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The precautionary approach to fisheries management advocates for risk-averse management strategies that include biological reference points and account for scientific uncertainty (i.e. process, model and observation uncertainty). In this regard, two approaches have been recommended: (a) biomass reference points to safeguard against low stock biomass, and (b) uncertainty buffers that reduce the catch limit as a function of the scientific uncertainty. This study compares the effectiveness of these two precautionary approaches in recovering over-exploited fish stocks. We evaluate the performance of more than 80 harvest control rules (HCRs) within a stochastic management strategy evaluation (MSE) framework for three stocks with contrasting life-history parameters and under various levels of scientific uncertainty. The results show that both approaches reduce the risk of overfishing at the expense of expected yield. This risk-yield trade-off strongly depends on the HCRs, life-history parameters of the species, as well as the level of the scientific uncertainty. Nevertheless, some combinations of biomass threshold and limit reference points as well as uncertainty buffers lead to a more favourable risk-yield trade-off than other rules. This study elucidates the multiple factors affecting the effectiveness of management strategies and highlights key features of HCRs for precautionary fisheries management.

Introduction: Patients with cancer are at risk of thrombotic events, mainly deep vein thrombosis and/or pulmonary embolism. The thrombosis risk is generally 4–6 times higher than in a healthy popul...

The optimal technique for the displaced greater tuberosity (GT) fractures remains unclear; those in favor of arthroscopic techniques emphasize on the feasibility of arthroscopic reduction and fixation, while others report that anatomic reduction and osteosynthesis of the fracture are optimal through open surgery. Therefore, we performed this study to evaluate the clinical results of arthroscopic fixation for displaced and/or comminuted GT fractures using a bridging arthroscopic technique. We studied the files of 11 patients (4 men, 7 women; mean age, 55 years; range, 28–74 years), with an isolated, displaced GT fracture treated with arthroscopic reduction and double-row suture anchor fixation technique from December 2016 to October 2018. All patients were operated at a mean time from their injury of 23 days (range, 1–85 days) using an arthroscopic technique. Any concomitant pathology that was arthroscopically identified was identified and repaired after arthroscopic fixation of the GT fracture. The mean follow-up was 12 months (range, 6–18 months). We evaluated pain using a 0–10 point visual analog scale (VAS), shoulder range of motion, fracture healing, Constant-Murley Shoulder Outcome Score, and patients’ satisfaction from the operation. Postoperative radiographs showed anatomic reduction without any displacement of the GT fracture in eight patients and residual displacement of

The optimal (SBJI) surgical treatment for acute acromioclavicular (AC) joint disruption remains controversial. What is being presented is the long-term functional outcomes of a double cross-looped coracoclavicular (CC) suture technique with the intention of restoring both anteroposterior and superior displacement of the clavicle. Between 2007 and 2016, 81 patients underwent surgical reconstruction for acute acromioclavicular joint (AC) disruption in two orthopaedic centers. Two patients died for reasons unrelated to the treatment, and seven missed the final follow-up appointment, leaving 72 patients (67 males; 5 females; age 37 ± 12.4; range 15–64 years) for clinical and radiological assessments. All cases were classified according to the Rockwood classification as type III (n = 34), IV (n = 14) or V (n = 24). The dislocation was repaired with double cross-looped CC fixation using four Ethibond sutures passing underneath the coracoid and through a 4.5 mm drill hole in the clavicle in opposing directions to control both anteroposterior and vertical displacement. Radiological investigation preoperatively and at the last follow-up included anteroposterior and/or Zanca views, axillary or Alexander views, and comparative stress radiography of both AC joints. Patients were evaluated clinically with the Constant-Murley score (CMS) and Acromio Clavicular Joint Instability Score (ACJIS). Loss of reduction, subluxation, CC ligament ossification, post-traumatic arthritis, and peri-implant fractures were also recorded. Seventy-two patients were available for the last clinical and radiological evaluations. At a median follow-up period of 6.3 ± 2.1 years (range 3–12 years), the CMS and ACJIS were 92.1 ± 7.2 (range 60–100 points) and 90.4 ± 8.6 (range 45–100 points), respectively. Complications included 9 (12.5%) patients with slight loss of reduction, 2 (1.7%) with dislocation recurrence, 1 (1.3%) with superficial infection, 1 (1.3%) with a fracture of the lateral end of the clavicle, and 2 (1.7%) with persistent tenderness in the AC joint. The incidence of periarticular ossification was 22.4% and did not affect the final outcome. This technique represents an effective and low-cost treatment for acute AC joint separations. IV.

This study aims to clarify some of the issues associated with the reliable measurement of muscle thickness on ultrasonographic images of the musculoskeletal system, namely the repeatability of measurements in different time frames, the effect of body side selection, and the effect of scan orientation. Ultrasound scans were performed on muscles associated with essential daily activities: geniohyoid, masseter, anterior arm muscles, rectus femoris, vastus intermedius, tibialis anterior, and gastrocnemius. Measurements of the muscle thickness were performed and repeated after 1, 6, and 24 h, on both dominant and nondominant side, using both transverse and longitudinal scans. Thirteen healthy volunteers (eight males and five females, mean age = 24 years, SD = 2.86, range = 19-29) were included. The intraclass correlation coefficient (ICC) was calculated between the baseline and the 1-, 6-, and 24-h interval, using a two-way mixed model of absolute agreement. The ICC ranged from 0.295 for the longitudinal scan of the left masseter muscle in the 6-h interval to 0.991 for the longitudinal scan of the nondominant anterior arm muscles in the 24-h interval. The results indicate that there is variable reliability of the measurements depending on the muscle, time frame, body side, and scan orientation. Consequently, the choice of these parameters can affect the validity of the measurements. Further investigation on a larger scale is required to establish the preferred parameters for each anatomical site.

Piriformis syndrome (PS), first described by Yeoman in 1928, is a general term referring to low back pain, sciatica, and instability. PS has a 6% incidence rate worldwide. In this study, we aim to retrospectively evaluate the effectiveness of computed tomography (CT)-guided percutaneous infiltration in a series of consecutive PS patients who have symptoms that are refractory to conservative therapies. An institutional database search identified 20 such consecutive patients who underwent infiltration with a mixture of long-acting corticosteroid and local anesthetic. Preoperational evaluation included physical examination and magnetic resonance imaging. The correct position of the 22-gauge spinal needle was verified with CT scan after contrast medium injection. Pain measured before the procedure and at 1 wk and 1, 6, and 12 mo after the procedure was compared by means of a numeric visual scale (NVS) questionnaire. The mean pain score before CT-guided percutaneous infiltration was 8.95 ± 1.432 NVS units. This score was reduced to a mean value of 0.85 ± 0.933 units at 1 wk, 0.90 ± 0.852 at 1 mo, 1.10 ± 1.165 at 6 mo, and 1.20 ± 1.399 at 12 mo follow-up (p < 0.001). Two patients of 20 (10%) underwent a second infiltration that was performed at 7 and 10 d after the first, respectively. No complications were observed. CT-guided infiltration seems to be a feasible, efficacious, and safe approach for pain reduction and mobility improvement in patients with symptomatic PS.

Aim It was investigated how preoperative botox injection in the abdominal musculature both facilitates the surgical repair of incisional hernias and reduce the rate of hernia recurrence. Material and Methods Botulinum toxin A injections was given to 12 patients (7 female and 5 male) suffering from complex incisional wall hernia, 4 to 6 weeks preoperatively. Mean age was 54 years. 9 patients were treated by anterior and/or posterior component separation repair and 3 by Rives-Stoppa repair. By all patients the mesh could be placed in the retromuscular position. No bridging was necessary. Results After a follow-up of 3 to 4 years we examined the patients clinically and by sonography. The rate of incisional hernia recurrence was low as well as the rate of side effects like chronic pain, persisting paresthesia and mobility disorders of the abdomen. Conclusions Preoperative injection of botulinum toxin A can help to reduce the risk of further hernia recurrence after surgical repair of complex incisional hernias of the abdominal wall.

Patient: Male, 42-year-old Final Diagnosis: Bilateral quadriceps tendon re-rupture Symptoms: Disability • pain Medication: — Clinical Procedure: — Specialty: Orthopedics and Traumatology Objective: Unusual clinical course Background: Bilateral simultaneous quadriceps tendon rupture is a relatively rare injury, more commonly seen in patients older than 50 years and is usually associated with underlying metabolic or inflammatory diseases. Case Report: We report the case of an otherwise healthy, 42-year-old man who sustained a bilateral, quadriceps tendon rupture while he was trying to pound a branch of an olive tree into the ground. On clinical examination, a defect in both proximal patella poles was found on palpation, with complete discontinuity of the extensor apparatus. A meticulous surgical repair was performed using 3 bone anchors with an uneventful postoperative rehabilitation. A biopsy specimen taken at surgery showed evidence of chronic inflammation. He had a second episode while walking fast on the beach 3.5 months postoperatively, and presented again with bilateral quadriceps rupture. He was successfully managed with bilateral allograft reconstructions, showing a very good outcome at 18 months of follow-up. Our systematic literature review covering a 20-year period (2000–2020) revealed 10 articles on bilateral quadriceps ruptures in 14 healthy patients without comorbidities. All these injuries occurred in males, with a mean age of 56.8 years, during walking, descending stairs, or participating in recreational sports; the functional outcome was good to excellent in most cases, without any reported re-ruptures. To the best of our knowledge, no similar case has been reported in the literature. Conclusions: Bilateral quadriceps tendons rupture is a rare injury, especially in young patients without associated comorbidities. The risk of recurrence is low, but when it occurs, more complex techniques of reconstruction are needed.

Bilateral Galeazzi fracture-dislocations are extremely rare injuries and only a few case reports have been described so far in the literature. Herein, we report the case of a 31-year-old bicyclist who sustained bilateral Galeazzi fracture-dislocations after a collision with a car. Both radial shaft fractures were simple (AO type 22-A2.3), at the same level (Type I

Background Unstable ‘extra-lateral' fractures of the distal clavicle (lateral to the coracoclavicular ligaments) are not distinguished in the Neer classification system and are commonly included with Neer IIb fractures. In the literature, there is no optimal surgical technique for managing unstable fractures of the distal clavicle, nonetheless for unique ‘extra-lateral' patterns. The aim of this study is to evaluate the effectiveness and safety of existing coracoclavicular fixation techniques for managing unstable Neer IIb and extra-lateral (IIc) fractures of the distal clavicle. Methods We performed a systematic search of the literature to capture all studies evaluating the safety and effectiveness of existing coracoclavicular loop techniques for unstable Neer IIb and extra-lateral (IIc) fractures of the distal clavicle. We searched the PubMed (Medline and PubMed Central), Scopus, Web of Science, Google Scholar, and Cochrane Central Register of Controlled Trials electronic databases to retrieve studies published between January 2000 and November 2020. Our study was guided by a prospectively developed protocol and reported in accordance with the latest PRISMA guidelines. Results Our database search yielded a total of 564 records, out of which 21 were deemed appropriate for inclusion in our qualitative synthesis. The total number of reported IIb/c fractures managed with a coracoclavicular stabilization technique in all studies was 421. In total, 139 (33%) patients received arthroscopic assisted treatment, and 282 (67%) patients were managed with open coracoclavicular stabilization. The reported clinical results were very good to excellent in most studies, whereas the overall major and minor complication rate was 2.6% and 12.8%, respectively. Major complications were more frequent in arthroscopic assisted techniques (4.3%) compared to open (1.8%). Conclusion The present systematic review of coracoclavicular stabilization techniques for unstable Neer IIb and extra-lateral fractures of the distal clavicle demonstrates promising clinical outcomes, including effectiveness and safety. We support the previously proposed modification of the Neer classification to include this unique type of unstable extra-lateral fracture (type IIc) to allow for targeted surgical management.

Background A metastatic lesion located in the ampulla of Vater is considered extremely rare, with only 32 cases reported globally. Case A 65-year-old patient was primarily diagnosed with a rectal adenocarcinoma. Twenty-four months later as part of the oncological follow-up, the patient was diagnosed with a single secondary tumor in the ampulla of Vater. After undergoing a pancreaticoduodenectomy (Whipple procedure), the patient experienced an uneventful recovery and received adjuvant chemotherapy. Sixteen months later the patient remained disease-free. Conclusion To the best of our knowledge, the present case represents the first reported metastatic tumor in the ampulla of Vater, originating from a rectal adenocarcinoma. This case underlines the critical role of immunohistochemistry in arriving at a correct diagnosis in order to guide clinical decision-making.

Background Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps. Methods Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided. Conclusions The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

The present paper provides a comparative evaluation of hybrid Singular Spectrum Analysis (SSA) and Artificial Neural Networks (ANN) against conventional ANN, applied on real time intraday traffic volume forecasting. The main research objective was to assess the applicability and functionality of intraday traffic volume forecasting, based on toll station measurements. The proposed methodology was implemented and evaluated upon a custom developed forecasting software toolbox, based on the software Mathworks MatLab, by using real data from Iasmos-Greece toll station. Experimental results demonstrated a superior ex post forecasting accuracy of the proposed hybrid forecasting methodology against conventional ANN, when compared to performance of usual statistical criteria (Mean Absolute Error, Mean Squared Error, Root Mean Squared Error, Coefficient of Determination R2, Theil's inequality coefficient). The obtained results revealed that the hybrid model could advance forecasting accuracy of a conventional ANN model in intraday traffic volume forecasting, while embedding hybrid forecasting algorithm in an Intelligent Transport System could provide an advanced decision support module for transportation system maintenance, operation and management.

While free tissue transfer has long been established as a reliable microsurgical technique in the adult population, its application in pediatric reconstruction is a relatively recent phenomenon. Despite initial concerns regarding minute vessel diameters, increased propensity for vasospasm, and limited tissue availability, pediatric free tissue transfer is now a widely used technique that has demonstrated an acceptable level of donor and recipient site morbidity in children. Five flaps commonly used in the reconstruction of lower extremity trauma are discussed in this paper: the latissimus dorsi, rectus abdominis, anterolateral thigh, gracilis, and the subscapular and parascapular flaps. The indications, blood supply, advantages, and disadvantages of each are detailed. Incredible progress has been made in the application of microsurgical techniques to the pediatric population over the last several decades. With a healthy understanding of the anatomy and functionality of the donor site, the reconstructive surgeon can repair a variety of complex injuries with an acceptable morbidity and mortality rate.

Diabetes mellitus type 2 (T2DM) is an emerging public health issue with high prevalence rates among older adults while fragility fractures constitute a significant public health burden with a great impact. Osteoporosis is the most important metabolic bone disease in patients with diabetes mellitus. Based on current evidence, individuals with T2DM are more vulnerable to fragility fractures than their non-diabetic counterparts, although until now, there aren’t any systematic reviews or meta-analyses concerning the impact of T2DM on the risk of fragility fractures in elderly patients. The aim of this study is to fill this gap in the current literature concerning this specific patient group. Literature in PubMed and Google Scholar was searched for relevant articles published up to January 2021. The keywords used were: elderly, diabetes mellitus type 2, and fragility fractures. Among the 180 articles retrieved, only four full-text articles were eligible and, finally, two studies (one population-based cohort study and one cross-sectional study) met the inclusion criteria for the review. Although we identified 15 records through the manual research, finally 17 records were included in the current review. The records retrieved from the manual research were 11 prospective cohort studies, two population-based studies, one prospective observational study, and one retrospective cohort study. The author's name, year of publication, country, type of study, and number of patients were reported. According to this systematic review, there is almost consensus about the increased prevalence of all kinds of fragility fractures and especially low-energy hip fractures among elderly patients with T2DM compared with their counterparts without T2DM while there is relative controversy concerning non-vertebral fractures. Vertebral fractures in the elderly with T2DM require further evaluation because the results from cohort studies are more conflicting. Finally, insulin usage can increase the possibility of fragility fractures and can even double this risk. Bone fragility should be recognized as a new complication of T2DM, especially in elderly patients, due to several additional aggravating factors such as senile osteoporosis, severe vitamin D deficiency, presence of many comorbidities, increased possibility of insulin usage, and the presence of diabetes-related complications (mainly neuropathy and retinopathy). Clinicians who treat these patients should be aware of the special diagnostic and therapeutic approaches concerning these patients.

Patient: Male, 45-year-old Final Diagnosis: Open tibia fracture with bone loss Symptoms: Numbness • pain • pulseness Medication: — Clinical Procedure: — Specialty: Orthopedics and Traumatology • Plastic Surgery Objective: Management of emergency care Background: The management of open Gustilo IIIC fractures can be challenging even for experienced orthopedic surgeons. The decision between limb salvage and amputation is extremely difficult and the scoring systems do not seem to affect it significantly. Although ischemic time has been proven to be a major factor, attempts at reconstruction of limbs with ischemic time over 6 hours have been made in past decades. A simultaneous management of skeletal, soft-tissues, and vascular injury should be performed. This requires an orthoplastic surgeon who is capable of doing all the necessary operations by him/herself with hand-surgery and microsurgery expertise. Case Report: We present a case of a 49-year-old man with a type IIIC open tibial fracture with bone loss and warm ischemia time of 13 hours, who underwent revascularization and reconstruction with good radiological and functional results after a follow-up of 3 years. A few similar cases have been presented in the literature but none of them had a combination of bone loss, severe soft tissue injury, and complete vascular disruption after a crush injury. Conclusions: The treatment of type IIIC open fractures of the tibia can be a demanding and time-consuming process. Detailed information about the necessity of multiple surgical interventions must be explained and fully understood by the patient in order to have realistic expectations.

Background Bullous pemphigoid is the most common bullous chronic autoimmune skin disease. Recent studies have suggested dipeptidyl-peptidase 4 inhibitors as possible predisposing agents of bullous pemphigoid. The objective of our study was to prospectively estimate the association between gliptins and the development of bullous pemphigoid. Methods We conducted a prospective study which included all patients diagnosed with biopsy-proven bullous pemphigoid in the Dermatology Department of our hospital between April 1, 2009 and December 31,2019. The diagnosis of bullous pemphigoid was based on specific clinical, histological and immunological features. Results Overall 113 consecutive patients (age 75 ± 13 years, 62 females) with the diagnosis of bullous pemphigoid were enrolled. Seventy-six patients (67.3%) suffered from type 2 Diabetes and 52 (46%) were treated with dipeptidyl-peptidase 4 inhibitors. The most frequent prescribed gliptin was vildagliptin, being administered to 45 cases (39.8% of total patients enrolled, 86.5% of the patients treated with gliptins). Gliptins were withdrawn immediately after the diagnosis of bullous pemphigoid, which together with steroid administration led to remission of the rash. Conclusions This study revealed that treatment with dipeptidyl-peptidase 4 inhibitors, especially vildagliptin, is significantly associated with an increased risk of bullous pemphigoid development.

Diabetes mellitus type 2 (T2DM) is an emerging public health issue with high prevalence among older adults (>60 years old). Taking into consideration the great increase in the elderly population (approximately 7.5 billion worldwide), we can easily understand the impact of this chronic disease and its complications. On the other hand, vitamin D deficiency (VDD) is also a serious public health problem with significant impacts and multiple health effects. The correlation between DM and VDD has been suggested and established from many observational studies, reviews, and meta-analyses. The literature in PubMed and Google Scholar was searched for relevant articles published up to October 2020. The keywords used were the following: vitamin D deficiency, elderly, and diabetes mellitus type 2. Among the 556 articles retrieved, 90 full texts were eligible and only 34 studies (12 retrospective studies, two prospective cohorts, three meta-analyses, seven cross-sectional studies, nine randomized control trials (RCTs), and one observational study) met the inclusion criteria for the review. The author's name, year of publication, country, type of study, and the number of patients were reported. According to this review there is adequate evidence to support the correlation between VDD and T2DM in the elderly. The results from the RCTs are more conflicting and more studies are needed to confirm the impact of vitamin D deficiency (VD) supplementation on metabolic and lipid profile, oxidative stress, and the complications of T2DM in older patients. VDD is clearly related with severe retinopathy, diabetic peripheral neuropathy, and poor cognition performance, while there is consensus about the beneficial effect of VD on peripheral artery disease, foot ulceration prevention, and wound healing. On the other hand, there is controversy about the effect of VD supplementation on cardiovascular adverse events, endothelial function, and estimated glomerular filtration rate (eGFR). Finally, the association of VDD with fragility fractures and depression in the elderly with T2DM is currently insufficiently studied and remains controversial.

Intraneural ganglion cysts of the peroneal nerve are rare, and there is lack of evidence for the surgical management of this entity. We performed this study to evaluate the imaging, diagnosis, treatment and outcome of seven patients with intraneural ganglion cysts of the peroneal nerve. We retrospectively studied the files of seven patients with intraneural ganglion cysts of the peroneal nerve, diagnosed and treated from 2016 to 2019. Diagnostic approach included clinical examination of the leg and foot, magnetic resonance imaging, nerve conduction studies, surgical excision of the cyst and histological examination. The mean follow-up was 2 years (range 1–3.5 years). We evaluated the time and methods for surgical treatment, and the clinical outcomes of the patients. All patients presented symptoms of peripheral compression neuropathy; three patients presented with foot drop. The intraneural ganglion cysts were excised in all cases in addition to knee articular nerve branch transection to avoid cysts recurrence. Postoperatively, all patients experienced complete neurological recovery without clinical evidence of intraneural ganglion cysts recurrences. The treating physicians should be aware of intraneural ganglion cysts of the peroneal nerve in patients presenting with limb weakness, sensory deficits at the lateral and anterior side of the leg and foot, paresis or paralysis of the foot and ankle. MR imaging is the imaging modality of choice for a clear and accurate preoperative diagnosis to avoid misdiagnosis and wrong treatment. In case of doubt, these patients should be managed in an orthopedic oncology setting with microsurgery facilities available for complete excision of the intraneural ganglion cyst.

Patient: Female, 65-year-old Final Diagnosis: Open tibia fracture with bone loss Symptoms: Pain • osteomyelitis Medication: — Clinical Procedure: — Specialty: Orthopedics and Traumatology • Plastic Surgery Objective: Challenging differential diagnosis Background: Type IIIB open bone fractures include loss of soft tissue with periosteal stripping and need rapid surgical repair. The Ilizarov method of bone lengthening and reconstruction offers limb salvage as an alternative to amputation. Case Report: We report a case of a neglected type IIIB open fracture of the tibia with inadequate soft tissue coverage and periosteal stripping requiring an Ilizarov approach for limb salvage in a 65-year-old woman. Surgical debridement resulted in a large bone deficit of 13 cm. Acute shortening facilitated wound closure, and the remaining skin defect was treated with skin grafting. Bone transport and limb lengthening techniques, in addition to skin expansion and support, were used to restore the length of the tibia. The regenerated bone had to be fused with the talus since the tibial plafond was excised during debridement. The external fixator was removed after 643 days of treatment. An external fixation index of 49.6 d/cm was estimated. Excellent bone and good functional results were obtained according to the criteria of the Association for the Study and Application of the Method of Ilizarov. Skin invagination, bone translocation, and pin tract infection were the major postoperative issues. Conclusions: This case showed that a multidisciplinary approach may be required for the successful management of neglected open fractures of the tibia and that the Ilizarov approach to both bone and soft tissue lengthening and reconstruction should be considered to ensure limb salvage and improve the final cosmetic appearance.

Performance demands in communications technology is driving research towards advanced network processors, which are able to handle huge rates of incoming packets via application-specific circuits, however, without sacrificing all of the conventional CPU flexibility. At the same time, the advent of RISC-V is disrupting the industry & academia by opening computer architecture to a broader research community. Combining the above, the current paper considers placing dedicated VHDL accelerators next to a RISC-V processor to accommodate network functions via customized HW/SW co-processing. We extend the ISA with a new instruction to perform search tree operations that accelerate Packet Classification tasks in routers. For rapid prototyping and design exploration, we implement the binary search of HyperSplit algorithm on an Xilinx Ultrascale xcku060 FPGA. Our design achieves up to 118× faster classification than RISC-V alone and sustains up to 25.4M packets/sec throughput.

Our aim was to identify predictors of mortality and limb loss in iatrogenic and civilian arterial trauma. Cases were identified by searching prospectively maintained registries. Multivariable logistic regression was used to identify independent outcome predictors. During the study period, 285 patients with arterial trauma were managed with endovascular (n = 20) or open (n = 265) repair. Iatrogenic injuries increased in frequency during the course of the study, from 23.9% during the first decade to 35.9 and 55.7% during the second and third decade, respectively (p

Cubital tunnel syndrome is the second most common upper extremity compressive neuropathy. Different procedures have been described for the release of the ulnar nerve at the elbow but there is still no clear consensus regarding the best one. Failure rates after primary surgery range from 3% to 35%, depending on the severity of the symptoms before surgery. If symptoms do not alleviate after the primary surgery and other causes have been excluded, then the goal of the revision surgery must be to completely decompress the ulnar nerve. For the revision surgery there is also no widely accepted superior technique. Submuscular transposition seems to the most recommended technique. Other options include simple neurolysis, subcutaneous transposition and intramusclular transposition. We aim to inform you about the literature regarding the surgical options for revision surgery on cubital tunnel syndrome and describe the most common surgical techniques.

Subtrochanteric fractures of the femur occur in an area with high mechanical stresses both axial and torsional. Consequently, optimum reduction and fixation are essential to avoid complications of implant failure and nonunion. Closed reduction can be difficult due to the effect of pulling forces from different muscle groups. Intramedullary devices remain the standard of care of stabilization of these fractures. In the herein chapter, the management of these fractures is discussed in relation to their fixation and reduction techniques.

In response to repeated complaints from recreational and commercial coastal fishermen about declining fishing opportunities in inner Danish waters, focus was directed to inshore fish stocks. However, without data targeting inshore areas, it was not possible to investigate potential changes in fish distribution or abundances, or their causes. As a first step, a voluntary catch registration system was initiated in 2002, in collaboration with locally organized recreational fishermen. Using citizen science as a methodology, scientists and the fishermen developed a protocol for data collection, which the fishermen then implemented. The aim was to establish regular monitoring of fish catches from gill net and fyke net fisheries in coastal waters around Denmark in order to provide data that could inform management. After three years, during which time recreational fishermen could use their own gear and fish where they normally fished, the data was evaluated. As a result, the fishing method was switched in 2005 to fixed gears and fixed positions, to enable comparison between areas, years and season. The project has been very successful in recruiting highly motivated fishermen, who register their entire catch regularly. The time-series of data spans more than a decade and covers over 16,000 instances of fishing. The data from this project are now being used to create coastal fish indicators for managers to assess environmental status at a regional scale. Here we present an analysis of a subset of the data on one species, the European flounder (Platichthys flesus), to illustrate how the spatial and seasonal coverage can be utilized further for investigation of coastal ecosystems and to inform management.

An accurate and efficient prediction method for noise emanating from rotating sources such as helicopter rotors and aircraft propellers, is presented. Combining bifurcation analysis of the retarded time equation with different emission surface topologies, a new Emission Porous Surface (EPS) algorithm has been developed. The algorithm can be used in the framework of hybrid methods that combine Computational Fluid Dynamics, for noise generation, and integral formulations for noise propagation. A panel-by-panel reconstruction of the supersonic emission surface is also proposed, which allows to manage an unstructured mesh. The noise prediction method is applied to the analysis of the UH1H rotor in strong shock delocalization conditions, a well known and extensively studied case of High Speed Impulsive (HSI) noise. The present results are compared with experimental and numerical data available in literature.

High communicational standards have been set for the 5G mobile networks. Therefore, it is of great importance that technological solutions that include all the significant features, such as the high coverage and capacity and low round-trip delays, are adopted for the next generation of mobile networks. Except for their technical efficiency, these technologies should be profitable for providers as well. As a result, the need for limiting the costs spent for the development of these technologies emerges. In this papers, four models two for each one of the two solutions for 5G networks are developed, namely the Multiple Input Multiple Output (MIMO) and the Distributed Antenna System. The architectural models assumed for the techno-economic analyses are presented. The mathematical models for both technologies are developed. Experiments are conducted using prices of the Greek market and also Sensitivity Analysis (SA) is used to pinpoint, which cost parameters are the most expensive ones and therefore it is likely that they discourage providers to invest in them. To our knowledge there are not many studies comparing and contrasting these technologies and there is no SA for MIMO. Therefore, it is considered that research for these models is of vital importance for the next generation of mobile communication networks, as they are foundation stonesfor the formation of 5G.

Background Brown tumors represent a rare clinical manifestation reported in approximately 3% of patients with primary hyperparathyroidism and correspond to radiologically osteolytic lesions with well-defined borders in different parts of the skeleton. Case presentation We report the case of a 53-year-old white man who presented to our hospital with osteolytic lesions of his distal ulna and radius, causing pain and swelling of 2-month duration. A subsequent biopsy revealed histological features consistent with giant cell tumor and a complete resection of his distal ulna was followed, along with curettage and cementoplasty of the distal radial metaphysis. Two weeks later, he was re-admitted with diffuse musculoskeletal soreness, anorexia, constipation, nausea, and localized abdominal pain and multiple osteolytic lesions on plain radiographs. A histopathological examination of the ulna and radius specimens showed similar findings and, given the multifocality, brown tumors related to primary or secondary hyperparathyroidism was included in the differential diagnosis. A laboratory examination showed high total serum calcium (14.5 mg/dl) and low serum phosphorus and 25-hydroxyvitamin D levels. Primary hyperparathyroidism was suspected and confirmed by the elevated parathyroid hormone levels of 1453 pg/mL. At radiological work-up, using computed tomography, ultrasonography, and parathyroid subtraction technetium-99m sestamibi scintigraphy, a 4.5 × 2.5 × 3.2 cm mass emanating from the right lobe of his thyroid gland was detected, displaying extensive uptake in the right lower parathyroid gland. After appropriate medical support including hyperhydration and high doses of diuretics and diphosphonates, his laboratory profile normalized and he underwent total thyroidectomy with removal of the parathyroid glands. Our patient is now recovering 12 months after surgery, with normal values of serum parathyroid hormone and calcium levels. The lytic bone lesions have almost disappeared and no other additional orthopedic intervention was necessary. Conclusions The present case report emphasizes the need of inclusion of brown tumors in the differential diagnosis of multifocal osteolytic bone lesions, in order to avoid harmful surgical interventions. Laboratory testing of serum phosphate, calcium levels, and parathyroid hormone levels should always be included in the routine survey of patients with multifocal osteolytic lesions.

Subtrochanteric fractures can result from high-energy trauma in young patients or from a fall or minor trauma in the elderly. Intramedullary nails are currently the most commonly used implants for the stabilization of these fractures. However, the anesthetic procedure for the patients, the surgical reduction and osteosynthesis for the fractures are challenging. The anesthetic management of orthopedic trauma patients should be based upon various parameters that must be evaluated before the implementation of any anesthetic technique. Surgery- and patient-related characteristics and possible comorbidities must be considered during the pre-anesthetic evaluation. Adequate fracture reduction and proper nail entry point are critical. Understanding of the deforming forces acting on various fracture patterns and knowledge of surgical reduction techniques are essential in obtaining successful outcomes. This article discusses the intraoperative reduction techniques for subtrochanteric fractures in adults and summarizes tips and tricks that the readers may find useful and educative.

BACKGROUND Psoriasis is a chronic inflammatory skin disease, which requires long-term, safe and effective treatment. Apremilast, a small-molecule PDE4 inhibitor, has been introduced as psoriasis (and psoriatic arthritis) treatment in Europe in 2015. OBJECTIVE We analysed and report the efficacy and safety of apremilast in the first 51 patients with psoriasis that have undergone treatment with this novel small molecule in our outpatient clinic. METHOD Our primary endpoint was the evaluation of clinical response to apremilast according to the percentage of Psoriasis Area Severity Index (PASI) reduction (ΔPASI) at 16 weeks after treatment initiation. Secondary endpoints were the evaluation at week 16 of (i) PASI; (ii) Dermatology Life Quality Index (DLQI); (iii) Physician Global Assessment (PGA); (iv) Psoriasis Scalp Severity Index (PSSI); and (v) the percentage of patients who achieved ΔPASI50, ΔPASI75, ΔPASI90 and ΔPASI100; (vi) adverse events (AE); (vii) reasons for drug discontinuation; and (viii) drug survival. RESULTS About 59.3% of the patients who remained on apremilast achieved at least ΔPASI75 at week 16, while 11.1% achieved combined 50% ≤ PASI < 75% and DLQI ≤ 5 (satisfactory response) adequate enough to maintain treatment. Five patients (18.5%) also achieved ΔPASI100. Patients discontinued apremilast (28%), mostly during the first 4 weeks due to adverse events (12%) with gastrointestinal symptoms being the most common, and later due to lack of efficacy (16%). A statistically significant improvement of PASI, DLQI, PGA and PSSI scores was observed after 4 and 16 weeks of treatment relative to pretreatment measurements. CONCLUSION Apremilast is a safe and efficacious treatment for psoriasis patients as it produces ΔPASI75 and ΔPASI50 responses combined with DLQI ≤ 5 in 16 weeks in 70.4% of the patients. These results, from a real-world setting, confirm the efficacy and safety of apremilast which has been demonstrated in large phase III clinical trials.

[Purpose] The main purpose of the study was to examine the relationship of a battery of frequently used functional assessment tests with quadriceps and hamstrings isokinetic strength in Knee-osteoarthritis (OA) patients. Secondarily, the predictability of isokinetic strength on these performance variables was also assessed. [Subjects and Methods] Seventeen males and 23 females with Knee-OA, were assessed via a) the common functional tests: 6-minute walk test, Timed up-and-go test, 30-second chair test and 12-stair test and b) isokinetic concentric extension-flexion at 120°/s and 180°/s. [Results] Both Knee Extension and Flexion Peak Torque per Body weight showed moderate to strong, statistically significant correlation, with all 4-functional performance tests, for both velocities. Both 12-stair test and 30-second chair test were significant predictors in all analyses, while the 6-minute walk test was an additional significant predictor of the 120°/s knee flexion. [Conclusion] Thigh muscle strength in both tested velocities proved to be significantly correlated with functional performance. The 12-stair test and 30-second chair test results were significant predictors for isokinetic extension and flexion in both velocities. It appears that those two tests challenge the knee and the surrounding musculature in a manner that reflects muscle strength.

Patient: Male, 51-year-old Final Diagnosis: Intraosseous ganglion cyst Symptoms: Discomfort • pain Medication: — Clinical Procedure: Athroscopy • bone graft Specialty: Orthopedics and Traumatology Objective: Rare disease Background: This article presents a rare case of 2 separate intraosseous ganglion cysts of the talus in a 51-year-old man, treated with a unique technique of precise lesion targeting to avoid extensive bone loss and minimize articular chondral injury of the talus. Case Report: Two separate intraosseous ganglion cysts of the talus were diagnosed in a 51-year-old man with chronic ankle pain. A single straight-line incision with an entry point through the talonavicular joint was created to spare the precarious blood supply of the talus network. The 2 distinct subchondral lesions were approached under fluoroscopic control for curettage and autologous bone grafting using the anterior cruciate ligament tibial guide in a pair-of-compasses fashion. In almost 5 years of follow-up the patient has been asymptomatic. Magnetic resonance imaging has revealed no signs of degenerative changes in the ankle or the talonavicular joint, and the intraosseous edema has almost disappeared. Conclusions: To the best of our knowledge, this case is the first report of 2 distinct intraosseous ganglion cysts of the talus. We recommend the precise targeting technique used in our case for treating intraosseous talar lesions with intact articular cartilage.

The mathematical formulation for the optical setup of a typical EARLINET lidar system is given here. The equations describing a lidar system from the emitted laser beam to the projection of the telescope aperture on the final receiving unit (i.e., photomultiplier or photodiode) are presented, based on paraxial approximation and geometric optics approach. The receiving optical setup includes a telescope, a collimating lens, an interference filter and the ensemble objective eyepiece. The set of the derived equations interconnects major parameters of the optical components (e.g., focal lengths, diameters, angles of incidence), revealing their association with the distance of full overlap of the system. These equations may used complementarily with an optical design software, for the preliminary design of a system or can be used as a quick check up tool of an existing lidar system. The evaluation of the formulation on a real system is performed with ray-tracing simulations, revealing an overall good performance with relative differences of the order of 5 % mainly attributed to the limitations of the thin lens approximation.

Tumors of the hand comprise a vast array of lesions involving skin, soft tissue and bone. The majority of tumors in the hand are benign. Malignant tumors, although rare, do occur and frequently have unique characteristics in this specific anatomic location. Careful staging, histological diagnosis and treatment are essential to optimize clinical outcome. However, straightforward most of the time, hand tumor management does have pitfalls; caution is advised, as a missed or delayed diagnosis or an improperly executed biopsy may have devastating consequences. This article reviews the clinical spectrum of the most common benign and malignant bone and soft tissue tumors of the hand and discusses the clinicopathological findings, imaging features and current concepts in treatment for these tumors.

Nerve injuries around the shoulder are common. They usually occur as a result of motor vehicle accidents, gunshot or athletic injuries, or overuse and chronic repetitive stress often observed in sports involving repetitive overhead or throwing activities. The mechanisms of nerve injury include direct pressure, repetitive microtrauma, and compression- or stretch-induced ischemia. The severity and extent of compression is related to the degree of the nerve injury. Several nerve injury grading systems have been developed, allowing for the correlation between microscopic changes occurring after the injury and the patient's symptoms; recovery and prognosis is related to the type and severity of the injury. Distinct clinical syndromes involving the shoulder joint area can develop after injuries to the axillary, musculocutaneous, suprascapular, long thoracic, and spinal accessory nerves, as well as the proximal brachial plexus trunks and the lower cervical nerve roots. When a patient complains of pain, weakness, or paresthesia in the absence of known bone, soft tissue, or vascular injury, nerve injury must be suspected. This article summarizes the most common nerve injuries around the shoulder and discusses the classification, mechanism, treatment, and prognosis for these injuries.

Benign peripheral nerve tumors encompass a wide range of neoplasms and non-neoplastic tumor like lesions. Some of these lesions if not encountered in the setting of genetic syndromes, are occurring sporadically. The principles of oncology should be respectfully followed in every step of diagnostic approach and surgical management. Albeit, classified as benign, some of them do have different level of malignant potential, thus the treating physicians should be aware of that to avoid possible pitfalls with devastating outcomes. This article reviews the most common benign peripheral nerve tumors discussing the clinicopathological findings, imaging appearance and the current trend in their approach.

Introduction In upper brachial plexus injuries (C5-C6-C7), selective nerve transfers appear as a favourable technique. For this purpose, transfer of an ulnar nerve fascicle to the biceps motor branch (Oberlin's procedure) is often used. In this paper we present our modified Oberlin technique, as well as a comparison of this method with the classic Oberlin procedure. Materials and Methods We present two groups of patients that where operated by two different surgeons. The first group, consisting of 16 patients was treated with the classic Oberlin procedure. The second group included 5 patients treated with a modified Oberlin procedure, where two fascicles from the ulnar nerve were transferred to both the motor branch of the biceps and the motor branch of the brachialis muscles. Results In the last follow-up of the 16 patients from the first group with the classic Oberlin procedure, 15 patients (93.75%) had Medical Research Council (MRC) grade of biceps strength 4 and 1 patient (6.25%) had MRC grade 3, whereas in the group where the modified Oberlin procedure was used the muscle strength was very durable with 4 out of 5 the patients reached MRC grade of 4+ and one MRC grade of 4, and with a mean elbow strength at 5.4 kg (3–8 kg). No sensitivity or motor problems were encountered on the ulnar territories for both groups. Conclusion With the modified Oberlin technique, the median nerve is reserved and both elbow flexors are innervated. The results of this technique compare favourably with those of other methods. Thus, we propose using the double fascicle transfer from the ulnar nerve to both elbow flexors in order to restore a strong elbow flexion in patients with upper brachial plexus injuries.

Several clinical studies demonstrated the safety and efficacy of the interleukin-17 inhibitor secukinumab in the systemic treatment of moderate-to-severe psoriasis, as well as psoriatic arthritis (PsA) in adults, whereas real-world data is limited. A single-center clinical study was performed to evaluate in real-world practice the efficacy of secukinumab up to Week 104 of treatment in moderate-to-severe chronic plaque psoriasis, including scalp and palmoplantar involvement, according to Physician Global Assessment (PGA), PASI75/90/100 and scalp, and palmoplantar PGA. Drug survival, the safety profile of secukinumab, and patient's quality of life were also assessed during a 2-year observation period. Out of 83 patients included, 56.3% were biologic-naïve, and 94% had scalp, 25.3% palmoplantar, and 43.9% joint involvement. At Week 16, PASI75/PASI90/PASI100 were observed in 83.8/70.0/46.3%, respectively. Scalp and palmoplantar PGA were rapidly improved, with 98.7 and 95.5%, respectively, reaching clear/almost clear skin at Week 16. After 104 weeks, drug survival was 74.5%. A significant improvement of the quality of life was observed. Biologic-naïve patients without coexisting PsA benefited the most. Real-world data demonstrated secukinumab efficacious in chronic plaque psoriasis, including specific locations such as scalp and palmoplantar psoriasis with a safety profile similar to that in clinical trials.

Surgical fasciotomy is the only effective treatment for compartment syndrome. However, it is associated with complications, including long hospital stay, wound infection and osteomyelitis, need for further surgery for delayed wound closure or skin grafting, scarring, delayed bone healing, pain and nerve injury, permanent muscle weakness, chronic venous insufficiency, cosmetic problems, and an overall increased cost of care. To reduce the risk of complications, the fasciotomy wound should be closed as quickly as possible. However, closure of fasciotomy wounds is challenging, and a plethora of techniques have been proposed. With no consensus existing in the literature regarding the best method for closure of fasciotomy wounds, the technique applied each time is based mostly on surgeon’s preference, condition of the soft tissues, and availability of materials and devices. This chapter aims to summarize the available techniques employed in fasciotomy wound closure and to discuss the indications, advantages, disadvantages, and complications of these techniques in a way that readers may find useful and educative.

Radial tunnel syndrome is a painful syndrome caused by compression of the posterior interosseous nerve at the proximal forearm. There are no specific radiologic or electrodiagnostic findings. Nonsurgical treatment is recommended initially; if not successful, surgical decompression is indicated, releasing all the potential sites of entrapment. Surgical treatment has usually good outcomes; however, workers’ compensation patients or those who have coexisting lateral epicondylitis have less successful results.

CASE A 19-year-old male patient with isolated posterior cruciate ligament (PCL) rupture underwent arthroscopic reconstruction using reinforced synthetic ligament (LARS system). Three weeks postoperatively, he presented with active bleeding from the medial side of his knee, near the proximal interference screw. An angiogram revealed extravasation from the medial superior genicular artery which was successfully embolized. One week later, he returned with active bleeding from the same area, located just under the initial coiling; a second embolization during superselective angiography was successful. CONCLUSION Although rare, minor vascular injuries are a risk inherent to PCL surgery.

Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [ Orthopedics. 2016; 39(4):249–259.]

The management of complex tibial plateau fractures is ever evolving. The severity of the injury to the surrounding soft tissues influences the timing and the method of fixation. Minimal invasive techniques continue to dominate our philosophy of reduction and reconstruction whereas augmentation of depressed intra-articular fragments remains an accepted strategy to maintain reduction and prevent secondary collapse. Locking plates, conventional plates and fine wire fixators all have been used successfully with satisfactory outcomes. In this article we report on the latest advances made in the management of these complex injuries.

Oceans are exposed to anthropogenic climate change shifting marine systems toward potential instabilities. The physical, biological and social implications of such shifts can be assessed within individual scientific disciplines, but can only be fully understood by combining knowledge and expertise across disciplines. For climate change related problems these research directions have been well-established since the publication of the first IPCC report in 1990, however it is not well-documented to what extent these directions are reflected in published research. Focusing on the Nordic region, we evaluated the development of climate change related marine science by quantifying trends in number of publications, disciplinarity, and scientific focus of 1362 research articles published between 1990 and 2011. Our analysis showed a faster increase in publications within climate change related marine science than in general marine science indicating a growing prioritisation of research with a climate change focus. The composition of scientific disciplines producing climate change related publications, which initially was dominated by physical sciences, shifted toward a distribution with almost even representation of physical and biological sciences with social sciences constituting a minor constant proportion. These trends suggest that the predominantly model-based directions of the IPCC have favoured the more quantitatively oriented natural sciences rather than the qualitative traditions of social sciences. In addition, despite being an often declared prerequisite to successful climate science, we found surprisingly limited progress in implementing interdisciplinary research indicating that further initiatives nurturing scientific interactions are required.