"Five steps four quadrants" modularized en bloc dissection technique for accessing hepatic hilum lymph nodes in laparoscopic pancreaticoduodenectomy

BACKGROUND Although en bloc dissection of hepatic hilum lymph nodes has many advantages in radical tumor treatment,the feasibility and safety of this approach for laparo-scopic pancreaticoduodenectomy(LPD)require further clinical evaluation and investigation.AIM To explore the application value of the"five steps four quadrants"modularized en bloc dissection technique for accessing hepatic hilum lymph nodes in LPD patients.METHODS A total of 52 patients who underwent LPD via the"five steps four quadrants"modularized en bloc dissection technique for hepatic hilum lymph nodes from April 2021 to July 2023 in our department were analyzed retrospectively.The patients'body mass index(BMI),preoperative laboratory indices,intraoperative variables and postoperative complications were recorded.The relationships between preoperative data and intraoperative lymph node dissection time and blood loss were also analyzed.RESULTS Among the 52 patients,36 were males and 16 were females,and the average age was 62.2±11.0 years.There were 26 patients with pancreatic head cancer,16 patients with periampullary cancer,and 10 patients with distal bile duct cancer.The BMI was 22.3±3.3 kg/m²,and the median total bilirubin(TBIL)concentration was 57.7(16.0-155.7)µmol/L.All patients successfully underwent the"five steps four quadrants"modularized en bloc dissection technique without lymph node clearance-related complications such as postoperative bleeding or lymphatic leakage.Correlation analysis revealed significant associations between preoperative BMI(r=0.3581,P=0.0091),TBIL level(r=0.2988,P=0.0341),prothrombin time(r=0.3018,P=0.0297)and lymph node dissection time.Moreover,dissection time was significantly correlated with intraoperative blood loss(r=0.7744,P<0.0001).Further stratified analysis demonstrated that patients with a preoperative BMI≥21.9 kg/m²and a TIBL concentration≥57.7μmol/L had significantly longer lymph node dissection times(both P<0.05).CONCLUSION The"five steps four quadrants"modularized en bloc dissection technique for accessing the hepatic hilum lymph node is safe and feasible for LPD.This technique is expected to improve the efficiency of hepatic hilum lymph node dissection and shorten the learning curve;thus,it is worthy of further clinical promotion and application.

Half-integer Shapiro steps in MgB_(2) focused He ion beam Josephson junctions

Half-integer microwave induced steps(Shapiro steps)have been observed in many different Josephson junction systems,which have attracted a lot of attention because they signify the deviation of current phase relation(CPR)and uncover many unconventional physical properties.In this article,we first report the discovery of half-integer Shapiro steps in MgB_(2)focused He ion beam(He-FIB)Josephson junctions.The half-integer steps'dependence on microwave frequency,temperature,microwave power,and magnetic field is also analyzed.We find that the existence of half-integer steps can be controlled by the magnetic field periodically,which is similar to that of high temperature superconductor(HTS)grain boundary junctions,and the similarity of the microstructures between gain boundary junctions and He-FIB junctions is discussed.As a consequence,we mainly attribute the physical origin of half-integer steps in MgB_(2)He-FIB junctions to the model that a He-FIB junction is analogous to a parallel junctions'array.Our results show that He-FIB technology is a promising platform for researching CPR in junctions made of different superconductors.

Evolution of United States Technology Alliance Strategy and Reshaping of International Strategic Landscape

Building a technology alliance is the main strategy for the United States to maintain its scientific and technological hegemony under its technopolitical strategic framework.After Joe Biden took office,the United States implemented“small yard with high fences”strategy for scientific and technological competition,as the first step toward building a technology alliance.The main goal is to restrict the flow of strategic emerging technologies and factors of innovation to rival countries.

Zero-determinant strategies in iterated multi-strategy games

Self-serving,rational agents sometimes cooperate to their mutual benefit.The two-player iterated prisoner′s dilemma game is a model for including the emergence of cooperation.It is generally believed that there is no simple ultimatum strategy which a player can control the return of the other participants.The zero-determinant strategy in the iterated prisoner′s dilemma dramatically expands our understanding of the classic game by uncovering strategies that provide a unilateral advantage to sentient players pitted against unwitting opponents.However,strategies in the prisoner′s dilemma game are only two strategies.Are there these results for general multi-strategy games?To address this question,the paper develops a theory for zero-determinant strategies for multi-strategy games,with any number of strategies.The analytical results exhibit a similar yet different scenario to the case of two-strategy games.The results are also applied to the Snowdrift game,the Hawk-Dove game and the Chicken game.

A Clean Switch Inner Mongolian town takes giant steps in transitioning to clean energy production

Staff at the Ruichen Wanniu Livestock Farm in Jungar Zhao Town,Jungar Banner,Inner Mongolia,are consistently busy,even during important festivals.

Two-step strategy—conjunctival flap covering surgery combined with secondary deep anterior lamellar keratoplasty for the treatment of high-risk fungal keratitis

AIM:To investigate whether the two-step strategy[conjunctival flap covering surgery(CFCS)combined with secondary deep anterior lamellar keratoplasty(DALK)]is effective for patients with high-risk fungal keratitis(FK).METHODS:In this noncomparative,retrospective case series,10 subjects(6 males,4 females)with a mean age of 56.5±7.1(range 47-72)y with high-risk FK undergone the two-step strategy were included.Reported outcome measures were healing of the corneal ulcer,recurrence of FK,reject reaction,improvement in best corrected visual acuity(BCVA)and relevant complications.RESULTS:The average diameter of corneal infiltrates was 7.50±0.39 mm,ranging from 6.94 to 8.13 mm.The mean depth of corneal infiltrates was 422.4±77.1μm,ranging from 350 to 535μm.The mean corneal thickness was 597.4±117.3μm,ranging from 458 to 851μm.Hypopyon and endothelial plaques were presented in all patients.The period between the two steps was 3.65±0.9(ranging from 3 to 5)mo.The graft diameter was 7.75±0.39 mm.At the last follow-up(average 9.25±3.39,ranging from 5.5 to 17mo),no fungal recurrence or graft rejection appeared,and all patients showed improvement of BCVA.One patient suffered from liver function impairment due to oral voriconazole for 4wk and recovered spontaneously after 1wk of drug withdrawal.CONCLUSION:The two-step strategy is safe and effective in the treatment of high-risk FK by transforming intentional therapeutic penetrating keratoplasty during acute infection to later optical DALK.It is a practical strategy,especially in areas lacking fresh donor corneas and eye bank services.

Significant risk factors for intensive care unit-acquired weakness:A processing strategy based on repeated machine learning

BACKGROUND Intensive care unit-acquired weakness(ICU-AW)is a common complication that significantly impacts the patient's recovery process,even leading to adverse outcomes.Currently,there is a lack of effective preventive measures.AIM To identify significant risk factors for ICU-AW through iterative machine learning techniques and offer recommendations for its prevention and treatment.METHODS Patients were categorized into ICU-AW and non-ICU-AW groups on the 14th day post-ICU admission.Relevant data from the initial 14 d of ICU stay,such as age,comorbidities,sedative dosage,vasopressor dosage,duration of mechanical ventilation,length of ICU stay,and rehabilitation therapy,were gathered.The relationships between these variables and ICU-AW were examined.Utilizing iterative machine learning techniques,a multilayer perceptron neural network model was developed,and its predictive performance for ICU-AW was assessed using the receiver operating characteristic curve.RESULTS Within the ICU-AW group,age,duration of mechanical ventilation,lorazepam dosage,adrenaline dosage,and length of ICU stay were significantly higher than in the non-ICU-AW group.Additionally,sepsis,multiple organ dysfunction syndrome,hypoalbuminemia,acute heart failure,respiratory failure,acute kidney injury,anemia,stress-related gastrointestinal bleeding,shock,hypertension,coronary artery disease,malignant tumors,and rehabilitation therapy ratios were significantly higher in the ICU-AW group,demonstrating statistical significance.The most influential factors contributing to ICU-AW were identified as the length of ICU stay(100.0%)and the duration of mechanical ventilation(54.9%).The neural network model predicted ICU-AW with an area under the curve of 0.941,sensitivity of 92.2%,and specificity of 82.7%.CONCLUSION The main factors influencing ICU-AW are the length of ICU stay and the duration of mechanical ventilation.A primary preventive strategy,when feasible,involves minimizing both ICU stay and mechanical ventilation duration.

Engineering Strategies for Suppressing the Shuttle Effect in Lithium–Sulfur Batteries

Lithium–sulfur(Li–S)batteries are supposed to be one of the most potential next-generation batteries owing to their high theoretical capacity and low cost.Nevertheless,the shuttle effect of firm multi-step two-electron reaction between sulfur and lithium in liquid electrolyte makes the capacity much smaller than the theoretical value.Many methods were proposed for inhibiting the shuttle effect of polysulfide,improving corresponding redox kinetics and enhancing the integral performance of Li–S batteries.Here,we will comprehensively and systematically summarize the strategies for inhibiting the shuttle effect from all components of Li–S batteries.First,the electrochemical principles/mechanism and origin of the shuttle effect are described in detail.Moreover,the efficient strategies,including boosting the sulfur conversion rate of sulfur,confining sulfur or lithium polysulfides(LPS)within cathode host,confining LPS in the shield layer,and preventing LPS from contacting the anode,will be discussed to suppress the shuttle effect.Then,recent advances in inhibition of shuttle effect in cathode,electrolyte,separator,and anode with the aforementioned strategies have been summarized to direct the further design of efficient materials for Li–S batteries.Finally,we present prospects for inhibition of the LPS shuttle and potential development directions in Li–S batteries.

Drug resistance mechanisms in cancers:Execution of prosurvival strategies

One of the quintessential challenges in cancer treatment is drug resistance.Several mechanisms of drug resistance have been described to date,and new modes of drug resistance continue to be discovered.The phenomenon of cancer drug resistance is now widespread,with approximately 90% of cancer-related deaths associated with drug resistance.Despite significant advances in the drug discovery process,the emergence of innate and acquired mechanisms of drug resistance has impeded the progress in cancer therapy.Therefore,understanding the mechanisms of drug resistance and the various pathways involved is integral to treatment modalities.In the present review,I discuss the different mechanisms of drug resistance in cancer cells,including DNA damage repair,epithelial to mesenchymal transition,inhibition of cell death,alteration of drug targets,inactivation of drugs,deregulation of cellular energetics,immune evasion,tumor-promoting inflammation,genome instability,and other contributing epigenetic factors.Furthermore,I highlight available treatment options and conclude with future directions.

Equilibrium Strategy of the Pursuit-Evasion Game in Three-Dimensional Space

The pursuit-evasion game models the strategic interaction among players, attracting attention in many realistic scenarios, such as missile guidance, unmanned aerial vehicles, and target defense. Existing studies mainly concentrate on the cooperative pursuit of multiple players in two-dimensional pursuit-evasion games. However, these approaches can hardly be applied to practical situations where players usually move in three-dimensional space with a three-degree-of-freedom control. In this paper,we make the first attempt to investigate the equilibrium strategy of the realistic pursuit-evasion game, in which the pursuer follows a three-degree-of-freedom control, and the evader moves freely. First, we describe the pursuer's three-degree-of-freedom control and the evader's relative coordinate. We then rigorously derive the equilibrium strategy by solving the retrogressive path equation according to the Hamilton-Jacobi-Bellman-Isaacs(HJBI) method, which divides the pursuit-evasion process into the navigation and acceleration phases. Besides, we analyze the maximum allowable speed for the pursuer to capture the evader successfully and provide the strategy with which the evader can escape when the pursuer's speed exceeds the threshold. We further conduct comparison tests with various unilateral deviations to verify that the proposed strategy forms a Nash equilibrium.

How do the landslide and non-landslide sampling strategies impact landslide susceptibility assessment? d A catchment-scale case study from China

The aim of this study is to investigate the impacts of the sampling strategy of landslide and non-landslide on the performance of landslide susceptibility assessment(LSA).The study area is the Feiyun catchment in Wenzhou City,Southeast China.Two types of landslides samples,combined with seven non-landslide sampling strategies,resulted in a total of 14 scenarios.The corresponding landslide susceptibility map(LSM)for each scenario was generated using the random forest model.The receiver operating characteristic(ROC)curve and statistical indicators were calculated and used to assess the impact of the dataset sampling strategy.The results showed that higher accuracies were achieved when using the landslide core as positive samples,combined with non-landslide sampling from the very low zone or buffer zone.The results reveal the influence of landslide and non-landslide sampling strategies on the accuracy of LSA,which provides a reference for subsequent researchers aiming to obtain a more reasonable LSM.

Overview of the immunological mechanisms in hepatitis B virus reactivation:Implications for disease progression and management strategies

Hepatitis B virus(HBV)reactivation is a clinically significant challenge in disease management.This review explores the immunological mechanisms underlying HBV reactivation,emphasizing disease progression and management.It delves into host immune responses and reactivation’s delicate balance,spanning innate and adaptive immunity.Viral factors’disruption of this balance,as are interac-tions between viral antigens,immune cells,cytokine networks,and immune checkpoint pathways,are examined.Notably,the roles of T cells,natural killer cells,and antigen-presenting cells are discussed,highlighting their influence on disease progression.HBV reactivation’s impact on disease severity,hepatic flares,liver fibrosis progression,and hepatocellular carcinoma is detailed.Management strategies,including anti-viral and immunomodulatory approaches,are critically analyzed.The role of prophylactic anti-viral therapy during immunosuppressive treatments is explored alongside novel immunotherapeutic interventions to restore immune control and prevent reactivation.In conclusion,this compre-hensive review furnishes a holistic view of the immunological mechanisms that propel HBV reactivation.With a dedicated focus on understanding its implic-ations for disease progression and the prospects of efficient management stra-tegies,this article contributes significantly to the knowledge base.The more profound insights into the intricate interactions between viral elements and the immune system will inform evidence-based approaches,ultimately enhancing disease management and elevating patient outcomes.The dynamic landscape of management strategies is critically scrutinized,spanning anti-viral and immunomodulatory approaches.The role of prophylactic anti-viral therapy in preventing reactivation during immunosuppressive treatments and the potential of innovative immunotherapeutic interventions to restore immune control and proactively deter reactivation.

基于TeamSTEPPS理论的案例情景教学法在急诊护理团队培训中的应用

急诊科具有危重患者多,突发状况多,医疗风险高等特点,目前国内大多数医院急诊科护士以团队形式开展工作,但临床工作中易出现职责分工不明确、配合不协调、组织抢救混乱等问题^([1])。团队培训是增强团队优质高效协作的重要途径^([2]),为进一步提升急诊护理团队协作,保障患者安全,本次研究将前期基于提高医疗质量和患者安全的团队策略与工具(team strategies and tools to enhance performance and patient safety,TeamSTEPPS)理论构建的急诊护理团队培训方案^([3])进行临床应用,取得了较好的效果。现报道如下。

Progress on Transition Metal Ions Dissolution Suppression Strategies in Prussian Blue Analogs for Aqueous Sodium-/Potassium-Ion Batteries

Aqueous sodium-ion batteries(ASIBs)and aqueous potassium-ion batteries(APIBs)present significant potential for large-scale energy storage due to their cost-effectiveness,safety,and environmental compatibility.Nonetheless,the intricate energy storage mechanisms in aqueous electrolytes place stringent require-ments on the host materials.Prussian blue analogs(PBAs),with their open three-dimensional framework and facile synthesis,stand out as leading candidates for aqueous energy storage.However,PBAs possess a swift capacity fade and limited cycle longevity,for their structural integrity is compromised by the pronounced dis-solution of transition metal(TM)ions in the aqueous milieu.This manuscript provides an exhaustive review of the recent advancements concerning PBAs in ASIBs and APIBs.The dissolution mechanisms of TM ions in PBAs,informed by their structural attributes and redox processes,are thoroughly examined.Moreover,this study delves into innovative design tactics to alleviate the dissolution issue of TM ions.In conclusion,the paper consolidates various strategies for suppressing the dissolution of TM ions in PBAs and posits avenues for prospective exploration of high-safety aqueous sodium-/potassium-ion batteries.

English Writing Strategy-Based on Three Steps

Many junior high school students have trouble in writing English composition, and this paper is primarily divided into three steps of pre-writing, while-writing and post-writing to answer the question: How to write a composition.

In Her Father's Footsteps

Chinese nurse chooses to join a medical mission to Mali, just like her father Hong Min will never forget 18 July 2017. It was the day when the nurse received the medal of the Order of Health Merit of Mali for her service in the country as part of the 24th Chinese medical team.The award, in the words of Samba Ousmane Sow, then minister of health and public hygiene.

LDAS&ET-AD:Learnable Distillation Attack Strategies and Evolvable Teachers Adversarial Distillation

Adversarial distillation(AD)has emerged as a potential solution to tackle the challenging optimization problem of loss with hard labels in adversarial training.However,fixed sample-agnostic and student-egocentric attack strategies are unsuitable for distillation.Additionally,the reliability of guidance from static teachers diminishes as target models become more robust.This paper proposes an AD method called Learnable Distillation Attack Strategies and Evolvable Teachers Adversarial Distillation(LDAS&ET-AD).Firstly,a learnable distillation attack strategies generating mechanism is developed to automatically generate sample-dependent attack strategies tailored for distillation.A strategy model is introduced to produce attack strategies that enable adversarial examples(AEs)to be created in areas where the target model significantly diverges from the teachers by competing with the target model in minimizing or maximizing the AD loss.Secondly,a teacher evolution strategy is introduced to enhance the reliability and effectiveness of knowledge in improving the generalization performance of the target model.By calculating the experimentally updated target model’s validation performance on both clean samples and AEs,the impact of distillation from each training sample and AE on the target model’s generalization and robustness abilities is assessed to serve as feedback to fine-tune standard and robust teachers accordingly.Experiments evaluate the performance of LDAS&ET-AD against different adversarial attacks on the CIFAR-10 and CIFAR-100 datasets.The experimental results demonstrate that the proposed method achieves a robust precision of 45.39%and 42.63%against AutoAttack(AA)on the CIFAR-10 dataset for ResNet-18 and MobileNet-V2,respectively,marking an improvement of 2.31%and 3.49%over the baseline method.In comparison to state-of-the-art adversarial defense techniques,our method surpasses Introspective Adversarial Distillation,the top-performing method in terms of robustness under AA attack for the CIFAR-10 dataset,with enhancements of 1.40%and 1.43%for ResNet-18 and MobileNet-V2,respectively.These findings demonstrate the effectiveness of our proposed method in enhancing the robustness of deep learning networks(DNNs)against prevalent adversarial attacks when compared to other competing methods.In conclusion,LDAS&ET-AD provides reliable and informative soft labels to one of the most promising defense methods,AT,alleviating the limitations of untrusted teachers and unsuitable AEs in existing AD techniques.We hope this paper promotes the development of DNNs in real-world trust-sensitive fields and helps ensure a more secure and dependable future for artificial intelligence systems.

Interpretation of Chinese Expert Consensus on the Diagnosis and Management Strategy of Patients with Statin Intolerance: A guiding file for helping to lipid management for Chinese population

It is well-known that elevated low-density lipoprotein cholesterol(LDL-C)is a causal risk factor for atheroscler-otic cardiovascular disease(ASCVD),statins are cornerstone drugs for the cause-based treatment of ASCVD,which has created a new era for ASCVD therapy.However,statin intolerance is not clinically uncommon,which there are several issues with confu-sion and misunderstandings.Hence,a file named Chinese Expert Consensus on the Diagnosis and Management Strategy of Pa-tients With Statin Intolerance,like a navigator,has recently been published written by a team of experts from the Cardiovascular Metabolic Medicine Professional Committee,Expert Committee of the National Center for Cardiovascular Diseases aiming to en-hance the standardized clinical application of statins and improve the prevention and clinical outcome.In this article,author briefly summarized the key points of above consensus in order to helping to comprehending the content of the consensus sugges-tions.

Eradication Treatment of Helicobacter pylori Infection: Evaluation of Therapeutic Strategies in N’Djamena

Background: Helicobacter pylori (Hp) infection is the most widespread bacterial infection in the world. The infection is generally acquired in childhood, but can persist into adulthood. Eradication therapy has undergone several modifications. The aim of this study was to evaluate the different therapeutic strategies used in the eradication of Helicobacter pylori infection in the Centre Hospitalier Universitaire La Reference Nationale of N’Djaména. Patients and Methods: This was a prospective, descriptive analytical study spread over one year, from September 2021 to September 2022. Patients at least 15 years of age presenting with dyspeptic symptoms, seen consecutively in a hepato-gastroenterology consultation and with a positive stool test for H. pylori infection, were included in the study. Equally, 1/3 of patients were treated with dual or triple therapy. The remaining third received quadritherapy. Results: A total of 268 patients were included in the study (mean age 38.40 ± 14.66 with extremes of 16 and 80 years). Males predominated in 58% of cases. Overall therapeutic efficacy was 88.9%. According to different therapeutic strategies, efficacy was 90.75% for dual therapy with PPI (Rabeprazole) and Amoxicillin. On the other hand, efficacy was 87% and 88.88% for PPI-based triple therapy and dual antibiotic therapy, and for PPI-based quadruple therapy and triple antibiotic therapy. Conclusion: H. pylori infection is a common disease in Chad. Dual therapy with rabeprazole combined with a high dose of amoxicillin over a period of at least two weeks showed similar if not better efficacy than triple or quadruple therapy.

Performance improvement in stepped solar still modified by sponge layer

In this paper,the experimental investigation on the performance improvement of conventional stepped solar still is conducted.The steps are covered by the porous material to improve the performance of the conventional device and increase the evaporation rate.All the parameters,including the temperature on the glass surface,the water temperature inside the evaporation zone,and the amount of water produced in both conventional and modified stepped solar stills are measured and compared.The efficiency of two devices and their exergy efficiency have been calculated.Finally,the economic analysis of both devices has been done to check the economic feasibility of the modified device.The amount of freshwater generated during one day was 2244.4 and 3076.2 mL/m^(2),respectively for the conventional and modified stepped solar stills.As a result,the amount of water produced in one day by modified stepped solar still is 35.5% more than the conventional one.Also,the costs for the conventional and modified stepped solar stills have been calculated as 0.0359 and 0.029$/(L·m^(-2)),respectively.