Access Approach Research Articles

Short-axis versus long-axis approach for ultrasound-guided vascular access: An updated systematic review and meta-analysis of randomised controlled trials.

There are two approaches for ultrasound (US)-guided vessel cannulation: the short axis (SA) approach and the long axis (LA) approach. However, it remains to be seen which approach is better. Therefore, we performed the present updated systematic review and meta-analysis to assess the effectiveness and safety of US-guided vascular cannulation between the SA and LA techniques. We performed a comprehensive electronic database search in PubMed, Embase, Cochrane Library and Web of Science for the relevant studies from inception to June 2022. Randomised controlled trials comparing the SA approach and the LA approach for US-guided vascular access were incorporated in this updated meta-analysis. The first-attempt success rate was the primary outcome. The secondary outcomes were the overall success rate, cannulation time, number of attempts and the incidence of complications. The statistical analysis was conducted using RevMan software (version 5.4; the Nordic Cochrane Centre, the Cochrane Collaboration, Copenhagen, Denmark). The Cochrane risk of bias tool was used to evaluate each study's potential risk for bias. In total, 16 studies consisting of 1885 participants were incorporated in this updated meta-analysis. No statistically significant difference was found between the SA and LA vascular access techniques for first-pass success rate (risk ratio = 1.07, 95% confidence interval: 0.94-1.22). The overall cannulation success rate, complication rate, average cannulation time and average number of attempts were not significantly different between the SA and LA groups. This updated meta-analysis demonstrated that the SA and LA approaches of US-guided vessel cannulation are similar regarding first-pass success, overall cannulation success rate, total complication rate, cannulation time and the number of attempts.

Abstract 220: Transradial Access Versus Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta‐analysis

Introduction Carotid artery stenting (CAS) has emerged as a viable alternative to carotid endarterectomy for managing carotid artery stenosis in high‐risk patients (1). While the transfemoral arterial approach (TF) remains the preferred method, it is associated with inherent limitations and potential complications (2‐4). Consequently, exploring the transradial artery access (TR) as a potential option becomes crucial in optimizing patient outcomes and procedural success rates. Limited data exists comparing the outcomes of TR approach in CAS to TF approach. This study aims to systematically review and meta‐analyze the outcomes and complication rates between TR and TF access for CAS. Methods A systematic electronic search was conducted in four databases up to May 10th, 2023. Studies with randomized or non‐randomized designs, involving CAS through TR or TF approach, were included. Outcomes of interest were stroke, transient ischemic attack (TIA), death, myocardial infarction (MI), and access site complications. A meta‐analysis was performed, analyzing pooled odds ratios (ORs) and 95% confidence intervals (CI) to assess the effect size of the vascular access approaches. Results Six studies with a total of 6,917 patients were included, out of which 602 (8.7%) underwent the TR approach, and 6,315 (91.3%) underwent the TF approach. Meta‐analysis results showed no significant difference in stroke occurrence between TR and TF groups (TR: 1.7% vs. TF: 1.9%; OR = 0.98; 95% CI 0.49 – 1.96; I2 = 0%). Similarly, no significant difference was found in death (TR: 1% vs. TF: 0.9%; OR = 0.95; 95% CI 0.38 – 2.37; I2 = 0%), MI (TR: 0.2% vs. TF: 0.3%; OR = 1.53; 95% CI 0.20 – 11.61; I2 = 0%), TIA (TR: 0.4% vs. TF: 1%; OR = 0.46; 95% CI 0.11 – 1.95; I2 = 0%), and access site complications (TR: 2.2% vs. TF: 1%; OR = 0.97; 95% CI 0.48 – 1.98; I2 = 0%). Conclusion In the comparison of TR and TF approaches for CAS, no significant differences were observed in stroke, death, MI, TIA, or access site complications. TR approach shows promise as an alternative method for CAS, offering potential benefits without increased risk of complications. However, further studies are needed to confirm these findings and establish guidelines for optimal access site selection.

Efficacy and Safety of Distal Radial Artery Approach for Coronary Angiography: A Retrospective Study

Background: The distal radial artery approach has been employed as a potential alternative technique for coronary angiography. Nevertheless, its clinical implementation is significantly constrained by the narrow diameter of the radial artery. A comprehensive investigation of the efficacy and safety of the distal radial artery approach for coronary angiography is lacking. The objective of this study is to investigate the impact of the distal radial artery approach for coronary angiography and transradial artery access for interventional diagnosis and treatment. In addition, the effectiveness and safety of the distal radial artery approach for coronary artery angiography will be analyzed, for the wider adoption of this technique in clinical practice. Methods: A total of 68 patients with coronary heart disease (CHD) who underwent coronary catheterization via the left distal radial artery approach from December 2020 to December 2022 using the Distal radial artery approach (TRA) comprised the case-control study group. Seventy-three CHD patients who underwent routine left Transradial Artery Access coronary catheterization were selected as the Regular TRA group during the same period. Clinical data including age, body mass index (BMI), gender, CHD risk factors, routine drug treatment, ultrasonic-related indicators and operation-related indicators were collected from electronic medical records and the catheterization database from the two groups of patients. Results: The diameter and Endothelium-dependent vasodilation (noe FMD) of puncture vessels in the Distal TRA group were significantly lower than those in the Regular radial artery approach (TRA) group (p-value < 0.05). After a period of 48 hours following the catheterization, the puncture vessel diameter and flow-mediated dilation (FMD) of the Distal TRA group were significantly lower compared to those of the Regular TRA group (p-value < 0.05). The effectiveness of transradial artery access was then compared between the two groups. It was determined that the Distal TRA group exhibited significantly higher values in terms of the Visual Analog Scale (VAS) score, puncture time, and heparin usage, in comparison to the Regular TRA group (p-value < 0.05). The occurrence rates of local hematoma, mediastinal hematoma, retroperitoneal hematoma, pseudoaneurysm, arteriovenous fistula, vagal reflex, vasospasm, blood transfusion, and other complications among patients in the Distal TRA group were comparable to those in the Regular TRA group (p-value > 0.05). The incidence of puncture and X-ray radiation in the Distal TRA group was found to be marginally higher compared to the Regular TRA group. This study suggests that the safety profile of patients undergoing coronary artery catheterization via the distal radial artery is relatively higher than those undergoing the procedure via the transradial artery, although the difference was not statistically significant (p-value > 0.05). Conclusions: The Distal radial artery approach can be used for conducting comprehensive coronary interventional diagnosis and treatment procedures, offering benefits such as reduced postoperative compression time, better hemostasis through the distal radial artery approach, and enhanced patient comfort. This approach demonstrates favorable efficacy and safety, making it a suitable routine puncture method for clinical treatment.

Last mile access-based FSO and VLC systems

Free-space optics (FSO) and visible light communication (VLC) are interesting solutions for last mile access due to their benefits over conventional wired and wireless communication systems, including easy installation, low latency, high bandwidth, and low cost. This study aims to present last mile access using hybrid FSO/VLC, addressing the shortcomings of each technology. A hybrid system might, for instance, use VLC to give last meter connectivity to specific buildings and FSO to provide high-bandwidth outdoor connectivity across vast distances. In this paper, three proposed scenarios are designed using Optisystem and Matlab software, employing pulse amplitude modulation with four levels (PAM-4). The first scenario involves designing the last mile of the FSO-VLC system. In contrast, the second uses wavelength division multiplexing (WDM) technology to increase the data transmission capacity by enabling multiple optical signals at various wavelengths. The last scenario entails using VLC systems and the non-orthogonal multiple access (NOMA) approach to accommodate several users simultaneously. The simulation results show that the proposed system can fulfill outdoor link distances of more than 10 km and indoor coverage of about 2 m with a bit-error rate (BER) of 1.5×10−32 for a 10 Gbps data rate. However, the proposed systems can achieve the same data rate with a reduced FSO distance under different turbulence and weather conditions.

Transferable lessons learned from improving health literacy responsiveness in Dutch rheumatology care

Abstract Background Health literacy difficulties among (groups of) individuals represent a significant public health challenge. Improving health literacy responsiveness of systems and services could reduce health inequalities in communities and patient populations. Methods We conducted a mixed-methods study to improve health literacy responsiveness in three Dutch rheumatology centres, using the OPtimising HEalth LIteracy and Access (Ophelia) approach. Patients and health professionals were involved in an inclusive needs assessment (n = 895 and 39, respectively) and co-design consultations to identify local solutions (n = 14 and 38, respectively). Based on all steps, we formulated transferable lessons learned (outcome-related or process-related) for public health and health care. Results Outcome-related lessons: a mixed-methods Ophelia approach was successful in identifying health literacy challenges and 175 potential solutions. Challenges are similar between disease groups and centres, but require solutions specific to the local context. Recognising challenges at the point of care is difficult. For a healthcare service to be responsive to health literacy needs, increased awareness alone is not enough; it will require a conscious actions and systemic change at multiple levels, including training. Process-related lessons: prerequisites for a successful health literacy responsiveness project include using multidimensional measurements, an inclusive participatory approach with all stakeholders, collaboration with experts in a community of practice, and strong project governance. Conclusions The Ophelia project in rheumatology care was successful in its aims of finding solutions to improve health literacy responsiveness. Public health and healthcare organisations should consider improving their health literacy responsiveness using a grassroots co-design approach. However, project success will depend on the quality of its governance; future programmes should follow a systematic approach. Key messages • Using a grassroots co-design approach such as Ophelia can help identify locally relevant solutions to health literacy challenges and support organisational efforts to reduce health inequalities. • Successfully improving health literacy responsiveness requires, at minimum, inclusion of people with most complex health literacy challenges, strong project governance, and stakeholder engagement.

Arm-only combined transarterial and transvenous access for neurointerventional procedures: a double-center retrospective study.

This study aims to share our experience with the arm-only combined transarterial and transvenous access approach for neurointerventional procedures and evaluate its efficacy and safety. The arm-only combined transarterial and transvenous access approach was performed using the right/bilateral proximal radial arteries and the right forearm superficial vein system, guided by ultrasonic guidance. Arterial access closure was achieved using a transradial band radial compression device, while manual compression was utilized for venous approach closure. Thirteen procedures were successfully performed using the arm-only combined transarterial and transvenous access approach, yielding favorable outcomes. The procedures included dural arteriovenous fistula embolization (seven cases), cerebral arteriovenous malformation embolization (four cases), venous sinus thrombosis catheter-directed thrombolysis and intravenous thrombectomy (one case), and cerebral venous sinus stenosis manometry (one case). All procedures were uneventful, allowing patients to ambulate on the same day. At discharge, all patients exhibited modified Rankin scores of 0-2, without any access site or perioperative complications. This double-center study preliminarily demonstrates the feasibility and safety of arm-only combined transarterial and transvenous access applied in neurointerventional procedures for complicated cerebrovascular diseases. The proximal radial artery and forearm superficial vein are recommended as the primary access sites. Unobstructed compression is strongly recommended for radial approach closure. This study aimed to add evidence and experience on the arm-only combined transarterial and transvenous access, as a new approach, for neurointerventional treatment that required arteriovenous approaches.

No-one left behind: An open access approach to estimating the carbon footprint of a Danish clothing company

The textile and garment industry has faced ongoing scrutiny for its environmental impacts, prompting pledges like the UN's Fashion Industry Charter for Climate Action (FICCA) targeting net-zero emissions by 2050. Building on FICCA's report on sector limitations, this study introduces an action-oriented case study using a GHG Protocol compliant open-access emissions inventory of MASCOT, a Danish clothing company. We identify most emissions are found in scope 3 (85%), specifically purchased goods and services (76%). Yet, supplier-specific data is limited across global supply chains and often displays methodological inconsistencies. Establishing a common data language between buyer and seller must be achieved for decarbonisation and decision support. Open access databases supplement supplier gaps but often lack the resolution or consistency required for sector specific investigations and decision support. A need for open access standardized data emerges as a crucial first step toward net-zero, filling the sector's data gaps. This study has resulted in greater carbon literacy and data awareness within MASCOT and established a language for supplier-firm dialogue, however, the limitations ultimately prevent these findings from commercial use, as clear and structured methods are still lacking in the sector. For tangible progress, a collaborative sector-specific database is required, alongside structured and verified data exchanges between stakeholders. The CSRD and proposals such as the Digital Product Passport are expected to bring attention to these gaps and expedite progress, however, dedicated sector-specific working groups like FICCA will continue to be essential in driving the necessary focus and informed decarbonisation efforts.

Early exploration of the economic impact of transradial access (TRA) versus transfemoral access (TFA) for neurovascular procedures in Spain

IntroductionTransfemoral access (TFA) is the primary access approach for neurointerventional procedures. Transradial access (TRA) is established in cardiology due to its lower complications, yet, it is at its early stages in neuroprocedures. This study performs an early exploration of the economic impact associated with the introduction of TRA in diagnostic and therapeutic neuroprocedures from the Spanish NHS perspective.MethodsAn economic model was developed to estimate the cost and clinical implications of using TRA compared to TFA. Costs considered access-related, complications and recovery time costs obtained from local databases and experts’ inputs. Clinical inputs were sourced from the literature. A panel of eight experts from different Spanish hospitals, validated or adjusted the values based on local experience. Hypothetical cohorts of 10,000 and 1000 patients were considered for diagnostic and therapeutic neuroprocedures respectively. Deterministic sensitivity analysis was performed.ResultsTRA in diagnostic procedures was associated with lower costs with savings ranging between €486 and €157 depending on the TFA recovery time considered. TRA is estimated to lead to 158 fewer access-site complications. In therapeutic procedures, TRA resulted in 76.4 fewer complications and was estimated to be cost-neutral with an incremental cost of €21.56 per patient despite recovery times were not included for this group. Variation of the parameters in the sensitivity analysis did not change the direction of the results.LimitationsClinical data was obtained from literature validated by experts therefore results generalizability is limited. In therapeutic neuroprocedures, there is an experience imbalance between approaches and recovery times were not included hence the total impact is not fully captured.ConclusionsThe early economic model suggests that implementing TRA is associated with reduced costs and complications in diagnostic procedures. In therapeutic procedures, TRA lead to fewer complications and it is estimated to be cost-neutral, however its full potential still needs to be quantified.

Limited Effect of Prevention Strategies on Incidence of Clinically Detectable Venous Thromboembolism After Lung Transplantation

Thromboembolic complications are common post-lung transplant, leading to significant morbidity. We instituted multiple interventions because of an observed 36.8% incidence of venous thromboembolism (VTE) (Incidence rate (IR) 5.74/1000 pt days) in our recipients. Our initiative commenced January 2015 with enoxaparin initiation within 6-8 hours of intensive care unit arrival and continuation for 4-6 weeks. We evaluated the IR of VTE in lung transplant recipients within 90 days of transplant. In 2017, the protocol was modified to extend the time to initiation of prophylaxis to within 72 hours of ICU arrival. In 2019, we further amended our intraoperative vascular access strategy. Eighteen of 26 lung transplant recipients (LTR) met inclusion criteria in the 2015 cohort. Six of 18 (33.3%) developed VTE, 50% of which were upper extremity (UE), line associated. Fifty two of 75 LTR were eligible for enoxaparin prophylaxis in the 2017 cohort. Fifteen of 52 subjects (28.8%) developed VTE, 77.8% of which were UE and line associated. Despite improved adherence in 2017, there was little change in VTE IR (3.90/1000 pt days compared with 3.85/1000 pt days). Twenty six of 43 LTR met protocol inclusion criteria in the 2019 cohort. Ten subjects (38.5%) developed VTE, 67% of which were UE and line associated (IR 5.18/1000 pt days). Our prospective study found that LTR remain at high risk for VTE despite aggressive prophylaxis with 4-6 weeks of enoxaparin and adjustment of vascular access approach. Alternative interventions should be investigated to minimize VTE development in this vulnerable population.

The Arterial Risk Posed by the Posterolateral Approach to the Ankle: An Anatomical Cadaveric Observational Study

Category: Ankle; Trauma Introduction/Purpose: The most commonly used approach for posterior malleolar access is the posterolateral approach. This approach gives good access to the fibula and lateral aspect of the posterior tibia, however; there is little known on the vascular risks with this approach. Methods: The aim of this study was to assess and describe the anatomy of the peroneal artery and its branches at the ankle region. Methodology: Eleven cadaveric foot and ankle specimens were dissected in layers, preserving the peroneal artery, anterior tibial artery (ATA) and posterior tibial artery (PTA). Results: The peroneal artery was consistently found between the peroneal compartment and deep muscular compartment of the posterior leg. A wide range of anatomical variation was found in the peroneal artery, in its location, muscular branches, anastomosis and anterior perforating branch. The peroneal artery was the largest diameter artery in one specimen. There was great variation in number and location of muscular branches. The mean proximal distance between the medial malleolus and the posterior communicating branch of the peroneal artery was 37.93mm (range: 19.03- 85.43mm). The mean proximal distance from the medial malleolus to the anterior peroneal perforating artery was 44.23mm (range:35.44-62.32mm). Distal to the anterior perforating branch of the peroneal artery, the peroneal artery was immobile. Conclusion: Understanding the common variations within the ankle’s arterial anatomy can help surgeons protect these vessels from damage during the surgical approach. The posterolateral surgical approach, specifically puts the peroneal artery at risk and knowledge of its anatomy and variability is important when undertaking this approach.

Towards a novel cyber physical control system framework: a deep learning driven use case

PurposeThe health crisis has highlighted the shortcomings of the industry sector which has revealed its vulnerability. To date, there is no guarantee of a return to the “world before”. The ability of companies to cope with these changes is a key competitive advantage requiring the adoption/mastery of industry 4.0 technologies. Therefore, companies must adapt their business processes to fit into similar situations.Design/methodology/approachThe proposed methodology comprises three steps. First, a comparative analysis of the existing CPSs is elaborated. Second, following this analysis, a deep learning driven CPS framework is proposed highlighting its components and tiers. Third, a real industrial case is presented to demonstrate the application of the envisioned framework. Deep learning network-based methods of object detection are used to train the model and evaluation is assessed accordingly.FindingsThe analysis revealed that most of the existing CPS frameworks address manufacturing related subjects. This illustrates the need for a resilient industrial CPS targeting other areas and considering CPSs as loopback systems preserving human–machine interaction, endowed with data tiering approach for easy and fast data access and embedded with deep learning-based computer vision processing methods.Originality/valueThis study provides insights about what needs to be addressed in terms of challenges faced due to unforeseen situations or adapting to new ones. In this paper, the CPS framework was used as a monitoring system in compliance with the precautionary measures (social distancing) and for self-protection with wearing the necessary equipments. Nevertheless, the proposed framework can be used and adapted to any industrial or non-industrial environments by adjusting object detection purpose.

Front Cover: A Dual Photoredox‐ and Cp2TiCl2‐Catalyzed Approach for the Direct Access to α‐Vinyl‐β‐hydroxy Esters (Eur. J. Org. Chem. 38/2023)

Front Cover: A Dual Photoredox‐ and Cp₂TiCl₂‐Catalyzed Approach for the Direct Access to α‐Vinyl‐β‐hydroxy Esters (Eur. J. Org. Chem. 38/2023)

Catalytic Amination of Alcohols Using Diazo Compounds under Manganese Catalysis Through Hydrogenative N-Alkylation Reaction.

Sustainable chemical production requires fundamentally new types of catalysts and catalytic technologies. The development of coherent and robust catalytic systems based on earth-abundant transition metals is essential, but highly challenging. Herein, we systematically explored a general hydrogenative cleavage/N-alkylation tandem of cyclic and acyclic diazo (N=N) compounds to value-added amines under manganese catalysis. The reaction is catalyzed by a single-site molecular manganese complex and proceeds via tandem dehydrogenation, transfer hydrogenation, and borrowing hydrogenation strategies. Interestingly, the reaction involves abundantly available renewable feedstocks, such as alcohols, that can act as (transfer)hydrogenating and alkylating agents. The synthetic application of our approach in large-scale pharmaceutical synthesis and easy access to highly demanding N-CH3 /CD3 derivatives are also demonstrated. Kinetic studies show that the reaction rate depends on the concentration of alcohol and Mn-catalyst and follows fractional orders. Several selective bond activation/formation reactions occur sequentially via amine-amide metal-ligand cooperation.

Kemudahan Mencari Referensi Dengan LMS UNIKOM

The Covid-19 pandemic has profoundly impacted the education and work sectors, resulting in significant transformations. The prevalence of online learning and remote employment has necessitated adaptation within numerous institutions, including university libraries like the Unikom Library, to cater to the needs of their readers effectively. Initially, the Unikom Library encountered challenges due to its primary emphasis on printed books in its collection, with digital collections not yet receiving significant attention. This poses a challenge in delivering sufficient services. To address this issue, the Unikom Library implemented an innovative approach by incorporating electronic materials into the Learning Management System (LMS), namely Moodle, a platform for online education. This aims to comprehensively account for successfully integrating the Unikom Library e-resources program with the LMS, employing a unified access approach. Consequently, incorporating library materials into the LMS has demonstrated significant efficacy amidst the epidemic, as evidenced by increased user engagement. This observation indicates that the electronic resources accessible through the LMS at the Unikom Library have emerged as a viable and efficient option for readers seeking reference materials. The integration of electronic resources with the LMS has been beneficial for the Unikom Library, enabling it to maintain its relevance and effectively cater to the needs of its users among the challenges posed by the current circumstances. The statement above underscores the significance of adaptability and innovation as crucial factors in addressing the various issues encountered by educational institutions and libraries amidst the digital era and ongoing pandemic.

Percutaneous versus Cutdown Access for Endovascular Aortic Repair.

This study aimed to compare the outcomes of the percutaneous femoral access and open surgical cutdown access approaches in patients undergoing thoracic/abdominal endovascular aortic repair. We retrospectively reviewed the medical records of 59 patients who underwent a thoracic/abdominal endovascular aortic repair at a single tertiary care hospital between 2015 and 2022. Based on their femoral access type, the patients were categorized into the "percutaneous" or "cutdown" groups. Using a computerized sheet, relevant patient data (including demographic information and patient risk factors) were collected. The operative duration, complication rates, mortality rates, intensive care unit admission and stay durations, and total hospital stay were compared between the two groups. The primary outcomes were differences in the postoperative morbidity and mortality associated with the two approaches. The cutdown and percutaneous groups comprised 24 (41%) and 35 (59%) patients, respectively. The two groups displayed comparable demographic and clinical characteristics (p > 0.05). However, the vascular anatomy differed with the common femoral artery diameter being larger in the percutaneous group compared to the cutdown group (9.63 ± 1.81 mm vs. 8.49 ± 1.54 mm, p = 0.028). The ratio of the sheath diameter to the common femoral artery diameter was significantly lower in the percutaneous group than in the cutdown group (0.73 ± 0.16 vs. 0.85 ± 0.20, p = 0.027). A ratio of ≥0.74 was associated with a higher risk of complications (odds ratio, 12.0; 95% confidence interval, 1.4-102.2; p = 0.023) and mortality (odds ratio, 5.79; 95% confidence interval, 1.13-29.6; p = 0.035). Additionally, the operative duration was significantly shorter in the percutaneous group than in the cutdown group (141.43 ± 97.05 min vs. 218.46 ± 126.31 min, p = 0.001). Compared to the cutdown group, the percutaneous group experienced a shorter total hospital stay (21.54 ± 21.49 days vs. 11.60 ± 12.09 days, p = 0.022) and lower intensive care unit-admission rates (66.7% vs. 40%, p = 0.044). The percutaneous approach is a viable and more time-efficient alternative to the traditional cutdown method for delivering vascular endografts. It is associated with a significantly shorter operative duration and briefer hospital stays. Additionally, the ratio of the sheath diameter to the common femoral artery diameter can help surgeons preoperatively predict and anticipate the risks of complications and mortality. Future in-depth research is necessary to better understand the association between this ratio and postoperative outcomes and complications.

Incorporating Heat Vulnerability into Local Authority Decision Making: An Open Access Approach

High temperatures and heatwaves are becoming more frequent, but heat vulnerability is rarely considered within local authority city design and statutory land-use planning processes. Here, we describe an approach to assess heat vulnerability in Birmingham, the second largest city in the UK. The approach uses open access data and GIS techniques that are available for built environment practitioners. Heat vulnerability is assessed by combining four datasets: surface temperatures, Local Climate Zones, green space, and Indices of Multiple Deprivation. The assessment shows that central and eastern areas of Birmingham that have the most compact urban form, least green space, and highest levels of deprivation are most vulnerable to heat. We evaluated the approach against previous climate research, examined the approach and datasets at the local scale, and described how heat vulnerability can be (and is being) incorporated into decision making. This project combines three key innovations: (1) the decision-centric process that focuses the method on the decision that needs to be made, minimizing inertia related to scientific or modeling uncertainty and reducing resource-intensity; (2) the co-creation process with Birmingham City Council, who have statutory powers for planning within the city, thereby ensuring that heat vulnerability is embedded within decisions on the suitability, design, and location of sites for future development; and (3) the open access and technically appropriate methodology which can be applied to any urban area in the UK, using the open access datasets described here, or globally, using locally applicable data sources.

Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity.

Colonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion. We conducted a qualitative study with providers in rural Oregon who worked in endoscopy centers or primary care clinics. Semistructured interviews, conducted in July and August, 2021, focused on clinician experiences providing colonoscopy to rural Medicaid patients, including workflows, barriers, and access. We used thematic analysis, through immersion crystallization, to analyze interview transcripts and develop emergent themes. We interviewed 19 providers. We found two categories of colonoscopy providers: primary care providers (PCPs) doing colonoscopy on their own patients (n=9; 47%) and general surgeons providing colonoscopy to patients referred to their services (n=10; 53%). Providers described barriers to colonoscopy at the provider, community, and patient levels and suggested patient supports could help overcome them. Providers found current colonoscopy capacity sufficient, but noted PCPs trained to perform colonoscopy would be key to continued accessibility. Finally, providers shared concerns about the shrinking number of PCP endoscopists, especially with anticipated increased screening demand related to the CRC screening guideline shift. These themes reflect opportunities to address multilevel barriers to improve access, colonoscopy capacity, and patient education approaches. Our results highlight that PCPs are an essential part of the workforce that provides colonoscopy in rural areas.

Indwelling Vascular Access Ports: Application, Advantages, and Management in Nonhuman Primates

Animals in the veterinary and experimental settings, including nonhuman primates (NHPs), often require repeated and prolonged vascular access for indications including blood sampling or administration of fluids, blood products, medication, or other therapies. A vascular access approach should be tailored to experimental or clinical use meeting the needs of the individual animal such that benefits outweigh risks. The optimal device and placement technique is based on the inherent advantages and disadvantages of specific anatomic sites and planned use. Totally implanted vascular access ports (VAPs) enable reliable central venous access for frequent sample collection and/or intravenous therapies. VAPs minimize discomfort with IV access to facilitate cooperation with handling and minimize stress-induced physiologic changes which can confound biologic data and drug responses. VAPs do not limit species-typical behavior and social group activities and are compatible with animal enrichment programs that include play and swim because there are no externalized components. VAPs are typically used long-term and demonstrate excellent durability with high patency and low complication rates over time, presenting a safe and dependable vascular access approach.

A CA and ML approach for M-MIMO optical non-orthogonal multiple access power efficiency

Abstract The non-orthogonal multiple access (NOMA) multiple access approach can be used in future wireless communication systems to support massive connections and increase spectrum efficiency. Because user signal intensities and interference levels vary, precise channel assessment is essential in NOMA. Optimal power allocation and decoding order are made possible by precise algorithms, increasing system effectiveness and performance. However, NOMA can be adversely impacted by high peak-to-average power ratio (PAPR) values, leading to worsened system performance and more complex power amplifiers. In order to solve this issue, this paper recommends PAPR reduction in NOMA using companding methods for 512, 256, and 64 sub-carriers. Nonlinear companding techniques, such as MA and A-law companding, can efficiently reduce the high peak power of NOMA signals while reducing distortion and enhancing overall system dependability. The effectiveness of the proposed companding methods is evaluated using simulations, and the results demonstrate a significant decrease in PAPR, ensuring higher bit error rate (BER) effectiveness and transmission resilience in NOMA-based communication systems. The proposed approach is compared to the traditional Ml (C- Ml) and A-Law (C- A-Law).

A Dual Photoredox‐ and Cp2TiCl2‐Catalyzed Approach for the Direct Access to α‐Vinyl‐β‐hydroxy Esters

AbstractFor the first time, a dual photoredox‐ and titanocene‐catalyzed methodology for the regioselective access to α‐vinyl‐β‐hydroxy esters towards aldehyde allylation with 4‐bromobut‐2‐enoate is reported. The protocol is based on the Barbier‐type properties of the inexpensive and available Cp2TiCl2 in catalytic amount (5 mol%). The developed mild reaction conditions gave access to a library of differently functionalized α‐vinyl‐β‐hydroxy esters in moderate diastereoselectivity, employing the commercially available ethyl 4‐bromobut‐2‐enoate and both aromatic and aliphatic aldehydes. The reaction was realized under visible light irradiation, in the presence of an organophotocatalyst (3DPAFIPN, 2 mol%) combined with Hantzsch's ester as the sacrificial reductant. In contrast to other Barbier‐type reactions employing ethyl 4‐bromobut‐2‐enoate, the photoredox system ensures a better regioselectivity. Moreover, the use of preformed organometallic nucleophilic species (e. g., dienolborinates), and the need of metal reductants or stoichiometric amount of transition metals in low oxidation state for Barbier‐type reactions, is avoided. To support the experimental evidence, a detailed photophysical study shed light on the mechanism of the reaction.