Direct Peritoneal Resuscitation (DPR) Improves Acute Physiology and Chronic Health Evaluation (APACHE) IV and Acute Physiology Score When Used in Damage Control Laparotomies: Prospective Cohort Study on 37 Patients.

INTRODUCTION: Using direct peritoneal resuscitation (DPR) as an adjunct when managing patients undergoing damage control laparotomy (DCL) shows promising results. We report our initial experience in utilizing DPR when managing patients who underwent DCL for emergent surgery at the index operation. MATERIALS AND METHODS: We prospectively collected data on 37 patients between August 2020 to October 2021 who underwent DCL with open abdomens after the index operation and utilized DPR. DPR was performed using peritoneal lavage with DIANEAL PD-2-D 2.5% Ca 3.5 mEq/L at a rate of 400ml/hour. Patients' physiological scores and clinical outcomes were evaluated. RESULTS: 86% required DCL and DPR due to septic abdomen/bowel ischemia. The median (interquartile range [IQR]) age was 62 years (53-70); 62% were male, and median (IQR) body mass index was 30.0kg/m2 (25.5-38.4). On DPR initiation, median (IQR) APACHE-IV score was 48 (33-64) and median (IQR) Acute Physiology Score (APS) was 31 (18-54). After initiation, median (IQR) APACHE-IV score and median (IQR) APS were 39 (21-62) and 19 (11-56), respectively, and both showed significant improvement in survivors (p<0.05). Median (IQR) DPR duration was four days (2-8) and primary abdominal closure was achieved in 30 patients (81%). There were eight mortalities (21.6%) within 30 days postoperatively, of which seven were within 3-24 days due to uncontrolled sepsis/multiple organ failure. The most frequent complication was surgical-site infection recorded in 12 patients (32%). Twenty-four patients (67%) were discharged home/transferred to a rehab center/nursing home. CONCLUSION: DPR application showed significant improvement of APACHE-IV score and APS in patients with peritonitis/septic abdomen.

Electronic Cigarettes: Common Questions and Answers.

Electronic cigarettes (e-cigarettes) are popular devices designed to heat a liquid solution, often containing nicotine, that generates an inhaled aerosol, or vapor. e-Cigarettes have been marketed as healthier alternatives to traditional cigarettes. Thus, most adult users are current or former smokers who use e-cigarettes to reduce or quit cigarette smoking. Switching completely from cigarettes to e-cigarettes is associated with reduced toxicant exposure and reduced short-term respiratory symptoms; however, long-term health effects of e-cigarettes are unknown. Although a recent randomized trial suggests that e-cigarettes may promote smoking cessation, systematic reviews have had low certainty of evidence regarding cessation. e-Cigarettes pose several potential health risks, including exposure to heavy metals and toxicants, and nicotine poisoning. e-Cigarettes are also popular among youth, with rates of e-cigarette use surpassing those of cigarette use in this population. Youth e-cigarette use is associated with increased risk of subsequent cigarette and marijuana use. Screening for e-cigarette use in youth and adults, including pregnant women, in conjunction with screening for tobacco use, is advised. Education and interventions to prevent e-cigarette use should be provided to all youth. Youth should be counseled to stop using nicotine/tobacco products, including e-cigarettes. Although the impact of e-cigarette use in pregnancy is unknown, nicotine is a teratogen; thus, pregnant women should be counseled to abstain from using all nicotine/tobacco products.

Future Supply of Pediatric Surgeons: Analytical Study of the Current and Projected Supply of Pediatric Surgeons in the Context of a Rapidly Changing Process for Specialty and Subspecialty Training.

OBJECTIVE: To describe the future supply and demand for pediatric surgeons using a physician supply model to determine what the future supply of pediatric surgeons will be over the next decade and a half and to compare that projected supply with potential indicators of demand and the growth of other subspecialties. BACKGROUND: Anticipating the supply of physicians and surgeons in the future has met with varying levels of success. However, there remains a need to anticipate supply given the rapid growth of specialty and subspecialty fellowships. This analysis is intended to support decision making on the size of future fellowships in pediatric surgery. METHODS: The model used in the study is an adaptation of the FutureDocs physician supply and need tool developed to anticipate future supply and need for all physician specialties. Data from national inventories of physicians by specialty, age, sex, activity, and location are combined with data from residency and fellowship programs and accrediting bodies in an agent-based or microsimulation projection model that considers movement into and among specialties. Exits from practice and the geographic distribution of physician and the patient population are also included in the model. Three scenarios for the annual entry into pediatric surgery fellowships (28, 34, and 56) are modeled and their effects on supply through 2030 are presented. RESULTS: The FutureDocs model predicts a very rapid growth of the supply of surgeons who treat pediatric patients-including general pediatric surgeon and focused subspecialties. The supply of all pediatric surgeons will grow relatively rapidly through 2030 under current conditions. That growth is much faster than the rate of growth of the pediatric population. The volume of complex surgical cases will likely match this population growth rate meaning there will be many more surgeons trained for those procedures. The current entry rate into pediatric surgery fellowships (34 per year) will result in a slowing of growth after 2025, a rate of 56 will generate a continued growth through 2030 with a likely plateau after 2035. CONCLUSIONS: The rate of entry into pediatric surgery will continue to exceed population growth through 2030 under two likely scenarios. The very rapid anticipated growth in focused pediatric subspecialties will likely prove challenging to surgeons wishing to maintain their skills with complex cases as a larger and more diverse group of surgeons will also seek to care for many of the conditions and patients which the general pediatric surgeons and general surgeons now see. This means controlling the numbers of pediatric surgery fellowships in a way that recognizes problems with distribution, the volume of cases available to maintain proficiency, and the dynamics of retirement and shifts into other specialty practice.

Conclusions and data analysis: a 6-year study of Raman spectroscopy of solid tumors at a major pediatric institute.

PURPOSE: Create a Raman spectroscopic database with potential to diagnose cancer and investigate two different diagnostic methodologies. Raman spectroscopy measures the energy of photons scattered inelastically by molecules. These molecular signatures form the basis of identifying complex biomolecules and can be used to differentiate normal from neoplastic tissue. METHODS: 1,352 spectra from 55 specimens were collected from fresh or frozen normal brain, kidney and adrenal gland and their malignancies. Spectra were obtained utilizing a Renishaw Raman microscope (RM1000) at 785 nm excitation wavelength with an exposure time of 10 to 20 s/spectrum over three accumulations. Spectra were preprocessed and discriminant function analysis was used to classify spectra based on pathological gold standard. RESULTS: The results of leave 25 % out training/testing validation were as follows: 94.3 % accuracy for training and 91.5 % for testing adrenal, 95.1 % accuracy for training and 88.9 % for testing group of brain, and 100 % accuracy for kidney training/testing groups when tissue origin was assumed. A generalized database not assuming tissue origin provided 88 % training and 85.5 % testing accuracy. CONCLUSION: A database can be made from Raman spectra to classify and grade normal from cancerous tissue. This database has the potential for real time diagnosis of fresh tissue and can potentially be applied to the operating room in vivo.

Identification of pediatric brain neoplasms using Raman spectroscopy.

PURPOSE: Raman spectroscopy can quickly and accurately diagnose tissue in near real-time. This study evaluated the capacity of Raman spectroscopy to diagnose pediatric brain tumors. EXPERIMENTAL DESIGN: Samples of untreated pediatric medulloblastoma (4 samples and 4 patients), glioma (i.e. astrocytoma, oligodendroglioma, ependymoma, ganglioglioma and other gliomas; 27 samples and 19 patients), and normal brain samples (33 samples and 5 patients) were collected fresh from the operating room or from our frozen tumor bank. Samples were divided and tested using routine pathology and Raman spectroscopy. Twelve Raman spectra were collected per sample. Support vector machine analysis was used to classify spectra using the pathology diagnosis as the gold standard. RESULTS: Normal brain (321 spectra), glioma (246 spectra) and medulloblastoma (82 spectra) were identified with 96.9, 96.7 and 93.9% accuracy, respectively, when compared with each other. High-grade ependymomas (41 spectra) were differentiated from low-grade ependymomas (25 spectra) with 100% sensitivity and 96.0% specificity. Normal brain tissue was distinguished from low-grade glioma (118 spectra) with 91.5% sensitivity and 97.8% specificity. For these analyses, the tissue-level classification was determined to be 100% accurate. CONCLUSION: These results suggest Raman spectroscopy can accurately distinguish pediatric brain neoplasms from normal brain tissue, similar tumor types from each other and high-grade from low-grade tumors.

Anatomy and relationships of the early diverging Crocodylomorphs Junggarsuchus sloani and Dibothrosuchus elaphros.

The holotype of Junggarsuchus sloani, from the Shishugou Formation (early Late Jurassic) of Xinjiang, China, consists of a nearly complete skull and the anterior half of an articulated skeleton, including the pectoral girdles, nearly complete forelimbs, vertebral column, and ribs. Here, we describe its anatomy and compare it to other early diverging crocodylomorphs, based in part on CT scans of its skull and that of Dibothrosuchus elaphros from the Early Jurassic of China. Junggarsuchus shares many features with a cursorial assemblage of crocodylomorphs, informally known as "sphenosuchians," whose relationships are poorly understood. However, it also displays several derived crocodyliform features that are not found among most "sphenosuchians." Our phylogenetic analysis corroborates the hypothesis that Junggarsuchus is closer to Crocodyliformes, including living crocodylians, than are Dibothrosuchus and Sphenosuchus, but not as close to crocodyliforms as Almadasuchus and Macelognathus, and that the "Sphenosuchia" are a paraphyletic assemblage. D. elaphros and Sphenosuchus acutus are hypothesized to be more closely related to Crocodyliformes than are the remaining non-crocodyliform crocodylomorphs, which form several smaller groups but are largely unresolved.

The right ventricular systolic to diastolic duration ratio: a simple prognostic marker in congenital diaphragmatic hernia?

AIMS: (i) To compare the ratio of right ventricular systolic to diastolic duration (SD/DD) in infants with congenital diaphragmatic hernia (CDH) and normal controls and (ii) to examine its association, if any, with outcomes in CDH. METHODS: Retrospective chart and echocardiographic review of consecutive neonates (<1 month old) with CDH and term controls without structural heart defects. Right ventricular SD/DD was calculated by a single reader. RESULTS: Infants with CDH (n = 29) were comparable to controls (n = 27) in their mean (SD) age [2.2 (3.3) vs. 2 (4.0) days], birthweight [3 (0.67) vs. 3 (0.69) kg] and proportion of males (48.2% vs. 72.4%). The DD and SD/DD were significantly abnormal in the CDH group, compared to controls. Among infants with CDH, those who died (n = 15) and those who died or required ECMO (n = 17) had significantly shorter DD and higher SD/DD ratio. At a cut-off of 1.3, SD/DD ratio had a sensitivity of 92.8 (95% CI 64-99%) and specificity of 61.5 (32-85%) for prediction of mortality. Significant independent associations with mortality were observed with antenatal diagnosis (p = 0.003) and higher SD/DD ratio (p = 0.04). CONCLUSION: The right ventricular SD/DD ratio is a sensitive objective prognostic marker in infants with CDH. Further studies incorporating SD/DD ratio as a guide to intervention are warranted.

Clinical risk factors for gastroschisis and omphalocele in humans: a review of the literature.

Gastroschisis and omphalocele are usually considered together since they are both congenital abdominal wall defects, and yet their anatomy, embryogenesis, and clinical presentation and problems are quite different. In addition, it appears that the risk factors for their occurrence differ. Etiologic factors contributing to the development of these defects are unknown. To investigate this we have reviewed reports of risk factors for each anomaly and report them here. We conducted a literature search using PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) for risk factors implicated in the development of gastroschisis and omphalocele. The data reviewed here from clinical studies in the literature, closely parallels the data in animal studies which we reported earlier. There is little evidence for a genetic cause in the development of gastroschisis and much evidence supporting the possibility that environmental teratogens are important contributors to the development of this defect. On the other hand, in the case of omphalocele, there was little evidence for environmental factors and substantial data indicating that genetic or familial factors may play an important role.

Teratogens inducing congenital abdominal wall defects in animal models.

Congenital abdominal wall defects are common anomalies which include gastroschisis, omphalocele and umbilical cord hernia. Recent reports indicate that gastroschisis is increasing in prevalence, whereas omphalocele has remained steady, suggesting that environmental factors may play a part in their pathogenesis. The aim of this study is to review animal teratogen studies resulting in abdominal wall defects to investigate their possible causes. Each report was examined not only for the teratogens causing the defects, but also to carefully identify the defect occurring and its correlation with the known clinical anomalies. We found many discrepancies between the nomenclature used by animal teratology investigators and that used by clinicians. We were able to confirm the induction of gastroschisis by 22 teratogens, omphalocele by 9 teratogens and umbilical cord hernia by 8. There is no doubt that environmental factors may be responsible, at least in part, for all three of the clinical abdominal wall defects. Future studies should take care to appreciate the differences between these anomalies and describe them in detail, so that accurate and meaningful conclusions can be obtained.

The benefit (and cost) of drawing as an encoding strategy.

Drawing, as an encoding strategy for to-be-remembered words, has previously been shown to provide robust memory benefits. In the current study, we investigated the effect of drawing on false memory endorsements during a recognition test. We found that while drawing led to higher hit rates relative to writing (Experiment 1) and creating visual mental imagery (Experiment 2), it also led to higher false alarm (FA) rates to critical lures in a variant of the Deese-Roediger-McDermott (DRM) paradigm. When compared with an encoding strategy requiring listing of object features (Experiment 3), drawing led to a lower FA rate. We suggest that drawing enhances memory by promoting recollection of rich visual contextual information during retrieval, and this leads to the unintended side effect of increasing FA rates to related information.

Performance of basic manipulation and intracorporeal suturing tasks in a robotic surgical system: single- versus dual-monitor views.

BACKGROUND: Technical advances in the application of laparoscopic and robotic surgical systems have improved platform usability. The authors hypothesized that using two monitors instead of one would lead to faster performance with fewer errors. METHODS: All tasks were performed using a surgical robot in a training box. One of the monitors was a standard camera with two preset zoom levels (zoomed in and zoomed out, single-monitor condition). The second monitor provided a static panoramic view of the whole surgical field. The standard camera was static at the zoomed-in level for the dual-monitor condition of the study. The study had two groups of participants: 4 surgeons proficient in both robotic and advanced laparoscopic skills and 10 lay persons (nonsurgeons) who were given adequate time to train and familiarize themselves with the equipment. Running a 50-cm rope was the basic task. Advanced tasks included running a suture through predetermined points and intracorporeal knot tying with 3-0 silk. Trial completion times and errors, categorized into three groups (orientation, precision, and task), were recorded. RESULTS: The trial completion times for all the tasks, basic and advanced, in the two groups were not significantly different. Fewer orientation errors occurred in the nonsurgeon group during knot tying (p=0.03) and in both groups during suturing (p=0.0002) in the dual-monitor arm of the study. Differences in precision and task error were not significant. CONCLUSIONS: Using two camera views helps both surgeons and lay persons perform complex tasks with fewer errors. These results may be due to better awareness of the surgical field with regard to the location of the instruments, leading to better field orientation. This display setup has potential for use in complex minimally invasive surgeries such as esophagectomy and gastric bypass. This technique also would be applicable to open microsurgery.

An integrated movement capture and control platform applied towards autonomous movements of surgical robots.

Robotic surgery has gradually gained acceptance due to its numerous advantages such as tremor filtration, increased dexterity and motion scaling. There remains, however, a significant scope for improvement, especially in the areas of surgeon-robot interface and autonomous procedures. Previous studies have attempted to identify factors affecting a surgeon's performance in a master-slave robotic system by tracking hand movements. These studies relied on conventional optical or magnetic tracking systems, making their use impracticable in the operating room. This study concentrated on building an intrinsic movement capture platform using microcontroller based hardware wired to a surgical robot. Software was developed to enable tracking and analysis of hand movements while surgical tasks were performed. Movement capture was applied towards automated movements of the robotic instruments. By emulating control signals, recorded surgical movements were replayed by the robot's end-effectors. Though this work uses a surgical robot as the platform, the ideas and concepts put forward are applicable to telerobotic systems in general.

Cystic lung disease.

Cystic lung disease is divided into congenital and acquired lesions. Congenital cystic lung disease includes several malformations with distinct anatomical and histological features. There is significant overlap between these lesions to suggest a common pathologic mechanism for their occurrence. Congenital cystic lung lesions include cystic adenomatoid malformations, pulmonary sequestrations, congenital lobar emphysema, and peripheral bronchogenic cysts. These lesions are commonly diagnosed prenatally with high accuracy. Prenatal imaging has allowed us to better understand their natural history and devise strategies for prenatal and postnatal management. Some lesions warrant resection (even prenatally), whereas others can be managed expectantly.

Comparison of a supplemental wide field of view versus a single field of view with zoom on performance in minimally invasive surgery.

BACKGROUND: The limited space and high magnification involved in minimally invasive surgery (MIS) can cause surgeons to lose sight of an instrument while performing tasks such as suturing and knot-tying. A current strategy employed to locate the instrument is zooming out and in with the endoscope, which can be a time-intensive and iterative task. This study investigates the use of a supplemental wide field of view (FOV) via a second endoscope for locating an instrument outside the FOV in a MIS setting. METHODS: Ten surgically naïve subjects performed a simple aimed movement task with either hand (dominant or nondominant) under two display conditions: (1) conventional single monitor with zoom, and (2) supplemental wide FOV monitor with no zoom. The task emulated the need to locate an instrument outside the surgeon's FOV and return it to a home position. RESULTS: The supplemental wide FOV produced significantly faster times [F(3,716) = 173.2, p < 0.001)] compared to a single monitor. The task was accomplished most quickly with the dual monitor with the dominant hand, followed by dual monitor with nondominant hand followed by a single monitor with either hand. There were also significantly fewer errors (t = 3.734, df = 9, p = 0.005) with the supplemental wide FOV. None of the subjects were slower with the dual monitor, and all but one had fewer errors. The variance for both task times and errors were also significantly smaller (p < 0.001 and p = 0.008, respectively) with the supplemental wide FOV indicating that subjects performed with increased reliability. CONCLUSION: The supplemental wide FOV gave the subjects the ability to see their instrument at all times providing a more efficient display than zooming out and in. This enabled faster times and fewer errors while allowing the user to perform the task with more consistency.

Making time: Estimation of internally versus externally defined durations.

Most research on the topic of duration estimation has examined the mechanisms underlying estimation of durations that are demarcated by experimental stimuli. It is not clear whether the estimation of durations that are instead defined by our own mental processes (e.g., response times) is underlain by the same mechanisms. Across five experiments, we tested whether the pattern of interference between concurrent temporal and nontemporal tasks was similar for the two types of intervals. Duration estimation of externally defined intervals slowed performance on a concurrent equation verification task, regardless of whether participants were required to report their estimate by clicking within an analogue scale or by reproducing the duration. Estimation of internally defined durations did not slow equation verification performance when an analogue scale response was required. The results suggest that estimation of internally defined durations may not depend on the effortful temporal processing that is required to estimate externally defined durations.

Automated robot-assisted surgical skill evaluation: Predictive analytics approach.

BACKGROUND: Surgical skill assessment has predominantly been a subjective task. Recently, technological advances such as robot-assisted surgery have created great opportunities for objective surgical evaluation. In this paper, we introduce a predictive framework for objective skill assessment based on movement trajectory data. Our aim is to build a classification framework to automatically evaluate the performance of surgeons with different levels of expertise. METHODS: Eight global movement features are extracted from movement trajectory data captured by a da Vinci robot for surgeons with two levels of expertise - novice and expert. Three classification methods - k-nearest neighbours, logistic regression and support vector machines - are applied. RESULTS: The result shows that the proposed framework can classify surgeons' expertise as novice or expert with an accuracy of 82.3% for knot tying and 89.9% for a suturing task. CONCLUSION: This study demonstrates and evaluates the ability of machine learning methods to automatically classify expert and novice surgeons using global movement features.

Pediatric robotic surgery: lessons from a clinical experience.

PURPOSE: Robotic surgery may improve minimally invasive surgery at high magnification by tremor filtration, motion-scaling, and improved dexterity with the provision of a wrist at the end of the robotic instrument. MATERIALS AND METHODS: We chose the Zeus Microwrist robotic surgical system as more applicable to small children than the competing da Vinci surgical system. We attempted 57 surgical procedures and completed 54. RESULTS: Completed procedures included Nissen fundoplication (n = 25), cholecystectomy (n = 18), Heller myotomy (n = 2), splenectomy (n = 2), Morgagni hernia repair (n = 2), and single cases of complex pyloroplasty in the chest, bowel resection, left Bochdalek congenital diaphragmatic hernia repair, esophageal atresia and tracheoesophageal fistula repair, and choledochal cyst excision. There were no complications related to the use of the robot. The mean time for the surgeon at the console using the robot was 117 +/- 39 minutes for Nissen fundoplication, and the total operating room time was 250 +/- 60 minutes. Surgeons found dissection, suturing, and knot tying easier than with conventional laparoscopy. None of the surgeons thought the lack of touch feedback (haptics) was crucial. CONCLUSION: Robotic surgery offers increased dexterity to the pediatric minimally invasive surgeon, but procedures require more time, and there is no defined patient benefit. The fact that robotic surgery digitalizes minimally invasive surgery creates exciting possibilities for training surgeons, planning operations, and performing surgery at great distances from the operator.

Distance-based time series classification approach for task recognition with application in surgical robot autonomy.

BACKGROUND: Robotic-assisted surgery allows surgeons to perform many types of complex operations with greater precision than is possible with conventional surgery. Despite these advantages, in current systems, a surgeon should communicate with the device directly and manually. To allow the robot to adjust parameters such as camera position, the system needs to know automatically what task the surgeon is performing. METHODS: A distance-based time series classification framework has been developed which measures dynamic time warping distance between temporal trajectory data of robot arms and classifies surgical tasks and gestures using a k-nearest neighbor algorithm. RESULTS: Results on real robotic surgery data show that the proposed framework outperformed state-of-the-art methods by up to 9% across three tasks and by 8% across gestures. CONCLUSION: The proposed framework is robust and accurate. Therefore, it can be used to develop adaptive control systems that will be more responsive to surgeons' needs by identifying next movements of the surgeon. Copyright © 2016 John Wiley & Sons, Ltd.

Bioimpedance monitoring of cellular hydration during hemodialysis therapy.

Introduction The aim of this paper is to describe and demonstrate how a new bioimpedance analytical procedure can be used to monitor cellular hydration of End Stage Renal Disease (ESRD) patients during hemodialysis (HD). Methods A tetra-polar bioimpedance spectroscope (BIS), (UFI Inc., Morro Bay, CA), was used to measure the tissue resistance and reactance of the calf of 17 ESRD patients at 40 discrete frequencies once a minute during dialysis treatment. These measurements were then used to derive intracellular, interstitial, and intravascular compartment volume changes during dialysis. Findings The mean (± SD) extracellular resistance increased during dialysis from 92.4 ± 3.5 to 117.7 ± 5.8 Ohms. While the mean intracellular resistance decreased from 413.5 ± 11.7 to 348.5 ± 8.2 Ohms. It was calculated from these data that the mean intravascular volume fell 9.5%; interstitial volume fell 33.4%; and intracellular volume gained 20.3%. Discussion These results suggest that an extensive fluid shift into the cells may take place during HD. The present research may contribute to a better understanding of how factors that influence fluid redistribution may affect an ESRD patient during dialysis. In light of this finding, it is concluded that the rate of vascular refill is jointly determined with the rate of "cellular refill" and the transfer of fluid from the intertitial compartment into the intravascular space.

The surgeon and the child.

For many reasons pediatric surgeons have been asked to do all general and thoracic procedures in children. The profession has responded by training more, but the core of special cases requiring pediatric surgical expertise has not changed, and there is concern that the many surgeons now in training will not each do enough cases to attain and maintain operative expertise. This presentation examines the psychological, educational, and surgical literature on the development of expertise, especially operative expertise. From this I conclude that individual surgeon volume when gained in deliberate practice with a coach and with effort is essential, and that several technologies hold promise for allowing deliberate practice in simulation environments. I propose that in order to avoid a decline in pediatric surgical operative expertise we must reorganize pediatric surgical training and practice to align with Optimal Resources for Children's Surgery and the evolution of training in general surgery.