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BACKGROUND The effectiveness of colonoscopy strictly depends on adequate bowel cleansing. Recently, a 1 L polyethylene glycol plus ascorbate (PEG-ASC) solution (Plenvu; Norgine, Harefield, United Kingdom) has been introduced on the evidence of three phase-3 randomized controlled trials, but it had never been tested in the real-life. AIM To assess the effectiveness and tolerability of the 1 L preparation compared to 4 L and 2 L- PEG solutions in a real-life setting. METHODS All patients undergoing a screening or diagnostic colonoscopy after a 4, 2 or 1 L PEG preparation, were consecutively enrolled in 5 Italian centers from September 2018 to February 2019. The primary endpoints of the study were the assessment of bowel cleansing success and high-quality cleansing of the right colon. The secondary endpoints were the evaluation of tolerability, adherence and safety of the different bowel preparations. Bowel cleansing was assessed through the Boston Bowel Preparation Scale. Adherence was defined as consumption of at least 75% of each dose, while tolerability was evaluated through a semi-quantitative scale. Safety was systematically monitored through adverse events reporting. RESULTS Overall, 1289 met the inclusion criteria and were enrolled in the study. Of these, 490 patients performed a 4 L-PEG preparation (Selgesse®), 566 a 2 L-PEG cleansing (Moviprep® or Clensia®) and 233 a 1 L-PEG preparation (Plenvu®). Bowel cleansing by Boston Bowel Preparation Scale was 6.5 ± 1.5 overall and 6.3 ± 1.5, 6.2 ± 1.5, 7.3 ± 1.5 (P < 0.001) in the subgroups of 4 L, 2 L and 1 L-PEG preparation, respectively. Cleansing success was achieved in 72.4%, 74.1% and 90.1% (P < 0.001), while a high-quality cleansing of the right colon in 15.9%, 12.0% and 41.4% (P < 0.001) for 4 L, 2 L and 1 L-PEG preparation groups, respectively. The 1 L preparation was the most tolerated compared to the 2 and 4 L-PEG solutions in the absence of serious adverse events within any of the three groups. Multiple regression models confirmed 1 L PEG-ASC preparation as an independent predictor of overall cleansing success, high-quality cleansing of the right colon and of tolerability. CONCLUSION This study supports the effectiveness and tolerability of 1 L PEG-ASC, also showing it is an independent predictor of overall cleansing success, high-quality cleansing of the right colon and of tolerability.

Online coupling of a micromotor-based immunoassay and a microfluidic electrochemical detection was explored as a new approach for C-reactive protein (CRP) determination in serum and preterm neonatal plasma samples with sepsis suspicion. The approach combines the advantages of micromotors (self-fluid mixing capabilities leading to a faster assay in low sample volumes) and electrochemical microfluidic (flow-controlled ultraminiaturized electrochemical detection, high sensitivity, and low-cost) technologies. Both technologies elegantly meet the point of care testing or bed side device requirements such as low analysis times, miniaturization and simplification, and single use. Anti-CRP functionalized micromotors (anti-CRP-rGO(reduced graphene oxide)/Ni/PtNPs (platinum nanoparticles))-based immunoassay coupled to thin layer Au-based electrochemical microfluidics operating at -0.20 V under controlled fluidic detection operations (30 μL min-1) allowed the sensitive (LOD = 0.54 μg/mL) and accurate CRP determination using very low volume preterm neonatal clinical samples (

The relationship between hospital volume and patient outcome is globally known; thus, hospital volume is widely used as a quality indicator. In Japan, however, recent studies on this topic are scarce. The present study examined whether hospital surgery volume is associated with postoperative 5‐year survival among cancer patients. Using the Osaka Cancer Registry, we identified a sample of 86 145 patients who were diagnosed with cancer at any of five different sites (stomach, colorectum, lung, breast and uterus) and underwent surgeries between 2007 and 2011 in Osaka. We ranked hospitals by annual surgical volume, sorted patients in descending order by hospital volume, and assigned them into quartiles (high, medium, low and very low volume). We analyzed the association between hospital volume and 5‐year survival among 80 959 patients aged between 15 and 84 years using Cox proportional hazard models. Adjustments were made for characteristics of patients, type of surgery and adjuvant treatment received. The mortality hazard of patients treated at very low‐volume hospitals was 1.36‐1.82‐fold higher than that of patients treated at high‐volume hospitals. Absolute differences in adjusted survival rates between high‐volume and very low‐volume hospitals varied with the cancer site: 14.9 in stomach, 11.5 in colorectal, 10.8 in lung, 2.4 in breast and 3.3 in uterine cancers. Hospitals with lower surgery volumes showed higher mortality risks after cancer surgery than those with higher volumes. Monitoring site‐specific surgery volumes and referring patients from low‐volume to high‐volume hospitals may be beneficial for improving the long‐term survival of cancer patients., Postoperative 5‐year survival of 80 959 patients diagnosed with stomach, colorectal, lung, breast or uterine cancers was compared among hospitals categorized by quartiles of surgery volume, using the Osaka Cancer Registry database. Very low hospital volume was significantly associated with higher mortality hazards, whereas absolute differences in survival probability between high‐volume and very low‐volume hospitals varied with the cancer site. Monitoring site‐specific surgery volume and referring patients from low‐volume to high‐volume hospitals are recommended to improve postoperative survival of cancer patients.

Our recently demonstrated innovative concept of electronic nose (eNose) based on a combination of gas sensors is further tested and benchmarked in the present study. The system is a test bed for gas sensors of different principal technologies distributed within three compartments, which share a compact, very low volume, temperature-controlled sensing chamber. Here, the eNose-based analyser contains three sensing arrays of commercially available semiconducting metal oxide (MOX) gas sensors: one compartment contains 8 analog MOX sensors, while the other two compartments comprise 10 digital MOX sensors. The presented instrument is explicitly tested for the discrimination between mid-range (3-18 ppm) concentrations of different volatile organic compounds (VOCs) including acetaldehyde, acetone, ethanol, ethyl acetate, isoprene and n-pentane under dry and humid conditions, which are all considered relevant gases in future breath diagnostic applications. Since the experiments were performed in periods of time separated by around 20 days, they are affected by drift. For this reason, we explore the opportunity of drift mitigation using methods based on component removal computed by linear discriminant analysis, partial least squares discriminant analysis and direct orthogonalization, which lend themselves to future in-field applications of the developed device and sensing methodology.

To compare the acute physiological responses of three different very low-volume cycling sessions (6 × 5 s, 3 × 30 s, and 3 × 60 s) and their dependence on age and training status. Subjects were untrained young men (mean ± SD; age 22.3 ± 4.6 years, VO2peak 42.4 ± 5.5 ml/kg/min, n = 10), older untrained men (69.9 ± 6.3 years, 26.5 ± 7.6 ml/kg/min, n = 11), and endurance-trained cyclists (26.4 ± 9.4 years, 55.4 ± 6.6 ml/kg/min, n = 10). Maximal voluntary contraction (MVC) and electrically stimulated knee extension torque, and low-frequency fatigue, as ratio of stimulation torques at 20–100 Hz (P20/100), were measured only 24 h after exercise. Serum testosterone (Te) and blood lactate concentrations were measured only 1 h after exercise. All protocols increased the blood lactate concentration and decreased MVC and P20/100 in young men, but especially young untrained men. In old untrained men, 6 × 5 s decreased P20/100 but not MVC. Te increased after 3 × 30 s and 3 × 60 s in young untrained men and after 3 × 60 s in older untrained men. The increase in Te correlated with responses of blood lactate concentration, MVC, and P20/100 only in old untrained men. As little as 6 × 5 s all-out cycling induced fatigue in young and old untrained and endurance-trained cyclists. Slightly higher-volume sessions with longer intervals, however, suppressed contractile function more markedly and also transiently increased serum testosterone concentration in untrained men.

Non-metallic inclusions (NMIs) occur typically in low or very low volume fractions (from 10−2 in a high oxygen weld deposit to 10−5 in very clean bearing steels) but play an important role in many properties of steel. NMIs play a decisive role in processes involving ductile fracture, fatigue and corrosion, for instance. These are some of the properties more relevant to the performance of steel in structural and mechanical applications. Furthermore, NMIs may influence nucleation during phase transformations of steel. In this work, the relation of these properties to NMIs is reviewed, highlighting progress and difficulties in each area. Perhaps because of their very low volume fraction, NMIs are sometimes overlooked in the basic physical metallurgy education and their study is left to the realm of those interested in steelmaking. In the last decades a dramatic evolution in the understanding of their relationship to properties, however, has led to significant improvements in many steel products: the outstanding increase of fatigue life in automotive springs and in bearings is one of many such examples. It is concluded that steel improvement in many cases requires “inclusion engineering” and this can only be achieved through close collaboration between physical metallurgy, process metallurgy and steelmaking. Those who realized this have made significant progress in steel development in recent decades as highlighted in this short review. Keywords: Non-metallic inclusions, Fracture, Fatigue, Ductility, Steel, Steelmaking

Rapid diagnosis by using small, simple, and portable devices could represent one of the best strategies to limit the damage and contain the spread of viral, bacterial or protozoa diseases, principally when they can be transmitted by air and are highly contagious, as some respiratory viruses are. The presence of antibodies in blood or serum samples is not the best option for deciding when a person must be quarantined to stop transmission of disease, given that cured patients have antibodies, so the best diagnosis methods rely on the use of nucleic acid amplification procedures. Here we present a very simple device and detection principle, based on paper discs coupled to contactless conductivity (C4D) sensors, can provide fast and easy diagnostics that are needed when an epidemic outbreak develops. The paper device presented here solves one of the main drawbacks that nucleic acid amplification tests have when they are performed outside of central laboratories. As the device is sealed before amplification and integrally disposed in this way, amplimers release cannot occur, allowing repetitive testing in the physician’s practice, ambulances, or other places that are not prepared to avoid cross-contamination of new samples. The use of very low volume samples allows efficient reagent use and the development of low cost, simple, and disposable point-of-care diagnostic systems., Author summary In 2005, the World Health Organization (WHO) recognized Chagas Disease as a neglected tropical disease. Meanwhile the serological tests, recommended by WHO, can be performed for chronic disease diagnosis, the nucleic acid amplification tests must be performed for the detection of the acute phase of the disease. Although the existing laboratory diagnosis tests for Chagas Disease are sensitive and highly reproducible, they cannot be performed in rural, low infrastructure environments, where this disease prevails. In this sense, the use of simple and portable analytical devices may be able to offer an affordable solution to this problem, allowing fast sampling, diagnosis and treatment prescription in one simple and fast intervention, as the performed by short term medical missions. In this study we show for the first time a diagnosis test comprising low cost materials and employing a contactless and label-free conductivity detection system that is used to read the result of a nucleic acid amplification reaction. The test showed high sensitivity for Chagas Disease diagnosis showing the potential to be used in rural and low income places.

An adequate bowel preparation is essential for a successful colonoscopy, in particular, in the setting of colorectal cancer screening. However, up to one-quarter of colonoscopies are associated with inadequate bowel preparation, which may result in reduced polyp and adenoma detection rates, prolonged procedural time, and an increased likelihood of repeat the procedure. : The ideal intestinal preparation should provide an optimal observation of the mucosa (at least > 90% of the visible surface), with adequate acceptability and safety for the patient. : With this premise, a very low-volume 1 L PEG-ASC solution (Plenvu; Norgine, Harefield, United Kingdom) has been recently introduced to improve patients’ experience in colonoscopy by reducing the total intake of liquids to be consumed. This could represent a valid option for bowel cleansing, considering CRC screening and surveillance programs, improving both the quality of the examination and the patients’ compliance. : Nevertheless, it must be emphasized that a “one size fits all” preparation strategy is not feasible and that a bowel preparation regime must always be selected and tailored by the clinician for each patient, evaluating the best options on a case by case basis. : This narrative review aims to sum up the evidence regarding new bowel preparation regimens in order to help clinicians to tailor the best choice for patients undergoing colonoscopy.

To investigate whether minimally invasive mitral valve repair (MIMVR) can be transferred from a high-volume center into a very small volume center and to clarify how many cases are necessary for maintenance of this program, early outcomes of MIMVR in Asahikawa Medical University were compared with those results in patients operated by a single surgeon in Duesseldorf University Hospital. Sixty-five patients who underwent MIMVR in Asahikawa Medical University (group A) between May 2014 and July 2018 and 134 patients who underwent MIMVR in Duesseldorf University Hospital (group D) between September 2009 and January 2014 by a surgeon who started MIMVS later in Asahikawa were retrospectively analyzed. In group D, there were more patients with ischemic mitral valve regurgitation and with annular calcification than in group A. Survival rate at 6 months and 1 year was 98.5% and 98.5% in group A and 92.9% and 91.3% in group D, respectively. EuroSCORE II was significantly higher in patients dead within 30 days and within the first year. The present study demonstrated that MIMVR programs can be transferred with acceptable early results into very low volume centers, if the team is developed by surgeons who are well trained and experienced in MIMVR. Moreover, the present study suggested that case number for maintenance of acceptable results may be obviously less than the previous recognition that this kind of specialized surgery could be maintained with at least 50 cases annually. However, meticulous preparations for surgery are essential for satisfactory surgical outcomes.

Aim Increasing scrutiny on both individual and unit outcomes after surgical procedures is now expected. In the field of inflammatory bowel disease, this is particularly pertinent for outcomes after ileoanal pouch surgery. Method The Surgical Workload and Outcomes Research Database (SWORD) relies on administrative data derived from Hospital Episode Statistics collected in England. The platform was interrogated for pouch procedures undertaken in England between April 2009 and December 2016 to assess national caseload and, between April 2012 and December 2016, to assess variation in caseload and outcomes after pouch surgery. Results In England there is a suggestion that numbers of pouch procedures may be decreasing. Over 80% of Trusts offering pouch surgery do so at very low volume with less than five procedures per year. There is also a clear phenomenon of the occasional pouch surgeon with 126 surgeons undertaking just one pouch operation during the study period of almost 5 years. Laparoscopic practice varies but 60% of pouches overall were done via an open approach. Mean length of stay was 10.1 days and average 30-day readmission rates were 27.4%. Outside London there appears to be an increasing trend for higher volume units to do more adult pouch procedures and lower volume units to do fewer. Conclusion Low volume units and occasional pouch surgeons present a strong argument for centralization of pouch surgery. Data from England outside London suggest that this may already be happening.

Introduction The purpose of this study is to identify issues faced by Federally Qualified Health Centers (FQHCs) in implementing lung cancer screening in low-resource settings. Methods Medical directors of 258 FQHCs serving communities with tobacco use prevalence above the median of all 1,202 FQHCs nationally were sampled to participate in a web-based survey. Data were collected between August and October 2016. Data analysis was completed in June 2017. Results There were 112 (43%) FQHC medical directors or surrogates who responded to the 2016 survey. Overall, 41% of respondents were aware of a lung cancer screening program within 30 miles of their system’s largest clinic. Although 43% reported that some providers in their system offer screening, it was typically at a very low volume (less than ten/month). Although FQHCs are required to collect tobacco use data, only 13% indicated that these data can identify patients eligible for screening. Many FQHCs reported important patient financial barriers for screening, including lack of insurance (72%), preauthorization requirements (58%), and out-of-pocket cost burdens for follow-up procedures (73%). Only 51% indicated having adequate access to specialty providers to manage abnormal findings, and few reported that leadership had either committed resources to lung cancer screening (12%) or prioritized lung cancer screening (12%). Conclusions FQHCs and other safety-net clinics, which predominantly serve low-socioeconomic populations with high proportions of smokers eligible for lung cancer screening, face significant economic and resource challenges to implementing lung cancer screening. Although these vulnerable patients are at increased risk for lung cancer, reducing patient financial burdens and appropriately managing abnormal findings are critical to ensure that offering screening does not inadvertently lead to harm and increase disparities.

It remains to be established whether centralization to high volume centers is essential for all patients undergoing pancreatic surgery. The aims of this study were to identify the optimal cut-off volume to optimize patient outcomes and to determine if patient comorbidity affected the volume-outcome relationship.Patients undergoing pancreatectomy from 2012 to 2015 were retrospectively identified (n = 12 333) in the French nationwide database. The 90-day Post-Operative Mortality (POM) was analyzed according to hospital volume of pancreatectomy (very low:10, Low:10-19, High:20-49 and very high:≥50 resections/year) and Charlson Comorbidity Index (ChCI).The overall POM was 6.9%. The cut-off of 20 pancreatic resections per year was identified as predictor of POM. Compared to high volume centers, POM was significantly higher in low and very low volume centers whatever the ChCl. Regarding surgical procedures, there was a significant decrease in POM with increasing hospital volume only after pancreaticoduodenectomy regardless of the ChCl. On multivariable analysis, low and very low volume centers were independently associated with increased mortality rates.The optimal cut-off of annual caseload was 20 pancreatic resections. POM following pancreaticoduodenectomy is high in low and very low volume centers independently of ChCl, suggesting that this procedure should be centralized.

A broadband and compact stacked microstrip patch antenna has been developed using stacked configuration. The antenna comprises two parasitic patches stacked above the driven patch fed by shifted microstrip feed and a step transformer between feed and patch to achieve broadband coupling. Cross polarization has been improved by inserting a vertical slot in the direction of feed. The antenna occupies very low volume of ${\mathbf{0}}.{\mathbf{36}}{\lambda _{{\mathbf{o}}}}\,\times\,{\mathbf{0}}.{\mathbf{39}}{\lambda _{{\mathbf{o}}}}\,\times\,{\mathbf{0}}.{\mathbf{096}}{\lambda _{\mathbf{o}}}$ (radiating elements volume), while overall dimensions with ground plane are ${\mathbf{0}}.{\mathbf{7}}{\lambda _{{\mathbf{o}}}}\,\times\,{\mathbf{0}}.{\mathbf{7}}{\lambda _{{\mathbf{o}}}}\,\times\,{\mathbf{0}}.{\mathbf{096}}{\lambda _{\mathbf{o}}}$ . The overall bandwidth achieved is 35% (4.9–7.05 GHz) and a peak gain of 8.2 dBi with average gain of 6 dBi. Antenna radiation patterns are quite unidirectional with ${\mathbf{F}}\text{/}{\mathbf{B}} > {\mathbf{21}}$ dB and significantly low cross-polarization levels, suitable for target scanning applications. In the class of printed broadband antennas with unbroken ground plane, the proposed antenna achieves minimum volume with good bandwidth and radiation properties.

The excessive use of antibiotics in human and veterinary medicine causes the emergence of multidrug resistant bacteria. In this context, the surveillance of many different antibiotics provokes a worldwide challenge. Hence, fast and versatile multianalyte single-use biosensors are of increasing interest for many fields such as medical analysis or environmental and food control. Here we present a microfluidic platform enabling the electrochemical readout of up to eight enzyme-linked assays (ELAs), simultaneously. To demonstrate the applicability of this platform for the surveillance and monitoring of antibiotics, we used highly sensitive biomolecular sensor systems for the simultaneous detection of two commonly employed antibiotic classes tetracycline and streptogramin. Thus, microfluidic channel networks are designed, comprising distinct numbers of immobilization sections with a very low volume of 680 nL each. These passively metered sections can be actuated separately for an individual assay procedure. The limits of detection (LOD) are determined, with high precision, to 6.33 and 9.22 ng mL–1 for tetracycline and pristinamycin, respectively. The employed channel material, dry film photoresist (DFR), allows an easy storage of preimmobilized assays with a shelf life of at least 3 months. Multianalyte measurements in a complex medium are demonstrated by the simultaneous detection of both antibiotics in spiked human plasma within a sample-to-result time of less than 15 min., Analytical Chemistry, 88 (20), ISSN:1520-6882, ISSN:0003-2700

OBJECTIVE To perform a population-based analysis to first examine the changes in surgeon and hospital procedural volume for hysterectomy over time and then to explore the association between very low surgeon procedural volume and outcomes. METHODS All women who underwent hysterectomy in New York State from 2000 to 2014 were examined. Surgeons were classified based on the average annual procedural volume as very low-volume surgeons if they performed one procedure per year. We used multivariable models to examine the association between very low-volume surgeon status and morbidity, mortality, transfusion, length of stay, and cost. RESULTS Among 434,125 women who underwent hysterectomy, very low-volume surgeons accounted for 3,197 (41.0%) of the surgeons performing the procedures and operated on 4,488 (1.0%) of the patients. The overall complication rates were 32.0% for patients treated by very low-volume surgeons compared with 9.9% for those treated by other surgeons (P

Introduction Treatment of recurrent and metastatic melanoma has been revolutionised by targeted therapy. Inhibitors of mutant BRAF are a systemic treatment offered for patients with stage III/IV melanoma who are known to carry a mutation in BRAF. Currently patients’ BRAF mutation status is assessed through molecular analysis of tissue specimens. Cell-free DNA (cfDNA) released from tumours can be used to non-invasively detect active disease and predict survival in melanoma. cfDNA also provides a method for detecting BRAF mutations. This project aimed to ascertain BRAF mutation status in cfDNA through digital droplet PCR (ddPCR) of plasma samples from patients with melanoma. We aimed to assess the relationship between cfDNA BRAF positivity and disease relapse and progression. Methods Plasma from 100 patients with active or recently resected melanoma was obtained during previous work. 85 samples had cfDNA extracted. Tissue BRAF status was known for 57 samples. cfDNA was extracted from 1–2 ml plasma with the QIAamp circulating nucleic acid kit (QIAGEN®) following manufacturer protocol, eluting cfDNA into 100µL. cfDNA was quantified with SYBR green quantitative real-time PCR (Life Technologies), based on an 87bp GAPDH gene amplicon. ddPCR™ was performed using the Bio-Rad QX200 Droplet Generator™ and Droplet Reader as per manufacturer protocol. Analysis was performed with Bio-Rad QuantaSoft Version 1.7.4. Results Median yield of cfDNA extracted from 85 samples was 1.97 ng/ml when eluted into 100µL. This was well-correlated with previous cfDNA extraction yields from this sample set (Pearson’s r=0.6687, p10,000 droplets and were included for analysis. 12 samples contained BRAF mutant positive droplets. A 74% concordance rate between tissue BRAF mutation status and the presence/absence of cfDNA BRAF mutant positive droplets was found. 7/18 tissue BRAF mutant samples contained BRAF mutant droplets, in comparison to 2/32 tissue BRAF wild-type samples. The presence of BRAF mutant positive droplets was significantly different between the tissue BRAF mutant and tissue BRAF wild-type groups (χ2 8.3145, p=0.004). Fractional abundance of BRAF mutant droplets in the samples containing mutant droplets ranged from 0.07–0.74%. When comparing BRAF mutant droplet-containing samples and samples without BRAF mutant droplets, there was no significant difference in rate of relapse (χ2 0.0948, p=0.758), nor mortality rate (χ2 3.3959, p=0.654). Conclusion cfDNA provides a non-invasive snapshot of the tumour genome and any potential therapeutic targets held within. This work demonstrates that a very low volume of cfDNA can be used to detect BRAF mutations in patients with melanoma through ddPCR. Previous work assessing BRAF status in cfDNA has used larger volumes of cfDNA. Though our concordance rates are comparable with other studies, it is possible that using a smaller amount of cfDNA in our ddPCR has resulted in some samples being below the limit of detection for ddPCR. Longitudinal study is warranted to monitor cfDNA BRAF status and mutant fractional abundance, and whether this better correlates with relapse of disease and disease progression.

Regionalization of surgical care has improved the quality of care for patients with bladder cancer. We explored whether regionalization has benefited white and black patients equally.We used a New York State inpatient database to identify all patients who underwent cystectomy for bladder cancer from 1997 to 2011. Hospital volume was classified in quintiles based on the number of cystectomies performed in the first 5 years of the study. Logistic regression was done to assess the association between race and low volume/very low volume hospitals. Racial disparities were further characterized using stratification by time and by the racial composition of the patient community.A total of 8,168 patients treated with cystectomy for bladder cancer were included in analysis. Compared with white race, black race was associated with a higher likelihood of low volume/very low volume hospital use (OR 1.59, 95% CI 1.26-2.02). The disparity was most prominent in 2002 to 2006 (OR 2.51, 95% CI 1.64-3.85) but it did not persist in 2007 to 2011 (OR 1.46, 95% CI 0.92-2.32). Black patients living in a black community had the highest likelihood of low volume/very low volume hospitalization during all periods of increased regionalization (2002 to 2006 OR 4.14, 95% CI 1.84-9.34 and 2007 to 2011 OR 2.40, 95% CI 1.07-5.39).Regionalization of cystectomy transiently worsened the racial disparity in bladder cancer care, although the disparity did not persist with time. Specific efforts may be needed to address the consequences of regionalization in particularly vulnerable subpopulations, such as black patients who live in a black community where disparities have persisted.

OBJECTIVE To examine trends in the frequency and quality of surgery for primary hyperparathyroidism (PHPT) in California during the period of 1999 to 2008. BACKGROUND The quality of surgery for PHPT can be measured by the complication rate and the success rate of surgery. A fraction of patients with failed initial surgery undergo reoperation. METHODS Data on patients undergoing parathyroidectomy (PTx) were obtained from the California Office of Statewide Health Planning and Development. Renal transplant recipients and dialysis patients were excluded. Hospitals were categorized by case volume: Very low: 1 to 4 operations annually; Low: 5 to 9; Medium, 10 to 19; High: 20 to 49; Very high: 50 or more. Complication rates and the percentage of cases requiring reoperation were analyzed. RESULTS A total of 17,082 cases were studied. Annual case volume grew from 990 to 2746 (177% increase) over the study period, corresponding to a 147% increase in the per capita PTx rate. The proportion of cases performed by very high-volume hospitals increased from 6.4% to 20.5% (P < 0.001). The overall complication rate declined from 8.7% to 3.8% (P < 0.001). Complication rates were inversely related to hospital volume (very high volume, 3.9% vs very low volume, 5.2%, P < 0.05). Reoperation was performed in 363 patients (2.1%). The reoperation rate increased from 0.91% to 2.73% during the study period (P < 0.01). The reoperation rate was inversely and nonlinearly related to hospital volume, as described by the equation % reoperation = 100/(total hospital case volume). CONCLUSIONS Surgery for PHPT has grown safer and more common over time. High-volume centers have lower rates of complication and reoperation.

We investigated the acute neuromuscular and stress responses to three different high-intensity interval training sessions in young (age 19.5±1.3 years) and older (age 65.7±2.8 years) women. Cycling exercise comprised either 6 × 5 s or 3 × 30 s all-out, or 3 × 60 s submaximal, efforts each performed 5 weeks apart in randomized order. Peak and average power was higher in young than in older women and was largest during the 6 × 5 s strategy in both groups (p<0.05). The decrease in the ratio of torques evoked by 20 and 100 Hz electrical stimulation, representing low-frequency fatigue, was more evident after the 3 × 30 and 3 × 60 s than the 6 × 5 s bout in both groups and was larger in young than in older women (p<0.05). Both groups preferred 6 × 5 s cycling for further training. In conclusion, in young women, very low volume (6 × 5 s) all-out exercise induces significant physiological stress and seems to be an effective means of training. For older women, longer exercise sessions (3 × 60 s) are more stressful than shorter ones but are still tolerable psychologically.

The lack of national standards for establishing speed limits on unpaved roads has put pressure on local governments to make judgment calls about their road networks. Unpaved roads have unique characteristics that differ from those of paved roads. They usually are very low volume and were not necessarily designed by engineers. This study was conducted to determine the necessary standards and guidelines for establishing speed limits on unpaved roads in Wyoming. The process used national standards and state practices to ensure that a comprehensive methodology was followed. A focus group composed of traffic and safety engineers was formed to find an efficient process for establishing speed limits on unpaved roads. The group examined four main aspects for establishing speed limits: data collection requirements, roadway safety, determination of the appropriate speed limit, and declaration of the speed limit. Once the standards and guidelines were developed, five groups were asked to provide feedback to ensure that all stakeholders had an opportunity to review them. The Wyoming Technology Transfer Center–Local Technical Assistance Program developed and offered several training options for local jurisdictions to start their own speed limit programs. These options allowed for the standards and guidelines to be implemented by local jurisdictions in Wyoming. The findings of this study will provide states and counties with established standards for setting speed limits on unpaved roads as well as with a guide to different options for establishing speed limit programs.

Nanocellulose (NC) suspensions can form rigid volume-spanning arrested states (VASs) at very low volume fractions. The transition from a free-flowing dispersion to a VAS can be the result of either an increase in particle concentration or a reduction in interparticle repulsion. In this work, the concentration-induced transition has been studied with a special focus on the influence of the particle aspect ratio and surface charge density, and an attempt is made to classify these VASs. The results show that for these types of systems two general states can be identified: glasses and gels. These NC suspensions had threshold concentrations inversely proportional to the particle aspect ratio. This dependence indicates that the main reason for the transition is a mobility constraint that, together with the reversibility of the transition, classifies the VASs as colloidal glasses. If the interparticle repulsion is reduced, then the glasses can transform into gels. Thus, depending on the preparation route, either soft and reversible glasses or stiff and irreversible gels can be formed.

Overdiagnosis and overtreatment of ductal carcinoma in situ (DCIS) are concerns, especially for women with low-volume, screen-detected DCIS. This study aimed to evaluate the outcomes for such patients. Women who had minimal-volume DCIS (mDCIS, defined as DCIS diagnosed by core biopsy but with no residual disease on the surgical excision) treated with breast-conserving surgery from 1990 to 2011 were identified. Ipsilateral and contralateral breast events (IBE and CBE) were compared by competing-risk (CR) analysis. Kaplan–Meier (KM) estimates and log-rank tests were used to evaluate covariates. The study identified 290 cases of mDCIS. The median age of the patients was 53 years. Radiation therapy (RT) was performed for 27.6% and endocrine therapy for 16.2% of the patients. The median follow-up period was 6.8 years. Overall, the IBE rates were 4.3% at 5 years and 12.3% at 10 years. Among the women not receiving RT, the 5- and 10-year IBE rates (5.4 and 14.5%) were higher than the CBE rates (1.8 and 2.7%). Among those receiving RT, the IBE rates (1.5 and 6.0%) were lower than the CBE rates (4.1 and 15.6%). The women receiving RT trended toward significantly lower IBE rates (p = 0.07). Age, grade, and endocrine therapy were not significantly associated with IBE risk. Among the patients with mDCIS who did not receive RT, the IBE risk was substantially higher than the CBE risk, demonstrating that even DCIS of very low volume is associated with clinically relevant disease. The finding that the IBE risk was greater than the CBE risk supports current strategies that treat DCIS as a precursor rather than a risk marker. Women with mDCIS are not at negligible risk for IBE in the absence of adjuvant therapy.

Objective: This study is aimed to report and evaluate the experience and learning curve of extraperitoneal Laparoscopic Radical Prostatectomy (LRP) performed in Cipto Mangunkusumo General Hospital Jakarta. Material & method: We collected all data of patients that had been performed extraperitoneal LRP from June 2013 until February 2016, retrospectively. We divided those data into 3 groups with equal number in each group. We compared the preoperative (age, prostate volume, PSA level and prostate cancer staging), intraoperative (surgery time, total blood loss, conversion to open surgery and other organ injury), and postoperative (postoperative length of stay) variables between those 3 groups using ANOVA and Kruskal-Wallis test. Results: We performed 15 extraperitoneal LRP from June 2013 until February 2016 with patient’s mean age was 64.40 (SD ± 5.30) years old and mean prostate volume was 42.39 (SD ± 29.21). In this study, we found significant differences in surgery time, total blood loss, and postoperative length of stay (LOS) in all group with decrease on each intraoperative and postoperative variables. We also found no conversion to open surgery or other organ injury in all patients. Conclusion: The increase of surgeon’s experience and the number of surgery, and the consistency undergo the procedure of LRP demonstrate a decrease in surgery time, intraoperative blood loss and LOS in LRP patients.

We develop a paper based fuel cell in which fluids flow through a capillary transport mechanism. The pencil stroked graphite electrodes take oxygen from quiescent air. This simple and efficient paper fuel cell can generate energy to the tune of 32 mW cm(-2) over a prolonged duration of around 1000 minutes, and with the consumption of a very low volume of formic acid as fuel (~1 mL).

The formation of colloidal gels is strongly dependent on the volume fraction of the system and the strength of the interactions between the colloids. Here we explore very dilute solutions by the means of numerical simulations, and show that, in the absence of hydrodynamic interactions and for sufficiently strong interactions, percolating colloidal gels can be realised at very low values of the volume fraction. Characterising the structure of the network of the arrested material we find that, when reducing the volume fraction, the gels are dominated by low-energy local structures, analogous to the isolated clusters of the interaction potential. Changing the strength of the interaction allows us to tune the compactness of the gel as characterised by the fractal dimension, with low interaction strength favouring more chain-like structures.

Multiple intraluminal impedance in combination with pH measurement on a single catheter in the esophagus allows the detection of bolus movements, even of very low volume. With this technology, which has become the new diagnostic standard for gastroesophageal reflux, it is possible to analyze bolus direction, velocity, height, and clearance. With simultaneous recording of the symptom under investigation, a temporal symptom-reflux association can be established.

The link between higher procedure volume and better outcomes for surgical procedures is well established. We aimed to determine whether procedure volume affected inpatient mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS). An epidemiological analysis of an all-payer database recording hospitalizations during 2013 in the United States (Nationwide Readmissions Database) was performed. All patients ≥ 18 years old undergoing TIPS during a hospital admission (n = 5529) without concurrent or prior liver transplantation were selected. All-cause inpatient mortality was assessed. Risk-adjusted mortality was assessed for hospitals categorized into quintiles based on annual TIPS volume (very low, 1-4/year; low, 5-9/year; medium, 10-19/year; high, 20-29/year; and very high, ≥ 30/year). TIPS were placed in all 5529 patients (mean age, 57 years [standard deviation, ± 10.9 years]; women, n = 2071; men, n = 3458). Mortality decreased with rising annual TIPS volume (13% for very low to 6% for very high volume hospitals; P 0.01). Elective admissions were more common in hospitals with higher annual TIPS volume (20.3% for very low to 30.8% for very high; P 0.01). On multivariate analysis, compared with hospitals performing ≥30 TIPS per year, only hospitals performing 1-4/year (adjusted odds ratio [aOR], 1.9; 95% confidence interval [CI], 1.21-3.01; P = 0.01), 5-9/year (aOR, 2.0; 95% CI, 1.25-3.17; P 0.01), and 10-19/year (aOR, 1.9; 95% CI, 1.17-3.00; P = 0.01) had higher inpatient mortality (20-29/year: aOR, 1.4; 95% CI, 0.84-2.84; P = 0.19). The absolute difference between risk-adjusted mortality rate for very low volume and very high volume hospitals was 6.1% (13.9% versus 7.8%). TIPS volume of ≤ 20 TIPS/year, variceal bleeding, and nosocomial infections were independent risk factors for inpatient mortality in patients with both elective and emergent admissions. Conclusion: The risk of inpatient mortality is lower in hospitals performing ≥20 TIPS per year. Future research exploring preventable factors for higher mortality and benefits of patient transfer to higher volume centers is warranted. (Hepatology 2018;67:690-699).

Although centralization of surgical procedures to high volume centers has been described previously, patterns of care for adrenal surgery are largely unknown. We determined the extent of regionalization of care for adrenal surgery and the extent to which this centralization has evolved with time.Using 1996 to 2009 hospital discharge data from New York, New Jersey and Pennsylvania we identified all patients 18 years old or older treated with adrenalectomy. Hospital volume quintiles were created using 1996 hospital volumes. These cutoffs were then applied to subsequent years. Outcome variables were examined by hospital volume status with time using logistic regression models.A total of 8,381 patients underwent adrenalectomy from 1996 to 2009 with a significant 17% to 42% shift toward regionalization to very high volume hospitals, defined as 15 or greater procedures per year (p0.001). For each successive year the odds of having surgery performed at a very low volume hospital decreased by 13% (OR 0.87, 95% CI 0.84-0.89). There were significant differences in patient age, race and payer group for very low volume hospitals, defined as less than 1 procedure per year, compared to very high volume hospitals (p0.0001). Patients at very high volume hospitals were less likely to be 55 years old or older (OR 0.73, 95% CI 0.61-0.88), insured through Medicaid (OR 0.60, 95% CI 0.45-0.79) or uninsured (OR 0.34, 95% CI 0.17-0.70). When controlling for year treated, patients were less likely to die in the hospital if treated at a very high volume hospital (OR 0.38, 95% CI 0.19-0.75).These data reveal the increasing centralization of adrenalectomy to very high volume hospitals since 1996 with improved clinical outcomes. Inequities in access to care to higher volume centers appear to exist and require further investigation.

Pollen accumulation rates (PARs) provide a potential proxy for quantitative tree volume (m3 ha 1) reconstruction with reliable absolute pollen productivity estimates (APPEs). We obtained APPEs for pine, spruce and birch at their range limits in northern Finland under two temperature periods ('warm' and 'cold') based on long-term pollen trap and tree volume records within a 14-km radius of each trap. APPEs (mean SE; 108 grains m 3 a 1) tend to be higher for the 'warm' periods (pine 123.8 24.4, birch 528.0 398.4, spruce 434.3 113.7) compared with the 'cold' periods (pine 95.5 37.3, birch 317.3 282.6, spruce 119.6 37.6), although the difference is only significant for spruce. Using an independent temperature record and the APPEs obtained, we reconstruct a low-frequency record of pine volume changes over the last 1000 years at Palomaa mire, where a high-resolution record of Pinus PARs is available. Five phases are distinguished in the reconstruction: moderate pine volume, AD 1080-1170; high volume, AD 1170-1340; low volume, AD 1340-1630; very low volume, AD 1630-1810; and rising pine volume, AD 1810- 1950. These phases do not coincide with periods of high or low June-July-August temperatures, and thus appear to reflect regional variations in tree volume, while high-frequency changes within each time-period block show variations in PARs in response to temperature

The objective of this research is to examine the induction heating of mastic through the addition of electrically conductive fillers and fibers (graphite and steel wool), and to prove that this material can be healed with induction energy. The effect of fibers content, sand-bitumen ratio and the combination of fillers and fibers on the induction heating of mastic was investigated. It was found that there is an optimum content of fibers for each sand-bitumen ratio, above which mastic cannot be heated any more. This optimum seems to coincide with the optimum electrical conductivity of the mixture shown in [1]. It was found that the maximum temperature reached within a certain time period was a function of the sand-bitumen ratio (s-b) and of the volume content of fibers. The mastic could be heated with the addition of a very low volume of conductive fibers. The fastest heating power was obtained with the mix with the maximum electrical conductivity. Gel-Permeation Chromatography (GPC) was also used to show that there is not ageing of bitumen during the heating process. © 2010 The Author(s).

We sought to examine the impact of hospital surgical volume on the number of nodes harvested and survival in colorectal cancer (CRC). Between January 1994 and December 2004, a total of 8567 patients with T1, 2, 3, and 4 primary tumors and N0, N1, or N2 disease were studied. Hospitals were stratified into very low volume (VLV) (

The ZrC-reinforced steel-based composites have been synthesized by a two-step process, where in the first step, Fe–Zr–Al–Si–C master alloy has been synthesized by aluminothermic reduction of Fe2O3 and ZrSiO4. In the second step, this master alloy has been dissolved in molten mild steel to synthesize the ZrC-reinforced steel-based composites. The mechanical properties such as hardness, tensile strength and impact toughness of the composites have been evaluated. The wear resistance property of the composites has been evaluated as well. The hardness, tensile strength, and wear resistance of the composites increase significantly over mild steel, in spite of very low volume fraction of ZrC.

Purpose To examine the utility of a 3He spectroscopic q-space technique for detecting changes in lung morphometry in vivo. Materials and Methods A diffusion-weighted spectroscopy sequence was used to collect global diffusion data from healthy adults (N = 11), healthy children (N = 5), and chronic obstructive pulmonary disease (COPD) patients (N = 2) using 40 cc of hyperpolarized 3He gas within a two second breathhold. Displacement probability profiles (DPP) were obtained by Fourier transformation of diffusion data with respect to q. A bi-Gaussian model was used to decompose the DPPs into narrow and broad components, characterized by root-mean-square displacements Xrms1 and Xrms2, respectively. Results In healthy adults, the narrow component (Xrms,1) of the DPP had a mean displacement of 188 ± 10 μm, slightly less than the reported average size of the alveoli. The broad component (Xrms,2) had a mean value of 474 ± 44 μm, comparable to the diameter of the respiratory bronchioles in the acinus. In children, both Xrms1 (167 ± 4 μm) and Xrms2 (382 ± 22 μm) compared to healthy adults (P < 0.01). In COPD patients, the mean displacements were elevated (Xrms1: 265 ± 71 μm; Xrms2: 530 ± 109 μm) compared to healthy adults. Excellent correlation was found between rms displacements and age (age vs. Xrms,1: r = 0.78, P < 0.001; age vs. Xrms,2: r = 0.90, P < 0.001). Conclusion The q-space parameters agreed remarkably well with published alveolar morphometry data. The results suggest that the technique may be sensitive to disease, as evident from the elevated mean displacements in COPD patients compared to healthy volunteers. Detailed lung microstructural information can be obtained using a very low volume of inhaled 3He. J. Magn. Reson. Imaging 2006. © 2006 Wiley-Liss, Inc.

Background The relationship between surgical volume and clinical outcome is well established in adult pancreatic surgery. We examined whether this relationship is applicable in pediatric surgery, given that very few cases are done regularly by pediatric surgeons even at tertiary centers. Methods A retrospective analysis of all patients who underwent pancreaticoduodenectomies between 1993 and 2003 was done. Comparisons were made to the largest recent series of pancreaticoduodenectomies in the adult literature. Results With the age at presentation from 9 to 17 years, 5 patients were identified. Mean operative time was 451 minutes with a median of 363 minutes compared with the mean and median in the adult literature of 420 minutes. Clean margins were obtained in all patients compared with 71% in adults. Mean follow-up was 35 months. All patients are alive, with 1 patient who has underwent subsequent resections for local recurrence. Conclusion Although 5 consecutive cases of pancreaticoduodenectomies represent very low volume compared with high-volume adult centers, minimal difference in operative time, length of stay, and mortality (none) were observed in this series. Therefore, unlike adults, particular case volume in the pediatric population may not be a significant factor because of the nature of pancreatic pathology, patient characteristics, and hospital and surgical environment.

Partial nephrectomy (PN) remains underutilized within the United States and few reports have attempted to explain this trend. The aim of this study is to evaluate the nationwide incidence of unsuccessful PN and factors that predict its occurrence.Using the Premier Healthcare Database, we retrospectively analyzed a weighted sample of 66,432 patients undergoing curative surgery for renal mass between 2003 and 2015. PN intent was denoted by presence of insurance claims for the administration of mannitol. Unsuccessful PN was defined as an event in which patients were administered mannitol but received radical nephrectomy. A multivariate logistic regression model was generated to identify factors predicting unsuccessful PN.Overall rates of unsuccessful PN declined from 33.5% to 14.5% since 2003. Conversion to radical nephrectomy occurred most frequently during laparoscopic (34.7%) and least frequently during robotic approach (13.6%). There was significant difference in the rate of unsuccessful PN between very high and very low volume surgeons (open: 39.4% vs. 13.3%, laparoscopic: 51.2% vs. 32.2%, and robot assisted: 27.1% vs. 9.4%, all P0.001). After adjustment for patient- and hospital-related factors, surgical approach (laparoscopic vs. open, odds ratio = 1.74, 95% CI: 1.31-2.30, P0.001) and annual surgeon volume (very high vs. very low, odds ratio = 0.27, 95% CI: 0.21-0.34 P0.001) were associated with unsuccessful PN.Although the rate of unsuccessful PN appears to be declining, it still remains common for low volume surgeons and with the laparoscopic surgical approach. Further evaluation of its effect on health care outcomes is necessary.

Rwanda remains trading very low volume of beans inside the country and across borders thereby becoming unable to meet national and international demands. This is exacerbated by low market participation of bean growers. This study assessed factors that influence market participation and extent of participation among bean growers in Nyanza district. Probit model was used to analyze the factors influencing market participation among bean growers while the extent of market participation was analyzed using Tobit model. The probit results indicated that factors that positively and significantly influenced the probability of farmers to participate in output market were bean quantity produced, market experience, and access to credit while factors that negatively and significantly influenced market participation decisions included distance to nearest market, age and access to off-farm activities. Tobit results revealed that factors that were found to have positive statistical significant impact on the extent of market participation were bean quantity produced, marketing experience and selling price. Contrary to earlier expectation, land size was found to have negative significant impact on the quantity of bean marketed. This is possibly an indication that the increased household’s participation in output market is a function of farm productivity too.

A wettable powder formulation of Helicoverpa armigera nuclear polyhedrosis virus (NPV) was applied against larvae of the cotton bollworm ( Helicoverpa armigera ) (Hubner) in Thailand. Field trials were carried out on rainfed cotton in September and October 1995 to investigate the efficacy of spinning disk spray application, at very low volume (VLV) rates, compared to motorised knapsack mistblower spray application at medium volume (MV) rates. Trials were done to ascertain if any control benefits would arise from using VLV spinning disk sprayers as an alternative application method to mistblower sprayers (at medium volume) commonly used on cotton in Thailand. Sprayer performance was assessed by bioassay of leaves sampled from spinning disk VLV and mistblower MV spray application plots. Volumes of spray deposited were determined and measurements of droplets deposited on targets attached to leaves were made. The results of leaf sample bioassays indicated that VLV application by a spinning disk sprayer gave better control than did MV application by a mistblower.

Design and evaluation methodologies for low-volume rural roads have traditionally followed an agricultural focus, with an understanding that improved transport, by lowering transport costs, supports economic development through expanding exports and local incomes. More recently, the role of low-volume roads as a crucial complementary input to other activities has been recognized, especially the delivery of essential health and educational services, exchange of information, and basic social interactions. However, limited analytical work has been done to ensure that these benefits are systematically incorporated in the planning and evaluation of transport projects, and experience suggests that the current emphasis of design and evaluation on agricultural benefits can lead to inappropriate priorities and design standards, inasmuch as these are still typically guided by trading off infrastructure life-cycle costs (construction and maintenance) against motorized user savings (vehicle operating costs) and/or increased net income/value-added. There is a need to be more discerning in the application of existing methodologies, as well as to systematically incorporate the socioeconomic role of rural transport infrastructure (including poverty alleviation) into prioritizing improvements. Key to this analysis is the proposition that appropriate design standards need to balance the transport requirements of core economic and social activities with the impact of geography (geology, topography, and climate) on construction and maintenance costs. By taking into account the broader range of impact on local users, the proposed approach encompasses a wide array of options for providing minimum-cost, reliable infrastructure for both motorized and nonmotorized transport.

A practical methodology for prioritizing road works on low-volume and very low-volume roads in the rural areas of developing countries is described. The methodology is based on a system for estimating future traffic on improved roads on the basis of readily available data. Moreover, the method accommodates the need to consider the opening of roads that may be currently impassable to motor traffic. The procedure is simple and transparent, and therefore it is well suited to implementation at the district level. It allows for certain basic parameters, such as minimum thresholds for viability of investments, to be set by decision makers, thereby permitting and defining the role of politicians in the process.

Plant protection products often need to be applied to small areas, inaccessible to vehicular equipment, hence the need for manually carried equipment. While there are lever-operated knapsack and compression sprayers using conventional hydraulic nozzles, reduced-volume applications have been developed in combination with the use of rotary atomizers to provide a narrow droplet spectrum. Most of the initial development of these hand-carried battery-operated spinning disc sprayers was for their use in the semi-arid tropics to apply insecticides to cotton in the absence of plentiful water supplies. This continues to be the main market for these sprayers, although the trend recently has been away from oil-based ultra-low volume formulations to very-low volume spraying (typically 5-1 5 litre ha1) of water-based formulations to reduce costs and allow greater flexibility in choice of insecticide in integrated pest management programmes. Changes in equipment design have been made to suit this change in spray volume and formulation. Air-assisted sprayers have also been used in glasshouses. Subsequent development of rotary atomizers operated at slower speeds has led to the equipment being used for herbicide application. especially in forestry and urban situations where low weight of equipment and drift reduction have been important considerations. Formulations prepacked in containers to connect directly to the sprayers have been used to reduce operator contamination.