domains and reoperation status. Interrater and test-retest reliability was assessed using the kappa statistic. Sensitivity and specificity analyses were performed. RESULTS Six hundred and nine S&S images were evaluated for 231 patients. Each domain improved over time and correlated positively with EQ-5D scores (p < 0.05). Squat depth and support needed to squat correlated with the need for a reoperation (p ≤ 0.01), and both had high specificity (0.95 and 0.97, respectively) for ruling out the need for a reoperation at 1 year. All 3 domains had high test-retest reliability (κ = 0.95, 0.92, and 0.96). Squat depth and need for support also had strong interrater reliability (κ = 0.75 and 0.78). CONCLUSIONS The S&S is a potential tool for monitoring clinical and functional outcome of femoral shaft fractures in low-resource settings. Our data support the binary assessment of squat depth and need for support, but not facial expression, as a proxy for fracture-healing. Future prospective studies in external populations are warranted to evaluate the validity, reliability, and responsiveness of the S&S. CLINICAL RELEVANCE The S&S provides a valuable proxy for femoral shaft fracture assessment for middle to low-income countries because it is locally relevant (based on squatting), it is easy to administer, and assessment can be performed remotely via mobile telephone or text messaging.

Importance: Increasing evidence shows that physical activity is associated with reduced risk for depression, pointing to a potential modifiable target for prevention. However, the causality and direction of this association are not clear; physical activity may protect against depression, and/or depression may result in decreased physical activity.Objective: To examine bidirectional relationships between physical activity and depression using a genetically informed method for assessing potential causal inference.Design, Setting, and Participants: This 2-sample mendelian randomization (MR) used independent top genetic variants associated with 2 physical activity phenotypes-self-reported (n = 377 234) and objective accelerometer-based (n = 91 084)-and with major depressive disorder (MDD) (n = 143 265) as genetic instruments from the largest available, nonoverlapping genome-wide association studies (GWAS). GWAS were previously conducted in diverse observational cohorts, including the UK Biobank (for physical activity) and participating studies in the Psychiatric Genomics Consortium (for MDD) among adults of European ancestry. Mendelian randomization estimates from each genetic instrument were combined using inverse variance weighted meta-analysis, with alternate methods (eg, weighted median, MR Egger, MR-Pleiotropy Residual Sum and Outlier [PRESSO]) and multiple sensitivity analyses to assess horizontal pleiotropy and remove outliers. Data were analyzed from May 10 through July 31, 2018.Main Outcomes and Measures: MDD and physical activity.Results: GWAS summary data were available for a combined sample size of 611 583 adult participants. Mendelian randomization evidence suggested a protective relationship between accelerometer-based activity and MDD (odds ratio [OR], 0.74 for MDD per 1-SD increase in mean acceleration; 95% CI, 0.59-0.92; P = .006). In contrast, there was no statistically significant relationship between MDD and accelerometer-based activity (β = -0.08 in mean acceleration per MDD vs control status; 95% CI, -0.47 to 0.32; P = .70). Furthermore, there was no significant relationship between self-reported activity and MDD (OR, 1.28 for MDD per 1-SD increase in metabolic-equivalent minutes of reported moderate-to-vigorous activity; 95% CI, 0.57-3.37; P = .48), or between MDD and self-reported activity (β = 0.02 per MDD in standardized metabolic-equivalent minutes of reported moderate-to-vigorous activity per MDD vs control status; 95% CI, -0.008 to 0.05; P = .15).Conclusions and Relevance: Using genetic instruments identified from large-scale GWAS, robust evidence supports a protective relationship between objectively assessed-but not self-reported-physical activity and the risk for MDD. Findings point to the importance of objective measurement of physical activity in epidemiologic studies of mental health and support the hypothesis that enhancing physical activity may be an effective prevention strategy for depression.

OBJECTIVE To evaluate femoral growth after placement of retrograde intramedullary nails in the treatment of pediatric femoral shaft fractures. DESIGN Retrospective case series. SETTING Large urban trauma center in Mongolia. PATIENTS/PARTICIPANTS Twenty-nine pediatric patients who sustained a diaphyseal femoral shaft fracture were included in the study. INTERVENTION Retrograde intramedullary nail fixation with the standard, fin, or pediatric fin Surgical Implant Generation Network nail across an open distal femoral physis. MAIN OUTCOME MEASURES The main outcome measure was the distance traveled by the intramedullary nail with respect to the distal femoral condyles and distal femoral physis from initial surgery to follow-up. RESULTS The mean age of patients was 10.7 years (range: 7-14 years). Follow-up occurred at a mean of 292 days (range: 53-714 days). Both condyle distance and physis distance were significantly positively correlated with follow-up days, with Pearson R values of 0.90 (P < 0.001) and 0.84 (P < 0.001), respectively. Multiple regression analysis revealed that follow-up days was the only significant predictor of physis distance, whereas age, sex, percent growth plate violation, and nail fully traversing physis were not significant predictors. The nail completely crossed the physis in 5 patients and no growth arrests were found. CONCLUSIONS This is the first study, to our knowledge, to evaluate treating femoral shaft fractures with a retrograde nail across an open distal femoral physis. In the pediatric population, the use of a retrograde femoral intramedullary nails does not seem to cause growth arrest of the injured femur during the postoperative period and may be a reasonable treatment option when other surgical options are not available. Additional study is necessary to further evaluate the safety profile. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

There is significant interest in developing laser wavelengths between 700 and 800 nm that may then be frequency doubled to the UV for applications in spectroscopy and atomic physics. We present our most recent results on both a 739 nm AlGaAs/AlGaInP VECSEL, where we demonstrate 150 mW of CW power suitable for frequency doubling to the Yb+ cooling transition at 369.5 nm, and a 780nm AlGaAs/AlGaInP VECSEL which was utilised in a novel demonstration of second harmonic generation in a Zinc-indiffused MgO:PPLN waveguide. In the latter we have generated 1 mW of power at 390 nm.

AIM Photonics has had an active multi-project wafer (MPW) program since 2015 and in our latest work we will present our new integration aimed at the reduction of waveguide propagation losses. Often low losses are prioritized for passive MPWs runs but for key application spaces such as Telecommunications and Quantum Technology, it is imperative to incorporate both low-loss waveguides and active devices on a single die. Within this work we have demonstrated a loss of 1.0 dB/cm in Si strip waveguides and 0.48 dB/cm in SiN waveguides, a reduction of 0.4-3.5 dB/cm and 1-1.5 dB/cm, respectively, when compared to other MPW foundries.

“Cold atoms” can be used as ultra-sensitive sensors for measuring accelerations and are capable of mapping changes in the strength of gravity across the surface of the Earth. They could offer significant benefits to existing space based gravity sensing capabilities. Gravity sensors in space are already used for many Earth observation applications including monitoring polar ice mass, ocean currents and sea level. Cold atom sensors could enable higher resolution measurements which would allow monitoring of smaller water sources and discovery of new underground natural resources which are currently undetectable. The adoption of cold atom technology is constrained by low technology readiness level (TRL). Teledyne e2v and its partners are addressing this maturity gap through project Cold Atom Space PAyload (CASPA) which is an Innovate UK and Engineering and Physical Sciences Research Council (EPSRC) funded project, involving the University of Birmingham as science lead, XCAM, Clyde Space, Covesion, Gooch & Housego, and the University of Southampton. Through the CASPA project the consortium have built and vibration tested a 6U (approximate dimensions: 100 × 200 × 300 mm) cube Satellite (CubeSat) that is capable of laser cooling atoms down to 100’s of micro kelvin, as a pre-cursor to gravity sensors for future Earth observation missions.

With an ever-increasing interest in secure and reliable free-space optical communication, upconversion detectors enabled through nonlinear optical processes are an attractive route to transmitting data as a mid-infrared signal. This spectral region is known to have a higher transmissivity through the atmosphere. In this work, we present an upconversion scheme for detection in the silicon absorption band using magnesium-oxide doped periodically poled lithium niobate to generate 21 mW of a 3.4 µm signal from commercial laser sources using a difference frequency generation process. Following a further nonlinear frequency conversion, via sum-frequency generation, the resulting signal at 809 nm is detected. We achieve >50 µW of signal and bit error rates of 10−7 from a single-pass nonlinear conversion for both the transmitter and receiver systems without the need for additional optical amplifiers at the receiving end. The error rates due to potentially reduced laser powers at the receiver end are investigated and laser noise transfer through our system is discussed.

Case isolation and contact tracing can contribute to the control of COVID-19 outbreaks1,2. However, it remains unclear how real-world social networks could influence the effectiveness and efficiency of such approaches. To address this issue, we simulated control strategies for SARS-CoV-2 transmission in a real-world social network generated from high-resolution GPS data that were gathered in the course of a citizen-science experiment3,4. We found that tracing the contacts of contacts reduced the size of simulated outbreaks more than tracing of only contacts, but this strategy also resulted in almost half of the local population being quarantined at a single point in time. Testing and releasing non-infectious individuals from quarantine led to increases in outbreak size, suggesting that contact tracing and quarantine might be most effective as a 'local lockdown' strategy when contact rates are high. Finally, we estimated that combining physical distancing with contact tracing could enable epidemic control while reducing the number of quarantined individuals. Our findings suggest that targeted tracing and quarantine strategies would be most efficient when combined with other control measures such as physical distancing.

Purpose:. The Surgical Implant Generation Network (SIGN) intramedullary nail was designed for use in resource limited settings which often lack fluoroscopy, specialized fracture tables, and power reaming. A newer design iteration, the SIGN Fin nail, was developed to further simplify retrograde femoral nailing by making proximal interlocking screw placement unnecessary. Instead, the leading end of the Fin nail achieves stability through an interference fit within the proximal femoral canal. While the performance of the traditional SIGN nail has been reported previously, no large series has examined long-term clinical and radiographic outcomes of femoral shaft fractures treated with the SIGN Fin nail. Methods:. The SIGN online surgical database was used to identify all adult femoral shaft fractures treated with the SIGN Fin nail since its introduction. All patients with minimum 6 month clinical and radiographic follow-up were included in the analysis. Available demographic, injury, and surgical characteristics were recorded. Fracture alignment was evaluated on final follow-up radiographs using a previously validated on-screen protractor tool. Coronal and sagittal plane alignment measurements were recorded as deviation from anatomic alignment (DFAA), with units in degrees. Fracture healing was assessed on final follow-up radiographs, with union defined as any bridging callus and/or cortical remodeling across one cortex on orthogonal views. Clinical outcomes available in the database included knee range of motion (ROM) greater than 90° and weight-bearing status at final follow-up. Clinical and radiographic outcomes were then compared between patients with united and nonunited fractures. Results:. The database query identified 249 femoral shaft fractures stabilized with the Fin nail in 242 patients who had minimum 6 month clinical and radiographic follow-up. Final follow-up radiographs were performed at an average of 48 weeks postoperatively. Average coronal and sagittal plane alignment measured on final follow-up radiographs were 2.18° and 2.58°, respectively. The rate of malalignment (DFAA > 10° in either plane) at final follow-up was 6%. Two hundred twenty-nine fractures (92%) were united at final follow-up. Overall, 209 (84%) of patients achieved full weight bearing and 214 (86%) achieved knee ROM >90° at final follow-up. Compared to patients with united fractures, those with nonunion were less likely to achieve full weight bearing (20% vs 90%, P 90° (30% vs 91%, P

We present the design and characterization of a zinc-indiffused periodically poled lithium-niobate ridge waveguide for second-harmonic generation of ∼ 390 n m light from 780 nm. We use a newly developed, broadband near-infrared vertical external-cavity surface-emitting laser (VECSEL) to investigate the potential for lower-footprint nonlinear optical pump sources as an alternative to larger commercial laser systems. We demonstrate a VECSEL with an output power of 500 mW, containing an intracavity birefringent filter for spectral narrowing and wavelength selection. In this first demonstration of using a VECSEL to pump a nonlinear waveguide, we present the ability to generate 1 mW of ∼ 390 n m light with further potential for increased efficiency and size reduction.

Case isolation and contact tracing can contribute to the control of COVID-19 outbreaks1,2. However, it remains unclear how real-world networks could influence the effectiveness and efficiency of such approaches. To address this issue, we simulated control strategies for SARS-CoV-2 in a real-world social network generated from high resolution GPS data3,4. We found that tracing contacts-of-contacts reduced the size of simulated outbreaks more than tracing of only contacts, but resulted in almost half of the local population being quarantined at a single point in time. Testing and releasing non-infectious individuals led to increases in outbreak size, suggesting that contact tracing and quarantine may be most effective when it acts as a ‘local lockdown’ when contact rates are high. Finally, we estimated that combining physical distancing with contact tracing could enable epidemic control while reducing the number of quarantined individuals. Our approach highlights the importance of network structure and social dynamics in evaluating the potential impact of SARS-CoV-2 control.

The Starbug technology1 developed by AAO-MQ allows fibre positioners to be built with large multiplexing capabilities. The Starbug robots are positionable individually and in parallel, which results in significant configuration time improvements over what can be achieved by single-arm pick and place robots. Their design allows the Starbugs to carry a complex payload, and their movement mechanism and vacuum adhesion to the instrument's glass field plate at the telescope's focal plane means that they can be used to position fibres on a non-planar surface.

We present our current work investigating telecommunication transmission in the mid-infrared region and detection in the silicon absorption band. We achieve 10-7 bit error rates using commercial lasers in single-pass nonlinear conversion stages using MgO:PPLN.

Objectives To report the clinical results after treatment of pediatric femoral shaft fractures with the SIGN Fracture Care International (SIGN) pediatric and standard fin nails. Design Retrospective review of prospectively collected data. Setting Sixteen global SIGN centers from 2003 to 2013. Patients/participants One hundred twelve pediatric patients who sustained a diaphyseal pediatric femoral shaft fracture. Intervention Intramedullary fixation with the standard or pediatric SIGN nail. Main outcome measurements Main outcome measurements include clinical and radiographic healing and postoperative complications. Results The mean age of the pediatric fin patients was 9.4 years (4-15) and 11.2 years (4-18) for the standard fin patients. Painless weight bearing was achieved in 94.7% and 94.5% of the patients at the last follow-up. In total, 23 patients had repeat surgery for the removal of implant. Failure of implant with bending of the nail and/or a valgus or varus deformity (>10 degrees) was noted in 7/57 (12.3%) of the patients treated with the pediatric fin nail, of which 6/7 were >10 years old. Five of these 7 patients were classified as technical errors attributed to inadequate nail diameter, length, or initial malreduction. No complications were noted at any age in the standard fin nail group. Conclusions In resource-poor settings, SIGN pediatric fin and standard fin nails seem to be an effective treatment option for femoral shaft fractures. In patients with larger canals, the surgeon should consider using the standard fin nail for improved stability and to minimize potential complications. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The issue of whether commercial publishers overcharge libraries for scholarly journal subscriptions has been an important practical concern for researchers and practicing librarians for decades. Recent studies of the issue have not been able to move the research literature toward a consensus but rather have created more controversy. This study addresses this debate in the fields of science, technology, and medicine. More important, an appropriate research methodology is used, including an effective econometric model, a large sample size, and regression analyses by subject area. The study conclusively shows that commercial publishers indeed overcharge libraries by a large margin. Researchers and librarians are urged to move beyond the debate and to focus their research efforts on more open and innovative ways of improving scholarly communication.

We have demonstrated the first MgO:PPLN ridge waveguides based on ZnO indiffusion and dicing. The fabrication process utilizes ductile regime dicing of a planar waveguide layer producing second harmonic generation (SHG) devices with a near-symmetric sinc2 spectral profile, indicating highly uniform 40 mm long devices. A near circular pump mode is also obtained enabling efficient coupling to single mode telecommunication fibers. A conversion efficiency of 145%/W, for 1560-780 nm SHG, has been measured.

Digital, Introduction. Switching from polluting (e.g. wood, crop waste, coal) to clean (e.g. gas, electricity) cooking fuels can reduce household air pollution exposures and climate-forcing emissions. While studies have evaluated specific interventions and assessed fuel-switching in repeated cross-sectional surveys, the role of different multilevel factors in household fuel switching, outside of interventions and across diverse community settings, is not well understood. Methods. We examined longitudinal survey data from 24 172 households in 177 rural communities across nine countries within the Prospective Urban and Rural Epidemiology study. We assessed household-level primary cooking fuel switching during a median of 10 years of follow up (∼2005–2015). We used hierarchical logistic regression models to examine the relative importance of household, community, sub-national and national-level factors contributing to primary fuel switching. Results. One-half of study households (12 369) reported changing their primary cooking fuels between baseline and follow up surveys. Of these, 61% (7582) switched from polluting (wood, dung, agricultural waste, charcoal, coal, kerosene) to clean (gas, electricity) fuels, 26% (3109) switched between different polluting fuels, 10% (1164) switched from clean to polluting fuels and 3% (522) switched between different clean fuels. Among the 17 830 households using polluting cooking fuels at baseline, household-level factors (e.g. larger household size, higher wealth, higher education level) were most strongly associated with switching from polluting to clean fuels in India; in all other countries, community-level factors (e.g. larger population density in 2010, larger increase in population density between 2005 and 2015) were the strongest predictors of polluting-to-clean fuel switching. Conclusions. The importance of community and sub-national factors relative to household characteristics in determining polluting-to-clean fuel switching varied dramatically across the nine countries examined. This highlights the potential importance of national and other contextual factors in shaping large-scale clean cooking transitions among rural communities in low- and middle-income countries., Ciencias Médicas y de la Salud

Tailored laser sources for UV/blue wavelengths are in ever-increasing demand due to the advancing fields of quantum ion-trapping, metrology and computation. In particular, compact sources are required for the field deployment of quantum technologies. In recent work, we demonstrated the ability to fabricate ridge waveguides in Periodically Poled Lithium Niobate (PPLN) for Rb atom trapping based on 1560 nm Second Harmonic Generation (SHG) and mode matched to standard telecommunications optical fibre [1]. Here, we present our advancement of this work toward UV generation at 369 nm for Yb+ Doppler cooling, with an emphasis on manufacturing scalability.Our first example is a zinc-indiffused PPLN ridge waveguide for conversion of ~780 nm to 390 nm light. Electric field poling was used to achieve periodic gratings in 5% MgO-doped lithium niobate with a width of 200 μm and a phase-matching period of 2.2 μm through the entire 500 μm thickness of the crystal. Metallic zinc was deposited and indiffused to create a planar waveguide in the MgO:PPLN crystal, followed by ridge and facet definition via ultra-precision ductile dicing.Fig. 1. (a) SHG spectra generated from a 5.6 μm wide PPLN ridge waveguide with an overlaid model of a theoretical sinc2 with the corresponding Fabry-Perot interference fringes. (b) Pump mode profile, demonstrating single-mode operation. (c) Photograph of the device and the input/output coupling optics for characterisation. (d) Colour photograph of prism separated fundamental and second harmonic output.Fig. 1(a) shows a SHG spectra from a 5.6 μm wide diced ridge waveguide. Detailed spectra in low power operation is taken using lock-in amplification. As the sample is non-AR coated, the associated Fabry-Perot interference fringes for a 14 mm cavity can modelled to explain the SHG spectrum, also shown in Fig. 1(a).Fig. 1(b), the corresponding pump 2nd moment MFD is calculated as 4.7 x 6.1 μm in the x and y axes, respectively.Fig. 1(c) shows the device and the characterisation optics for simple input coupling using a 15 mm focal length aspheric lens from a collimated, fibre coupled source; the 390nm signal can be seen in Fig. 1(d). A conversion efficiency of ~10 %/W/cm2 has been attained with a 14 mm-long waveguide. This device offers a higher efficiency than typical UV-transmissive, nonlinear crystals in low-power operation, such as LBO, which typically require cavity enhancement for application [2]. This approach provides a simpler fabrication process to other ridge-style PPLN waveguides achieved through thinning, resin bonding and dicing to 1.5 μm depth ridge waveguides [3].We will present the optimisation of parameters for both periodic poling and waveguide fabrication. Current results on device efficiency, spectra and advancements to longer devices will also be presented. The effects of ridge width variation to understand distortion from the expected sinc2 SHG spectra will also be discussed to further understand the fabrication limitations in these indiffused, ridge waveguides.References:1. L. G. , S. A. Berry, R. H. Bannerman, A. C. Gray, J. W. Field, C. Holmes, J. C. Gates, P. G. R. Smith and C. B. E. Gawith, “Developing PPLN Waveguides for Quantum Rubidium Atom Traps in Space” Nonlinear Photonics Optical Society of America, (pp. NpTh1C-6). (2018).2. M. Pizzocaro, D. Calonico, P. C. Pastor, J. Catani, G. A. Costanzo, F. Levi, and L. Lorini. "Efficient frequency doubling at 399nm" Applied optics, 53, 3388-3392 (2014).3. K. Mizuuchi, T. Sugita, K. Yamamoto, T. Kawaguchi, T. Yoshino, and M. Imaeda "Efficient 340-nm light generation by a ridge-type waveguide in a first-order periodically poled MgO:LiNbO3" Optics letters 28, 1344-1346 (2003).

Injuries involving the hip and femur, like many others, have two peaks of incidence. One is in the elderly involving fragility fractures and two are high-energy injuries involving more active members of society.

We report on the fabrication and characterization of Er:YGG films suitable for waveguide amplifiers that could in principle be used in integrated path differential absorption lidar systems. Presented is our fabrication technique, comprising pulsed-laser-deposition growth of ~10 μm-thick crystalline films, their channeling via ultraprecision ductile dicing with a diamond-blade, producing optical quality facets and sidewalls, and amplifier performance. Net gain at 1572 nm and 1651 nm is obtained for the first time in Er-doped YGG waveguide amplifiers. Additionally, in a channel waveguide a maximum internal gain of 3.5 dB/cm at the 1533 nm peak was realized. Recent crystal film quality improvements promise further performance enhancements needed for the intended application for high-peak power sources in the 1.6-μm spectral region targeting Earth observation systems for monitoring greenhouse gases.

Human culture is uniquely complex compared to other species. This complexity stems from the accumulation of culture over time through high- and low-fidelity transmission and innovation. One possible reason for why humans retain and create culture, is our ability to modulate teaching strategies in order to foster learning and innovation. We argue that teaching is more diverse, flexible, and complex in humans than in other species. This particular characteristic of human teaching rather than teaching itself is one of the reasons for human's incredible capacity for cumulative culture. That is, humans unlike other species can signal to learners whether the information they are teaching can or cannot be modified. As a result teaching in humans can be used to support high or low fidelity transmission, innovation, and ultimately, cumulative culture.

Integration of paper fluidics with Ge-on-Si waveguides for evanescent-field sensing of liquid analytes is demonstrated. Mid-infrared absorption spectroscopy of BSA protein in water and of toluene is shown in the fingerprint region of 1900-1000 cm−1.

BackgroundMajor depressive disorder (MDD) has a high personal and socio-economic burden and more than 60% of patients fail to achieve remission with the first antidepressant. The biological mechanisms behind antidepressant response are only partially known but genetic factors play a relevant role. A combined predictor across genetic variants may be useful to investigate this complex trait.MethodsPolygenic risk scores (PRS) were used to estimate multi-allelic contribution to: 1) antidepressant efficacy; 2) its overlap with MDD and schizophrenia. We constructed PRS and tested whether these predicted symptom improvement or remission from the GENDEP study (n=736) to the STAR*D study (n=1409) and vice-versa, including the whole sample or only patients treated with escitalopram or citalopram. Using summary statistics from Psychiatric Genomics Consortium for MDD and schizophrenia, we tested whether PRS from these disorders predicted symptom improvement in GENDEP, STAR*D, and five further studies (n=3756).ResultsNo significant prediction of antidepressant efficacy was obtained from PRS in GENDEP/STAR*D but this analysis might have been underpowered. There was no evidence of overlap in the genetics of antidepressant response with either MDD or schizophrenia, either in individual studies or a meta-analysis. Stratifying by antidepressant did not alter the results.DiscussionWe identified no significant predictive effect using PRS between pharmacogenetic studies. The genetic liability to MDD or schizophrenia did not predict response to antidepressants, suggesting differences between the genetic component of depression and treatment response. Larger or more homogeneous studies will be necessary to obtain a polygenic predictor of antidepressant response.

Periodically poled lithium niobate (PPLN) waveguides are a proven and popular means for efficient wavelength conversion. However, conventional PPLN waveguides typically have small mode field diameters (MFD) (≲6 µm) or significant insertion and/or propagation losses, limiting their ability to operate at multi-watt power levels. In this work we utilise zinc indiffused PPLN ridge waveguides that have a larger MFD, favourable pump/SHG modal overlap, and low insertion losses. Here for the first time, we have demonstrated continuous wave (CW) spectral narrowing from a PPLN waveguide, both with high efficiency and multi-watt second harmonic generation (SHG). 2.5 W of 780 nm has been produced by SHG of an amplified 1560 nm telecom laser with a device efficiency of 58% in a 4.0-cm long ridge waveguide. We have modelled conversion efficiency and applied experimentally measured waveguide parameters to show excellent agreement to the SHG spectra. Spectral narrowing of the full width half maximum (FWHM) of 35.7% has been measured as the nonlinear drive is increased. This work demonstrates that single-pass, multi-watt, CW SHG at 780 nm is feasible from our PPLN waveguide in the large conversion regime.

OBJECTIVES This study is a systematic review and meta-analysis of the clinical outcomes and pooled complication rate of femoral, tibial, and humeral fracture fixation using SIGN nails. We aimed at comparing the pooled rate of adverse events based on the country of study origin, acute versus delayed fracture fixation, and length of follow-up. METHODS We searched PubMed/MEDLINE/Cochrane databases from 2000 to 2016 for English language studies. There was substantial heterogeneity among included studies. Therefore, we used subgroup analysis of varying adverse events and removal of potential outlier studies based on the "remove one" sensitivity analysis to address the heterogeneity across studies. A funnel plot was drawn and inspected visually to assess publication bias. We reported pooled complication rates for each adverse event with 95% prediction interval. RESULTS There were 14 studies with 47,169 cases across 58 different low- and middle-income countries. The average age was 33 ± 14 years, with 83% men and 17% women. Sixty percent of SIGN nails used in these 14 studies were used in femur fracture fixation, 38% in tibial shaft fractures, and the remaining 2% for humeral shaft fractures. Approximately 23% of patients had follow-up data recorded. All studies that measured clinical outcome indicated that >90% achieved full weight-bearing status, favorable range of motion (knee range of motion >90 degrees according to the SIGN database), and radiographic or clinical union depending on the specific variable(s) measured in each study. The overall complication rate was 5.2% (4.4%-6.4%). Malalignment (>5 degrees of angulation in any plane) was the most common complication (7.6%), followed by delayed/nonunion (6.9%), infection (5.9%), and hardware failure, (3.2%). CONCLUSIONS Overall, the use of SIGN nails in fixing femoral, tibial, and humeral shaft fractures demonstrates good results with a high rate of return to full weight-bearing and radiographic/clinical union. The most common complications when using the SIGN nail are malalignment, delayed/nonunion, infection, and hardware failure. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

We present a metallic zinc indiffused diced ridge waveguide in magnesium doped periodically poled lithium niobate (MgO:PPLN) capable of generating over 1 W of 780 nm with 70% efficiency. Our 40 mm long waveguide has near circular fundamental mode output with diameter 10.4 um and insertion loss of -1.17 dB. Using a commercial 2 W EDFA-based system, the SHG output power did not exhibit roll-off at maximum available pump power., 9 pages

Retrograde femoral nailing in skeletal immature patients would broaden the surgical options for fracture care and reconstructive procedures but involves violation of the open, active distal femoral physis with the potential for growth disturbance. The tolerance for putting a large diameter metal implant across the physis is largely unknown. The purpose of this pilot investigation was to define the upper limit of cross-sectional violation with a metal implant before causing premature growth arrest or inhibition using a sheep model.Eighteen sheep underwent placement of a retrograde, intramedullary implant at 3-months of age through an open distal femoral physis. The cross-sectional area of the physis was measured preoperatively and implants were selected that violated 3% to 8% of the cross-sectional area of the physis. Growth across the distal femoral physis was examined radiographically following surgery. Following euthanasia, both operative and no operative femurs were removed to compare differences in maximal lengths.The distal femora grew an average of 10.6±2.2 mm radio graphically after implantation. When compared with control specimens, only operative specimens with 8% of physeal violation demonstrated significant growth discrepancy with operative femurs measuring2.1 mm in length compared with the contralateral control femur. Histologic analysis did not demonstrate any significant physeal bars formation.Distal femoral growth continues across the physis when 3% to 7% of the cross-sectional area of the physis is violated using a retrograde intramedullary implant. Specimens with 8% of growth violation demonstrated significant growth inhibition. As such, retrograde nailing through the distal femoral physis appears safe up to 7%. On the basis of previous anatomic data in humans and average nail sizes, violations of6% of the physis with pediatric retrograde nailing would be uncommon. These findings suggest that retrograde nailing may be a viable option and merits further study.Level IV-case series.

Integrated Optical Fiber is a new optical platform that planarizes optical fiber through Flame Hydrolysis Deposition. It demonstrates robustness when exposed to harsh environments; features low propagation loss; and planar integration advantages. In this work we summarize the latest developments made and the future trajectory for the technology in quantum technology and harsh environment sensing.

We report a ductile dicing process capable of producing optical quality facets in lithium niobate waveguides with an average surface roughness of 0.29 nm. This result represents a nine fold reduction in surface roughness when compared to previous results.

We demonstrate single mode zinc-indiffused MgO:PPLN ridge waveguides with insertion losses of

A continuously-tunable fractional Hilbert transformer based on a high-birefringence planar silica waveguide is demonstrated. The fractional transform order is precisely controlled, with TE/TM phase-matching via a precision dicing technique.

A thermally tunable Bragg grating device has been fabricated in a silica-on-silicon integrated optical chip, incorporating a suspended microbeam improving power efficiency. A waveguide and Bragg grating are defined through the middle of the microbeam via direct ultraviolet writing. A tuning range of 0.4 nm (50 GHz) is demonstrated at the telecommunication wavelength of 1550 nm. Power consumption during wavelength tuning is measured at 45 pm/mW, which is a factor of 90 better than reported values for similar bulk thermally tuned silica-on-silicon planar devices. The response time to a step change in heating is longer by a similar factor, as expected for a highly power-efficient device. The fabrication procedure involves a deep micromilling process, as well as wet etching and metal deposition. With this response, the device would be suitable for trimming applications and wherever low modulation frequencies are acceptable. A four-point-probe-based temperature measurement was also done to ascertain the temperature reached during tuning and found an average volume temperature of $48\ ^{\circ}\hbox{C} $ , corresponding to 0.4 nm of tuning. The role of stress-induced buckling in device fabrication is included.

The Colorado River below Glen Canyon Dam, Arizona, is part of an adaptive management programme which optimizes dam operations to improve various resources in the downstream ecosystem within Grand Canyon. Understanding how populations of federally endangered humpback chub Gila cypha respond to these dam operations is a high priority. Here, we test hypotheses concerning temporal variation in juvenile humpback chub apparent survival rates and abundance by comparing estimates between hydropeaking and steady discharge regimes over a 3-year period (July 2009–July 2012). The most supported model ignored flow type (steady vs hydropeaking) and estimated a declining trend in daily apparent survival rate across years (99.90%, 99.79% and 99.67% for 2009, 2010 and 2011, respectively). Corresponding abundance of juvenile humpback chub increased temporally; open population model estimates ranged from 615 to 2802 individuals/km, and closed model estimates ranged from 94 to 1515 individuals/km. These changes in apparent survival and abundance may reflect broader trends, or simply represent inter-annual variation. Important findings include (i) juvenile humpback chub are currently surviving and recruiting in the mainstem Colorado River with increasing abundance; (ii) apparent survival does not benefit from steady fall discharges from Glen Canyon Dam; and (iii) direct assessment of demographic parameters for juvenile endangered fish are possible and can rapidly inform management actions in regulated rivers. Copyright © 2015 John Wiley & Sons, Ltd.

OBJECTIVES The purpose of this study was to evaluate the effectiveness of SIGN Pediatric and Fin nails in treating pediatric diaphyseal femur fractures. DESIGN Prospective case series. SETTING Level I trauma center from 2010 to 2013. PATIENT/PARTICIPANTS Eighteen patients (13 male and 5 female) with pediatric diaphyseal femur fractures who did not achieve skeletal maturity. INTERVENTION Femoral nailing was done using either SIGN Pediatric or Fin nail with hand-reaming without using bone-grafting or image intensifier. MAIN OUTCOME MEASUREMENTS Patients were evaluated for infection, radiographic parameters, range of movements, time to weight-bearing (partial and complete), revision surgery (if needed), and complications. RESULTS The average age of patients was 10.2 (±2.1) (range: 6-13) years and average time between injury and surgery was 13 (1-112) days. Fin nail was used in 13 patients, and Pediatric nail in 5 patients. There were no infections in either group. The average time for full weight-bearing was 7.07 weeks in the Fin nail group, and 8.4 weeks in the Pediatric nail group. No repeat surgeries were performed, and there was no case of avascular necrosis of femur head, limb length discrepancy, or any other complication. CONCLUSIONS SIGN Pediatric and Fin nails are an effective treatment modality for pediatric diaphyseal femur fractures with excellent fracture healing with no major complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A single-step ductile dicing process capable of manufacturing optical quality facets in lithium niobate (LiNbO3) ridge waveguides with an average surface roughness of 0.29 nm is reported. This result is comparable with surface roughnesses achieved by lapping and polishing and represents an order of magnitude improvement over the prior state of the art in LiNbO3 waveguide facet dicing.

Every country struggles with how best to meet the demand for health care services with the available resources. This commentary offers a perspective on the Israeli physician workforce and the analyses of Horowitz et al., which found age and gender differences in physician productivity and career longevity, differences across specialties, and a sizeable fraction of licensed Israeli physicians living abroad. Workforce planning can be subject to data collection and statistical uncertainties, but even more important are the assumptions and forecasts related to demand for services and organizational arrangements for care delivery. Readers should be cautious in analyzing productivity just by counting hours or years worked, and comparisons across countries may not account for differences in the nature of physician work. The question of whether Israel has enough physicians for the future has to go “beyond the count” to looking at the roles of other health professionals, the use of new technologies and new team configurations, and the overall efficiency and effectiveness of health care delivery systems such as hospitals, ambulatory care clinics, and community-based care.

Comparative effectiveness research (CER) in genomic medicine (GM) measures the clinical utility of using genomic information to guide clinical care in comparison to appropriate alternatives. We summarized findings of high-quality systematic reviews that compared the analytic and clinical validity and clinical utility of GM tests. We focused on clinical utility findings to summarize CER-derived evidence about GM and identify evidence gaps and future research needs. We abstracted key elements of study design, GM interventions, results, and study quality ratings from 21 systematic reviews published in 2010 through 2015. More than half (N = 13) of the reviews were of cancer-related tests. All reviews identified potentially important clinical applications of the GM interventions, but most had significant methodological weaknesses that largely precluded any conclusions about clinical utility. Twelve reviews discussed the importance of patient-centered outcomes, although few described evidence about the impact of genomic medicine on these outcomes. In summary, we found a very limited body of evidence about the effect of using genomic tests on health outcomes and many evidence gaps for CER to address.Genet Med advance online publication 13 April 2017.

The aim of the current study was to compare bone loading due to physical activity between lean, and overweight and obese individuals. Fifteen participants (lower BMI group: BMI 2, n = 7; higher BMI group: 25 kg/m2 2, n = 8) wore a tri-axial accelerometer on 1 day to collect data for the calculation of bone loading. The International Physical Activity Questionnaire (short form) was used to measure time spent at different physical activity levels. Daily step counts were measured using a pedometer. Differences between groups were compared using independentt-tests. Accelerometer data revealed greater loading dose at the hip in lower BMI participants at a frequency band of 0.1–2 Hz (P = .039, Cohen’sd = 1.27) and 2–4 Hz (P = .044,d = 1.24). Lower BMI participants also had a significantly greater step count (P = .023,d = 1.55). This corroborated with loading intensity (d ≥ 0.93) and questionnaire (d = 0.79) effect sizes to indicate higher BMI participants tended to spend more time in very light activity, and less time in light and moderate activity. Overall, participants with a lower BMI exhibited greater bone loading due to physical activity; participants with a higher BMI may benefit from more light and moderate level activity to maintain bone health.

Objectives To document the current state of pelvic and acetabular surgery in the developing world and to identify critical areas for improvement in the treatment of these complex injuries. Design A 50-question online survey. Setting International, multicenter. Patients/participants One hundred eighty-one orthopaedic surgeons at Surgical Implant Generation Network (SIGN) hospitals, which represent a cross-section of institutions in low- and middle-income countries that treat high-energy musculoskeletal trauma. Interventions Administration and analysis of 50-question survey. Main outcome measures Surgeon training and experience; hospital resources; volume and patterns of pelvic/acetabular fracture management; postoperative protocols and resources for rehabilitation; financial responsibilities for patients with pelvic/acetabular fractures. Results Complete surveys were returned by 75 institutions, representing 61.8% of the global SIGN nail volume. Although 96% of respondents were trained in orthopaedic surgery, 53.3% have no formal training in pelvic or acetabular surgery. Emergency access to the operating room is available at all responding sites, but computed tomography scanners are available at only 60% of sites, and a mere 21% of sites have access to angiography for pelvic embolization. Cannulated screws (53.3%) and pelvic reconstruction plates (56%) are available at just over half of the sites, and 68% of sites do not have pelvic reduction clamps and retractors. 21.3% of sites do not have access to intraoperative fluoroscopy. Responding hospitals see an average of 38.8 pelvic ring injuries annually, with 24% of sites treating them all nonoperatively. Sites treated an average of 22.5 acetabular fractures annually, with 34.7% of institutions treating them all nonoperatively. Patients travel up to 1000 km or 20 hours for pelvic/acetabular treatment at some sites. Although 78.7% of sites have inpatient physical or occupational therapy services, only 17% report access to home physical therapy, and only 9% report availability of nursing or rehabilitation facilities postdischarge. At over 80% of hospitals, patients and their families are at least partially responsible for payment of surgical, implant, hospital, and outpatient fees. Government aid is available for inpatient fees at over 40% of sites, but outpatient services are subsidized at only 28% of sites. Conclusions We report the current state of pelvic and acetabular surgery in low- and middle-income countries. Our results identify significant needs in surgeon training, hospital resources, availability of instruments and implants, and access to appropriate postoperative rehabilitation services for pelvic and acetabular surgery in the developing world. Targeted programs designed to overcome these barriers are required to advance the care of pelvic and acetabular fractures in the developing world.

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.