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To determine the oncologic impact of prospectively assigned tertiary pattern 4 in contemporary Gleason score (GS) 3 + 3 = 6 radical prostatectomy (RP) specimens.Oncologic outcomes were retrospectively reviewed for 720 consecutive patients from a single National Comprehensive Cancer Network (NCCN) center with at least 6 months follow-up after RP for GS3 + 3 = 6 (GS6, N = 222), GS6 with tertiary pattern 4 (GS6t4, N = 62), or GS3 + 4 = 7 (N = 436) prostate cancer, as prospectively graded since 2006 using the 2005 International Society of Urologic Pathologists criteria. Preoperative NCCN risk category, RP pathology, progression-free survival (PFS) and metastasis-free survival (MFS) were compared among the GS6, GS6t4, and GS3 + 4 = 7 groups using χ(2) , Kaplan-Meier, and log-rank analyses.The incidence of low NCCN preoperative risk classification for GS6t4 patients (63%) was less than that for GS6 patients (77%) while greater than that for GS3 + 4 = 7 patients (30%, P 0.001). GS6t4 patients had RP pathologic features which were intermediate in risk between that of GS6 and GS3 + 4 = 7 based on extraprostatic extension (27% vs. 6% vs. 31%, respectively, P 0.001) and mean percentage of prostate gland involvement (13% vs. 10% vs. 16%, respectively, P 0.001). With a mean overall follow-up of 42 months, PFS for GS6t4 patients (5-year 85%) was intermediate between that of GS6 (5-year 93%) and GS3 + 4 = 7 (5-year 76%) patients (P 0.001). The 5-year MFS rate was 100% for GS6 and GS6t4 patients compared to 97% for GS3 + 4 = 7 patients (P = 0.07).This study provides the longest follow-up to date for RP patients with prospectively assigned GS6t4 and supports a risk for adverse RP pathology and postoperative disease progression that is intermediate between GS6 and GS3 + 4 = 7. Whether a tertiary pattern 4 in GS6 disease increases the risk of metastasis is uncertain and requires longer term study. Given favorable oncologic outcomes, less stringent postoperative surveillance for both GS6 and GS6t4 patients may be warranted.

Background Seatbelts significantly reduce the risk of death in motor vehicle accidents, but a certain number of individuals from some subgroups tend not to wear their seatbelts. Objectives In this study, we hypothesized that obese drivers (in fatal crashes) were less likely to wear seatbelts than their normal-weight counterparts. Methods A retrospective study was conducted on the drivers in motor vehicle crashes entered into the Fatality Analysis Reporting System database between 2003 and 2009. A number of precrash variables were found to be significantly associated with seatbelt use. These were entered into a multivariate logistic regression model using stepwise selection. Drivers were grouped into weight categories based on the World Health Organization definitions of obesity by body mass index. Seatbelt use was then examined by body mass index, adjusted for precrash variables that were significantly associated with seatbelt use. Results The odds of seatbelt use for normal-weight individuals were found to be 67% higher than the odds of seatbelt use in the morbidly obese. The relationship of seatbelt use between the different weight groups and the morbidly obese is as follows (odds ratios [ORs] for each comparison are listed with 95% confidence limits [CL]): underweight vs morbidly obese (OR, 1.62; CL, 1.47-1.79), normal weight vs morbidly obese (OR, 1.67; CL, 1.54-1.81), overweight vs morbidly obese (OR, 1.60; CL, 1.48-1.74), slightly obese vs morbidly obese (OR, 1.40; CL, 1.29-1.52), and moderately obese vs morbidly obese (OR, 1.24; CL, 1.13-1.36). Conclusion Seatbelt use is significantly less likely in obese individuals compared with their normal-weight counterparts.

A technique is described here to carry out combined aortic and mitral valve replacement (DVR) in a patient with rheumatic valve disease utilising a minimally invasive approach without major modification in the conventional technique. An incision of approximately 5 cm is made on the upper sternum followed by partial sternal split with ‘J’ extension in the right third inter costal space (ICS). The mitral and aortic valves can be replaced with ease and excellent outcome. The technique is reproducible and does not require any special instrumentation. We carried out DVR with this approach in 17 patients.

What happens when your organization practices Agile software development for many years? Well, you get pretty good at Agile and you are able to apply Agile with reducing effort on challenging projects. But there is another interesting outcome which is that your people internalize Agile values, so much so that Agile becomes second-nature to everyone! In this paper we will show you how our culture is infected with Agile thinking, we will show you how we apply Agile to many “non-software” development activities like training- sessions, recruitment, staffing, office reforms, strategic decision making and more.