Explore the vast range of titles available.

IntroductionThere has been increased interest in assessing the surgeon learning curve for new skill acquisition. While there is no consensus around the best methodology, one of the most frequently used learning curve assessments in the surgical literature is the cumulative sum curve (CUSUM) of operative time. To demonstrate the limitations of this methodology, we assessed the CUSUM of console time across cohorts of surgeons with differing case acquisition rates while varying the total number of cases used to calculate the CUSUM.MethodsWe compared the CUSUM curves of the average console times of surgeons who completed their first 20 robotic-assisted (RAS) cases in 13, 26, 39, and 52 weeks, respectively, for their first 50 and 100 cases, respectively. This analysis was performed for prostatectomy (1094 surgeons), malignant hysterectomy (737 surgeons), and inguinal hernia (1486 surgeons).ResultsIn all procedures, the CUSUM curve of the cohort of surgeons who completed their first 20 procedures in 13 weeks demonstrated a lower slope than cohorts of surgeons with slower case acquisition rates. The case number at which the peak of the CUSUM curve occurs uniformly increases when the total number of cases used in generation of the CUSUM chart changes from 50 to 100 cases.ConclusionThe CUSUM analyses of these three procedures suggests that surgeons with fast initial case acquisition rates have less variability in their operative times over the course of their learning curve. The peak of the CUSUM curve, which is often used in surgical learning curve literature to denote “proficiency” is predictably influenced by the total number of procedures evaluated, suggesting that defining the peak as the point at which a surgeon has overcome the learning curve is subject to routine bias. The CUSUM peak, by itself, is an insufficient measure of “conquering the learning curve.”

• Traits enabling seeds to survive post-dispersal desiccation and subsequently germinate are important aspects of plant regeneration for species with desiccation-sensitive seeds. However, how desiccation and germination-related traits co-vary and relate to patterns of climate variation are unknown. • We investigated physiological traits related to desiccation and germination of desiccation-sensitive seeds from 19 Quercus species, which typically dominate subalpine, subtropical and temperate forests in China. • The results demonstrate a strong relationship between climate and seed traits consistent with a hypothesis of minimizing seed death from desiccation. Seeds of subalpine species were most desiccation sensitive and died fastest when dried. These species avoided drought and cold by germinating rapidly. Subtropical and temperate oaks had more variable strategies to minimize the risk of mortality reflecting a continuum between traits that facilitate rapid germination (with the risk of rapid desiccation) and slow germination (and slow desiccation). • Across the Quercus species, the relative level of seed desiccation sensitivity, which we predicted to be important for reducing the risk of drying related mortality, was independent of climate. For desiccation-sensitive seeds this suggests a more diverse range of strategies for minimizing desiccation risk than reported previously.

As one of the most important photocatalysts, TiO 2 has triggered broad interest and intensive studies for decades. Observation of the interfacial reactions between water and TiO 2 at microscopic scale can provide key insight into the mechanisms of photocatalytic processes. Currently, experimental methodologies for characterizing photocatalytic reactions of anatase TiO 2 are mostly confined to water vapor or single molecule chemistry. Here, we investigate the photocatalytic reaction of anatase TiO 2 nanoparticles in water using liquid environmental transmission electron microscopy. A self-hydrogenated shell is observed on the TiO 2 surface before the generation of hydrogen bubbles. First-principles calculations suggest that this shell is formed through subsurface diffusion of photo-reduced water protons generated at the aqueous TiO 2 interface, which promotes photocatalytic hydrogen evolution by reducing the activation barrier for H 2 (H–H bond) formation. Experiments confirm that the self-hydrogenated shell contains reduced titanium ions, and its thickness can increase to several nanometers with increasing UV illuminance. Photocatalytic water splitting on TiO 2 is a promising route to H 2 fuel production, but the mechanistic pathway at the water–TiO 2 interface remains poorly understood. Here, using liquid environmental TEM and first-principles calculations, the authors unveil the formation of a self-hydrogenated shell on the TiO 2 surface that further promotes H 2 production.

We document distinctly different clientele effects on investor attention and return responses to information. Macro news crowds out retail investor attention to firms’ earnings news by 49%. For stocks with high retail ownership, macro news dampens earnings announcement returns by 17% and substantially increases post-announcement drift, especially during high VIX periods. In contrast, macro news increases institutional investor attention to scheduled earnings announcements but not their attention to unscheduled analysts’ forecast revisions. The findings confirm the implications of rational inattention models and highlight the importance of considering clientele effects in understanding the effect of news on attention and asset prices.

Surgical staplers are essential tools in minimally invasive surgery (MIS), enabling tissue division, hemostasis, and secure anastomoses. With the growth of robotic-assisted surgery, robotic staplers such as SureForm have recently become available. These staplers offer precise articulation and real-time tissue compression monitoring. However, the clinical advantages of robotic staplers over bedside staplers remain uncertain. Studies show mixed results across specialties, mainly due to small sample sizes, outdated data, and data heterogeneity. This study protocol proposes a series of future analyses that will evaluate the clinical outcomes and resource utilization of robotic versus bedside staplers in robotic-assisted surgeries across multiple specialties using recent real-world data. This retrospective cohort study will use data from the Premier Healthcare Database (PHD), a large hospital-based database covering patients with varied payers across the United States. Adult patients (≥18 years) who underwent elective, fully robotic-assisted lung, colorectal, gastric, or bariatric surgeries from 2019 to 2023 will be included. Each surgical specialty will be analyzed in a separate paper. Patients will be categorized into two groups based on the type of surgical stapler used: robotic staplers (SureForm) and bedside staplers (manual or powered). The primary outcome will be postoperative leak (air leak for lung resection; anastomotic leak for colorectal, gastrectomy, and bariatric). Key secondary outcomes are other complications, conversion to open surgery, operative time, transfusion requirements, length of stay (LOS), and cost. Overlap weighting will be applied to minimize bias. Results will be disseminated through peer-reviewed surgical journals and presentations at relevant surgical meetings.

We show that institutional investors are more likely to invest in firms from regions to which they have stronger social ties but find no evidence that these investments earn a differential return. Firms in regions with stronger social ties to locations with many institutional investors have higher valuations and liquidity. These effects are largest for small firms with little analyst coverage, suggesting that the investors’ behavior is explained by their increased awareness of firms in socially proximate locations. Our results highlight that the social structure of regions affects firms’ access to capital and contributes to geographic differences in economic outcomes.

Background Robot‐assisted surgery has short‐term benefits in rectal cancer surgery; however, its long‐term advantages remain unclear. This study compared short‐ and long‐term outcomes of open, laparoscopic, and robot‐assisted rectal cancer surgeries using large‐scale, database‐driven evidence. Methods Patients (28 711) diagnosed with clinical stages I–III rectal cancer who underwent rectal resection and were registered in the Japanese Medical Data Vision Co. Ltd. database were included. Open rectal resection (ORR), laparoscopic rectal resection (LRR), and robot‐assisted rectal resection (RARR) were identified. The primary outcomes were 5‐year overall survival (OS) and relapse‐free survival (RFS). Secondary outcomes included perioperative outcomes. Results After applying overlap weight, the RARR, LRR, and ORR groups had 3635 (15.3%), 17 142 (72.3%), and 2935 (12.4%) patients, respectively. Among the cohort (mean age: 69.5 years), 64.9% were male, and 24.7%, 31.5%, and 43.8% had clinical stages I, II, and III, respectively. The RARR group demonstrated the lowest postoperative complication rate, 30‐ and 90‐day mortality rates, and shortest hospital stay. The RARR group had the highest 5‐year OS (95%) and RFS (93%) compared to LRR (OS: 89%, RFS: 86%) and ORR (OS: 81%, RFS: 77%; p < 0.001). Multivariable analysis revealed that RARR was significantly associated with improved OS, whereas higher risks were observed for LRR (hazard ratio [HR]: 2.18, 95% confidence interval [CI]: 1.69–2.81) and ORR (HR: 3.96, 95% CI: 3.03–5.19). Conclusions The RARR group demonstrated superior short‐ and long‐term outcomes than the LRR and ORR groups, indicating robot‐assisted surgery as a potential new standard treatment for rectal cancer. Robot‐assisted rectal resection demonstrated superior short and long‐term outcomes compared to laparoscopic and open approaches.

The fast development of single-particle cryogenic electron microscopy (cryo-EM) has made it more feasible to obtain the 3D structure of well-behaved macromolecules with a molecular weight higher than 300 kDa at ~3 Å resolution. However, it remains a challenge to obtain the high-resolution structures of molecules smaller than 200 kDa using single-particle cryo-EM. In this work, we apply the Cs-corrector-VPP-coupled cryo-EM to study the 52 kDa streptavidin (SA) protein supported on a thin layer of graphene and embedded in vitreous ice. We are able to solve both the apo-SA and biotin-bound SA structures at near-atomic resolution using single-particle cryo-EM. We demonstrate that the method has the potential to determine the structures of molecules as small as 39 kDa. It remains a challenge to obtain high-resolution structures of molecules smaller than 200 kDa using single particle cryo-EM. Here, the authors apply the Cs-corrector-VPP coupled cryo-EM and solve structures of the 52 kDa streptavidin (SA) protein at near-atomic resolution.

Background and purpose In recent years, there has been extensive research on the role of exercise as an adjunctive therapy for cancer. However, the potential mechanisms underlying the anti-tumor therapy of exercise in lung cancer remain to be fully elucidated. As such, our study aims to confirm whether exercise-induced elevation of epinephrine can accelerate CD8 + T cell recruitment through modulation of chemokines and thus ultimately inhibit tumor progression. Method C57BL/6 mice were subcutaneously inoculated with Lewis lung cancer cells (LLCs) to establish a subcutaneous tumor model. The tumor mice were randomly divided into different groups to performed a moderate-intensity exercise program on a treadmill for 5 consecutive days a week, 45 min a day. The blood samples and tumor tissues were collected after exercise for IHC, RT-qPCR, ELISA and Western blot. In addition, another group of mice received daily epinephrine treatment for two weeks (0.05 mg/mL, 200 µL i.p.) (EPI, n  = 8) to replicate the effects of exercise on tumors in vivo. Lewis lung cancer cells were treated with different concentrations of epinephrine (0, 5, 10, 20 µM) to detect the effect of epinephrine on chemokine levels via ELISA and RT-qPCR. Results This study reveals that both pre- and post-cancer exercise effectively impede the tumor progression. Exercise led to an increase in EPI levels and the infiltration of CD8 + T cell into the lung tumor. Exercise-induced elevation of EPI is involved in the regulation of Ccl5 and Cxcl10 levels further leading to enhanced CD8 + T cell infiltration and ultimately inhibiting tumor progression. Conclusion Exercise training enhance the anti-tumor immunity of lung cancer individuals. These findings will provide valuable insights for the future application of exercise therapy in clinical practice.

Whether amino acids act on cellular insulin signaling remains unclear, given that increased circulating amino acid levels are associated with the onset of type 2 diabetes (T2D). Here, we report that phenylalanine modifies insulin receptor beta (IRβ) and inactivates insulin signaling and glucose uptake. Mice fed phenylalanine-rich chow or phenylalanine-producing aspartame or overexpressing human phenylalanyl-tRNA synthetase (hFARS) develop insulin resistance and T2D symptoms. Mechanistically, FARS phenylalanylate lysine 1057/1079 of IRβ (F-K1057/1079), inactivating IRβ and preventing insulin from promoting glucose uptake by cells. SIRT1 reverse F-K1057/1079 and counteract the insulin-inactivating effects of hFARS and phenylalanine. F-K1057/1079 and SIRT1 levels in white blood cells from T2D patients are positively and negatively correlated with T2D onset, respectively. Blocking F-K1057/1079 with phenylalaninol sensitizes insulin signaling and relieves T2D symptoms in hFARS -transgenic and db/db mice. These findings shed light on the activation of insulin signaling and T2D progression through inhibition of phenylalanylation. Whether amino acids act on cellular insulin signaling remains unclear. Here, the authors find that phenylalanine modifies insulin receptor beta (IRβ) and inactivates insulin signaling and glucose uptake and positively correlated with T2D onset.