Testing and Evaluation of a Novel Hemostatic Matrix in a Swine Junctional Hemorrhage Model.

INTRODUCTION: In an ongoing effort to improve survival and reduce blood loss from hemorrhagic injuries on the battlefield, new hemostatic dressings continue to be developed. This study aimed to determine the efficacy of a novel silicon dioxide-based hemostatic matrix (HM) and compare it with the current military standard Quikclot Combat Gauze (QCG) utilizing a lethal femoral artery injury model. MATERIALS AND METHODS: The femoral arteries of 20 anesthetized swine were isolated, and an arteriotomy was performed. After a 45 s free bleed, the wound was treated with either HM or QCG (n = 10 per group). Following a 60-min observation period, ipsilateral leg manipulations and angiography were performed. Animal survival, hemostasis, blood loss, exothermic reaction, and femoral artery patency were analyzed. RESULTS: Despite a volumetric size discrepancy between the two products tested, the survival rate was similar between the two groups (80% HM, 90% QCG, n = 10, P = 0.588). Immediate hemostasis was obtained in 50% of HM animals and 40% of QCG animals. There was no difference in total blood loss recorded between the two groups (P = 0.472). Femoral artery patency rates following ipsilateral leg manipulations were similar between the two groups (50% HM, 33% QCG, P = 0.637), with no contrast extravasation in HM-treated wounds (0% HM, 33% QCG, P = 0.206). There was no significant difference in either pretreatment or posttreatment laboratory values, and there were no exothermic reactions in either group. CONCLUSIONS: The SiOxMed HM demonstrated comparable hemostatic efficacy to QCG. The tested form of HM may be appropriate for surgical or topical hemostasis applications, and with further product development, it could be used for battlefield trauma implementation.

The effect of an attending versus neutral observer on peg transfer and intracorporeal knot-tying laparoscopic tasks.

BACKGROUND: Surgery is an outcome-based specialty where maintaining peak performance is crucial to patient care. There are a variety of identified surgeon stressors that can have an impact on performance, but one factor unique to surgical residents is the observation by an attending surgeon. This study explored how the perceived authority of the observer had an impact on the participants' physiologic markers of stress and task completion times. METHODS: Eighteen general surgery residents performed the Fundamentals of Laparoscopic Surgery skills intracorporeal knot-tying and peg transfer tasks in a crossover study design while under the observation of an attending and a neutral observer. Heart rate variability, mean R-R interval, the time between R spikes on an EKG, minimum heart rate, maximum heart rate, average heart rate, and time to task completion were recorded. Analyses were completed via 2 × 2 analysis of variance with repeated measures. RESULTS: When observed by an attending, participants demonstrated higher minimum, average, and maximum heart rates (P = .046, = .007, and < .001, respectively) than when observed by a neutral observer. Attending observation also significantly shortened time to task completion, relative to neutral observation (P = .022). CONCLUSION: Attending observation is linked to increased objective measures of stress at the time of performance with decreased task completion times. Educational efforts to optimize the response to stress during learning may lead to better outcomes.

Evaluating outcomes for robotic-assisted inguinal hernia repair in males with prior urologic surgery: a propensity-matched analysis from a national database.

BACKGROUND: Controversy exists regarding the safety and effectiveness of minimally invasive inguinal hernia repairs in patients with a history of prior urologic pelvic operations (PUPO), such as a prostatectomy, which causes scarring and disruption of the retropubic tissue planes. Our study sought to examine whether a history of PUPO impacts surgical outcomes in males undergoing robotic-assisted inguinal hernia repair. METHODS: The Americas Hernia Society Quality Collaborative (AHSQC) database was queried to identify male patients who underwent a robotic inguinal hernia repair with 30-day follow-up. A sub-query was performed to identify subjects within the cohort with a documented history of PUPO. Propensity score matching was subsequently utilized to evaluate for differences in intra-operative complications and short-term post-operative outcomes. RESULTS: In total, 1664 male patients underwent robotic-assisted inguinal hernia repair, of whom 65 (3.9%) had a PUPO. After a 3:1 propensity score matching with hernia repair patients who did not have prior procedures, 195 (11.7%) males were included in the comparison cohort. There were no documented vascular, bladder, or spermatic cord injuries in either group. There was no difference in 30-day readmission rate (5% vs. 3%, respectively, p = 0.41). No hernia recurrences were recorded within the 30-day follow-up period in either group. There was no statistical difference in post-operative complications (including seroma formation, hematoma, and surgical site occurrences) between the two groups (14% vs. 8%, p = 0.18). CONCLUSIONS: In an experienced surgeon's hands, robotic-assisted minimally invasive inguinal hernia repair may be an alternative to open repair in patients with PUPO who were previously thought to be poor minimally invasive surgical candidates.

Environmental regulation in transition: Policy officials' views of regulatory instruments and their mapping to environmental risks.

This study re-analysed 14 semi-structured interviews with policy officials from the UK Department for Environment, Food and Rural Affairs (Defra) to explore the use of a variety of regulatory instruments and different levels of risk across 14 policy domains and 18 separately named risks. Interviews took place within a policy environment of a better regulation agenda and of broader regulatory reform. Of 619 (n) coded references to 5 categories of regulatory instrument, 'command and control' regulation (n = 257) and support mechanisms (n = 118) dominated the discussions, with a preference for 'command and control' cited in 8 of the policy domains. A framing analysis revealed officials' views on instrument effectiveness, including for sub-categories of the 5 key instruments. Views were mixed, though notably positive for economic instruments including taxation, fiscal instruments and information provision. An overlap analysis explored officials' mapping of public environmental risks to instrument types suited to their management. While officials frequently cite risk concepts generally within discussions, the extent of overlap for risks of specific significance was low across all risks. Only 'command and control' was mapped to risks of moderate significance in likelihood and impact severity. These results show that policy makers still prefer 'command and control' approaches when a certainty of outcome is sought and that alternative means are sought for lower risk situations. The detailed reasons for selection, including the mapping of certain instruments to specific risk characteristics, is still developing.

Alexis St. Martin Gastropexy: A Novel Technique for Gastropexy During Percutaneous Endoscopic Gastrostomy Tube Placement.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a preferred method of long-term enteral nutritional support. Despite its ease of placement, it has a 4% major complication rate, requiring surgical intervention or hospitalization. Early PEG tube dislodgment can cause peritonitis, requiring emergent laparotomy at significant morbidity and cost. T-fasteners have been used as an adjunct gastropexy, but nearly one third migrate into the abdominal wall within the first 2 weeks. We describe a low-cost, minimally invasive technique using widely available surgical instruments to appose the gastric and abdominal walls. METHODS: All PEG procedures were performed in our 60-bed surgical intensive care unit. Institutional IRB approval was obtained along with procedure specific consent for all patients. The adjunctive gastropexy procedure was performed on four patients at high risk for early PEG tube dislodgment. Following routine PEG tube placement, both ends of four 2-0 polyglactin ties were brought through the gastric and abdominal walls through separate stab incisions adjacent to the PEG tube exit site in the 3, 6, 9, and 12 o'clock positions. These were tied in the subcutaneous tissue, securing the gastric wall to the abdominal wall. RESULTS: No PEG tube complications occurred. All patients were discharged to long-term care facilities with PEG tubes intact or electively removed. CONCLUSIONS: We describe the results of a pilot study for a cost-effective, easily implementable, adjunct technique, named after the namesake of our institution, to decrease the incidence and severity of complications associated with PEG tube dislodgment. It was used in 4 patients at high risk for PEG tube dislodgment with satisfactory early results in all 4. Further recruitment of larger numbers of patients using this technique is ongoing to determine if this technique is truly effective at reducing PEG tube complications.

T1-T2 Disk Herniation Presenting With Horner Syndrome: A Case Report With Literary Review.

Horner syndrome or oculosympathetic paresis is caused by interruption of the sympathetic nerve supply to the face and eye that manifests as facial anhidrosis, blepharoptosis, and miosis. This sympathetic pathway begins in the hypothalamus and synapses in the intermediolateral gray substance of the spinal cord at C8-T2 levels making it susceptible to disruption via a high thoracic intervertebral disk herniation. We present a rare case of a patient with T1-T2 intervertebral disk herniation and Horner syndrome who was treated surgically. After confirming the diagnosis with MRI, the patient was treated with standard posterior approach with laminoforaminotomy and diskectomy. Although posterior approach surgery is most commonly used for laminectomy and/or foraminotomy, successful anterior approaches to upper thoracic lesions are valid as well. Our patient had resolution of his back pain, paresthesias, and grip weakness at 6 weeks postoperatively, but his Horner syndrome persisted at latest follow-up. Patients with cervical radiculopathy symptoms and physical examination findings consistent with Horner syndrome should be evaluated with a MRI that includes the upper thoracic spine. An accurate diagnosis and timely surgical intervention may provide the patient the best chance for regression of symptoms and a satisfactory outcome.

Monetising the impacts of waste incinerators sited on brownfield land using the hedonic pricing method.

In England and Wales planning regulations require local governments to treat waste near its source. This policy principle alongside regional self-sufficiency and the logistical advantages of minimising distances for waste treatment mean that energy from waste incinerators have been built close to, or even within urban conurbations. There is a clear policy and research need to balance the benefits of energy production from waste incinerators against the negative externalities experienced by local residents. However, the monetary costs of nuisance emissions from incinerators are not immediately apparent. This study uses the Hedonic Pricing Method to estimate the monetary value of impacts associated with three incinerators in England. Once operational, the impact of the incinerators on local house prices ranged from approximately 0.4% to 1.3% of the mean house price for the respective areas. Each of the incinerators studied had been sited on previously industrialised land to minimise overall impact. To an extent this was achieved and results support the effectiveness of spatial planning strategies to reduce the impact on residents. However, negative impacts occurred in areas further afield from the incinerator, suggesting that more can be done to minimise the impacts of incinerators. The results also suggest that in some case the incinerator increased the value of houses within a specified distance of incinerators under specific circumstances, which requires further investigation.

Better by design: business preferences for environmental regulatory reform.

We present the preferences for environmental regulatory reform expressed by 30 UK businesses and industry bodies from 5 sectors. While five strongly preferred voluntary regulation, seven expressed doubts about its effectiveness, and 18 expressed no general preference between instrument types. Voluntary approaches were valued for flexibility and lower burdens, but direct regulation offered stability and a level playing field. Respondents sought regulatory frameworks that: are coherent; balance clarity, prescription and flexibility; are enabled by positive regulatory relationships; administratively efficient; targeted according to risk magnitude and character; evidence-based and that deliver long-term market stability for regulatees. Anticipated differences in performance between types of instrument can be undermined by poor implementation. Results underline the need for policy makers and regulators to tailor an effective mix of instruments for a given sector, and to overcome analytical, institutional and political barriers to greater coherence, to better coordinate existing instruments and tackle new environmental challenges as they emerge.

Learning curve and early clinical outcomes for a robotic surgery novice performing robotic single site cholecystectomy.

BACKGROUND: A rapid training protocol has been developed for robotic surgery novices to learn robotic single-incision techniques. This study assesses the learning curve and early clinical results for a robotic surgery novice starting single-site cholecystectomy. METHODS: A chart review was performed on the surgeon's first 55 patients to undergo this procedure. RESULTS: Average patient age was 46.01 ± 4.25 (range 21-86) years and BMI was 26.57 ± 4.25 (range 19.4-36.6) kg/m(2) . The mean port placement with docking time was 11.34 ± 3.74 (range 7-23) min. Mean console time was 28.74 ± 11.04 (range 15-66) min. Average total OR time was 61.84 ± 14.66 (range 40-105) min. All procedures were successfully completed without conversion or added ports. Complications included several minor procedural gall bladder perforations and miscellaneous postoperative symptomatic complaints. CONCLUSION: Robotic single site cholecystectomy can be safely performed by a robotic novice within a minimal learning curve and have early clinical results that are comparable to the published data of robotic experts.