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Background: The role of cytoreductive local radiotherapy (RT) in metastatic prostate cancer (mPCa) has recently been established. This study aimed to evaluate the biochemical outcome of local RT in mPCa. Methods: This randomised controlled phase III study was conducted at the Clinical Oncology Department, Suez Canal University Hospital. Eligible participants were de-novo or metachronous mPCa patients with Eastern Cooperative Oncology Group performance status of 0-2. Participants were randomised to receive either cytoreductive prostate-directed RT in addition to standard care or standard care alone. The conventional radiation schedule of 70 Gy/35 fractions or the hypofractionated schedule of 55 Gy/20 fractions were delivered. The primary endpoint was biochemical progression-free survival (BPFS), and the secondary endpoint was overall survival (OS). Survival and post-hoc analyses were performed using Cox regression and the Kaplan-Meier method with the log-rank test. Results: Between 23 November 2020 and 21 2022, 70 patients were enrolled in this study. Of them, 34 patients were assigned to the prostate RT group, and 29 patients were assigned to the control group. At a median follow-up of 12 months, the median BPFS has not been reached for the prostate RT group compared to 4.067 months for the control group (HR: 0.147, p < 0.001). Subgroup analysis showed that the median BPFS was statistically significantly correlated with low-volume (95% CI, 0.004 to 0.262, p = 0·001) and hormonal-sensitive metastatic disease (95% CI, 0.010 to 0.192, p < 0·001). The median OS was 16.33 months for the prostate-RT group compared to 11.33 months for the control group (HR: 0.313, p = 0.003). Conclusion: Prostate-directed RT improved BPFS and OS in mPCa patients, particularly in those with low volume and hormonal-sensitive disease. [ABSTRACT FROM AUTHOR]

Two-stage revision with an antibiotic-loaded cement articulating spacer is a standard treatment for chronic prosthetic knee infection (PKI); however, mechanical complications can occur during the spacer period. There is limited evidence on the association between surgeon volume and mechanical complications after resection arthroplasty (RA) using an articulating spacer. This study aimed to compare the rates of mechanical complications and reoperation after RA with articulating spacers by surgeons with high volumes (HV) and low volumes (LV) of RA performed and analyzed the risk factors for mechanical failure. The retrospective study investigated 203 patients treated with PKIs who underwent RA with articulating spacers and were divided according to the number of RAs performed by the surgeons: HV (≥14 RAs/year) or LV (<14 RAs/year). Rates of mechanical complications and reoperations were compared. Risk factors for mechanical complications were analyzed. Of the 203 patients, 105 and 98 were treated by two HV and six LV surgeons, respectively. The mechanical complication rate was lower in HV surgeons (3.8%) than in LV surgeons (36.7%) (p < 0.001). The reoperation rate for mechanical complications was lower in HV surgeons (0.9%) than in LV surgeons (24.5%) (p < 0.001). Additionally, 47.2% of patients required hinge knees after mechanical spacer failure. Medial proximal tibial angle < 87°, recurvatum angle > 5°, and the use of a tibial spacer without a cement stem extension were risk factors for mechanical complications. Based on these findings, we made the following three conclusions: (1) HV surgeons had a lower rate of mechanical complications and reoperation than LV surgeons; (2) mechanical complications increased the level of constraint in final revision knee arthroplasty; and (3) all surgeons should avoid tibial spacer varus malalignment and recurvatum deformity and always use a cement stem extension with a tibial spacer. [ABSTRACT FROM AUTHOR]

Blood doping is prohibited for athletes but has been a well‐described practice within endurance sports throughout the years. With improved direct and indirect detection methods, the practice has allegedly moved towards micro‐dosing, that is, reducing the blood doping regime amplitude. This narrative review evaluates whether blood doping, specifically recombinant human erythropoietin (rhEpo) treatment and blood transfusions are performance‐enhancing, the responsible mechanism as well as detection possibilities with a special emphasis on micro‐dosing. In general, studies evaluating micro‐doses of blood doping are limited. However, in randomized, double‐blinded, placebo‐controlled trials, three studies find that infusing as little as 130 ml red blood cells or injecting 9 IU × kg bw−1 rhEpo three times per week for 4 weeks improve endurance performance ~4%–6%. The responsible mechanism for a performance‐enhancing effect following rhEpo or blood transfusions appear to be increased O2‐carrying capacity, which is accompanied by an increased muscular O2 extraction and likely increased blood flow to the working muscles, enabling the ability to sustain a higher exercise intensity for a given period. Blood doping in micro‐doses challenges indirect detection by the Athlete Biological Passport, albeit it can identify ~20%–60% of the individuals depending on the sample timing. However, novel biomarkers are emerging, and some may provide additive value for detection of micro blood doping such as the immature reticulocytes or the iron regulatory hormones hepcidin and erythroferrone. Future studies should attempt to validate these biomarkers for implementation in real‐world anti‐doping efforts and continue the biomarker discovery. [ABSTRACT FROM AUTHOR]

Small, single-layer microfluidic paper-based analytical devices (µPADs) offer potential for a range of point-of-care applications; however, they have been limited to low flow rates. Here, we investigate the role of laser cutting paper channels in maximizing flow rate in small profile devices with limited fluid volumes. We demonstrate that branching, laser-cut grooves can provide a 59.23–73.98% improvement in flow rate over a single cut, and a 435% increase over paper alone. These design considerations can be applied to more complex microfluidic devices with the aim of increasing the flow rate, and could be used in stand-alone channels for self-pumping. [ABSTRACT FROM AUTHOR]

Background: Ultrasonography-assisted supraclavicular block is an efficacious and practical method and allows us to use a lower volume of local anesthetic in compactly arranged brachial plexus. The study envisioned evaluating the analgesic and anesthetic effects of Inj. dexamethasone (8mg) as an adjuvant to 0.5% levobupivacaine to determine the time for first rescue analgesia and number of rescue analgesics needed in 24 hours duration in brachial plexus blockade in adult patients listed for upper limb surgeries. Results: This prospective randomized double-blind interventional study was carried out in ASAI and II, aged 20 to 55 years. In group A (n=30) Inj. Levobupivacaine 20ml and Inj. Normal saline 2ml was given. In group B (n=30) Inj. Levobupivacaine 20ml and Inj. Dexamethasone 2ml was given. The time for the demand of the first rescue analgesia was 431.50 ± 46.15 minutes in group A and 749.38 ± 62.41 minutes in group B, with a p-value < 0.001. The demand for rescue analgesics was more in Group A in contrast to Group B. Conclusion: We deduce with our study, with the addition of dexamethasone, the time for rescue analgesia is prolonged, and the number of rescue analgesic demands is reduced, with a faster onset and extended duration of both sensory and motor block.

Background: Currently, the use of FE is decreasing and neonatal adverse outcomes following FE are underreported. We aimed to evaluate the rate of neonatal adverse outcomes in current obstetric practice at two university hospitals with a low FE volume. Methods: A multicentre retrospective study. All singleton pregnancies delivered by forceps extraction between 2011 and 2020 were analyzed. The characteristics of the deliveries with a composite neonatal adverse outcome (CNAO) were analyzed and compared with those without. Results: The study cohort included 861 neonates delivered by FE. The CNAO was recorded in 131 (15.2%). Women in the CNAO group gained less weight during pregnancy (mean 13 kg vs. 15 kg, p = .014). Factors found to be associated with CNAO were preterm delivery (gestational age < 37°7) (26 (19.8%) vs. 44 (6.0%), OR [95% CI]: 3.86 (2.28–6.52), p < .001), low birth weight (23 (17.6%) vs. 44 (6.0%), OR [95% CI] 3.32 (1.92–5.71), p < .001), and smaller head circumference (329 vs. 331 mm, OR [95% CI] 0.79 (0.67–0.93), p = .035). In a multivariate analysis, gestational age (adjusted OR [95% CI] 0.672 (0.546–0.826), p < .001) and maternal weight gain during pregnancy (adjusted OR [95% CI]: 0.950 (0.904–0.998), p = .042), were both negatively associated with CNAO. Among term deliveries, the only factor found to be independently associated with CNAO was maternal weight gain during pregnancy (adjusted OR [95% CI]: 0.951 (0.910–0.994), p = .025). Conclusions: In the setting of low volume FE, this mode of delivery is associated with a relatively low rate of neonatal morbidity. Synopsis: Performance of forceps extraction in the setting of low volume practice is associated with a relatively low rate of neonatal morbidity. [ABSTRACT FROM AUTHOR]

• Time to mCRPC and OS differences can be observed for De Novo vs. secondary mHSPC patients. • After stratification according to metastatic disease volume, patients with DNHV mHSPC harbored the worst outcomes, while patients with SecLV mHSPC harbored best prognosis. • These effects can also be observed after progression to mCRPC. In recently published phase III trials, overall survival (OS) differences were demonstrated in patients with secondary vs. De Novo and low vs. high volume metastatic hormone-sensitive prostate cancer (mHSPC). We hypothesized that these factors may also be attributable in real-world setting of new intensified combination therapies and in metastatic castration resistant prostate cancer (mCRPC) patients. We relied on an institutional tertiary-care database to identify mHSPC and subsequent mCRPC patients. The main outcome consisted of time to mCRPC and OS. Patients were stratified according to De Novo vs. secondary and low vs. high volume mHSPC and mCRPC, respectively. Of 504 mHSPC patients, 371 (73.6%) were De Novo vs. 133 (26.4%) secondary mHSPC. Patients with De Novo and high volume mHSPC harbored shorter time to mCRPC and OS than secondary and low volume mHSPC patients (both P < 0.01). After stratification regarding disease volume, median time to mCRPC differed significantly between De Novo high volume (DNHV) vs. De Novo low volume (DNLV) vs. secondary high volume (SecHV) vs. secondary low volume mHSPC patients (SecLV, P < 0.001). Similarly in OS analyses, median OS was 44 vs. 53 vs. 88 vs. 120 months for respectively DNHV vs. SecHV vs. SecLV vs. DNLV mHSPC (P < 0.001). After progression to mCRPC, the effect of onset of metastatic disease and metastatic volume was still observed (all P < 0.01). Patients with DNHV mHSPC harbor worse prognosis in a real world setting and in the light of combination therapies. This effect is also discernible in the context of mCRPC. [ABSTRACT FROM AUTHOR]

Abstract Background The right colon is difficult to cleanse compared with other colon segments. This post hoc analysis of two randomised clinical trials (MORA and NOCT) examined whether 1L polyethylene glycol (PEG) NER1006 and two mid-volume alternatives could improve adequate and high-quality cleansing in the right colon among patients with complete cleansing assessments. Methods Patients received NER1006 (N2D), 2L PEG plus ascorbate (2LPEG) or oral sulphate solution (OSS) as a 2-day evening/morning split-dosing regimen or NER1006 as a same-day morning-only dosing regimen (N1D). Patients had full segmental scoring assigned by treatment-blinded central readers using the Harefield Cleansing Scale. The right colon adequate (score ≥ 2) and high-quality (score ≥ 3) cleansing success of NER1006 (N2D and N1D) versus 2LPEG and OSS was analysed individually and as pooled groups (N2D vs. 2LPEG/OSS). We assessed the comparative right colon cleansing rates of the N2D versus 2LPEG/OSS in overweight males. We also performed a multivariable regression analysis to examine factors affecting cleansing in the right colon. Results A total of 1307 patients were included. Pooled N2D showed significantly improved rates of adequate-level cleansing in the right colon compared with 2LPEG (97.5% [504/517] vs. 94.6% [246/260]; p = 0.020) and OSS (97.5% [504/517] vs. 93.8% [244/260]; p = 0.006). In MORA, the rate of adequate right colon cleansing did not significantly differ between N1D and 2LPEG (95.2% [257/270] vs. 94.6% [246/260]; p = 0.383). The rate of right colon high-quality cleansing was significantly improved with N2D or N1D vs. 2LPEG (p

Marques, DL, Neiva, HP, Marinho, DA, and Marques, MC. Velocity-monitored resistance training in older adults: the effects of low-velocity loss threshold on strength and functional capacity. J Strength Cond Res 36(11): 3200–3208, 2022—This study analyzed the effects of velocity-monitored resistance training (RT) with a velocity loss of 10% on strength and functional capacity in older adults. Forty-two subjects (79.7 ± 7.1 years) were allocated into an RT group (n = 21) or a control group (CG; n = 21). Over 10 weeks, the RT group performed 2 sessions per week, whereas the CG maintained their daily routine. During RT sessions, we monitored each repetition's mean velocity in the leg press and chest press exercises at 40–65% of 1 repetition maximum (1RM). The set ended when a velocity loss of 10% was reached. At pretest and post-test, both groups were assessed in the 1RM leg press and chest press, handgrip strength, medicine ball throw (MBT), walking speed (T10), and 5-repetition sit-to-stand (STS). After 10 weeks, the RT group significantly improved the 1RM leg press (p < 0.001; Hedge's g effect size [ g ] = 0.55), 1RM chest press (p < 0.001; g = 0.72), MBT 1kg (p < 0.01; g = 0.26), T10 (p < 0.05; g = −0.29), and STS (p < 0.05; g = −0.29), whereas the CG significantly increased the T10 (p < 0.05; g = 0.15). Comparisons between groups at post-test demonstrated significant differences in the 1RM leg press (p < 0.001; mean difference [MD] = 14.4 kg), 1RM chest press (p < 0.001; MD = 7.52), MBT 1kg (p < 0.05; MD = 0.40 m), T10 (p < 0.001; MD = −0.60 seconds), and STS (p < 0.001; MD = −1.85 seconds). Our data demonstrate that velocity-monitored RT with velocity loss of 10% results in a few repetitions per set (leg press: 5.1 ± 1.2; chest press: 3.6 ± 0.9) and significantly improves strength and functional capacity in older adults. [ABSTRACT FROM AUTHOR]

Very low-volume bowel preparation (BP) for colonoscopy with 1-liter polyethylene glycol plus ascorbate (1L-PEG-Asc) has displayed high tolerability and quality of bowel cleansing. Concerns have been raised regarding its safety. We aimed to evaluate the incidence of adverse events (AEs) following BP with 1L-PEG-Asc or 2L-PEG-Asc. From January 2019 to September 2020, data from all consecutive adult outpatients who underwent colonoscopy in Our Unit were collected. AEs were assessed by reviewing the clinical and laboratory data of patients who attended the Emergency Department (ED) of Modena District Hospitals in the 7 days following the colonoscopy, and were classified as "BP-related" or "BP-unrelated". During the study, 4069 (68.03%) and 1912 (31.97%) patients underwent colonoscopy after taking 2L-PEG-Asc or 1L-PEG-Asc, respectively. Regarding AEs, 77 (1.29%) patients attended ED, 53 (53/4069, 1.30%) and 24 (24/1912, 1.25%) after taking 2L-PEG-Asc and 1L-PEG-Asc. BP-related AEs were observed in 5 (5/4069, 0.12%) and 4 (4/1912, 0.21%) patients, respectively. The most frequent BP-related AEs were tachyarrhythmias (6/5981, 0.10%). The incidence rate of clinically relevant BP-related AEs is extremely low. This strongly suggests that 1L-PEG-Asc colonoscopy BP is as safe as 2L-PEG-Asc BP in a real-life clinical setting of unselected patients. [ABSTRACT FROM AUTHOR]

In this study, we aimed to analyze (i) the strength and power changes after resistance training (RT) in elite futsal players, and (ii) the associations between the session rate of perceived exertion (sRPE) and perceived total quality recovery (TQR), and the sRPE and TQR with the volume load of the RT program. Ten elite futsal players (24.8 ± 5.4 years; 76.2 ± 7.1 kg; 1.77 ± 0.05 m) performed an in-season 8-week RT program twice per week. RT consisted of 2-3 sets x 3-6 reps at 45-65% of one-repetition maximum (1RM) with maximal velocities in the full squat and complementary exercises with the same volume. We assessed the TQR before every session, while the sRPE was calculated after each RT session. One week before and after the intervention, we measured the countermovement jump (CMJ) height, isometric hip adduction strength (IHAS), 1RM, and peak power (PP) in the full squat progressive loading test. After the 8-week training program, there was a significant improvement in most outcomes, yet the gains (%Δ) remained below the minimal detectable change (MDC), except for IHAS (CMJ: p < 0.05, %Δ = 6.7, MDC% = 7.2; IHAS: p < 0.001, %Δ = 19.1, MDC% = 14.6; 1RM: p > 0.05, %Δ = 9.2, MDC% = 21.5; PP: p < 0.05; %Δ = 14.4, MDC% = 22.4). We also found a significant negative correlation between TQR and the sRPE (r = -0.45, p < 0.001). Our data suggest that RT based on low-volume and low-to-moderate loads may not produce a sufficient stimulus to induce meaningful dynamic strength and power gains in elite futsal players, although it improves isometric strength. Furthermore, monitoring TQR before sessions may show coaches how the elite futsal player will perceive the session's intensity. [ABSTRACT FROM AUTHOR]

Introduction: The relationship between surgeon and hospital case volumes and postoperative risk following total hip and total knee arthroplasty (THA and TKA) has been described independently. This study aimed to assess the risk of periprosthetic joint infection (PJI) following primary TKA and THA to determine if lower volume surgeons operating at higher volume centers would have lower rates of complications compared to lower volume surgeons operating at lower volume hospitals., Methods: A healthcare database was used to retrospectively identify all primary, and elective total joint arthroplasties (TJAs) from October 2015 to December 2021. Using restricted cubic splines, high-volume hospitals were defined using Markov chain Monte Carlo simulation, which identified a volume beyond which PJI rates no longer decreased significantly with increasing hospital volume. A similar methodology was used to identify low-volume surgeons operating in high- and low-volume hospitals. There were 605,254 patients who underwent TJA (total hip arthroplasty [THA]: 37.71%; total knee arthroplasty [TKA]: 62.29%) by low-volume surgeons (< 57 THAs and < 68 TKAs) identified and divided into high-volume and low-volume hospital cohorts. High-volume hospitals were defined as > 508 THA and > 812 TKAs per year, and low-volume hospitals were defined as < 145 THAs and < 243 TKAs per year. Multivariable models accounting for potential confounding covariates were created to determine the odds of PJI between cohorts., Results: After taking confounding variables into account, low-volume surgeons at high-volume hospitals had lower rates of PJI relative to their counterparts at low-volume hospitals (THA 0.67 versus 0.80%, aOR [adjusted odds ratio] = 0.69 [95% confidence interval (CI) = 0.54 to 0.88], P = 0.002; TKA 0.51 versus 0.69%, aOR = 0.73, [95%-CI = 0.61 to 0.87], P = 0.007)., Conclusion: Increasing institutional case volume may mitigate the increased risk of PJI associated with low annual surgeon case volume., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To examine the simultaneous effect of high-volume Foley catheter (HVFC) (60 ml) and vaginal misoprostol on labor induction in nulliparous women. Methods: A randomized, double- blind, controlled trial was conducted among nulliparous post-date (>40 weeks) pregnant women between June and December 2019. At enrollment 100 women were randomized into each group (either HVFC and vaginal misoprostol or low-volume Foley catheter [LVFC] [30 ml] and vaginal misoprostol), for labor induction. Demographic and clinical data were collected at enrollment and delivery. Results: Women in the HVFC group had statistically significantly shorter induction to delivery interval (median 860 min, interquartile range [IQR] 840-940 min vs. 1160 min, IQR 1080-1320 min, P < 0.001) and duration of labor (median 615 min, IQR 600-680 min vs. 750, IQR 692.5-800 min, P < 0.001). Mode of vaginal delivery (n = 94 vs. n = 78, P = 0.002), number of doses of misoprostol required (median 2, IQR 1-2 vs. 2, IQR 1-3), and need of oxytocin augmentation (n = 22 vs. n = 39, P = 0.014 and P < 0.001), was significantly better in the HVFC group. However, there was no significant difference with respect to other maternal or neonatal outcomes. Conclusion: Simultaneous use of HVFC and vaginal misoprostol for labor induction significantly shortens the induction to delivery interval and duration of labor in nulliparous women. Trial Registration: Clinical Trial Registry of India CTRI/2019/05/019394 (http://ctri. nic.in/Clini caltr ials/pmain det2.php?trial id=31554 &EncHi d=&userN ame=Foley %20cat heter). [ABSTRACT FROM AUTHOR]

Purpose: Correct placement of the femoral and tibial tunnels in the anatomic footprint during anterior cruciate ligament reconstruction (ACLR) is paramount for restoring rotatory knee stability. Recent studies have looked at surgeon volume and its outcomes on procedures such as total knee arthroplasty and infection rates, but only few studies have specifically examined tunnel placement after ACLR based on surgeon volume. The purpose of this study was to compare the placement of femoral and tibial tunnels during ACLR between high-volume and low-volume surgeons. It was hypothesized that high-volume surgeons would have more anatomic tunnel placement compared with low-volume surgeons. Methods: A retrospective review of all ACLR performed between 2015 and 2019 at an integrated health care system consisting of both academic and community hospitals with 68 orthopaedic surgeons was conducted. Surgeon volume was categorized as less than 35 ACLR per year (low volume) and 35 or more ACLR per year (high volume). Femoral tunnel placement for each patient was determined using an exact strict lateral radiograph (less than 6 mm of offset between the posterior halves of the medial and lateral condyles) taken after the primary ACLR using the quadrant method. The centre of the femoral tunnel was measured in relation to the posterior–anterior (PA) and proximal–distal (PD) dimensions (normal centre of anatomic footprint: PA 25% and PD 29%). Tibial tunnel placement for each patient was determined on the same lateral radiographs by measuring the mid-sagittal tibial diameter and the centre of the tibial attachment area of the ACL from the anterior tibial margin (normal centre of anatomic footprint: 43%). Each lateral radiograph was reviewed by one of two blinded reviewers. Results: A total of 4500 patients were reviewed, of which 645 patients met all the inclusion/exclusion criteria and were included in the final analysis. There were 228 patients in the low-volume group and 417 patients in the high-volume group. Low-volume surgeons performed a mean of 5 ACLRs per year, whereas surgeons in the high-volume group performed a mean of 40 ACLRs per year. In the PA dimension, the low-volume group had significantly more anterior femoral tunnel placement compared with the high-volume group (32 ± 10% vs 28 ± 9%, p < 0.01). In the PD dimension, the low-volume group had statistically significant more proximal femoral tunnel placement compared to the high-volume group (32 ± 9% vs 35 ± 9%, p < 0.01). For the tibial tunnel, the low-volume group had significantly more posterior tibial tunnel placement compared with the high-volume group (41 ± 10% vs 38 ± 7%, p < 0.01). Conclusion: Low-volume surgeons placed their femoral tunnels significantly more anterior and proximal (high) during ACLR, and placed their tibial tunnels significantly more posterior, compared with high-volume surgeons. Prior research has indicated that anatomic placement of the femoral and tibial tunnels during ACLR leads to improved rotatory knee stability. The findings of this study demonstrate the importance of surgical volume and experience during ACLR. Level of evidence: III. [ABSTRACT FROM AUTHOR]

Summary: DDoS attacks are rapidly growing bigger and upsetting online businesses than ever before. During 2012, DDoS attacks were performed on six US banks, viz, Bank of America, JP Morgan Chase, US Bancorp, Citigroup, and PNC Bank. The attacker(s) bombarded their targets with crest traffic of more than 60 gigabits per second. In 2013, Spamhaus, an antispam organization, was the victim for a DDoS attack of 300 gigabits per second. CyberBunker, a Dutch company, outwardly performed this attack on Spamhaus and got blacklisted after it. During 2014, the security company named Cloudflare was struck by 400 gigabits per second of traffic. Initially, the attack was aimed at one of Cloudflare's customers, but it later spread to the Cloudflare's own network. In 2018, a record‐breaking attack was performed on GitHub, a popular code hosting website, with an impulsive blitz of traffic that marked the scales at 1.35 terabits per second. At this moment, from freelance websites to multinational banks, it sounds like nobody has enough online security. This paper presents a novel low and high–rate DDoS attack detection using statistical metrics. The NS3 simulation result shows that the proposed method detects the low and high volume of attacks in minimum time with reduced false positive and false negative than the existing method. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to identify factors that hinder 24-h patient discharge after laparoscopic Roux-en-Y gastric bypass (LRYGB) in a low-volume practice. Material and Methods: Consecutive patients who fulfilled regional criteria and underwent primary LRYGB from 2018 to 2020 were retrospectively analyzed. Patients were discharged on the morning of the first postoperative day (POD1) after meeting the predefined criteria. The assessed outcome measures (POD1 vital signs, laboratory findings, pain scores and nausea/vomiting) and 30-day postoperative complications were compared between the early (stay ≤ 24 h) and delayed (>24 h) groups. Results: For 107 patients who fulfilled the inclusion criteria, 48 (44.9%) were discharged within 24 h. There were no differences in the baseline demographics, except that the early group was more likely to have a previous abdominal operation (35.4% vs. 16.9%). Both groups had similar operation durations (89 min vs. 92 min), but the early group had a markedly shortened length of stay (23 (24–22) h vs. 27 (47–26) h). The POD1 parameters were the same between the groups, except that the delay group had a significantly higher visual analog scale score, with fewer patient scores of 0. Patients who were younger and female were more likely to need additional IV analgesics. No POD1 antiemesis was required throughout the study. There was no increase in the 30-day complications. Conclusion: Patient discharge at 24 h post-LRYGB is feasible and safe in a low-volume practice. A more comprehensive pain relief strategy may be required before generalizing this approach. [ABSTRACT FROM AUTHOR]

Background: The right colon is difficult to cleanse compared with other colon segments. This post hoc analysis of two randomised clinical trials (MORA and NOCT) examined whether 1L polyethylene glycol (PEG) NER1006 and two mid-volume alternatives could improve adequate and high-quality cleansing in the right colon among patients with complete cleansing assessments.Methods: Patients received NER1006 (N2D), 2L PEG plus ascorbate (2LPEG) or oral sulphate solution (OSS) as a 2-day evening/morning split-dosing regimen or NER1006 as a same-day morning-only dosing regimen (N1D). Patients had full segmental scoring assigned by treatment-blinded central readers using the Harefield Cleansing Scale. The right colon adequate (score ≥ 2) and high-quality (score ≥ 3) cleansing success of NER1006 (N2D and N1D) versus 2LPEG and OSS was analysed individually and as pooled groups (N2D vs. 2LPEG/OSS). We assessed the comparative right colon cleansing rates of the N2D versus 2LPEG/OSS in overweight males. We also performed a multivariable regression analysis to examine factors affecting cleansing in the right colon.Results: A total of 1307 patients were included. Pooled N2D showed significantly improved rates of adequate-level cleansing in the right colon compared with 2LPEG (97.5% [504/517] vs. 94.6% [246/260]; p = 0.020) and OSS (97.5% [504/517] vs. 93.8% [244/260]; p = 0.006). In MORA, the rate of adequate right colon cleansing did not significantly differ between N1D and 2LPEG (95.2% [257/270] vs. 94.6% [246/260]; p = 0.383). The rate of right colon high-quality cleansing was significantly improved with N2D or N1D vs. 2LPEG (p < 0.001 for both), and was numerically higher with N2D versus OSS (p = 0.11). In overweight males, NER1006 delivered numerically higher adequate (p = 0.398) and superior high-quality (p = 0.024) cleansing rates versus 2LPEG/OSS. Multivariable regression analysis showed NER1006 was associated with adequate and high-quality cleansing (p = 0.031 and p < 0.001), while time between preparation and colonoscopy was negatively associated (p = 0.034 and p = 0.006).Conclusions: NER1006 delivered improved rates of adequate and high-quality right colon cleansing compared with 2LPEG and OSS. The increased rate of high-quality cleansing with NER1006 versus its comparators was also seen in overweight males. [ABSTRACT FROM AUTHOR]

The straddle monorail system gradually loses its competitiveness in the medium-volume rail transit system, but the low-volume straddle monorail system has great advantages in the low-volume rail transit system and has a wide range of applications and broad market prospects. Presently, there has been no low-volume and miniaturized straddle monorail project application case in China. This paper analyzes the light-weight requirements of straddle-type monorail transportation system, and studies the core components of lightweight straddle-type monorail transportation system, such as new vehicles, bogie structures, bridges and turnouts, and proposes articulated straddle-type monorail vehicles and technical schemes such as juxtaposition of track beams and flexible joints to determine the professional technical conditions. A domestic air track train line is taken as an example to carry out simulation design, and the results show that the technical and economic indicator of the new lightweight straddle-type transportation system is 145 million Yuan/km, and the lightweight of vehicles and the simplification of supporting facilities are fulfilled with evident economic advantages . [ABSTRACT FROM AUTHOR]

Purpose: It is known that in uni-compartmental knee arthroplasty (UKA) low-volume surgeons have a higher complication and revision rate than high-volume surgeons. Further, robotic-assisted UKA leads to lower early revision rate as well as fewer limb and joint line outliers compared to conventional UKA. The purpose of this study was to retrospectively analyze the outliers' and revision rate of low-volume UKA surgeons with different robotic systems at short-term follow-up. Methods: In this case–control study, 103 robotic-assisted UKAs were included. The procedures were performed between 2016 and 2019 from two low-volume UKA surgeons with an imageless (IL) (63 patients) and image-based (IB) (40 patients) robotic system. Alignment outliers, joint line (JL) reconstruction, complication and revision rates of the two different robotic systems were analyzed. The minimum follow-up was two years. Outliers were defined as a postoperative valgus malalignment greater than 182°. The surgery time for all procedures was evaluated. Results: The overall revision rate was 3.9% (4 of 103). Two occurred in the IB group (5.0%) and two in the IL group (3.2%). No valgus malalignment outliers were observed in both groups. The mean JL was not distalized by more than 2 mm in both groups (IL: 1.3 ± 1.6 mm vs. IB: 1.8 ± 0.9 mm, p value 0.08). The IL procedures had a significant lower mean surgery time (55 ± 13 min vs. 68 ± 14, p value 0.001). Conclusion: Robotic-assisted UKA is a safe procedure in the hand of low-volume UKA surgeons. Robotic-assisted UKA minimizes overcorrection into valgus mal-alignment. Low revision rates are observed at short-term follow-up for robotic-assisted UKA. The choice of the different robotic systems has no impact on the outcome. [ABSTRACT FROM AUTHOR]

Objectives: Preoperative diagnosis is important for patients who need revision surgery due to PJI. Microbial culture plays an important role in PJI diagnosis, but the sensitivity of cultures is low when the sample amount is limited or when a patient is treated with antibiotics before sample collection. In this study, metagenomic next-generation sequencing (mNGS) was used to detect bacteria in preoperative puncture synovial fluid samples from patients with suspected PJI, and the preoperative and intraoperative culture results were compared to estimate its diagnostic efficiency. Methods: From July 2016 to December 2018, patients with suspected PJI who underwent prosthetic joint revision surgery were included, and the results of those who had been tested by preoperative synovial fluid culture and mNGS were obtained. The demographic characteristics, medical history, laboratory test results, culture results, and mNGS results of each patient were recorded. Then, the efficiency of preoperative synovial fluid mNGS was compared to that of synovial fluid culture for diagnosing PJI. Results: A total of 37 patients were included, and 24 patients (25 joints) were diagnosed with PJI. The sensitivity, specificity, and accuracy of preoperative synovial fluid mNGS were 92%, 91.7%, and 83.7%, respectively. The sensitivity, specificity, and accuracy of preoperative synovial fluid culture were 52%, 91.7%, and 43.7%, respectively. Conclusions: With a low volume of synovia (1 ml), mNGS can be performed with higher sensitivity and specificity compared to synovial culture. Thus, mNGS can be a useful supplemental method to improve diagnostic efficiency during the preoperative period.

Men who initially present with localized prostate cancer and later develop metachronous metastases have a better prognosis than men with de novo metastatic disease and often have a low burden of disease on conventional imaging. Some have disease amenable to metastasis-directed therapy for lymph node or bone metastases, a strategy used by some because no documented overall survival (OS) benefit of combination systemic therapy in this setting. We report data for patients prospectively classified as "M0" at initial diagnosis from the interim analysis of the ENZAMET trial, with 34 mo of median follow-up for survivors. A total of 312 (28%) of the 1125 enrolled patients were classified as M0 at diagnosis, and 205 (66%) of the 312 patients had low-volume disease at study entry as per the CHAARTED criteria. The hazard ratio for OS, that is, HR(OS), was 0.56 (95% confidence interval [CI]: 0.29–1.06) with the addition of enzalutamide for all patients with metachronous metastatic hormone-sensitive prostate cancer, and for the low-volume subset the HR(OS) was 0.40 (95% CI: 0.16–0.97). The 3-yr OS was 83% without and 89% with enzalutamide for all patients with metachronous metastases, and 83% and 92%, respectively, for the low-volume subset. Intensification of hormonal therapy should strongly be considered for these men. Many men present with prostate cancer that has spread to distant sites beyond the prostate gland years after their initial diagnosis and treatment, while others have distant spread at the time the cancer is diagnosed. On average, men whose cancer comes back years after the initial diagnosis often survive much longer than men whose cancer has been found to spread to distant sites when it is first diagnosed. In this report, we demonstrate strong evidence for the first time that the survival of men whose cancer comes back years later is improved when drugs such as enzalutamide or apalutamide are added to testosterone suppression in this setting. Patients with metachronous metastatic hormone-sensitive prostate cancer, including those with low-volume disease, have an overall survival benefit with the addition of potent androgen receptor inhibition to testosterone suppression and should be offered this therapy if there are no contraindications. [ABSTRACT FROM AUTHOR]

Biologically inert elastomers such as silicone are favorable materials for medical device fabrication, but forming and curing these elastomers using traditional liquid injection molding processes can be an expensive process due to tooling and equipment costs. As a result, it has traditionally been impractical to use liquid injection molding for low-cost, rapid prototyping applications. We have devised a method for rapid and low-cost production of liquid elastomer injection molded devices that utilizes fused deposition modeling 3D printers for mold design and a modified desiccator as an injection system. Low costs and rapid turnaround time in this technique lower the barrier to iteratively designing and prototyping complex elastomer devices. Furthermore, CAD models developed in this process can be later adapted for metal mold tooling design, enabling an easy transition to a traditional injection molding process. We have used this technique to manufacture intravaginal probes involving complex geometries, as well as overmolding over metal parts, using tools commonly available within an academic research laboratory. However, this technique can be easily adapted to create liquid injection molded devices for many other applications.

The assembly process of most low-volume, complex products (LVCP) suffers from disruptions. Disruptions are deviations from the planned assembly schedule, which harm the economic performance of LVCP manufacturers. This research investigates how the quality of data on disruption events influences an effective disruption management. For this purpose, we combine a literature review and a single case study at a LVCP manufacturer. The results reveal three areas of action around data completeness to improve data quality and increase the efficiency of disruption management: Increasing population completeness, ensuring column completeness, and designing proper schema completeness. [ABSTRACT FROM AUTHOR]

Background: Standard of care management for synchronous metastatic castration-sensitive prostate cancer (mCSPC) includes androgen deprivation therapy with a second-generation antiandrogen therapy and/or docetaxel. Recently, randomized data have demonstrated that prostate-directed therapy (PDT) is associated with an improvement in overall survival (OS) among patients with low-volume metastatic disease. Tumor genomics represents an additional dimension to define the clinical trajectory of patients with mCSPC., Objective: To evaluate a high-risk (HiRi) genomic signature to predict the benefit from PDT., Design, Setting, and Participants: We performed a single-institution retrospective review of men with synchronous low-volume mCSPC who underwent DNA panel sequencing of their tumor. Patients were classified according to the presence of HiRi mutation including pathogenic mutations in TP53, ATM, BRCA1, BRCA2, or Rb1., Outcome Measurements and Statistical Analysis: The primary endpoint was to determine the effect of PDT on OS in patients with and without a HiRi mutation. A survival analysis was performed with the Kaplan-Meier method compared with log-rank test and multivariable Cox regression. The interaction between HiRi mutation and PDT was evaluated., Results and Limitations: A total of 101 patients with synchronous low-volume CSPC were included with a median follow-up of 44 mo. Approximately half of patients were found to have a HiRi pathogenic mutation (49%). Patients with HiRi mutations demonstrated median OS of 73 versus 66.8 mo (p = 0.3) for no PDT versus PDT. Conversely, patients without a HiRi mutation demonstrated a significant improvement in OS of 60 versus 105.3 mo (p < 0.001) for no PDT versus PDT. The p value for interaction for OS between PDT and HiRi mutation was statistically significant (p < 0.001). Limitations include the retrospective nature of the study., Conclusions: Here, we have identified a HiRi genomic biomarker that appears predictive for the lack of benefit from PDT in men with synchronous low-volume mCSPC. Further work validating these results is warranted., Patient Summary: In this report, we evaluated a high-risk genomic biomarker to predict the benefit from prostate-directed therapy for men with synchronous low-volume metastatic castration-sensitive prostate cancer. We found that men without a high-risk mutation appear to experience a greater clinical benefit from prostate-directed therapy than those with a high-risk mutation., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Supraclavicular block is the most commonly used block in upper limb surgeries, right from the day it was introduced into clinical practice in Germany by Kulenkampff in 1911. The block underwent many changes in its application due to the advent of peripheral nerve stimulator and ultrasonographic application in regional anesthesia. This case report focuses on supraclavicular block's application in a multicomorbid patient, the drug dose required, and how the scope of regional anesthesia can be extended in times of pandemic, like coronavirus disease 2019 (COVID-19), in coming future. [ABSTRACT FROM AUTHOR]

• The preoperative synovial fluid volume used for mNGS analysis was only 1 ml, so it does not conflict with the microbial culture process. • mNGS can improve PJI diagnosis of cases with low-volume preoperative aspirated synovial fluid compared with synovial fluid culture. • mNGS was recommended as an effective supplemental diagnostic tool to improve PJI diagnosis preoperatively. Preoperative diagnosis is important for patients who need revision surgery due to PJI. Microbial culture plays an important role in PJI diagnosis, but the sensitivity of cultures is low when the sample amount is limited or when a patient is treated with antibiotics before sample collection. In this study, metagenomic next-generation sequencing (mNGS) was used to detect bacteria in preoperative puncture synovial fluid samples from patients with suspected PJI, and the preoperative and intraoperative culture results were compared to estimate its diagnostic efficiency. From July 2016 to December 2018, patients with suspected PJI who underwent prosthetic joint revision surgery were included, and the results of those who had been tested by preoperative synovial fluid culture and mNGS were obtained. The demographic characteristics, medical history, laboratory test results, culture results, and mNGS results of each patient were recorded. Then, the efficiency of preoperative synovial fluid mNGS was compared to that of synovial fluid culture for diagnosing PJI. A total of 37 patients were included, and 24 patients (25 joints) were diagnosed with PJI. The sensitivity, specificity, and accuracy of preoperative synovial fluid mNGS were 92%, 91.7%, and 83.7%, respectively. The sensitivity, specificity, and accuracy of preoperative synovial fluid culture were 52%, 91.7%, and 43.7%, respectively. With a low volume of synovia (1 ml), mNGS can be performed with higher sensitivity and specificity compared to synovial culture. Thus, mNGS can be a useful supplemental method to improve diagnostic efficiency during the preoperative period. [ABSTRACT FROM AUTHOR]

Purpose: While the increased rates of high degree perineal tears were previously associated with the use of forceps, in the current era of low volume of forceps practice, factors associated with the occurrence of this potential complication remain understudied. We aim to evaluate factors associated with obstetric anal sphincter injury (OASIS) in obstetric units with a low volume forceps practice.Methods: A retrospective cohort study was conducted at two tertiary medical centers. All singleton pregnancies delivered by forceps extraction between 2011 and 2019 were analyzed. Women who experienced anal sphincter injury were compared to those who did not.Results: The study cohort included 764 forceps deliveries. There were 19 (2.5%) cases of OASIS. Women with anal sphincter injury had higher rates of gestational diabetes mellitus (21% vs. 5.6%, OR [95% CI] 4.46 (1.41-14.04), p = 0.02). Birth weights and the rate of macrosomia did not differ between groups. Induction of labor was more common among the OASIS group (68% vs. 41.7%, OR [95% CI] 3.0 (1.1-8.0), p = 0.02). Sequential use of forceps (after failed vacuum attempt) was associated with OASIS (8 (42%) vs. 76 (10.2%), OR [95% CI] 6.4 (2.5-16.4), p < 0.001). In a multivariate logistic regression, sequential forceps was the only factor independently associated with OASIS (OR [95% CI] 4.7 (1.3-18.2), p = 0.02).Conclusions: Rate of OASIS was relatively low in the current cohort. Sequential use of forceps was found to be the most important determinant in OASIS occurrence. [ABSTRACT FROM AUTHOR]

Study Design: Database analysis.Objective: To evaluate complications and mortality in patients undergoing surgical management of extradural spinal tumors in New York State.Summary Of Background Data: Metastatic spine surgery has a high rate of complications but most studies are limited to single institutions.Methods: The Statewide Planning and Research Cooperative System was used to identify patients with extradural spinal tumors undergoing surgery in New York State from 2006 to 2015. Bivariate and multivariate logistic regression analyses were used to estimate outcomes.Results: Four thousand seven hundred sixty-seven patients were identified, the majority of patients were male and white a median age of 61. The complication rate was 17.6% and the mortality rate within 30 days of discharge was 12.2%. Multivariate analysis showed the odds of complications were higher in males compared with females (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.05-1.52, P = 0.01), and patients on Medicaid compared with patients on private insurance (OR: 1.42; 95% CI: 1.03-1.96, P = 0.03). Analysis of hospital characteristics showed lower volume hospitals (OR 1.48; 95% CI: 1.03-2.13, P value = 0.03), and teaching hospitals (OR: 1.47; 95% CI: 1.03-2.09, P = 0.04), have higher odds of complications compared with high-volume hospitals and nonteaching hospitals. Multivariate analysis showed higher odds of mortality within 30 days of discharge in patients of older age (OR: 1.02; 95% CI: 1.01-1.03, P value = 0.001), low-volume hospitals compared with high-volume hospitals (OR: 1.36; 95% CI: 1.09-1.79, P value = 0.02), hospitals with low bed size compared with high bed size (OR: 1.43; 95% CI: 1.12-1.83, P value = 0.01), and urban hospitals compared with rural hospitals (OR: 3.04; 95% CI: 2.03-4.56, P value = 0.001).Conclusion: Low-volume hospitals are associated with complications and mortality in patients with metastatic spine disease.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

The costs for low-volume production moulds (1–200 production components) are related to the mould material, the process planning time and the fabrication costs. Researchers have explored using additive manufacturing (AM) processes to fabricate moulds directly from their digital models as this reduces the process planning time and some fabrication costs, but there are issues with directly employing an AM solution. Material costs are high for metallic AM processes, and there are thermal conductivity and material compatibility issues when using plastic-based AM processes. Both the metal- and plastic-based AM processes have surface finish issues; so post processing activities must be part of the fabrication plan. In this research, a methodology is found to fabricate low-volume production moulds using a high-temperature moulding material. A general solution is provided, with a case study focusing on an over moulding process in which the injection material being moulded is Technomelt-PA 7846 black. A hybrid mould fabrication is applied where a material extrusion–based process is used to make a sacrificial product-shaped pattern. This pattern is used to form a resin-based insert which is to be assembled into a mould base frame. Customised inserts can be readily built and exchanged to provide a rapid response to a customer request. An assessment of the digital model, the manufacturing, assembly and the final validated assembly model is provided. [ABSTRACT FROM AUTHOR]

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Introduction: Colonoscopy is the gold standard for evaluation of the colonic mucosa. Colon cleansing in preparation for colonoscopy depends on finding of polyps which can be adenomatous with malignant potential and the possibility of degenerating into colon cancer. Objective: This study's objective was to compare the efficacy and safety of three types of preparations for colon cleansing: a single four liter dose of polyethylene glycol (PEG) vs. two 2 liter doses of PEG vs. two low volume (1L + 1L) doses of PEG. Methods: This is a randomized controlled clinical trial of patients who underwent elective colonoscopy at a University clinic. It was blinded for the doctor who evaluated colon cleansing. Seventy four patients 74 patients were randomized into each group. The main parameter of effectiveness was integral preparation of adequate quality measured on the Boston scale. Secondary parameters were the percentage of adverse events, tolerability and detection rate of polyps. Results: Complete preparation of the entire colon was achieved significantly more often with 4 liters divided into two 2 liter doses followed by the other divided alternative (1 L + 1 L). It was achieved least frequently with in the single dose: 79.7%, 75.7% and 63.5%, respectively, p = 0.019. Differences were also found in the detection of polyps (13.5%, 24.3% and 9.5%, respectively, p = 0.037). ) There were no differences in presentation of at least one adverse event (p = 0.254) or in tolerability (p = 0.640). Conclusions: The two divided dose preparations had higher colon cleansing and polyp detection efficacies than did the single 4L dose while there were no differences in occurrence of adverse events and tolerability. The divided PEG 2L dose could be a very good option for elective colonoscopy preparation. [ABSTRACT FROM AUTHOR]

Introduction: Liver resection is a widely used surgical procedure for different benign and malignant pathology, which carries a significant morbidity and mortality (5-10%). Post-hepatectomy liver failure and bile leak are the major complications of major (>3 segments) hepatectomy, and is also the determinant factor for mortality. However, recently due to multimodality development like better surgeons experience, advanced imaging modality and better surgical planning, the outcome has significantly improved. Moreover, with relocation of experienced surgeons, selection of patients and sharing of operative techniques and perioperative care pathways had made possibility of performing major hepatectomy at even low volume academic centre, with almost comparable outcome to high volume centre. Aim: To study the outcome of major hepatectomy at an academic institute of Nepal, which has a specialised hepatopancreatobiliary unit with its trained surgeon from a high volume centre. Materials and Methods: Retrospective analysis of all patients undergoing major hepatectomy between December 2015 to July 2017 was done. Patient demographics, clinical characteristics, operative details, morbidity and mortality were recorded. Results: There were 6 (24%) major hepatectomy, out of 25 liver resection. Five (83.3%) were for malignant pathology: Right hepatectomy-1; Extended right hepatectomy-1; Central hepatectomy-1; Left hepatectomy-3. The mean age of the patient was 50.8 years, with M:F ratio of 1:2. Jaundice was seen in 50% of patients and none required preoperative biliary drainage or portal vein embolisation. The mean operating time, blood loss and transfusion requirement were 216 minutes, 408 mL and one pint respectively. Three (50%) patients developed major bile leak, which was managed conservatively. There was no postoperative, 30-day or 90-day mortality. Conclusion: Major hepatectomy is a safe and feasible option at our centre despite limited resources and low-volume set-up.