Anastomosis is one of the important factors affecting anastomotic complications after esophagectomy, and multiple reports have compared anastomotic complications among various techniques. However, there is insufficient evidence in the literature to definitively recommend one anastomotic technique over another.We retrospectively evaluated 34 consecutive patients who underwent an improved totally mechanical side‐to‐side: posterior‐to‐posterior linear stapled (TM‐STS) technique for minimally invasive Ivor Lewis esophagogastric anastomosis, performed by a single surgeon between February 2015 to November 2017. The operative techniques and short‐term outcomes are analyzed in this study.There were no conversions to an open approach and a complete resection was achieved in all patients undergoing this improved procedure. During the first half of the series, the median operation time was 355 minutes, ranging from 257 to 480 minutes. Over the second half of this series, the median operation time was reduced to 256 minutes. There were no mortalities or serious postoperative complications. Only one patient (2.9%) had an anastomotic leak, which resolved without intervention. Another patient (2.9%) experienced transient, delayed conduit emptying which upper gastrointestinal radiography determined was due to a mechanical obstruction caused by an abnormally long gastric tube in the chest cavity.The results of our study suggest that this improved TM‐STS technique is safe and effective for minimally invasive Ivor Lewis esophagectomy, and can be considered as one of the alternative procedure for patients with lower esophageal as well as Siewert types I/II gastroesophageal junction carcinoma. For over a century, esophagectomy has been the mainstay of curative treatment for esophageal cancer. A significant number of patients have experienced long‐term survival following an esophagectomy for early‐stage esophageal cancer with low operative mortality.As experience with MIE accumulates, there is a need to improve the MIE anastomotic technique. Methods of constructing the esophagogastric anastomosis have varied with the most common procedures advocated being hand sewn, circular stapled, linear stapled and modified Collard approach (combined linear and transverse stapled anastomosis). Different esophagogastric anastomotic techniques have their own characteristics, and multiple reports have compared anastomotic complications among various techniques.Carcinoma of the distal esophagus and esophagogastric junction has been increasing in recently years.To overcome this issue, we have developed an improved “totally mechanical side‐to‐side: posterior‐to‐posterior linear stapled” (TM‐STS) technique for minimally invasive Ivor Lewis (MIE‐IL) esophagogastric anastomosis, designed to offer not only a wider anastomotic diameter and fewer morbidities associated with anastomotic leaks and strictures, but also technical simplicity in constructing an intrathoracic esophagogastric anastomosis. In this study, we describe an improved esophagogastric anastomotic technique in 34 MIE‐IL procedures, and review the postoperative outcome.This retrospective study was approved by the ethics committee of The Affiliated Hospital of Qingdao University. Informed consent was signed by all 34 patients or their legal representatives regarding the scientific use of collected data, including data from their medical records, obtained while undergoing a MIE‐IL esophagectomy using an TM‐STS esophagogastric anastomosis from February 2015 to November 2017. Demographic characteristics, perioperative outcomes and postoperative morbidity of the patients were also recorded. Since the data from this study did not include any patient identifying information, Institutional Review Board approval was not required.et al.All patients had a standardized, preoperative evaluation as previously described by Ben‐David MIE‐IL is usually performed in two stages. First, laparoscopic stomach mobilization and intra‐abdominal lymphadenectomies are performed under general anesthesia, as previously described Fig .18, 19, Second, the patient is placed in the left lateral prone position. An esophagectomy is performed thoracoscopically using three access ports with the camera placed in the seventh intercostal space in the right posterior axillary line, and the utility port in the fourth intercostal space between the middle and posterior axillary line. The auxiliary port is placed in the seventh intercostal space in the right scapular line Fig B. The thAn intrathoracic totally mechanical side‐to‐side: posterior‐to‐posterior linear and transverse stapled (TM‐STS) anastomosis is then performed after removing the specimen from the utility port. The gastric conduit is brought up carefully until a sufficient length can be obtained for an esophagogastrostomy with the staple line facing towards the right side of the chest wall as a landmark for preventing the rotation of the conduit. Small incisions are made on the distal posterior wall of the esophageal stump and on the proximal posterior side of the gastric conduit 5 cm from the stump to make the TM‐STS anastomosis. A small incision on the conduit must be made transversely to prevent increasing the size of the anastomosis after closure of the common incision for insertion of the stapler. Three initial tacking sutures are placed between the adjacent conduit and esophageal walls beginning at the level of the transverse anastomosis. The anterior wall of the esophageal remnant and the remaining extroverted stump of the gastric conduit are then transected with a 60 mm golden cartridge (Ethicon Endo‐Surgery) 0.5 to 1 cm beneath the level of the tacking sutures. This is also performed through the fourth intercostal space port. Ultimately, a V‐shaped anastomosis is created by one or two 60 mm golden cartridges (Ethicon Endo‐Surgery) Fig . After tThe reconstructed conduit is placed in the inherent space of the thoracic esophagus to reduce anastomotic tension. The anastomosis is then inspected using endoscopy to ensure patency and determine that no leak is present during insufflation of intraluminal air on submerging the anastomosis under fluid Fig .Continuous variables were reported as the mean ranges and percentages were used for discrete characteristics. The improved TM‐STS technique for MIE‐IL anastomosis was the indicated treatment. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 25.0 .2. A history of smoking and drinking were noted in 76.5% and 70.6% of patients, respectively. Although cessation of smoking was strongly recommended, current smoking was not a contraindication to surgery.Demographic characteristics for the 34 patients who underwent TM‐STS intrathoracic esophagogastric anastomosis are shown in Table The perioperative data and pathological results are presented in Tables et al. first described a MIE using a combined thoracoscopic esophageal mobilization followed by fashioning of the gastric conduit laparoscopically and construction of a cervical esophagogastric anastomosis.In this study, we describe our initial experiences and results in 34 consecutive patients with esophageal and gastroesophageal junction malignancies using an intrathoracic totally mechanical side‐to‐side: posterior‐to‐posterior linear and transverse stapled anastomosis. Minimally invasive esophagectomies seem to contribute significantly to a smooth postoperative recovery by reducing postoperative complications and improving quality of life.A cervical anastomosis offers not only less severe morbidity associated with anastomotic complications but also technical simplicity when constructing the actual anastomosis. However, an intrathoracic anastomosis reduces the tension on the anastomosis for both the gastric conduit and the proximal esophagus, and is accompanied by a relatively well nourished conduit tissue, which subsequently would lead to a reduced incidence of anastomotic dehiscence. In addition, a cervical anastomosis may not guarantee an oncologically safe distal margin in some patients whose tumors have involved the gastroesophageal junction. In fact, some studies, including randomized controlled trials, suggest no significant difference in major surgical complications between the two types of anastomoses.Methods for constructing the esophagogastric anastomosis in minimally invasive surgical procedures vary because of difficulties related to technically accessing the area. Multiple reports have compared anastomotic leak rates among various techniques. A recent meta‐analysis found lower leak rates with a linear stapled esophagogastric anastomosis compared to a completely hand‐sewn technique.An analysis of the results from our current practice demonstrates outstandingly low rates of anastomotic leakage when we compared to other high‐volume, minimally invasive centers. We have identified only one anastomotic leak in 34 patients undergoing a MIE‐IL utilizing a linear stapler with a 60‐mm, side‐to‐side anastomosis. There are some possible reasons for our low leak rates associated with this improved technique. First, the technique utilizes a relatively well‐vascularized area on the posterior side of the esophagus and stomach where the gastric conduit staple line resides instead of at the end of the esophagus. Second, a 3 cm proximal gastric conduit was excised intraoperatively and the fundus of the stomach was formed at that time, which may reduce the influence of gastric juice reflux on the anastomosis and ensure sufficient blood flow to the anastomosis. Third, the large anastomotic opening spreads the distribution of pressure when the stapler is applied and reduces the shear forces on the anastomosis that tend to pull side to side.et al. reported that the incidence of anastomotic stenosis was inversely proportional to the diameter of the annular stapler, and the incidence of stenosis was 12.3% in 187 patients, among whom no anastomotic stenosis occurred in patients with an anastomotic circumference greater than 29 mm.P = 0.02).Petrin The results of this improved TM‐STS technique reveal that it can be employed safely and effectively in patients with lower esophageal as well as Siewert types I/II gastroesophageal junction carcinoma during MIE‐IL. The procedure described in this study utilized a linear 60 mm stapled intrathoracic anastomosis and was associated with excellent outcomes, including low leak and stricture rates. However, the optimal approach and anastomotic type may not be determined unless evaluated by a randomized trial comparing these techniques.In our study, there were several limitations that should be mentioned when interpreting our results. Whereas the leak rate is low utilizing this technique for a minimally invasive Ivor Lewis esophagectomy, it is a technically demanding operation and requires more minimally invasive skills than a cervical anastomosis. Although a relatively simple technique, nevertheless a learning curve may be required. Of note, in our series, reoperation for an anastomotic leak was not needed. In addition, there was no patients requiring dilatation for anastomotic stricture within the short‐term follow‐up period; however, long‐term follow‐up outcomes are unknown.In conclusion, this improved TM‐STS procedure is relatively adaptable and reproducible with promising short‐term outcomes, which can be considered as one of the alternative procedure for patients with lower esophageal as well as Siewert types I/II gastroesophageal junction carcinoma. The long‐term outcomes need to be investigated in the future, including a study of the effect of our technique on a patient's esophageal‐specific quality of life.


Globally over 2.6 million pregnancy ends with stillbirth annually. Despite this fact, only a few sherds of evidence were available about factors associated with stillbirth in Ethiopia. Therefore, the study aimed to spot factors related to stillbirth among women who gave birth at Hawassa University Comprehensive Specialized Hospital Hawassa, Sidama Ethiopia, 2019.Facility-based unmatched case-control study was conducted at Hawassa University Comprehensive Specialized Hospital. Cases were selected using simple random sampling technique and controls were recruited to the study consecutively after every case selection with case to control ratio of 1 to 3. Data were coded and entered into Epi-data version 3.1 and exported to SPSS version 24 for analysis.A total of 106 cases and 318 controls were included in the study. Number of antenatal care visit , lack of partograph utilization [AOR = 4.1 95% CI ], prolonged labor , obstructed labor , and congenital defect  were significantly associated with stillbirth.Absence of partograph utilization, prolonged labor, obstructed labor, antepartum hemorrhage and congenital anomaly were found to have positive association with stillbirth. Stillbirth is one of the public health problems and defined as a fetus born with no sign of life at or after 28 completed weeks of gestation with a birth weight of 1000 g or more and a body length of > 35 cm .Globally more than 2.6 million pregnancy ends with stillbirth per annum and the majority of them ensues in the middle and lower-income countries and 55% of this occurs during the intrapartum period , 5. Sub-Ethiopia showed a decline in maternal mortality by 50% from 1990 to 2016 and neonatal mortality from 55 per 1000 to 28 per 1000 live births between 1990 to 2015 . However, the odds of women whose birth weren’t followed up by partograph were 4 times higher risk of encountering stillbirth compared to labor monitored by partograph [AOR = 4.1]. On the other hand, the odd of women who gave birth by cesarean delivery were 67% less likely to have stillbirth than mothers who gave birth through vaginal delivery [AOR = 0.33 CI ]. The odds of a mother who had prolonged labor were 6 times more likely to have stillbirth [AOR = 6.5 CI ] compared to a mother who gave birth within 24 h. Also, the odds of women who had a diagnosis of obstructed labor were 3 times higher risk for [AOR = 3.5 CI ] stillbirth than women who did not have obstructed labor. Moreover, the odds of a mother who had antepartum hemorrhages were 4 times at risk [AOR = 4.3 CI ] for stillbirth than women who did not have antepartum hemorrhages. Finally, odds of women who had a diagnosis of congenital anomalies were 9 times at risk [AOR = 9.7 CI ] for stillbirth than women who did not have congenital anomalies (Table This study showed that antenatal care visits, lack of partograph utilization and mode of delivery, duration of labor, antepartum hemorrhages, obstructed labor, and congenital anomalies were statistically associated with stillbirth.The current study showed that odd of a mother who had four antenatal care visits were 62% less likely risk for stillbirth than odds of a mother who have less than four antenatal care visits. This finding was supported by a study conducted in southwest Ethiopia , a studyThis present study also showed that mother her labor not followed by using partograph was 4 times higher at risk for stillbirth than labor followed by partograph. This finding was consistent with a study in Nigeria , in UganThis study finds that the odds of mothers gave birth by cesarean delivery was 67% less likely risk of developing stillbirth than odds of mothers gave birth through vaginal delivery.The finding was consistent with the study in India , a studyThis study also showed odd of women’s diagnosis of prolonged labor was 6 times more at risk for stillbirth than odds of women gave birth within 24 h of the onset of labor. The finding was consistent with the study in Nigeria  and studIn the current study women who had a diagnosis of obstructed labor were 3 times more at risk for stillbirth than women who did not have obstructed labor during labor and delivery. The finding was consistent with a study conducted in south Ethiopia  This posOdd of who had a diagnosis of Antepartum hemorrhage was 4 times more at risk for stillbirth than odds of who women do not have antepartum hemorrhages. This finding was consistent with a study in Nigeria , in ZimbThis study finds the odd women gave fetal congenital anomaly was 9 times at risk for stillbirth than odd women gave fetally had no congenital anomalies. The finding was consistent with a study in Nigeria countries , 24. TheThe study reviews multiple exposures for stillbirth as well as both cases and controls were selected from the same setting and population this may reduce selection bias between cases and controls. This study was used secondary data as a source of information, there might be intra-observer bias and diagnosis as well as missing a variable during data collection.This study identified antenatal care and caesarian delivery was Negatively associated with stillbirth. Whereas not using partograph, prolonged labor, antepartum hemorrhages, obstructed labor, and congenital anomaly were positively associated with stillbirth. The current study indicated that National policy, structural, and process play a significant role in the quality of service provision. The government plays a role with respective stakeholders to decrease drop out of ANC visits and facilities must give orientation for their providers about respectful and compassionate care and the quality department of respective units must follow the providers during the intrapartum period to follow women with partograph. The study strongly recommended future researchers to do an interventional study that could be addressed preconception care utilization because in current study congenital anomaly the strongest factor associated with stillbirth.


To assess the therapeutic effect of a novel tension band using 3.0 mm cannulated screw combined with a titanium cable and specific shims comparatively with patellotibial tubercle cerclage in comminuted fractures of the inferior pole of the patella.U test and the chi‐squared test, respectively. Fisher's exact test was used for small data subsets.The retrospective study from March 2012 to July 2017 was conducted in Peking University Third Hospital and comprised 63 patients with comminuted fractures of the inferior pole of the patella: 41 treated with new tension band using 3.0 mm cannulated screw combined with a titanium cable and specific shims (new tension band group) and 22 with patellotibial tubercle cerclage (tubercle cerclage group). Gender, age, AO/OTA fracture type, injury mechanism, inter‐fragmentary gap, and follow‐up time of patients were recorded. Two groups were compared regarding: operation time, blood loss, partial weight‐bearing time, fracture‐healed time, Bostman score and knee mobility at 12‐month follow‐up, and postoperative complications. Continuous and categorical parameters were analyzed by Mann‐Whitney P > 0.05). The mean operation time of new tension band group was significantly longer than that of tubercle cerclage group , while there was no significant difference in blood loss. After surgery, new tension band group had a significantly earlier mean partial weight‐bearing time  and fracture‐healed time . At 12‐month follow‐up, patients of new tension band group had a significantly higher mean Bostman score  and knee mobility . Ten complications related with internal fixation were found in tubercle cerclage group including two cases of loose internal fixation, two cases of cerclage breakage, and six cases of low patella position who undertook secondary operation. No complications were found in new tension band group .Between the two groups, no statistically significant difference was found in mean age, gender, AO/OTA fracture type, injury mechanism, mean inter‐fragmentary gap, or mean follow‐up time (Patients with comminuted fractures of the inferior pole of the patella treated with a novel tension band experienced a longer operation time, but earlier partial‐weight‐bearing and fracture‐healed time, better clinical outcomes at 12‐month follow‐up, and less complications. It should be considered an alternative therapy for the treatment of distal pole patellar fractures. The patella is the biggest sesamoid bone in the human body, situated within the tendon of the quadriceps femoris muscle; it is functionally part of the knee extension system. Patella fractures result in a functional disability of the knee extension system, and constitute approximately 1% of all fracturesThe inferior pole is an anterior cortical extension of the patella body without articular cartilage. It is the origin of the patellar tendon and bears a high stress. Inferior pole fractures of the patella account for 9.3%–22.4% of all patellar fractureset al.et al.Complete patellectomy for comminuted fractures of patella was no longer recommended as studies have demonstrated a high rate of subjective dissatisfaction and poor knee function in patientsRecently, most surgeons attempted to retain some of the fragments of inferior pole and many treatment methods for retaining inferior pole fragments were reported, mainly in various forms of internal fixation, such as wire looping, basket plate, and anchor suture fixationTherefore, this retrospective study assessed the clinical outcome of a novel tension band using 3.0 mm cannulated screw combined with a titanium cable and specific shims comparatively with patellotibial tubercle cerclage in comminuted fractures of the inferior pole of the patella.The aim of the present study was to provide orthopaedic surgeons with: (i) an overview of different ORIF techniques for treating fractures of the inferior pole of the patella and their advantages and disadvantages; (ii) an introduction to the surgical technique of the novel tension band as an effective therapy for comminuted fractures of the inferior pole of the patella; and (iii) a summary of the difficulties of this surgical technique and proposed solutions.Patients treated with novel tension band were defined as new tension band group, and those who were treated with patellotibial tubercle cerclage were defined as tubercle cerclage group. We compared two groups regarding operation time, blood loss, partial weight‐bearing, fracture‐healed time, Bostman score and knee mobility at 12‐month follow‐up, and postoperative complications.This retrospective study included patients at our institution between March 2012 and July 2017. Inclusion criteria were: (i) patients experienced a patella fracture within 3 days; (ii) physical examination indicated patients with functional disability of the knee extension system due to patella fracture; (iii) X‐ray indicated that fractures were inferior pole patellar, including AO/OTA 34‐A1 fracture (inferior pole avulsion fracture with intact patellar articular surface) and AO/OTA 34‐C1.3 fracture Exclusion criteria were: (i) any difficulties to ambulate or functional limitations before injury; (ii) pathological fracture, delayed fracture, stress fracture, or periprosthetic fracture; and (iii) follow‐up less than 12 months.The study was approved by the Ethics Committee of the hospital and was subject to its supervision. Informed consent was obtained from all patients or their family members, and the study conformed to the provisions of the Declaration of Helsinki (as revised in Brazil in 2013).Patient demographics and clinical characteristics were recorded, including: gender, age at the time of operation, the AO/OTA classification, and injury mechanism. The preoperative inter‐fragmentary gap was also recorded, defined as the distance from the upper edge of the inferior fragment to the lower edge of the superior fragment of the patella on lateral position X‐ray of knee.Patients were divided into the new tension band group and patellotibial tubercle cerclage group, and undertook different surgical procedures. Operation was considered when articular displacement was greater than 2 mm or fragment separation exceeded 3 mm as assessed by radiography.All patients were treated with spinal anesthesia. Patients were placed in the supine position on a radiolucent table, and a pneumatic tourniquet was used in all cases. We performed a standard midline longitudinal incision extending from the upper end of the patella to patellar tendon. Full thickness skin flaps were raised medially and laterally to expose the transversely ruptured retinaculum, fracture, and patellar tendon. Fracture fragments were identified and irrigated with saline to remove hematomas. In inferior pole fractures of the patella, comminution was common, and care was taken to preserve soft tissue attachment of patellar tendon to distal fragments.In the novel tension band group, with the knee in extension, the fragments were clamped to reduce the fracture with small towel clamps. We drilled two K‐wires (1.5mm diameter) in parallel from the inferior pole to the superior pole of the patella. The K‐wire was inserted as far as possible from the center of the fracture fragment, 30° from the coronal plane of the patella to avoid the articular surface. The K‐wires did not penetrate the cortex of the superior patellar pole Fig. . We thenIn the patellotibial tubercle cerclage group, we used a similar method to reduce the inferior patellar fracture. Precisely, 3.0‐mm titanium cannulated or anchor screws or sutures were used to fix the small fragments. The extensor tendon and retinaculum were repaired with #1 Vicryl. The titanium cable circumscribed the patella. The proximal end of the patella was drilled transversely at the widest point. Another bone hole was drilled at the base of tibial tuberosity under direct view and as vertical to the long axis of the tibia as possible. The titanium cable was passed through the two bone holes, and the knee joint was flexed at a 30° position to form a tension band. A layered wound closure without suction drain was performed Fig. .All surgeries were operated by Zhi‐shan Zhang and Fang Zhou.No external splints were used in the novel tension band group. The patients performed quadriceps femoris contraction exercises soon after the operation, passive joint flexion and extension exercises 2 days postoperatively, and active joint flexion and extension exercises 7 days after surgery. Weight bearing was allowed. Knee flexion was allowed less than 45° in the first week and increased gradually to 90° in the second week. Patients were encouraged to gain full range of motion within 4 weeks.The patients of the patellotibial tubercle cerclage group need fixation splints for 3 weeks after the operation. The patients performed quadriceps femoris contraction exercises soon after the operation. Three weeks later, they were allowed passive and active joint exercises. After 2 weeks, partial weight‐bearing was allowed. Patients were encouraged to gain full range of motion within 8 weeks after operation Fig. .Operation time was recorded and defined as time from skin cut to sewed. Blood loss during surgical procedure was also recorded. Patients were reexamined at 1, 2, 3, 6, and 12 months postoperatively, including clinical examinations and radiographs.Partial weight‐bearing was defined as unpainful walking with aid of an auxiliary tool, usually a single cane. From 2 weeks after surgery, patients of the novel tension band group were recommended to step on a weighing scale with the injured leg every day while being supported by someone (by the patient's arm) and record the maximum weight without causing pain. Patients of the patellotibial tubercle cerclage group were asked for the same thing since fixation splints were removed. When maximum weight came up to 20 kg, partial weight‐bearing was allowed. Fracture‐healed was defined as absence of local pain or tenderness, ability to walk well without help, and evidence of trabecular bone growing across the fracture line.The Bostman score was used to assess functional recovery after surgery for fracture of the patellaComplications related to the implant included loosening of internal fixation, deep infection, revision operation due to breakage of the reduction band, and revision operation due to low patella position causing unbearable pain when the knee flexed. When breakage or unbearable pain caused by low patella position was found in patients, they were commended a lower‐limb braking on extension position. After fracture healed in these patients, a secondary operation would be performed to remove implant.For each patient, the time from operation to partial weight‐bearing and fracture‐healed were recorded, respectively. Knee range of motion was assessed, the Bostman score was evaluated at each follow‐up, and the results at 12‐month follow‐up were considered the final functional outcomes.U test and the chi‐squared test respectively. Fisher's exact test was used for small data subsets (n < 5). P < 0.05 was considered statistically significant.SPSS version 23.0  was used to compare the demographic data and clinical outcomes between the groups. Continuous and categorical parameters were analyzed by Mann‐Whitney vs 14 female to 8 male; P > 0.05), mean age , AO/OTA fracture type , injury mechanism , mean inter‐fragmentary gap , or mean follow‐up time .Overall, 63 fractures reviewed met the inclusion criteria for the study: 41 patients in the novel tension band group and 22 patients in the patellotibial tubercle cerclage group ; there was a longer time of 12.2 min. While there was no significant difference in blood loss .The mean operation time of new tension band group was significantly longer than that of tubercle cerclage group  and fracture‐healed time   and knee mobility  .No deep infection was found in 63 patients. Ten complications related with internal fixation in 22 patients were found in tubercle cerclage group, including two cases of loose internal fixation, two cases of cerclage breakage, and six cases of low patella position who undertook secondary operation Fig. . No compInferior pole fractures of the patella account for 9.3%–22.4% of all patellar fracturesConventional wire fixation with K‐wires or screws is suitable for big fragments. Problems with this fixation technique include loss of reduction and implant migration caused by soft tissue atrophy and lack of fixation rigidity. Prominent Kirschner pins and twisted wire ends in this subcutaneous location often cause soft tissue irritationet al.The tension band with the cannulated screw is the same as the K‐wire tension bandet al.Basket plate osteosynthesis has reported for the treatment of severe comminuted fractures of the inferior pole of the patellaet al.et al.et al.A separate vertical wiring technique for comminuted fractures of the distal patella introduced by Yang The new tension band using the φ3.0 mm cannulated screws with a special shim and the cable overcame the shortcomings of the above methods. This method has the following advantages: (i) it preserves the integrity of the patella and restores the original anatomical relationship of the knee extension device; (ii) after reducing the inferior pole fracture of the patella, the φ3.0 mm cannulated screw is inserted from the distal to proximal end; the screw does not need to penetrate the proximal bone, which reduces the difficulty of insertion from the proximal to distal end of the patella; the surgical procedure is simple; (iii) the φ3.0 mm cannulated screw can fix the distal pole fracture fragment reliably, avoiding that a larger diameter of the screw further crushes the inferior pole fracture block; the new special shim increases the area of the screw cap; (iv) the new tension band using the φ3.0 mm cannulated screw with the special shim and the cable can fix the inferior pole fracture of the patella reliably; therefore, knee function exercises can begin early; (v) the new tension band system has little effects on the patellar tendon, and all materials are titanium based; secondary removal operation is not required; (vi) the titanium cable is more flexible than traditional steel wires and easier to pass through the bone tunnel; in addition, soft tissue stimulation is limited, and it is easier to pull out when removing the internal fixation.In this study, compared with the patellotibial tubercle cerclage group, patients of the novel tension band group had a significantly earlier mean partial weight‐bearing time due to advantage (iv) and, thus, an earlier fracture‐healed time; a significantly higher mean Bostman score and knee mobility were achieved at 12‐month follow‐up due to advantage (i) and (iv). Although the operation time of patellotibial tubercle cerclage group was shorter, the position of the patella was more difficult to control in surgical procedure, causing low patella position and high stress in the titanium cable, resulting in a higher incidence of complications.The necessary precautions during surgery with the new tension band were as follows: (i) broken fracture fragments should remain connected with the soft tissue; (ii) when reducing the fracture, a small clamp should be used to hold the interface between the fragments and the patellar tendon, rather than directly clamping the broken fragments; otherwise, the fragments will be further crushed; (iii) two large fracture fragments of the inferior pole should be selected and fixed with two φ1.5 mm K‐wires inserted from the center of the fracture block as much as possible, 30° from the coronal plane of the patella to avoid the articular surface, not requiring to pass through the proximal end of the patella; (iv) repair of the torn quadriceps dilatation and anterior aponeurosis for fixation strength; (v) the inferior pole patellar fracture does not contain the articular surface. The goal of the operation is to restore the normal knee extension device and achieve bone healing between the fragments, rather than to treat intra‐articular fractures. Postoperative fluoroscopy revealing a small step between the bone blocks does not mean poor functional recovery.This study had some limitations. Firstly, the study design was retrospective and had a small sample size, patients were not randomized into the two treatment groups due to the 5 years period, and this cohort consists of only 63 cases. Secondly, this study only compared the outcomes of the novel tension band to patellotibial tubercle cerclage. No data prove its superiority to other surgical treatments.Compared with patellotibial tubercle cerclage, patients with comminuted fractures of the inferior pole of the patella treated with a novel tension band experienced longer operation time, but earlier partial weight‐bearing and fracture‐healed time, better clinical outcomes at 12‐month follow‐up, and less complications. Novel tension band should be considered an alternative therapy for the treatment of distal pole patellar fractures.


To evaluate the effect of paid family leave in California on statewide rates of preterm birth, low birthweight, postneonatal mortality, and overall infant mortality.Live birth and death certificates from all in‐hospital deliveries occurring in California (state exposed to the family leave policy) and two unexposed states (Missouri and Pennsylvania) from 1999 to 2008 (n = 6 164 203).We used a difference‐in‐differences approach to compare rates of infant health outcomes before and after implementation of the 2004 policy in California with rates in two states without paid family leave policies. Prespecified stratified analyses examined whether policy response differed by maternal characteristics. Conditional regression models using comparisons matched on a mother's likelihood of living in California in the pre–family leave period were then employed as sensitivity analyses to confirm our findings.Probabilistic methods were used to match live birth records to maternal and newborn hospital records. Only singleton births were included. Dyads were excluded if the infant gestational age was <23 weeks or greater than 44 weeks or if the birthweight was an outlier.Compared to the unexposed states, adjusted postneonatal mortality rates decreased by 12 percent in California after 2004 . There were no significant effects on the other outcomes. There were no differences in the effect by race/ethnicity or insurance status except for increased odds of low birthweight among privately insured women in California after 2004. Point estimates in the propensity score–matched sensitivity models were similar to the results of the fully adjusted models for all four outcomes, but confidence intervals crossed one.Implementation of paid family leave policies in California was associated with a 12 percent reduction in postneonatal mortality after adjusting for maternal and neonatal factors. Paid family leave has been linked to reduced infant mortality, especially in European nations.The effect of paid family leave policies on infant mortality using US data alone has not been explored.Postneonatal mortality rates dropped by 12 percent in California after its state legislature enacted the first partial pay family leave policy in the nation.An increased odds of low birthweight births among privately insured women were also seen after implementation of this paid family leave policy.1Despite modest improvements in the last 20 years, infant mortality rates (IMR) in the United States, long considered an important indicator of the health of a nation, have persistently been higher than economically matched peer countries.paid family leave and reduced postneonatal mortality.Several social determinants of health have been linked to an increased risk of these adverse outcomes among vulnerable women. In particular, maternal stressors such as shift work, high job stress, and high physical demands have been associated with increased risk of adverse outcomes among vulnerable infants.unpaid leave for up to three months to eligible workers.Evidence that parental leave improves birth outcomes in the United States has been accrued mainly from studying the effect of the federal Family and Medical Leave Act (FMLA) of 1993, which offers protected In 2004, California became the first state in the United States to implement a paid family leave (PFL) program.The 2004 Paid Family Leave program in California has been associated with improved rates of breastfeeding22.1We used a quasi‐experimental before and after design to compare infant health outcomes in California before and after passage of paid family leave legislation. California served as the exposed group, whereas Missouri and Pennsylvania served as two separate unexposed controls. These control states were chosen due to their data availability, large number of deliveries, and large diverse populations. The paid family leave policy was passed in California in 2002 but did not begin paying benefits to eligible parents until July 1, 2004.Our infant health outcomes were preterm birth (live birth occurring prior to 37 weeks), low birthweight (infant weighing < 2500 g), postneonatal mortality (death occurring between 29 and 365 days of life), and overall infant mortality (death occurring at any point in the first year of life).We analyzed live birth and death certificates linked to hospital deliveries occurring in all three states from 1999 to 2009. Using state vital statistics and administrative hospital discharge data, the linkage was done by the states' Departments of Health using probabilistic methods after we acquired IRB approval from each of these entities. More than 98 percent of all live birth records were able to be matched to maternal and newborn hospital records as previously described.2.2We first examined sample characteristics. To estimate the effect of the PFL law on the infant health outcomes, we used a difference‐in‐differences (DID) statistical approach. This econometric technique is commonly used in quasi‐experimental studies to analyze the effects of policy or legislation by comparing data in areas that have enacted a policy with data from areas that have not enacted the policy.To test the validity of this approach in our context, we examined whether trends in each outcome were statistically different between California and the other states in the pre‐PFL period , as this would violate the parallel trends assumption necessary for DID models.To estimate the impact of PFL on each outcome in our study, we constructed models that included year indicator variables to account for secular changes that affect all women similarly across states as well as state indicator variables that account for unobserved confounding fixed effects in each state that stay constant over time. Models also included an interaction term between California and the overall post‐PFL period. The interaction term is the difference‐in‐differences estimate of the association between paid family leave and the outcome.Table We then conducted a series of prespecified stratified analyses. These assessed potential heterogeneous effects on women of different demographic characteristics given previous research, demonstrating the differential effect of parental leave policies on other outcomes by socioeconomic status.Finally, we conducted a series of sensitivity analyses using propensity score matching. Difference‐in‐difference analyses are meant to control for differences that may exist between exposed and unexposed populations. However, given the underlying socioeconomic and racial/ethnic differences that exist between California and the two unexposed states, we created a propensity score based on a mother's likelihood of living in California. Mothers who lived in California in the pre‐PFL period were matched to mothers living in the unexposed states in the pre‐PFL period; mothers who lived in California in the post‐PFL period; and mothers living in the unexposed states in the post‐PFL period. Women were matched on the following factors: race, education, age, insurance coverage, urban vs. rural residence, residence county unemployment rate, presence of any prenatal care, perinatal complications, maternal comorbidities, and presence of congenital anomalies. Conditional logistic regression models adjusting for the same covariates as the difference‐in‐difference models were then conducted for the four outcomes of interest, using two caliper widths: 0.07 and 0.25 standard deviations of the logit odds of the estimated propensity score.P‐value of <.05 was considered statistically significant for the primary analyses. To avoid the bias of multiple comparisons, Bonferroni correction was used for the stratified analyses. All analyses were conducted in STATA (StataCorp), version 15. This study was deemed exempt by the local institutional review board due to the de‐identified nature of the data.A 2‐sided 33.1Initially, 6 495 042 births were identified across all three states. After exclusion criteria, there were 5 998 494 births in the nine‐year cohort: 4 323 697 births in California and 1 674 797 births in the unexposed states (1 045 005 births in Pennsylvania and 629 792 births in Missouri). Demographic characteristics that differed across exposed and unexposed states were maternal race/ethnicity and maternal education levels  in California in the post‐PFL period, even after Bonferroni adjustment. There were no significant interactions between race/ethnicity and the main outcomes in the post‐PFL period. Full details of these models are found in Table 3.4Tables 4We performed a quasi‐experimental study to assess the impact of the first state‐level paid family leave policy in the United States on several key infant health outcomes. Adjusted postneonatal mortality decreased by 12 percent after the passage of the 2004 Paid Family Leave policy in California. Given the associated effect size of reducing postneonatal deaths by 1.94 per 10,000 live births, we estimate that this translates into 747 fewer infants potentially dying in the first year of life as a result of this policy.paid parental leave contributes to fewer low birthweight infants and lower rates of both postneonatal and overall infant mortality.The benefits of paid family leave on infant mortality have been previously well documented in large cohort studies using data from European countries, where there has been widespread adoption of paid family leave at a federal level.These findings align with what we know about the drivers of infant mortality during different periods of infancy. According to the most recent data from the US National Vital Statistics System, the top five causes of infant mortality in this country are congenital malformations, preterm birth/low birthweight, sudden infant death syndrome (SIDS), maternal pregnancy complications, and accidents.We acknowledge some limitations. Administrative and vital statistics data have both advantages and disadvantages. While such datasets allow for the analysis of large cohorts, there is a potential measurement error due to inaccuracies in birth certificate data. In addition, data restrictions did not allow us to assess two important covariates in all three states: marital status and adequacy of prenatal care. As such, these variables could not be included in our adjusted models. Infants whose family moved to another state in the first year of life and then died would have had a death certificate filed in the receiving state, potentially leading to undercounting of deaths in our states of interest. This likely represents a very small percentage of births, but this could not be ascertained in our dataset. We also did not have employment data for individual women; thus, our sample included working and nonworking mothers. However, this means our analyses likely underestimated the effect of the paid family leave policy among employed women. Furthermore, difference‐in‐differences analyses rely on the assumption that the trends seen in the post‐PFL period in Missouri and Pennsylvania are a valid counterfactual for the trends that would have been observed in California had paid family leave not been enacted in 2004. Although we were unable to find any other major changes, events, or policies occurring in the post‐PFL period that might have affected birth outcomes, this cannot be completely excluded. Finally, as other states have continued to enact their own paid family leave policies that at times differ from California's policy with regard to eligibility, maximum benefit, or time provided, the estimated effect we found may not be generalizable to all states.5In 2004, California became the first state in the United States to implement a paid family leave (PFL) program. In our study of just under 6 million births among women from three populous states in the United States, California's paid family leave policy was associated with a decreased risk of postneonatal infant mortality. We believe this study offers important insight into our nation's discussion of the social and economic impact of implementing paid family leave policies. It is difficult to fully translate the findings of international studies of paid family leave to the United States, given that the majority of that data originate from countries with longer federally mandated leave or universal health care systems not present here. This study offers evidence of the impact paid family leave can have on postneonatal mortality in the United States, which is the major driver of the overall infant mortality rate disparity we suffer when compared to economically matched peer nations. Given that California has not seen any adverse effects on labor‐/economic‐related outcomesNone of the authors have any conflicts to disclose.Author MatrixClick here for additional data file.Tables S1‐S8Click here for additional data file.


To assess the cross‐sectional and prospective associations between depressive symptoms, neuroticism, and participation in breast and cervical screening in the UK.Women in the UK Biobank cohort with complete data who were eligible for breast cancer screening  and/or cervical screening  at baseline recruitment (2006‐2010) and those with follow‐up data (2014‐2019) were identified . Depressive symptoms and neuroticism were self‐reported at baseline (range 0‐12 with higher scores reflecting greater severity). Primary outcomes were reporting being up to date with breast and cervical screening. For prospective analyses, patterns of screening participation from baseline to follow‐up were identified. Logistic regression was used to analyse associations, adjusted for potential confounding factors.More severe depressive symptoms were associated with reduced likelihood of breast  and cervical  screening participation, in cross‐sectional analyses. Higher neuroticism scores were associated with reduced cervical screening participation, but the opposite was found for breast cancer screening. Examination of individual neuroticism items revealed that anxiety and worry were associated with increased breast screening. At follow‐up, higher baseline depressive symptoms were related to decreased cervical screening , but not with breast screening.More severe depressive symptoms may be a barrier for breast and cervical screening and could be an indicator for more proactive strategies to improve uptake. Several studies have demonstrated social inequalities in screening participation by education level,Few studies have examined the role of personality factors in cancer screening attendance.The aim of this study was to investigate both cross‐sectional and prospective associations between depressive symptoms, neuroticism, and participation in breast and cervical screening amongst women in the UK Biobank cohort. We had four key objectives: (a) to investigate the cross‐sectional associations between depressive symptoms  and participation in breast and cervical screening; (b) to examine the cross‐sectional associations between neuroticism  and participation in breast and cervical screening; (c) to examine whether baseline depressive symptoms and neuroticism scores predict future participation in breast and cervical screening; and (d) to investigate whether baseline depressive symptoms and neuroticism scores relate to longitudinal patterns of breast and cervical screening participation.22.1https://www.ukbiobank.ac.uk/), which achieved a 5.5% response rate.We used secondary data from UK Biobank  to women aged 50 to 70 years at baseline for the breast screening analysis (N = 208 726) and women aged under 65 years at baseline for the cervical screening analysis (N = 224 805). Participants who reported that they had undergone a hysterectomy at baseline were excluded from the cervical screening analysis (N = 12 804), as they are no longer eligible for screening recall.https://imaging.ukbiobank.ac.uk/). We identified 13 668 and 15 107 women from the breast and cervical screening baseline samples who attended a follow‐up assessment visit. Excluding participants who were no longer eligible for screening at follow‐up on the basis of age, a total of 11 458 women were included in the breast screening prospective sample and 10 578 in the cervical screening prospective sample.A repeat assessment of around 20 000 participants was carried out between August 2012 and June 2013 at the UK Biobank Co‐ordinating Centre in Cheadle, Stockport . A further 36 000 individuals have taken part in the UK Biobank Imaging Study at the Cheadle, Newcastle and Reading assessment centres between May 2014 and March 2019 where repeat assessment data were also collected  and whether they had ever had a cervical smear test. Those who answered “yes” were asked how many years ago their last mammogram or cervical smear test occurred. We combined these items to form baseline and follow‐up variables distinguishing those who were up to date with their breast screening (≤3 years since last screened) versus those who were not (never been for screening or >3 years since last screened). For cervical screening, “up to date with screening” was defined as those who had a cervical smear test ≤3 years ago for participants aged under 50 years and ≤5 years ago if aged 50 years and over. For the prospective analyses, we also grouped individuals into longitudinal patterns of engagement with breast and cervical screening including up to date with screening at baseline and follow‐up; up to date at baseline only; up to date at follow‐up only; or up to date at neither time point.2.3Recent depressive symptoms were measured at baseline via four questions adapted from the Patient Heath Questionnaire‐9 (PHQ‐9)Neuroticism was measured at baseline via 12 questions from the brief Eysenck Personality Inventory Neuroticism Scale (EPIN‐R)2.4We included several potential baseline confounding variables: age group; ethnicity ; region ; education level; area‐level socioeconomic deprivation assessed using Townsend score2.5We first descriptively examined mean neuroticism and depressive symptom scores for women who were up to date with their screening compared with those who were not. For the cross‐sectional analyses, a series of logistic regression models were calculated predicting whether participants were up to date with their breast and cervical screening (further details in the Supporting Information). We calculated logistic regression models for the two screening outcome variables including neuroticism scores, adjusted for education level, socioeconomic deprivation, ethnicity, region, and long‐standing illness or disability, followed by lifestyle factors .We then calculated models including the 12 individual neuroticism items (instead of the neuroticism scores as we hypothesised that there may be differences in the strength and/or direction of the associations between the different questions), adjusted for the potential confounding variables, followed by the addition of lifestyle factors.We then tested the summed depressive symptom scores and then the four individual depressive symptom items (both adjusted for neuroticism scores). Depressive symptoms were added after adding the neuroticism items as we hypothesised that any potential causal pathway would go from neuroticism to depressive symptoms as neuroticism is a more stable trait. Predicted probabilities were calculated and graphed to help interpret the results.We then calculated logistic regression models predicting whether participants were up to date with breast and cervical screening at follow‐up, adjusted for baseline neuroticism scores and depressive symptoms, baseline confounding variables and time between baseline and follow‐up. We then added the equivalent baseline screening variable, followed by baseline lifestyle factors.Multinomial logistic regression models were then calculated using the longitudinal screening pattern groups as the outcome variables (with the reference group being up to date at both time points), including baseline neuroticism and depressive symptom scores, adjusted for baseline confounders and time between baseline and follow‐up. We then added the baseline lifestyle variables. All statistical models in the prospective analyses adjusted for the number of years between the baseline and follow‐up data collection .We conducted complete case analyses, excluding participants with missing data for any variable. In the cross‐sectional analyses, 65 265 women in the breast cancer screening analyses and 70 248 in the cervical screening analyses had missing data and were excluded. In the prospective analyses, an additional 408 and 798 women had missing outcome data and were excluded from the breast and cervical screening analyses, respectively. Several sensitivity analyses were performed to test the robustness of the results (full details are available in the Supporting Information). Multicollinearity was checked by calculating the variance inflation factor, and potential nonlinearity was assessed but was not found to be an issue. All analyses were performed using Stata MP 15.1.33.1In the cross‐sectional analyses, a total of 143 461 women were included in the breast cancer screening sample and 141 753 in the cervical screening sample  in cross‐sectional analyses Table .Most depressive symptoms were related to reduced participation in both breast and cervical screening Figure , apart fExamination of the individual neuroticism items revealed some interesting findings Figure . Being “3.3Baseline depressive symptoms were not associated with breast screening at follow‐up (Table S5). A modest association was found between higher baseline depressive symptoms and reduced cervical screening at follow‐up, which persisted when adjusting for baseline cervical screening . However, this was attenuated when adjusting for baseline lifestyle factors. Baseline neuroticism scores were not associated with breast or cervical screening at follow‐up. We found little evidence of associations between baseline depressive symptoms and the subsequent pattern of breast cancer screening (Tables S6 and S7).4In this large study of UK Biobank participants, we found that more severe depressive symptoms were related to reduced likelihood of being up to date with both breast and cervical screening. However, differences between those with no depressive symptoms and those with more severe symptoms were not large. Feeling tired and lethargic almost every day in the last 2 weeks was related to decreased likelihood of being up to date with both breast and cervical screening. The pattern of results was less clear for neuroticism. Overall, higher neuroticism scores were related to reduced cervical screening participation and increased breast screening participation within cross‐sectional analyses. Examination of individual items revealed that those related to anxiety and worry tended to be associated with increased breast screening, which may be driving the overall positive association. Feeling lonely was associated with reduced likelihood of being up to date with both breast and cervical screening.Prospective analyses revealed little or no association between baseline depressive symptoms and breast cancer screening. For cervical screening, more severe depressive symptoms were associated with reduced likelihood of being up to date at follow‐up, but this was attenuated by lifestyle factors.Our results support the findings of previous studies demonstrating that psychiatric morbidity, poor self‐reported mental health, and a higher depressive symptom burden are associated with nonparticipation in breast cancer screening.Very few studies have assessed the relationship between personality and cancer screening behaviour, despite numerous studies investigating how personality may influence risk of cancerKey strengths of our study include the large sample size provided by UK Biobank, the inclusion of both cross‐sectional and prospective analyses, and the examination of both breast and cervical screening outcomes. To our knowledge, no other study has examined the potential influence of individual neuroticism items and specific depressive symptoms, or longitudinal patterns of cancer screening behaviour.4.1A number of limitations are acknowledged. Although large and with a spread of individuals from different social and educational backgrounds, UK Biobank is not fully representative of the general UK population and demonstrates a “healthy volunteer” effect.4.2Cancer screening should be accessible to all in society. Ensuring that women with poor mental health are able to participate in breast and cervical screening may help to prevent future cancer morbidity. For example, if cost‐effective, women presenting to their General Practitioner with poor mental health could be reminded and offered a screening appointment if required and any anxieties could be discussed. Research could also address the acceptability of self sampling5Depressive symptoms may influence participation in cancer screening programmes. Results for neuroticism were less clear. Future research may benefit from the use of administrative cancer screening data and incorporation of objective measures of depression, such as receipt of an antidepressant prescription.J.P.P. is a member of the UK Biobank Steering Committee. The authors declare no other conflict of interest.Figure S1: Samples included in the cross‐sectional and prospective analyses for breast and cervical screeningClick here for additional data file.Table S1: Descriptive statistics for the cross‐sectional samplesClick here for additional data file.Table S2: Descriptive statistics for the individual neuroticism items and depressive symptoms in the cross‐sectional sampleClick here for additional data file.Table S3: Descriptive statistics for the prospective samplesClick here for additional data file.Table S4: Results from logistic regression models predicting whether participants were up to date with breast (N=143 461) and cervical (N=141 753) cancer screening at baseline in UK BiobankClick here for additional data file.Table S5: Results from logistic regression models predicting whether participants were up to date with breast (N=11 050) and cervical (N=9 780) cancer screening at follow‐up in UK BiobankClick here for additional data file.Table S6: Results from multinomial logistic regression models (referent category is up to date at both time points) predicting the pattern of breast cancer screening from baseline to follow‐up in UK Biobank (N= 11 050)Click here for additional data file.Table S7: Results from multinomial logistic regression models (referent category is up to date at both time points) predicting the trajectory of cervical cancer screening from baseline to followup in UK Biobank (N=9 780)Click here for additional data file.


In recent years, various hydrogels with a wide range of functionalities have been developed. However, owing to the two major drawbacks of hydrogels—air‐drying and water‐swelling—hydrogels developed thus far have yet to achieve most of their potential applications. Herein, a bioinspired, facile, and versatile method for fabricating hydrogels with high stability in both air and water is reported. This method includes the creation of a bioinspired homogeneous fusion layer of a hydrophobic polymer and oil in the outermost surface layer of the hydrogel via a double‐hydrophobic‐coating produced through quenching. As a proof‐of‐concept, this method is applied to a polyacrylamide hydrogel without compromising its mechanical properties. The coated hydrogel exhibits strong resistance to both drying in air and swelling in multiple aqueous environments. Furthermore, the versatility of this method is demonstrated using different types of hydrogels and oils. Because this method is easy to apply and is not dependent on hydrogel surface chemistry, it can significantly broaden the scope of next‐generation hydrogels for real‐world applications in both wet and dry environments. A double‐hydrophobic‐coating method using a hydrophobic polymer and a viscous oil prepared via quenching is developed to fabricate hydrogels with strong resistance to drying in air and swelling in multiple aqueous environments. The method is not dependent on the type of oil or the surface chemistry of the hydrogel used; therefore, it is applicable to a wide range of hydrogels. Unless Figure−2 at the hydrogel surface was achieved for the best‐performing double‐hydrophobic‐coated gel (DC(DA/SA‐oil)@PAAm).Tg) of the SA homopolymer (≈48 °C) is higher than the ambient temperature (≈25 °C),Tg of the copolymer because the Tg of the DA homopolymer is very low (−55 °C).The chain length of the hydrophobic polymer affected the air‐drying performance of the hydrogel. The medium‐length hydrophobic monomer (DA) exhibited better efficiency than the shorter one (OA). However, the longest monomer (SA) exhibited unexpectedly poor performance ; this is because the glass transition temperature (Oil viscosity is another important parameter for tuning the air‐drying performance. Coatings based on high‐viscosity oils (1000 and 2000 cSt) provided far better drying resistance than a low‐viscosity oil (100 cSt) coating . This is comparable to human skin, which consists of high‐viscosity fats. The polymer chain length and molecular weight of high‐viscosity silicone oil are higher than that of low‐viscosity oil.The quenching process had a remarkable effect on the properties of the double‐hydrophobic‐coating; hence, it affected the air‐drying performance of the hydrogel Figure . When a We evaluated the mechanical properties of the double‐hydrophobic‐coated hydrogels via both tensile and compression testing  and discovered that the mechanical performance of the hydrogels did not decrease after the coating process; rather, the coated hydrogel exhibited better tensile properties than the noncoated one, probably due to an increase in the polymer density from the coating process (≈15% volume shrinkage). Interestingly, the coating layer of the hydrogels was not affected by harsh mechanical treatments. For example, the air‐drying performance of the DC(DA/SA‐oil)@PAAm hydrogel after ten consecutive loading–unloading cycles (at 50% compressive strain) was close to the performance of the intact coated hydrogel without mechanical treatment Figure . Additiom NaCl @PAAm hydrogel (after 7 d drying in air) in multiple aqueous environments . While l Figure . No appaFigure−2, which exhibited best air‐drying performance.Both the surface and internal structure of the hydrogel were characterized via scanning electron microscopy (SEM) using an air‐dried sample (xerogel). While the surface of the noncoated PAAm gel was flat , the coated gel surface had a compact and homogeneously patterned texture Figure. The thiThe single hydrophobic polymer coating process significantly increased the water contact angle on the hydrogel surface. The noncoated PAAm hydrogel had a contact angle of 30° , whereas the SC(DA/SA)@PAAm hydrogel had a contact angle of 111° . These results indicate that the hydrophobic polymer network covered the hydrophilic surface of the hydrogel efficiently. After the second coating via oil treatment with quenching, the contact angle decreased slightly to 95°, because the surface roughness reduced owing to the oil treatment. However, this is still notably larger than the contact angle of the noncoated PAAm hydrogel Figure .−2 , respectively. In conjunction with its strong resistance to both drying and swelling, this hydrogel is likely to find numerous applications in both air and wet environments.We also evaluated the mechanical properties of the Ca‐alginate/PAAm double‐network hydrogel. The coated and noncoated hydrogels exhibited similar tensile , which is an edible and biocompatible vegetable oil used for many healthcare purposes.In summary, we proposed a bioinspired, versatile, and noninvasive method for fabricating hydrogels with strong resistance to both drying and swelling. The method is based on double‐hydrophobic‐coating of a hydrophobic polymer  and viscous oil through quenching, which produces a ≈200 µm thick skin‐like robust hybrid layer on the hydrogel surface , which prevents both outward and inward transfer of water related to drying and swelling. The fabricated double‐hydrophobic‐coated hydrogels exhibited excellent stability in air and multiple aqueous environments . Additionally, the surface of the hydrogels serendipitously adhered to solid substrates owing to the adsorption of long alkyl chains of the hydrophobic polymer. This physical method is independent of the surface chemistry of hydrogels and the type of oil used. Therefore, our method overcomes the major drawbacks (drying and swelling) associated with hydrogels while paving the way for numerous applications of this elite class of materials in diverse air, water, marine, and physiological environments.Experimental details are provided in the Supporting Information.The authors declare no conflict of interest.Supporting InformationClick here for additional data file.


Organization of gold nanoobjects by oligonucleotides has resulted in many three‐dimensional colloidal assemblies with diverse size, shape, and complexity; nonetheless, autonomous and temporal control during formation remains challenging. In contrast, living systems temporally and spatially self‐regulate formation of functional structures by internally orchestrating assembly and disassembly kinetics of dissipative biomacromolecular networks. We present a novel approach for fabricating four‐dimensional gold nanostructures by adding an additional dimension: time. The dissipative character of our system is achieved using exonuclease III digestion of deoxyribonucleic acid (DNA) fuel as an energy‐dissipating pathway. Temporal control over amorphous clusters composed of spherical gold nanoparticles (AuNPs) and well‐defined core–satellite structures from gold nanorods (AuNRs) and AuNPs is demonstrated. Furthermore, the high specificity of DNA hybridization allowed us to demonstrate selective activation of the evolution of multiple architectures of higher complexity in a single mixture containing small and larger spherical AuNPs and AuNRs. Golden ratio: Four‐dimensional gold (Au) nanostructures were fabricated by a dissipative assembly strategy. The dissipative character of the system was realized by utilizing deoxyribonucleic acid (DNA) as the fuel and exonuclease III (Exo III) as the energy‐dissipating unit, to generate AuNPs functionalized with short single‐stranded DNA oligonucleotides. The assemblies possess surface plasmonic resonance properties. Since Mirkin and Alivisatos pioneered the utilization of oligonucleotides to organize gold nanoobjects by exploiting specific base paring, this concept has rapidly attracted a lot of attention in the field of nanoscience and flourished in a large number of deoxyribonucleic acid (DNA)‐based colloidal assemblies, including amorphous clusters,Such dissipative assembly strategies rely on the continuous consumption of energy to sustain functional structures that are not at thermodynamic equilibrium, and thus promise a novel approach that could readily result in materials with life‐like properties.To achieve such four‐dimensional (4D) assemblies of the important class of DNA–Au nanostructures, we herein present the implementation of a dissipative assembly principle in respect to DNA‐fueled gold nanoobjects (Au‐nanoparticles (AuNPs) and gold nanorods (AuNRs)), leading to the dissipative clustering of AuNPs accompanied by the evolution of surface plasmonic resonance properties. This further results in the first examples of well‐defined out‐of‐equilibrium core–satellite architectures with programmable life times. Moreover, the high specificity of DNA hybridization further allows us to selectively activate the transient assembly in systems of higher complexity.In previous studies, RNA strands were utilized as a fuel to drive the formation of polymeric colloid assemblies,Initially, we verified the selectivity of fuel strand digestion by Exo III under non‐dissipative conditions. The fuel strand consisting of 24mer DNA was hybridized with two corresponding DNA sequences without being attached to AuNPs or AuNRs. The as‐prepared double strands were incubated with Exo III and were then investigated by denaturing polyacrylamide gel electrophoresis (PAGE). The gel image clearly revealed that Exo III only digested the fuel DNA without affecting the integrity of the other two sequences  promoted by DNA fuel strands and the presence of Exo III was initially investigated by UV/Vis absorption spectroscopy. At the beginning of the experiment, the absorption spectrum showed a gradual redshift from 522 to 540 nm with decreasing absorbance intensity indicating that the 15‐AuNPs aggregated by the addition of the complementary fuel strand. After 15 minutes, the absorption spectrum shifted toward the blue end of the spectrum and the absorption maximum increased, indicating that the clusters started to dissemble due to the consumption of the fuel strands. After an overall reaction time of 25 minutes, the initial spectrum (0 min) with an absorption maximum at 522 nm was recovered , the recovery time decreased from 50 to 25 minutes . Upon increasing the concentration of Exo III from 2 to 8 U μL−1, energy dissipation occurred at such a high rate that the steady core–satellite architectures could not be achieved . Subsequently, we used TEM to investigate the structural evolution of the assemblies in the presence of 2U μL−1 enzyme. As shown in Figure Encouraged by achieving 4D amorphous clusters, we attempted to exploit this molecular system to construct well‐defined dissipative AuNP architectures. For this purpose, we synthesized AuNRs modified with DNA sequences that are complementary to one half of the fuel strand. These AuNRs were dedicated to act as the core when involved in the formation of finite molecule‐like core–satellite structures with spherical 15‐AuNPs at the rim  should be addressed to the authors.SupplementaryClick here for additional data file.


Early repolarization syndrome is associated with an increased risk of arrhythmic death caused by ventricular fibrillation (VF). VF is usually initiated by premature ventricular contractions (PVCs), and PVCs commonly arise from Purkinje system, the ventricular outflow tract, and papillary muscles. We report the case of a patient with J wave syndromes and recurrent VF, triggered by PVCs originating from the tricuspid annular region. VF was successfully suppressed by catheter ablation of the triggering PVCs, and there has been no recurrence of VF during a follow‐up period of 6 months. In some patients with no apparent structural heart disease, the underlying mechanism and etiology for the arrhythmia cannot be identified despite an extensive investigation. Reports suggest there is a clinical relationship between early repolarization (ER) and VF in patients without structural heart disease  presents significant J‐ST elevation in the inferior‐lateral leads and PVCs with left bundle branch block. A Holter ECG documented 17,854 PVCs and non‐sustained VF. Holter ECG monitoring revealed that the QRS morphology of the first beat in VF episode was identical to that of recorded PVCs. Interestingly, after an episode of VF, the QRS complexes showed clear accentuation of ER, as compared with baseline  with the CARTO mapping system . During electrophysiological study, no ventricular tachycardia and VF were induced, but frequent PVCs were present and allowed us to perform activation sequence mapping. At the site of tricuspid annulus, the local activation time was recorded for 36 msec prior to the earliest start of the QRS complexes Figure . No Purk3To the best of our knowledge, we firstly report a case that radiofrequency ablation for VF‐triggering PVCs originating from the tricuspid annular area successfully suppressed the recurrence of VF in a patient with ER syndrome. Recent studies demonstrated that J wave is related to ER abnormalities or delayed depolarization owing to microstructural alterations (Haissaguerre, Nademanee, Hocini, Duchateau, et al., 4Ventricular fibrillation is a lethal arrhythmia that may present in patients without structural heart disease. Catheter ablation of triggering PVCs is recognized as a reasonable therapy when the clinical‐triggering PVCs are high burden. Although suppression of VF can be achieved by the elimination of triggering PVCs, long‐term follow‐up is needed. Furthermore, ablation of VF substrates is effective in treating symptomatic ER syndrome patients (Nademanee et al., The authors declare that they have no conflict of interest.Dr Liu undertook the electrophysiology procedure, obtained the Figures and drafted the manuscript. Dr Huang and Dr Zhao wrote portions of the text. Dr Yang undertook the electrophysiology study and revised the manuscript.The reported study has received written consent as required by the appropriate ethics committee.


Endonasal balloon‐assisted dacryoplasty is a minimally invasive technique that uses a high‐pressure balloon catheter introduced into the lacrimal pathway through the nasal fossa into the neorhinostomy to treat recurrent epiphora after primary dacryocystorhinostomy. This procedure can be considered to be a reliable technique in patients unfit for general anesthesia. Endonasal balloon‐assisted dacryoplasty is a minimally invasive technique that uses a high‐pressure balloon catheter introduced into the lacrimal pathway through the nasal fossa into the neorhinostomy to treat recurrent epiphora after primary dacryocystorhinostomy. This procedure can be considered to be a reliable technique in patients unfit for general anesthesia. At present, the gold standard method for primary NLDO is external DCR (EXT‐DCR) with a success rate between 90%‐95%.Many treatments are available in case of recurrent epiphora after primary surgery, including EXT‐DCR, END‐DCR, balloon dacryoplasty, and observation, which can be considered the best choice in slightly symptomatic elderly patients.Balloon‐assisted dacryoplasty (DCP) is a less invasive procedure that is performed using a high‐pressure balloon catheter introduced into the lacrimal system passing through the superior or inferior canaliculus. The aim of this procedure was to enlarge the site of the stenotic lacrimal tract, which is typically located in proximity to the neorhinostomy.Herein, we present the case of a female patient who underwent transnasal balloon‐assisted DCP after failure of primary endoscopic DCR.2A 78‐year‐old woman complained of relapsing right‐side epiphora and recurrent dacryocystitis after failure of an END‐DCR performed 3 months before. Symptoms appeared immediately after surgery, even though the procedure was carried out without any intraoperative complications. On the 15 day of postoperative follow‐up, endoscopic endonasal examination demonstrated the presence of a sinonasal synechiae next to the neorhinostomy, determining a near‐total obstruction of the ostium created by the previous surgical procedure.2.1Lacrimal probing and irrigation were performed, by an ophthalmologist, and led to upper lacrimal punctum liquid spillage and total absence of lacrimal flow through the neorhinostomy. Surgical reintervention was deemed necessary. Considering the patient's age, comorbidities , presence of partially healed mucosa, and the recent surgery, we decided to adopt a less invasive endoscopic approach using a balloon catheter introduced through the nose to enlarge the stenotic neorhinostomy.®) was introduced under endoscopic guidance into the nasal neorhinostomy created during primary DCR passing through the nasal cavity. After connection of the catheter to the inflation device, the rhinostomy was enlarged by the balloon system, which was inflated to 12 atm for 20 seconds and then deflated for 10 seconds. The balloon was then reinflated to 8 atm for 20 seconds and deflated for 10 seconds. This last cycle was repeated twice. After completing 3 cycles, the balloon catheter was completely deflated and carefully removed from the nasal neorhinostomy  at the site of neorhinostomy can potentially reduce scarring through action on the inflammatory and proliferative phases of wound healing, respectively. Zeldovich et al reported a success rate of 89% in a prospective, nonrandomized series of 16 patients undergoing revision END‐DCR, in which betamethasone was injected into the lacrimal sac and scar tissue surrounding the ostium.Streptomyces caespitosus that inhibits the synthesis of DNA, RNA, and protein by through inhibition of collagen synthesis by fibroblasts.Conversely, many studies have been carried out on the efficacy of intraoperative MMC in EXT‐DCR and END‐DCR, although the results have not always been consistent.Finally, the use of postoperative antibiotic therapy is still questioned and there is no evidence that regular administration of oral antibiotic after surgery may improve surgical outcomes. Lehmann et al in a retrospective study on 596 cases showed that patients who failed primary END‐DCR were more likely to have postoperative complications, including infections; in addition, the occurrence of a postoperative complication was significantly associated with primary END‐DCR failure.In conclusion, transnasal balloon‐assisted revision DCP can be considered as a valid, safe, and minimally invasive surgical procedure to treat recurrent epiphora after failure of endoscopic or external DCR. The procedure should be considered as a feasible option in the case of recurrent epiphora after multiple surgical procedures or in patients who cannot undergo more aggressive treatment or prolonged general anesthesia due to age and comorbidity. The main advantages of this surgery are shorter surgical time and reduced postoperative complications.The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this paper.PI: drafted the article and made substantial contributions to acquisition of data; AV: made substantial contributions to acquisition of data and revised the manuscript critically for important intellectual content; AGR: made substantial contributions to acquisition of data; MT: conceptualized and designed the study, made substantial contributions to conception and acquisition of data, critically reviewed the manuscript for important intellectual content, and approved the final version.


Graph theory and network modelling have been previously applied to characterize motor network structural topology in multiple sclerosis (MS). However, between‐group differences disclosed by graph analysis might be primarily driven by discrepancy in density, which is likely to be reduced in pathologic conditions as a consequence of macroscopic damage and fibre loss that may result in less streamlines properly traced. In this work, we employed the convex optimization modelling for microstructure informed tractography (COMMIT) framework, which, given a tractogram, estimates the actual contribution (or weight) of each streamline in order to optimally explain the diffusion magnetic resonance imaging signal, filtering out those that are implausible or not necessary. Then, we analysed the topology of this ‘COMMIT‐weighted sensory‐motor network’ in MS accounting for network density. By comparing with standard connectivity analysis, we also tested if abnormalities in network topology are still identifiable when focusing on more ‘quantitative’ network properties. We found that topology differences identified with standard tractography in MS seem to be mainly driven by density, which, in turn, is strongly influenced by the presence of lesions. We were able to identify a significant difference in density but also in network global and local properties when accounting for density discrepancy. Therefore, we believe that COMMIT may help characterize the structural organization in pathological conditions, allowing a fair comparison of connectomes which considers discrepancies in network density. Moreover, discrepancy‐corrected network properties are clinically meaningful and may help guide prognosis assessment and treatment choice.  Inclusion criteria for patients with MS were age between 18 and 70 years, MS diagnosis fulfilling the revised McDonald criteria ; sagittal T1‐weighted 3D magnetization‐prepared rapid gradient echo ; twice‐refocused spin echo echo‐planar imaging sequence for diffusion MRI with b values of 1,000 and 2,000 s/mm2 and 30 directions each (repeated twice), in addition to b = 0 images .All subjects underwent MRI on a Siemens Skyra 3T scanner  with a 32‐channel head coil. The MRI protocol included the following sequences: axial T2‐weighted 3D  as described in Petracca et al. (https://fsl.fmrib.ox.ac.uk).Quantification of T2‐hyperintense and T1‐hypointense lesion volume was performed in each patient by a single experienced observer unaware of subject identity, employing a segmentation technique based on user‐supervised local thresholding  and we automatically segmented them  was computed as the sum of the volumes of all the above‐listed areas divided by intracranial volume.2.4http://www.mrtrix.org). In light of the discussion in Zalesky et al  and the COMMIT‐weighted connectomes  were built using the motor network parcellation described above Figure . As entrIn light of the recent results showed in Buchanan et al. , in Data2.5modularity (reflecting the segregation of the network), global efficiency (corresponding to the average inverse shortest path length in the network and inversely related to the characteristic path length), clustering coefficient (reflecting the degree to which the nodes tend to cluster together), mean strength , assortativity (reflecting if nodes tend to be connected to other nodes with similar strengths) and density (corresponding to the fraction of present connections to possible connections). For each node of the subjects' connectome we also computed local efficiency and nodal strength to investigate which node of the SMN was more affected by the disease.As it was done in previous works .Between‐group comparisons were performed via analysis of covariance analysis, entering age and gender as covariates. In order to assess differences in density estimation related to the application of COMMIT, we performed between‐group comparisons both on results from raw connectomes and COMMIT‐weighted connectomes and repeated the analysis entering density as additional covariate.The relationship between network global properties, T2 lesion load and GM atrophy were tested via partial correlation accounting for age and gender.The relationship between network properties and clinical disability was tested with stepwise regression models, entering age and gender in the first block and network global/local properties in the second block.p < .05 .Results were considered significant for 33.13.1.1SDs of the global network metrics are reported in Table Mean values and SDs of the local network metrics are reported in Table Mean values and 3.1.2SDs of the global network metrics are reported in Table Mean values and SDs of the local network metrics are reported in Table Mean values and 3.2r = −.655, p < .0001), clustering coefficient , modularity , density , mean strength . No correlations were identified between SMN GMF and global metrics.Accounting for age and gender, significant correlations were identified between T2 lesion volume and global efficiency , modularity  and density  as well as between SMN GMF and mean strength .Accounting for age and gender, significant correlations were identified between T2 lesion volume and global efficiency  and 32% of variance in 25FWT . No significant results were yielded by the model including demographic variables and node local properties.The models including demographic variables and network global properties accounted for 40% of variance in 9HPT scores . The model including demographic variables and node local properties accounted for 58% of variance in 9HPT scores  and 66% of variance in T25FWT scores .The models including demographic variables and network global properties accounted for 27% to 35% of variance in 9HPT scores  microstructure feature does not vary along the length of a tract and therefore it is possible to effectively estimate its value for the entire tract (rather than only voxel‐wise). This estimation is done simultaneously for all the streamlines by fitting them to a map related to the selected microstructure feature. If only diffusion‐weighted magnetic resonance imaging data are available, it is reasonable to assume that the intra‐axonal diffusion signal is constant along the tract and COMMIT uses any predefined microstructural model to estimate it. Similarly to what was recently found in Lipp et al. , using tDifferences in connectome global properties estimated after COMMIT application suggest that also the COMMIT‐weighted connectome presents the topology abnormalities previously described in MS  and progressive MS (PMS) patients computed on the raw connectomes after the application of proportional thresholding. All values are expressed as mean standard deviation. Analysis of covariance (ANCOVA) age and gender corrected (pa), ANCOVA age, gender and density corrected (pb). Statistically significant p‐values after Bonferroni correction are highlighted in boldTable S2: Nodes strength of healthy controls (HC) and progressive MS (PMS) patients computed on the raw connectomes after the application of proportional thresholding. All values are expressed as mean standard deviation. ANCOVA age and gender corrected (pa), ANCOVA age, gender and density corrected (pb). Statistically significant p‐values after Bonferroni correction are highlighted in boldTable S3: Nodes efficiency of healthy controls (HC) and progressive MS (PMS) patients computed on the raw connectomes after the application of proportional thresholding. All values are expressed as mean standard deviation. ANCOVA age and gender corrected (pa), ANCOVA age, gender and density corrected (pb). Statistically significant p‐values after Bonferroni correction are highlighted in boldTable S4: Global graph metrics of healthy controls (HC) and progressive MS (PMS) patients computed on the raw connectomes after the application of consistency thresholding. All values are expressed as mean standard deviation except for the density which is imposed to be 30% by the method. ANCOVA age and gender corrected p are reported in the last column. Statistically significant p‐values after Bonferroni correction are highlighted in boldTable S5: Nodes strength of healthy controls (HC) and progressive MS (PMS) patients computed on the raw connectomes after the application of consistency thresholding. All values are expressed as mean standard deviation. ANCOVA age and gender corrected p are reported in the last column. Statistically significant p‐values after Bonferroni correction are highlighted in boldTable S6: Nodes efficiency of healthy controls (HC) and progressive MS (PMS) patients computed on the raw connectomes after the application of consistency thresholding. All values are expressed as mean standard deviation. ANCOVA age and gender corrected p are reported in the last column. Statistically significant p‐values after Bonferroni correction are highlighted in boldClick here for additional data file.Figure S1 Comparison of the behaviour of the 91 connections in raw and COMMIT‐weighted connectomes for both healthy controls (HC) and progressive multiple sclerosis patients (PMS). The overall behaviour of the connections’ strength shows a high correlation between the methods but looking at individual connections we see how COMMIT is able to enlarge or shrink the differences between the two groups of subjects.Click here for additional data file.