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Internal multiples are very difficult to remove due to their complex raypaths and poor velocity discrimination with primaries. The layer-related common focus point (CFP) method has proven to be effective for internal multiple removal, however, single application leads to multiple leakage when there are several strong reflecting boundaries in the subsurface. In order to reduce this leakage, we propose successive application of the layer-related CFP method for internal multiple removal through cascaded processing of several time levels. In this paper, we concisely reformulate the theory of the boundary- and layer-related CFP methods and compare their robustness to velocity errors. For the layer-related version in particular, we illustrate the specific steps of the method using synthetic data examples. Finally, the successive layer-related CFP method is tested on Mississippi Canyon field data.

In women with a multiple pregnancy, spontaneous preterm delivery is the leading cause of perinatal morbidity and mortality. Interventions to reduce preterm birth in these women have not been successful. We assessed whether a cervical pessary could effectively prevent poor perinatal outcomes. We undertook a multicentre, open-label randomised controlled trial in 40 hospitals in the Netherlands. We randomly assigned women with a multiple pregnancy between 12 and 20 weeks' gestation (1:1) to pessary or control groups, using a web-based application with a computer-generated list with random block sizes of two to four, stratified by hospital. Participants and investigators were aware of group allocation. For women in the pessary group, a midwife or obstetrician inserted a cervical pessary between 16 and 20 weeks' gestation. Women in the control group did not receive the pessary, but otherwise received similar obstetrical care to those in the pessary group. The primary outcome was a composite of poor perinatal outcome: stillbirth, periventricular leucomalacia, severe respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular haemorrhage, necrotising enterocolitis, proven sepsis, and neonatal death. Analyses were by modified intention to treat. This trial is registered in the Dutch trial registry, number NTR1858. Between Sept 21, 2009, and March 9, 2012, 813 women underwent randomisation, of whom 808 were analysed (401 in the pessary group; 407 in the control group). At least one child of 53 women (13%) in the pessary group had poor perinatal outcome, compared with 55 (14%) in the control group (relative risk 0·98, 95% CI 0·69–1·39). In unselected women with a multiple pregnancy, prophylactic use of a cervical pessary does not reduce poor perinatal outcome. The Netherlands Organisation for Health Research and Development.

The complex nature of single organ failure potentially leading to multiple organ dysfunction syndrome (MODS) in critically ill patients necessitates integrated supportive therapy. Rather than a primary disease, acute kidney injury (AKI) is considered a window to a potentially serious underlying systemic disease, which may partially explain the high morbidity and mortality rates associated with the condition. Renal replacement therapy (RRT) has been routinely used for more than a decade in various intensive care settings and there has also been an increase in the use of extracorporeal membrane oxygenation and extracorporeal carbon dioxide removal. When these renal and cardiopulmonary modalities are used together, a multidisciplinary approach is necessary to minimize negative interactions and unwanted adverse effects. In this review, we describe the patterns of organ crosstalk between the native and artificial organs, the incidence of AKI and need for RRT and associated mortality after extracorporeal organ support (ECOS) therapy, including the potential short- and long-term advantages and disadvantages of organ support in terms of renal function. We also review potential indications of RRT outside its conventional indications in patients with MODS, as well as technical considerations when RRT is used alongside other organ support therapies. Overall, available literature has not definitely established the ideal timing of these interventions, and whether early implementation impacts organ recovery and optimizes resource utilization is still a matter of open debate: it is possible that future research will be devoted to identify patient groups that may benefit from short- and long-term multiple organ support.

The need for sustainable technological solutions for wastewater management at different scales has led to the emergence of several promising integrated bioelectrochemical technologies in the past decade. A thorough assessment of these technologies is imperative to understand their practical implementation feasibility and to identify the key challenges to prioritise the research and development work. Our multicriteria-based assessment reveals that the integrated technologies are efficient for wastewater treatment in terms of normalised land footprint [(0.31–1.39 m2/population equivalent (PE))] – and energy consumption (0.18–1.49 kWH/m3) as compared to the conventional biotechnologies, and suggests that they have potential for real-world application. Specifying the boundaries according to their treatment capabilities and scale-up potential besides niche application sites or geographical locations is required to expedite their transition to the real-world wastewater management sector. The key issues associated with the conventional and emerging wastewater treatment technologies, such as the energy-intensive operation of aerobic processes, slow-rate treatment or large land footprint of processes based on ecological principals and high capital expenditure and scalability concerns of microbial electrochemical technologies have led to the emergence of an integrated bioelectrochemical technology concept.The advancements in this area focus mainly on minimising the consumption of resources such as energy and land and enhancing resource recovery capabilities, as well as achieving low-cost and energy-efficient wastewater treatment on different scales.A thorough assessment of rapidly progressing integrated bioelectrochemical technologies is imperative to understand their practical implementation feasibility in the frame of sustainable wastewater management infrastructure.

Purpose Little is known about the prevalence, impact and change of the symptoms after implant removal due to irritation in multiple rib fractures. This study aims to explore these aspects to improve treatment decision-making. Methods Data was collected from two hospitals in the Netherlands and Switzerland. The study included only adults with operatively treated multiple rib fractures, regardless of whether the fractures were flail or non-flail. The primary outcome was the incidence of implant removal due to irritation. Secondary outcomes included implant irritation not leading to removal, other postoperative complications, and remission rates after implant removal. These outcomes were assessed during a follow-up phone call using a standardized questionnaire. Results Hundred-twenty patients were identified, with 83 (69.2%) completing the final follow-up after a median of 49 months (IQR 40–59). Twenty-five (30.1%) patients experienced implant irritation, of whom four (4.8%) got their implant removed. Two (2.4%) reported significant improvement, one (1.2%) moderate, and one (1.2%) no improvement of symptoms. Conclusion Implant irritation in patients with multiple rib fractures is a common problem, even years after surgery, without guaranteed symptom improvement post-removal. These results provide an additional argument to be more selective in offering rib fixation to patients with multiple rib fractures in the first place.

Autologous stem cell transplantation is a standard treatment strategy for patients with multiple myeloma that requires effective mobilization and apheresis of peripheral blood progenitor cells; however, in the current era of novel myeloma induction therapies, the optimal mobilization regimen to enhance stem cell yield while limiting toxicity and resource utilization remains unknown. In this multicenter retrospective study, we assessed apheresis and transplant outcomes in myeloma patients mobilized with granulocyte colony stimulating factor (G-CSF) alone ( n  = 62), G-CSF with chemotherapy ( n  = 43), or G-CSF with the CXCR4 antagonist plerixafor ( n  = 417). Compared to patients treated with G-CSF alone, the plerixafor group required significantly fewer median apheresis sessions (1 vs 2, p  = 0.0023) with higher CD34+ stem cell yield (9.9 vs 5.8 × 10 6 cells/kg, p  < 0.001) and had significantly faster engraftment of neutrophils (HR 1.54, 95% CI 1.17–2.03) and platelets (HR 2.24, 95% CI 1.69–2.96) after transplant. Additionally, the plerixafor group showed a significantly better toxicity profile and lower adverse event rate than patients treated with G-CSF alone ( p  = 0.0028) or chemomobilization ( p  < 0.0001), with a trend toward reduced survival in chemomobilization patients. Taken together, these data support the routine use of plerixafor-based mobilization to increase apheresis efficiency and reduce toxicity in myeloma patients undergoing transplant.

Multiple myeloma is the most common indication for high-dose chemotherapy with autologous stem cell support (ASCT) in North America today. Stem cell procurement for ASCT has most commonly been performed with stem cell mobilization using colony-stimulating factors with or without prior chemotherapy. The target CD34+ cell dose to be collected as well as the number of apheresis performed varies throughout the country, but a minimum of 2 million CD34+ cells/kg has been traditionally used for the support of one cycle of high-dose therapy. With the advent of plerixafor (AMD3100) (a novel stem cell mobilization agent), it is pertinent to review the current status of stem cell mobilization for myeloma as well as the role of autologous stem cell transplantation in this disease. On June 1, 2008, a panel of experts was convened by the International Myeloma Foundation to address issues regarding stem cell mobilization and autologous transplantation in myeloma in the context of new therapies. The panel was asked to discuss a variety of issues regarding stem cell collection and transplantation in myeloma especially with the arrival of plerixafor. Herein, is a summary of their deliberations and conclusions.

Many lymphoma and myeloma patients fail to undergo ASCT owing to poor mobilization. Identification of poor mobilizers (PMs) would provide a tool for early intervention with new mobilization agents. The Gruppo italianoTrapianto di Midollo Osseo working group proposed a definition of PMs applicable to clinical trials and clinical practice. The analytic hierarchy process, a method for group decision making, was used in setting prioritized criteria. Lymphoma or myeloma patients were defined as ‘proven PM’ when: (1) after adequate mobilization (G-CSF 10 μg/kg if used alone or ⩾5 μg/kg after chemotherapy) circulating CD34 + cell peak is <20/μL up to 6 days after mobilization with G-CSF or up to 20 days after chemotherapy and G-CSF or (2) they yielded <2.0 × 10 6 CD34 + cells per kg in ⩽3 apheresis. Patients were defined as predicted PMs if: (1) they failed a previous collection attempt (not otherwise specified); (2) they previously received extensive radiotherapy or full courses of therapy affecting SC mobilization; and (3) they met two of the following criteria: advanced disease (⩾2 lines of chemotherapy), refractory disease, extensive BM involvement or cellularity <30% at the time of mobilization; age ⩾65 years. This definition of proven and predicted PMs should be validated in clinical trials and common clinical practice.

To develop and evaluate a deep learning system for screening multiple abnormal findings including hemorrhages, drusen, hard exudates, cotton wool spots and retinal breaks using ultra-widefield fundus images. The system consisted of three modules: (I) quality assessment module, (II) artifact removal module and (III) lesion recognition module. In Module III, a heatmap was generated to highlight the lesion area. A total of 4,521 UWF images were used for the training and internal validation of the DL system. The system was evaluated in two external validation datasets consisting of 344 images and 894 images from two other hospitals. The performance of the system in these two datasets was compared with or without Module II. In both external validation datasets, the deep learning system made better performance when recognizing lesions on processed images after Module II than on original images without Module II. Module II-enhanced preprocessing improved Module III's five-lesion recognition performance by an average of 6.73% and 14.4% areas under the curves, 14.47% and 19.62% accuracy in the two external validations. Our system showed reliable performance for detecting MAF in real-world UWF images. For deep learning systems to recognize real-world images, the artifact removal module was indeed helpful.