One-stage Approach Research Articles

One-stage ventral correction of the secondary thoracolumbar kyphosis in a patient with failed transpedicular fixation of Th12 fracture

The main surgical treatment technique of thoracic and lumbar spine acute injuries is transpedicular fixation, the failure of which, according to the literature data, occurs in 1015% of cases. There are no common views on tactics and the surgical technique used to deal with the consequences of unstable transpedicular spondylosynthesis. And the publications devoted to the use of isolated anterior interventions are the least common.
 We present a case study of the surgical management of the 71 years old patient with secondary thoracolumbar kyphosis that progressed after failed transpedicular fixation of Th12 fracture. The deformity was corrected with one-stage anterior approach and ventral crew system.

Epidemiology of Fungal Periprosthetic Joint Infection: A Systematic Review of the Literature.

Fungal prosthetic joint infection (fPJI) is a rare complication; nonetheless, it represents a significant diagnostic and therapeutic challenge. There are no official guidelines on the most effective approach to identify and treat fPJIs. This systematic review aims to review the current literature on fPJI management and provide a comprehensive overview of this topic, especially from an epidemiologic point of view. Studies eligible for this systematic review were identified through an electronic systematic search of PubMed, Scopus, and Web of Science until 30 September 2022. Further references were obtained by cross-referencing. Sixty-three studies met the inclusion criteria, reporting on 372 cases of fPJI; such cases were described mostly in case reports and small case series with only a few larger cohort studies. Diagnosis of fPJI is challenging because of its chronic and indolent clinical course; it is further complicated by the technical difficulty of harvesting fungal cultures. A two-stage revision was the primary procedure in 239 (64.2%) patients whereas DAIR and one-stage approaches were reported in 30 (8.0%) and 18 (4.8 %) cases. In conclusion, our study highlights the heterogeneity of the reported treatments of fPJI, particularly in terms of medical management. With concern to a surgical approach, a two-stage revision arthroplasty is generally suggested, considering fPJI a delayed or late infection. The need for multicenter, prospective studies to provide standardized protocols and improve the treatment of fungal PJI clearly emerges.

PROspective Meta-analysis Of Trials of Initial Oxygen in preterm Newborns (PROMOTION): Protocol for a systematic review and prospective meta-analysis with individual participant data on initial oxygen concentration forresuscitation of preterm infants.

Clinicians favour low oxygen concentrations when resuscitating preterm infants immediately after birth despite inconclusive evidence to support this practice. Prospective meta-analysis (PMA) is a novel approach where studies are identified as eligible for inclusion in the meta-analysis before their results are known. To explore whether high (60%) or low (30%) oxygen is associated with greater efficacy and safety for the initial resuscitation (immediately after birth) of preterm infants born at <29 weeks' gestation. We will conduct a prospective meta-analysis (PMA) with individual participant data (IPD). We will perform a systematic search to identify ongoing RCTs including infants <29 weeks' gestation randomised to high (60%) or low (30%) oxygen for initial resuscitation after birth. IPD will be sought for all infants randomised for the purpose of meta-analysis. We will employ a one-stage random-effects approach to IPD meta-analysis. Potential heterogeneity and the differential effect of high or low oxygen will be explored through subgroup and interaction analyses. The primary outcome of this study is all-cause mortality prior to hospital discharge. There will be a follow-up analysis of neurodevelopmental outcomes once available. The results of neonatal outcomes at hospital discharge are expected by 2025, and neurodevelopmental outcomes by 2027.

A deep learning-based approach to facilitate the as-built state recognition of indoor construction works

PurposeRecognising the as-built state of construction elements is crucial for construction progress monitoring. Construction scholars have used computer vision-based algorithms to automate this process. Robust object recognition from indoor site images has been inhibited by technical challenges related to indoor objects, lighting conditions and camera positioning. Compared with traditional machine learning algorithms, one-stage detector deep learning (DL) algorithms can prioritise the inference speed, enable real-time accurate object detection and classification. This study aims to present a DL-based approach to facilitate the as-built state recognition of indoor construction works.Design/methodology/approachThe one-stage DL-based approach was built upon YOLO version 4 (YOLOv4) algorithm using transfer learning with few hyperparameters customised and trained in the Google Colab virtual machine. The process of framing, insulation and drywall installation of indoor partitions was selected as the as-built scenario. For training, images were captured from two indoor sites with publicly available online images.FindingsThe DL model reported a best-trained weight with a mean average precision of 92% and an average loss of 0.83. Compared to previous studies, the automation level of this study is high due to the use of fixed time-lapse cameras for data collection and zero manual intervention from the pre-processing algorithms to enhance visual quality of indoor images.Originality/valueThis study extends the application of DL models for recognising as-built state of indoor construction works upon providing training images. Presenting a workflow on training DL models in a virtual machine platform by reducing the computational complexities associated with DL models is also materialised.

Tuberous Breast Management: A Review of Literature and Novel Technique Refinements.

Sixteen women affected by grade 2 TBD treated with glandular flaps, silicone gel prosthesis, and only an hemiperiareolar incision between January 2018 and January 2019 were reviewed. The age range was 19-27 years (mean age was 25). Follow-up average was 25 months (range 16-33 months). To evaluate the results, we used two analogic scales with values from 1 to 3, where the lower value was the worst result. First, an independent medical team of three plastic surgeons evaluated two parameters: correction of deformity and symmetry. Then, patients were asked to judge the result obtained. The resulting breast has a normal-shaped areola without bulging, a natural shape, a volume matching the contralateral breast, and no evidence of "double-bubble" deformity or irregularities of the lower pole shape. We propose this one-stage approach with hemiperiareolar incision, to minimize time interval to obtain final results in TBD correction, with reduced scar dimensions to avoid all the possible complications related to the round block suture.

A O02 Few patients with bile duct stones are managed with a one-stage approach: Results from a prospective multicentre cohort study

Abstract Background Bile duct stones (BDS) are present in 10–20% of patients with symptomatic gallstones. They require treatment to reduce the risk of further morbidity. There are two accepted treatment methods. A two-stage approach is most common where preoperative magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are followed by laparoscopic cholecystectomy (LC). Less commonly, upfront LC is performed with laparoscopic bile duct exploration (LBDE). Recent evidence suggests patients who undergo ERCP+LC have higher stone clearance rates and a lower rate of bile leakage compared to those who undergo LC+LBDE. However, the latter have lower rates of postoperative pancreatitis and reduced length of stay. Overall morbidity and mortality rates are similar. Although the literature supports the single-stage approach, it is not commonly used across the United Kingdom (UK) or Republic of Ireland (RoI). The reasons for this are not clear. The lack of data on LDBE outcomes from large multicentre studies may be a contributing factor. Most published series are from single institutions and the outcomes of these are difficult to generalise to low-volume centres. This study aimed to analyse the CholeS study dataset to examine LBDE hospital volumes, LBDE-to-LC rates and LBDE outcomes. Methods The CholeS study was a multicentre, prospective population-based cohort study which investigated the variations in practice and outcomes of cholecystectomy. Data were collected from 166 UK/RoI hospitals from the months of March and April 2014. The hospitals were divided into high- and low-volume centres based on the number of LBDEs performed. High-volume centres performed at least two LBDEs per month during the study period and low-volume centres performed less than two per month. Most data were analysed and presented descriptively, using tables, graphs, and percentages for distribution. Where possible, we compared clinically relevant groups using the Chi-squared test to detect differences. A p value of less than 0.05 was considered statistically significant. Results In total, 8820 LCs were performed and 2.9% of patients underwent LBDE. Seventy-seven centres (46.1%) performed at least one LBDE. In these units, 5.4% of patients who underwent LC also underwent LBDE. Almost 90% of the hospitals that performed LBDE carried out less than or equal to five. In contrast, 10.6% of patients underwent ERCP and sphincterotomy. Of the 256 LBDEs, 28.5% underwent preoperative ERCP and 43.8% underwent preoperative MRCP. Eighty seven percent of LBDEs were performed by consultants and 13% by trainees. The laparoscopic-to-open conversion rate was 12.5% and the median operation time was 111 minutes (IQR: 75–155). Among the LBDE cases, the overall postoperative morbidity rate was 21.5% and the bile leak rate was 4.7%. 30-day readmission and 30-day mortality rates were 12.1% and 0.4%, respectively. Bile leak, acute pancreatitis, retained stone and overall morbidity rates following LBDE were compared between the low- and high-volume centres. Bile leak (OR 8.62, 95% CI: 2.26–32.84, p=0.0016) and 30-day morbidity (OR 1.90, 95% CI: 1.05–3.44, p=0.035) were significantly higher in the low-volume units. There was no difference in the rate of postoperative pancreatitis (OR 0.85, 95% CI:0.09–8.3, p=0.8887) or retained stone rate (OR 0.76, 95% CI:0.16–3.68, p=0.7376). Conclusions During the study period, just 2.9% of patients underwent LBDE. The majority of hospitals did not perform this procedure at all and very few were “high-volume” units. Our results suggest that the single-stage management of BDS was underutilised despite the recent evidence which suggests it is a safe and reasonable approach. Our results do not provide any insight into why uptake was low and we suspect the reasons for this are multiple. We argue large retrospective/prospective studies are required to investigate this and hope this information will further guide patient management.

HPB P62 Is it time to introduce intraoperative ultrasound into surgical training?

Abstract Background Gallstone disease is one of the most common causes of abdominal pain and emergency hospital admissions in the UK. Those patients that have symptomatic gallstones in the gallbladder will be offered a laparoscopic cholecystectomy (LC) as treatment and therefore reduce the risk of developing further complications. Confirmation of bile duct stones before or at the time of LC is essential in order to prevent complications. There are three main ways to identify bile duct stones intraoperatively: x-ray cholangiography, fluoroscopic cholangiography and intraoperative ultrasound (IOUS). X-ray cholangiography is the most commonly used method intraoperatively as it is effective in identifying biliary anatomy and bile duct stones, can be repeated and has good deep tissue penetration. However, it is an invasive procedure that requires the use of ionising radiation. IOUS on the other hand is non-invasive, does not involve ionising radiation, is able to detect vascular anatomy and arguably has a shorter learning curve compared to the other two methods. Methods IOUS is not currently taught on the surgical curriculum. In response to this, we have set up the Laparoscopic Hands-on Intra-operative Ultrasound (L-HOUS) course which takes place over a two-day period. The first day is delivered through interactive seminars and practice on phantom models. The topics covered are: the basic principles of the technique; the relevant anatomy; the role of IOUS in gallstone disease; and the role of IOUS in biliary surgery and various other non-HPB conditions. The afternoon is dedicated to demonstrating how to set up the equipment, the step-wise approach to IOUS of the biliary system, and hands-on practice using phantom models. The second day takes place in the operating theatre and offers delegates the opportunity to perform IOUS of the bile duct in real clinical cases. Delegates rotate around to practice their IOUS skills under the supervision of the operating surgeon, while un-scrubbed delegates are able to watch the surgery via a video link from the seminar room. Results The course has been run on four occasions and attracted 21 delegates since its inception in 2017. The vast majority of delegates have been senior general surgical trainees or post-CCT fellows, in addition to one consultant. The feedback received was overwhelmingly positive and the course has evolved at each iteration to reflect the comments from delegates. Conclusions This is the only course in Europe that offers delegates hands-on experience in developing IOUS skills under specialist guidance. Crucially, hands-on experience has been shown to have better outcomes in relation to ultrasound training when compared to simulation or classroom-based methods. This concept fits in unity with Edgar Dale's pyramid of learning whereby students are more likely to retain information that they have practiced ‘doing’ compared to other visual or auditory methods of teaching. Given the benefits of IOUS in terms of cost, and reduction in additional procedures or investigations, we argue that the technique should be included in the surgical training curriculum. One of the main reasons for poor uptake of a one-stage approach to bile duct stones using IOUS is lack of formal training. Given there will likely be an increase in the adoption of the IOUS technique in coming years, it is vital to equip current trainees with the necessary skills within their training pathway. However, prior to this it is imperative that trainees have access to high-fidelity training opportunities to develop skills that will be used routinely in future practice.

Study within a review (SWAR).

Study within a review (SWAR).

Multi-Vehicle Tracking Based on Monocular Camera in Driver View

Multi-vehicle tracking is used in advanced driver assistance systems to track obstacles, which is fundamental for high-level tasks. It requires real-time performance while dealing with object illumination variations and deformations. To this end, we propose a novel multi-vehicle tracking algorithm based on a monocular camera in driver view. It follows the tracking-by-detection paradigm and integrates detection and appearance descriptors into a single network. The one-stage detection approach consists of a backbone, a modified BiFPN as a neck layer, and three prediction heads. The data association consists of a two-step matching strategy together with a Kalman filter. Experimental results demonstrate that the proposed approach outperforms state-of-the-art algorithms. It is also able to solve the tracking problem in driving scenarios while maintaining 16 FPS on the test dataset.

Surgery for gastric cancer in patients with coronary heart disease (clinical cases)

The importance of a multidisciplinary approach in the surgical treatment of patients with severe combined oncological and cardiovascular pathologies is shown. In modern surgery, there is a place for both simultaneous and staged surgical treatment of this category of patients, which should be determined in each specific clinical case and requires an individual multidisciplinary approach with the inclusion in the discussion of such specialists as an oncosurgeon, a chemotherapist, a radiation therapist, a cardiologist/therapist, cardiovascular surgeon, anesthesiologist and resuscitator.&#x0D; Two clinical cases of a two-stage and one-stage surgical approach in the treatment of patients with competing gastric cancer and coronary heart disease are presented. One 47-year-old patient underwent two-stage surgical treatment: stage 1 aortocoronary bypass grafting from mini-thoracotomy (MICS CABG); stage 2 robot-assisted distal subtotal resection of the stomach (Balfour modification) with D2 lymphadenectomy, formation of intracorporeal gastroenteroanastomosis and interintestinal anastomosis according to Brown. Another 74-year-old patient underwent a one-stage surgical intervention: autovenous coronary artery bypass grafting of the anterior interventricular artery, posterior descending coronary artery on a beating heart, without cardiopulmonary bypass + extended-combined gastrectomy with resection of the distal esophagus, resection of the diaphragm, and D2+ lymphadenectomy. The postoperative period proceeded without complications.

MSA-MOT: Multi-Stage Association for 3D Multimodality Multi-Object Tracking.

Three-dimensional multimodality multi-object tracking has attracted great attention due to the use of complementary information. However, such a framework generally adopts a one-stage association approach, which fails to perform precise matching between detections and tracklets, and, thus, cannot robustly track objects in complex scenes. To address this matching problem caused by one-stage association, we propose a novel multi-stage association method, which consists of a hierarchical matching module and a customized track management module. Specifically, the hierarchical matching module defines the reliability of the objects by associating multimodal detections, and matches detections with trajectories based on the reliability in turn, which increases the utilization of true detections, and, thus, guides accurate association. Then, based on the reliability of the trajectories provided by the matching module, the customized track management module sets maximum missing frames with differences for tracks, which decreases the number of identity switches of the same object and, thus, further improves the association accuracy. By using the proposed multi-stage association method, we develop a tracker called MSA-MOT for the 3D multi-object tracking task, alleviating the inherent matching problem in one-stage association. Extensive experiments are conducted on the challenging KITTI benchmark, and the results show that our tracker outperforms the previous state-of-the-art methods in terms of both accuracy and speed. Moreover, the ablation and exploration analysis results demonstrate the effectiveness of the proposed multi-stage association method.

One Stage Monocular 3D Object Detection Utilizing Discrete Depth and Orientation Representation

On-road object detection is a critical component in an autonomous driving system. The safety of the vehicle can only be as good as the reliability of the on-road object detection system. Thus, developing a fast and robust object detection algorithm has been the primary goal of many automotive industries and institutes. In recent years, multi-purpose vision-based driver assistance systems have gained popularity with the emergence of a deep neural network. A monocular camera has been developed to locate an object in the image plane and estimate the distance of the said object in the real world or the vehicle plane. In this work, we present a monocular 3D object detection method that utilizes the discrete depth and orientation representation. Our proposed method strives to predict object locations on 3D space utilizing keypoint detection on the object’s center point. To improve the point detection, we employ center regression on the objects segmentation mask, reducing the detection offset significantly. The simplicity of our proposed network architecture and its one-stage approach allows our algorithm to achieve competitive speed compared with prior methods. Our proposed method is able to achieve 26.93% detection score on the Cityscapes 3D object detection dataset, outperforming the preceding monocular method by a margin of 2.8 points.

A boundary-preserving conditional convolution network for instance segmentation

Single-stage instance segmentation approaches have been attracting increasing attention in research communities because of faster speed, more straightforward design, and competitive accuracy than two-stage methods. However, the currently available methods only generate pixel-level classification , which ignores the information of shapes and object boundaries and thus results in wild and fuzzy mask predictions and inaccurate localization . To address these issues, we propose BCondInst, an effective boundary-preserving conditional convolution network aiming at adopting object boundary information to improve the accuracy of mask localization. Specifically, BCondInst replaces the original mask branch with a boundary-mask branch containing two sub-networks designed to jointly learn object boundaries and masks. Different from the existing segmentation approaches, in which the parameters of filters in the boundary head remain unchanged for all instances, the filters in the mask’s head and boundary’s head in BCondInst are created according to specific instances. Furthermore, we design a post-processing mechanism that adopts the predicted boundaries to further improve the quality of predicted masks in the testing phase. Consequently, masks predicted by BCondInst generally preserve more details and more accurate boundaries. Extensive experimental results on Microsoft COCO 2017 benchmark indicate that the performance of the proposed BCondInst exceeds the current popular one-stage instance segmentation approaches by a large margin.

Applying Occam's Razor and Descending the Reconstructive Ladder: The Modified Cheek Advancement Flap for Reconstruction of Nasal Defects.

Nasal reconstruction has important functional and cosmetic considerations, as proper repair of nasal defects is necessary to maintain function of the nasal airway and to recreate the normal appearance of this central facial structure. Cheek advancement flaps provide matched, mobile, and highly vascularized tissue for the reconstruction of nasal defects, allowing for the concealment of incisions within natural creases in a one-stage approach. However, cheek advancement flaps are often underutilized for nasal reconstruction because of their difficulty in restoring nasal contour. We describe reconstruction of 19 nasal dorsal and sidewall defects 0.8 to 3 cm in size. We incorporated a periosteal anchoring suture to maintain/restore nasal contour and additionally removed a half standing cone inferior to the defect to prevent encroachment of the nasal ala or alar crease. All patients were evaluated at least 3 months postoperatively. In all patients, we were able to restore concavity of the nasofacial sulcus, preserve the biconvex nasal tips, prevent alar flaring and retraction, and conserve the alar groove. All patients had excellent functional and cosmetic outcomes. We believe this modified cheek advancement flap provides functionally and aesthetically superior results and can be considered as a first-line approach for repair of nasal dorsal and sidewall defects in subselected patients.

Graph Convolutional Network for 3D Object Pose Estimation in a Point Cloud.

Graph Neural Networks (GNNs) are neural networks that learn the representation of nodes and associated edges that connect it to every other node while maintaining graph representation. Graph Convolutional Neural Networks (GCNs), as a representative method in GNNs, in the context of computer vision, utilize conventional Convolutional Neural Networks (CNNs) to process data supported by graphs. This paper proposes a one-stage GCN approach for 3D object detection and poses estimation by structuring non-linearly distributed points of a graph. Our network provides the required details to analyze, generate and estimate bounding boxes by spatially structuring the input data into graphs. Our method proposes a keypoint attention mechanism that aggregates the relative features between each point to estimate the category and pose of the object to which the vertices of the graph belong, and also designs nine degrees of freedom of multi-object pose estimation. In addition, to avoid gimbal lock in 3D space, we use quaternion rotation, instead of Euler angle. Experimental results showed that memory usage and efficiency could be improved by aggregating point features from the point cloud and their neighbors in a graph structure. Overall, the system achieved comparable performance against state-of-the-art systems.

Improving customer segmentation via classification of key accounts as outliers

Customer segmentation and key account management are important use cases for clustering algorithms. Here, a data set of a Portuguese wholesaler for food and household supplies is used as an exemplary application. To increase the quality of the analysis, a two-stage approach is proposed. First, key accounts are filtered by a density-based outlier detection. Second, a Gaussian Mixture Model (GMM) is applied to cluster smaller customers. This two-stage approach is aligned with the business implications of key accounts as outstanding and very differently behaving customers as well as with the core idea of an ABC analysis. Also, the exclusion of key accounts corresponds to the definition of outliers as the results of a different underlying mechanism. Using this two-stage approach shows better clustering results compared to using a one-stage approach applying only a GMM. Therefore, it is concluded that density-based detection of key accounts followed by a clustering using a GMM is beneficial for customer segmentation within B2B applications.

Accuracy of dental implant placement with 3D-printed surgical templates by using Implant Studio and MGUIDE. An observational study.

The purpose of the present study was to report early surgical template-related and postoperative complications of computer-guided implant placement and to evaluate its accuracy. Data were collected retrospectively from records of patients who had undergone computer-guided implant surgery between 2016 and 2018. Incidence of early surgical template-related and postoperative complications was recorded. Accuracy of implant placement was evaluated by comparing the data from postoperative CBCT records with that from the preoperative virtual implant planning by using appropriate image registration software. Depth, coronal, apical, and angular deviations were measured. A final number of 27 partially edentulous patients who received 52 implants with 31 static surgical templates were included in the study. All implants had been inserted in a fully guided manner using a flapless technique and following a one-stage approach. All implants were reported to have been successfully osseointegrated. Except for one template fracture, no other complication was recorded. The mean depth deviation was 0.57 ± 0.4 mm (95% CI 0.48 to 0.71 mm), the mean coronal deviation was 0.89 ± 0.7 mm (95% CI 0.73 to 1.07 mm), the mean apical deviation was 1.4 ± 1 mm (95% CI 1.16 to 1.71 mm), and the mean angular deviation was 2.74 ± 1.8 degrees (95% CI 2.29 to 3.26 degrees). The use of static surgical templates for fully guided implant placement demonstrated acceptable clinical performance. However, there are some factors affecting accuracy that should be considered during implant planning and surgery for further improvement of the technique. (Int J Comput Dent 2022;25(3):249-256; doi: 10.3290/j.ijcd.b2599735).

Comparing One-Stage vs Two-Stage Approaches for the Management of Choledocholithiasis

BackgroundThe management of symptomatic choledocholithiasis remains a controversial issue. At present, the three most common management options for choledocholithiasis include a preoperative endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction followed by laparoscopic cholecystectomy, then by either an intraoperative endoscopic retrograde cholangiopancreatography with sphincterotomy or a laparoscopic common bile duct exploration. The purpose of this study was to assess the consequences of the decision to pursue each of these three methods. MethodsWe conducted a review of the existing data comparing these three management options. The literature from 2009 to 2021 pertaining to these three methods was reviewed for data on duct clearance, morbidity, mortality, recurrence rate, length of stay, and operative time. Next, we constructed decision trees for each method using a utility score analysis, and these utility scores were used to create a sensitivity analysis based on stone clearance rate. ResultsLaparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography had a utility score of 0.9910, a stone clearance rate of 95.5%, a morbidity of 6.3%, and a mortality of 0.2%. Preoperative endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy had a utility score of 0.9629, a stone clearance rate of 85.5%, a morbidity of 13.3%, and a mortality of 0.8%. Laparoscopic cholecystectomy with common bile duct exploration had a utility score of 0.9882, a stone clearance rate of 88.3%, a morbidity of 12.9%, and a mortality of 0.3%. ConclusionWe have shown that a laparoscopic cholecystectomy with an intraoperative endoscopic retrograde cholangiopancreatography is associated with the best overall outcomes.

Clinical evaluation of S1 alar screws application in short-segment lumbosacral fixation and fusion for spine infection with severe S1 vertebral body loss

BackgroundThe one-stage posterior approach for treating spinal infection has recently been generally accepted. However, severe vertebral body loss caused by infection remains a major challenge in posterior surgery. This study was conducted to evaluate the clinical application and outcomes of S1 alar screws used in the one-stage posterior surgery of short-segment lumbosacral fixation and fusion after debridement for infection with severe S1 vertebral body loss.MethodsThe clinical features and treatment outcomes of 7 patients with spinal infections from August 2016 to August 2021 who were treated with one-stage posterior surgery using S1 alar screws were retrospectively analyzed. The clinical data, including patient data, visual analogue scale (VAS), Oswestry Disability Index (ODI), fusion time and complications of the patients, were recorded.ResultsAll 7 patients were followed up for an average duration of 14.57 months (range, 12—18 months). The VAS score decreased significantly from 7.3 preoperatively (range, 6—8) to 2.6 postoperatively (range, 2—3). The ODI score demonstrated a steady and gradual increase from 73.8 preoperatively (range, 68—75) to 33.6 postoperatively (range, 30—37). Bony fusion time was observed approximately 6.8 months after surgery. Two patients in our study experienced the postoperative local pain, which could be relieved by analgesics and disappeared 3 months after the operation. There were no complications of intraoperative fracture, posterior wound infection or neurovascular injury.ConclusionsS1 alar screws are suitable for use in the operation and could be an alternative option to S1 pedicle screws for short-segment lumbosacral fixation and fusion with severe S1 vertebral body loss caused by spinal infection, which could provide satisfactory clinical outcomes.

Ovarian Stimulation Strategies for Intrauterine Insemination in Couples with Unexplained Infertility - A Systematic Review and Individual Participant Data Meta-analysis

Background: Intrauterine insemination with ovarian stimulation (IUI-OS) is a first-line treatment for couples with unexplained infertility. Individual participant data meta-analysis (IPD-MA) is the gold standard for evidence synthesis. Aim: To compare the effectiveness and safety of ovarian stimulation with gonadotrophin, Letrozole and clomiphene citrate (CC) and to explore treatment-covariate interactions for important baseline characteristics in women undergoing IUI. Method: We searched electronic databases including PubMed, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL). We included randomised controlled trials (RCTs) comparing IUI-OS with gonadotropins, Letrozole or CC among couples with unexplained infertility. We excluded dose comparing studies of the same drug. We contacted the authors of eligible RCTs to share the IPD and established the IUI IPD-MA collaboration. The primary effectiveness outcome was live birth and the primary safety outcome was multiple pregnancy. We used a one-stage approach using a random effects model. Results: Six RCTs (n= 2299) provided IPD. Gonadotropins increased the chance of a live birth compared to both CC (5 RCTs, 1946 women, RR 1.28, 95%CI 1.10 to 1.49, I2 = 25%, moderate-quality evidence) whereas there was insufficient evidence of a difference between Letrozole and CC (1 RCT, 599 women, RR 0.77 95%CI 0.58 to 1.03). Gonadotropins increased the risk of a multiple pregnancy compared to both CC (4 RCTs, 1696 women, RR 2.17, 95%CI 1.33 to 3.55, I2 = 69%, low-quality evidence) whereas there was insufficient evidence of a difference between Letrozole and CC (1 RCT, 599 women, RR 0.71, 95%CI 0.33 to 1.56). No strong evidence on the treatment-covariate interactions (female age, BMI or primary versus secondary infertility) was found. Conclusion: Gonadotropins increased the chance of a live birth compared to both CC and Letrozole but also increased the chance of a multiple pregnancy. Further RCTs comparing Letrozole and other interventions in couples with unexplained infertility are needed.