Metastability-Containing Circuits

Communication across unsynchronized clock domains is inherently vulnerable to metastable upsets; no digital circuit can deterministically avoid, resolve, or detect metastability (Marino, 1981). Traditionally, a possibly metastable input is stored in synchronizers, decreasing the odds of maintained metastability over time. This approach costs time, and does not guarantee success. We propose a fundamentally different approach: It is possible to \emph{contain} metastability by logical masking, so that it cannot infect the entire circuit. This technique guarantees a limited degree of metastability in---and uncertainty about---the output. We present a synchronizer-free, fault-tolerant clock synchronization algorithm as application, synchronizing clock domains and thus enabling metastability-free communication. At the heart of our approach lies a model for metastability in synchronous clocked digital circuits. Metastability is propagated in a worst-case fashion, allowing to derive deterministic guarantees, without and unlike synchronizers. The proposed model permits positive results while at the same time reproducing established impossibility results regarding avoidance, resolution, and detection of metastability. Furthermore, we fully classify which functions can be computed by synchronous circuits with standard registers, and show that masking registers are computationally strictly more powerful

Reoperation After Cholecystectomy. The Role of the Cystic Duct Stump

The so-called “Postcholecystectomy Syndrome” may be due to various pathological biliary causes. The aim of this study was to evaluate the significance of the cystic duct stump syndrome and if so, how often a long (>1.5 cm) cystic duct stump was an indication for reoperation on the bile ducts after cholecystectomy in our patients. Three hundred and twenty two patients underwent a second operation on the bile ducts after cholecystectomy in the last ten years. In 35 patients (10.8%) a striking finding was a long cystic duct stump (>1.5 cm). In 24 of these patients, a pathological finding, in addition to the long cystic duct stump, was found on exploration. Out of these 24 patients there were 14 with common bile duct stones; 6 with stenosis of the sphincter of Oddi; 3 with chronic pancreatitis and in one patient hepatitis was the cause of the symptoms. From the remaining 11 patients 8 had a stone in a partial gall bladder or cystic duct stump. One patient had a fistula between the cystic duct stump and duodenum and one a suture granuloma. There was only one patient where a 1.5 cm long cystic duct stump remnant was the only pathological finding. Four years after reoperation this patient is still suffering from the same intermittent gastrointestinal symptoms. We conclude that the cystic duct stump is hardly ever a cause for recurrent symptoms in itself. Total excision of the cystic duct does not eliminate the existence of postcholecystectomy symptoms

Asynchronous Byzantine Approximate Consensus in Directed Networks

In this work, we study the approximate consensus problem in asynchronous message-passing networks where some nodes may become Byzantine faulty. We answer an open problem raised by Tseng and Vaidya, 2012, proposing the first algorithm of optimal resilience for directed networks. Interestingly, our results show that the tight condition on the underlying communication networks for asynchronous Byzantine approximate consensus coincides with the tight condition for synchronous Byzantine exact consensus. Our results can be viewed as a non-trivial generalization of the algorithm by Abraham et al., 2004, which applies to the special case of complete networks. The tight condition and techniques identified in the paper shed light on the fundamental properties for solving approximate consensus in asynchronous directed networks.Comment: 25 pages, 2 figure

Lost gallstones during laparoscopic cholecystectomy as a common but underestimated complication—case report and review of the literature

IntroductionLaparoscopic cholecystectomy (LC) represents one of the most commonly performed routine abdominal surgeries. Nevertheless, besides bile duct injury, problems caused by lost gallstones represent a heavily underestimated and underreported possible late complication after LC.MethodsCase report of a Clavien-Dindo IVb complication after supposedly straightforward LC and review of all published case reports on complications from lost gallstones from 2000-2022.Case ReportAn 86-year-old patient developed a perihepatic abscess due to lost gallstones 6 months after LC. The patient had to undergo open surgery to successfully drain the abscess. Reactive pleural effusion needed additional drainage. Postoperative ICU stay was 13 days. The patient was finally discharged after 33 days on a geriatric remobilization ward and died 12 months later due to acute cardiac decompensation.ConclusionIntraabdominal abscess formation due to spilled gallstones may present years after LC as a late complication. Surgical management in order to completely evacuate the abscess and remove all spilled gallstones may be required, which could be associated with high morbidity and mortality, especially in elderly patients. Regarding the overt underreporting of gallstone spillage in case of postoperative gallstone-related complications, focus need be put on precise reporting of even apparently innocuous complications during LC

A paired-kidney allocation study found superior survival with HLA-DR compatible kidney transplants in the Eurotransplant Senior Program

The Eurotransplant Senior Program (ESP) has expedited the chance for elderly patients with kidney failure to receive a timely transplant. This current study evaluated survival parameters of kidneys donated after brain death with or without matching for HLA-DR antigens. This cohort study evaluated the period within ESP with paired allocation of 675 kidneys from donors 65 years and older to transplant candidates 65 years and older, the first kidney to 341 patients within the Eurotransplant Senior DR-compatible Program and 334 contralateral kidneys without (ESP) HLA-DR antigen matching. We used Kaplan-Meier estimates and competing risk analysis to assess all cause mortality and kidney graft failure, respectively. The log-rank test and Cox proportional hazards regression were used for comparisons. Within ESP, matching for HLA-DR antigens was associated with a significantly lower five-year risk of mortality (hazard ratio 0.71; 95% confidence interval 0.53-0.95) and significantly lower cause-specific hazards for kidney graft failure and return to dialysis at one year (0.55; 0.35-0.87) and five years (0.73; 0.53-0.99) post-transplant. Allocation based on HLA-DR matching resulted in longer cold ischemia (mean difference 1.00 hours; 95% confidence interval: 0.32-1.68) and kidney offers with a significantly shorter median dialysis vintage of 2.4 versus 4.1 yrs. in ESP without matching. Thus, our allocation based on HLA-DR matching improved five-year patient and kidney allograft survival. Hence, our paired allocation study suggests a superior outcome of HLA-DR matching in the context of old-for-old kidney transplantation.</p

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Unfaithful Glitch Propagation in Existing Binary Circuit Models

International audienceWe show that no existing continuous-time, binary value-domain model for digital circuits is able to correctly capture glitch propagation. Prominent examples of such models are based on pure delay channels (P), inertial delay channels (I), or the elaborate Delay Degradation Model (DDM) channels proposed by Bellido-Díaz et al. We accomplish our goal by considering the border between solvability and non-solvability of a simple problem called Short-Pulse Filtration (SPF), which is closely related to arbitration and synchronization. On one hand, we prove that SPF is solvable in bounded time in any such model that provides channels with non constant delay, like I and DDM. This is in opposition to the impossibility of solving bounded SPF in real (physical) circuit models. On the other hand, for binary circuit models with constant-delay channels, we prove that SPF cannot be solved even in unbounded time; again in opposition to physical circuit models. Consequently, indeed none of the binary value-domain models proposed so far (and that we are aware of) faithfully captures glitch propagation of real circuits. We finally show that these modeling mismatches do not hold for the weaker eventual SPF problem

Metastability-Containing Circuits

Communication across unsynchronized clock domains is inherently vulnerable to metastable upsets; no digital circuit can deterministically avoid, resolve, or detect metastability (Marino, 1981). Traditionally, a possibly metastable input is stored in synchronizers, decreasing the odds of maintained metastability over time. This approach costs time, and does not guarantee success. We propose a fundamentally different approach: It is possible to \emph{contain} metastability by logical masking, so that it cannot infect the entire circuit. This technique guarantees a limited degree of metastability in---and uncertainty about---the output. We present a synchronizer-free, fault-tolerant clock synchronization algorithm as application, synchronizing clock domains and thus enabling metastability-free communication. At the heart of our approach lies a model for metastability in synchronous clocked digital circuits. Metastability is propagated in a worst-case fashion, allowing to derive deterministic guarantees, without and unlike synchronizers. The proposed model permits positive results while at the same time reproducing established impossibility results regarding avoidance, resolution, and detection of metastability. Furthermore, we fully classify which functions can be computed by synchronous circuits with standard registers, and show that masking registers are computationally strictly more powerful