Liposomal versus plain bupivacaine for pain control following vaginal reconstruction.

INTRODUCTION: Liposomal bupivacaine (LB) is a depot formulation of bupivacaine, which releases the drug over 72 hours to prolong local pain control. This retrospective study compares the effect of using LB versus plain bupivacaine on postoperative pain control, length of hospital stay and cost among patients undergoing vaginal reconstructive surgery. MATERIALS AND METHODS: Patients who underwent vaginal reconstructive surgery with levatorplasty and received an injection of 20 cc of either plain bupivacaine or LB for pudendal nerve block were included. The primary outcomes included postoperative narcotic use and subjective pain score. The secondary outcome was postoperative length of stay. Comparisons between groups were performed using the T test, Mann Whitney U and Chi-square tests with p < 0.05 considered significant. RESULTS: Between June 2016 and December 2021, 25 patients had received LB as a pudendal nerve block and 25 had received plain bupivacaine. Demographics between groups were similar. There was no difference between postoperative morphine equivalent dose (MED) for plain bupivacaine versus LB (25.3 ± 65.8 vs. 24.9 ± 31.7 MED; p = 0.159) or length of hospital stay (15.8 ± 12.0 hours vs. 23.8 ± 20.0; p = 0.094). Furthermore, subjective pain was also similar between groups (0 vs. 1.6 ± 2.6, p = 0.68), (4.6 ± 2.3 vs. 4.9 ± 2.0 average POD 1 pain, p = 0.534) and (4.3 ± 2.1 for vs. 4.9 ± 2.1 average POD 2 pain, p = 0.373). CONCLUSION: LB is not superior to plain bupivacaine for controlling pain following vaginal reconstructive surgery, and justification for the exponentially greater cost of LB is not supported. Prospective investigations with larger sample sizes are needed to determine the optimal pain management for levatorplasty in vaginal reconstructive surgery.

Thulium versus holmium for in situ lower pole laser lithotripsy.

INTRODUCTION: During in situ lower pole laser lithotripsy, the dependent location may result in increased challenge fragmenting stones and a risk for stone regrowth if residual fragments remain. The purpose of this study was to compare the thulium fiber laser (TFL) with the holmium laser (HL) for in situ lower pole lithotripsy. MATERIALS AND METHODS: In a 3D printed kidney benchtop model, sixty 1 cm BegoStones were placed in the lower pole and fragmented in situ until fragments passed through a 2 x 2 mm mesh. Laser lithotripsy was performed using twelve energy, frequency and fiber size combinations and residual fragments were compared. In addition, laser fiber diameters and subsequent ureteroscope deflections and flow rates were compared between fibers. RESULTS: The TFL resulted in decreased residual fragments compared to the HL (11% vs. 17%, p < 0.001) and the three settings with least residual fragments were all TFL. Compared to the 150 µm TFL (265° deflection), there was a loss of 9° and 34° in the 200 µm TFL and 272 µm HL fibers, respectively. The measured fiber sizes were greater than manufacturer specified fiber size in every instance. Irrigation rates inversely correlated with fiber size. CONCLUSION: The TFL resulted in 35% less residual stone fragments, up to 34° additional deflection, and an increased irrigation rate when compared to the HL. Optimal fragmentation settings are identified to further improve lower pole lithotripsy. The combination of reduced residual fragments, improved deflection, and better flow rates make the TFL advantageous for in situ lower pole lithotripsy.

Quality of English inpatient mental health services for people with anxiety or depressive disorders: Findings and recommendations from the core audit of the National Clinical Audit of Anxiety and Depression.

BACKGROUND: Clinical audit is a sustained cyclical quality improvement process seeking to improve patient care and outcomes by evaluating services against explicit standards and implementing necessary changes. National audits aim to improve population-level clinical care by identifying unwarranted variations and making recommendations for clinicians, managers and service commissioners. The National Clinical Audit of Anxiety and Depression aimed to improve clinical care for people admitted to English hospitals for treatment of anxiety and depression, to provide comparative data on quality of care, and to support local quality improvement initiatives by identifying and sharing examples of best practice. PROCEDURES: Thirteen standards were developed based on NICE guidelines, literature review and feedback from a steering committee and reference group of service users and carers. All providers of NHS inpatient mental health services in England were asked to submit details of between 20 and 100 eligible service users/patients admitted between April 2017 and September 2018. To ascertain data reliability, participating services re-audited 5 sets of case-notes with a second auditor, and the coordinating team checked 10 randomly-selected sets of case-notes from 3 services, also selected at random. The reference group and steering committee identified key findings and developed a series of recommendations, which were discussed in regional quality improvement workshops and on-line webinars. FINDINGS: Data from 3795 case notes were analysed. A sizeable proportion of records indicated that at least one important aspect of initial assessment was not documented. Many service users/patients who could have benefited from an intervention targeted at optimising physical health did not receive it. Only a minority (39%) were referred for psychological therapy. Use of outcome measures varied considerably but no single outcome measure was being used routinely. Most individuals had a care plan recorded in the notes, but a review date was documented in only two-thirds, and almost half of individuals had not received a copy. CONCLUSIONS: There was considerable variation between English mental health services across many variables, and much scope for improvement. Clinicians should ensure that care plans are developed collaboratively with service users/patients and identified carers should be provided with information about support services. Health services should investigate the reasons for low referral rates for psychological therapies. Clinicians should ensure all service users have jointly developed crisis plans in place at discharge. Service managers should agree outcome measures to evaluate the treatment provided and clinicians should use these measures at initial assessment and review appointments. The implementation of such changes provides an opportunity for collaborative research into mental health service delivery and quality.

Does qSOFA score predict ICU admission and outcomes in patients with obstructed infected ureteral stones?

INTRODUCTION: Obstructing stones with infection represent a true urologic emergency requiring prompt decompression. Historically the systemic inflammatory response syndrome (SIRS) criteria has been used to predict outcomes in patients with sepsis. The quick Sequential Organ Failure Assessment (qSOFA) score has been proposed as a prognostic factor in patients with acute pyelononephritis associated with nephrolithiasis. However there has been limited application of qSOFA to patients undergoing ureteral stenting with obstructive pyelonephritis. The purpose of this study was to evaluate the predictive value of the qSOFA score for postoperative outcomes following renal decompression in this patient population. MATERIALS AND METHODS: A retrospective review was conducted at three medical centers within one academic institution to identify patients with obstructive pyelonephritis secondary to ureteral stones. All patients underwent emergent ureteral stent placement for decompression. The primary outcome was the predictive value of preoperative qSOFA score ≥ 2 for intensive care unit (ICU) admission postoperatively. Univariate analysis and multivariate regression analysis were performed to identify factors associated with postoperative outcomes, with p < 0.05 considered significant. RESULTS: Of the 289 patients who had ureteral stents placed, 147 patients met inclusion criteria. Twenty-four (16.3%) patients required ICU admission and there were 3 (2%) mortalities, all of these within the ICU admission group. The sensitivity and specificity of the qSOFA score ≥ 2 for ICU admission was 70.8% and 79.5% respectively which outperformed SIRS criteria, which had a sensitivity and specificity of 100% and 33.6% respectively. CONCLUSION: A preoperative qSOFA score ≥ 2 was a significant predictor for postoperative ICU admission in patients undergoing ureteral stent placement for obstructive pyelonephritis. The qSOFA score can be used to determine which patients will require ICU admission.

Guidewire type and prior use affects ureteral stent insertion force.

INTRODUCTION: To improve the success rate and safety of ureteral stent insertion, we sought to identify the effect of guidewire type and prior use upon the force needed to advance a 6Fr ureteral stent over various guidewires. MATERIALS AND METHODS: Two-hundred forty stent insertion trials were performed in an ex vivo porcine urinary tract model. Ten trials were randomly performed over 12 new and 12 used guidewires. For each trial, the force required to advance a 6Fr Cook double-pigtail ureteral stent was recorded. Guidewires included the Olympus Glidewire, Cook Fixed Core, and Boston Scientific Amplatz Super Stiff, Sensor, ZIPwire, and Zebra wire. RESULTS: The mean force needed for stent advancement was the lowest for the new Glidewire (0.18N) and ZIPwire (0.22N), with no significant difference to each other (p = 0.90). The following new wires required increasingly higher stent insertion forces compared to the Glidewire, the Zebra (0.60N; p < 0.01), Fixed Core (1.25N; p < 0.01), Sensor (1.43N; p < 0.01), and Amplatz Super Stiff wires (2.03N; p < 0.01). There was no statistical difference between new and used Glidewires (0.18N versus 0.29N; p = 0.14) and Zebra wires (0.59N versus 0.60N; p = 0.88). All other used wires required a significantly greater advancement force than their new counterparts (p < 0.01). CONCLUSIONS: For the same stent, the force required for stent advancement varies greatly between guidewire types. In addition, used guidewires typically required more force compared to new guidewires. In long or difficult cases, switching to a new wire may improve the ease of stent placement and reduce potential complications.

A systematic review of specialist inpatient dementia care services versus standard inpatient dementia care in acute hospitals.

BACKGROUND: Specialist inpatient dementia units (SIDU) have been developed to address adverse outcomes often experienced by people living with dementia admitted to acute hospitals. However, the evidence base of their effectiveness remains limited. AIM: To review the current literature to establish the comparative effectiveness of acute hospital SIDU vs. standard ward care (SWC). METHODS: We did an online search of 12 biomedical databases from inception to 31st October 2017. Studies of inpatients with any form of dementia in acute hospitals, published in English language peer-reviewed journals, using experimental, observational or qualitative study designs, comparing SIDU with SWC and which measured any qualitative or quantitative outcome of the patient or carer experience were included in the search criteria. We used a standardised data extraction and appraisal form. RESULTS: Three of 46 full-text studies evaluated were suitable for analysis. Due to study heterogeneity, pooled odds ratios were only possible for mortality [OR 1.06 (CI 1.0-1.4)]. Otherwise, a narrative synthesis was performed. Although quantitative measures of length of stay, mortality and behavioural and psychiatric symptoms of dementia are not significantly lower, SIDU are associated with greater patient and carer satisfaction, reduced readmission rates, more accurate and comprehensive assessment processes, documentation of resuscitation decisions, and increased rates of discharge to the patient's own home. CONCLUSIONS: Although SIDU may be associated with improved care outcomes, the current evidence of their effectiveness is markedly limited. Further research and service evaluation of SIDU as a method for providing high-quality dementia care in acute NHS Trusts is needed. PROSPERO: CRD42017078364.

Elevated Renal Pelvic Pressures during Percutaneous Nephrolithotomy Risk Higher Postoperative Pain and Longer Hospital Stay.

PURPOSE: Renal pelvic pressure may vary during percutaneous nephrolithotomy. We sought to determine the relationship of postoperative pain to endoscope caliber, renal pelvic pressure and hospital stay. MATERIALS AND METHODS: We reviewed the records of 20 percutaneous nephrolithotomies done under ureteroscopic guidance with renal pelvic pressure monitoring. The ureteroscope working channel was connected to a pressure transducer and used to determine renal pelvic pressure at baseline, when irrigating with a 26Fr rigid nephroscope and a 16Fr flexible nephroscope, and during suction. Patient demographics, operative characteristics, Likert pain scores and length of hospital stay were compared as stratified by average renal pelvic pressure. The Mann-Whitney U and Fisher exact tests were used with p <0.05 considered significant. RESULTS: A total of 220 measurements were recorded in 20 patients undergoing single access percutaneous nephrolithotomy. Mean patient age was 55.2 years (range 20 to 77) and mean body mass index was 32.4 kg/m2 (range 18 to 53.3). Rigid nephroscopy resulted in significantly higher average renal pelvic pressure than flexible nephroscopy (30.3 vs 12.9 mm Hg, p = 0.007). Average renal pelvic pressure was 30 mm Hg or greater in 7 patients (35%) undergoing rigid nephroscopy and in none (0%) undergoing flexible nephroscopy (p <0.01). Patients exposed to an average renal pelvic pressure of 30 mm Hg or greater during rigid nephroscopy had significantly higher average pain scores (p = 0.004) and longer hospital stays (p = 0.04) than patients with renal pelvic pressure less than 30 mm Hg. Average renal pelvic pressure 30 mm Hg or greater during rigid nephroscopy was also associated with a longer skin to calyx distance (105.5 vs 79.7 mm, p = 0.03). CONCLUSIONS: Knowledge of the factors that influence renal pelvic pressure and methods to control pressure extremes may improve patient outcomes during percutaneous nephrolithotomy.

Predictors of narcotic use after percutaneous nephrolithotomy.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is associated with significant variability in postoperative pain and subsequent narcotic use. The purpose of this study was to determine the factors associated with high narcotic use following PCNL. MATERIALS AND METHODS: A single-center retrospective review of patients undergoing initial PCNL between 2004 and 2014 was performed. Preoperative, intraoperative and postoperative factors associated with postoperative narcotic usage were analyzed. The primary outcome variable was mean narcotic usage, standardized to intravenous morphine-equivalents. Patients in the lowest 75th percentile were compared to those in the highest 25th percentile. Univariate and multivariate statistical analyses were performed, with p < 0.05 considered significant. RESULTS: When the 243 patients were compared from lowest to highest quartile, total narcotic use during the first 48 hour period was 2.3, 8.4, 15.6, and 41.7 mg of morphine-equivalents. On univariate analysis, predictors of high narcotic use included age 20-39 (p < 0.001), preoperative narcotic use (p < 0.001), presence of a postoperative complication (p = 0.044), and high stone burden (p = 0.002). Age < 20 (p < 0.001) and > 60 years (p = 0.014) were associated with low narcotic use. On multivariate analysis, age 20-39 (OR 6.87, 95% CI 2.22-21.23, p = 0.001), male gender (OR 2.47, CI 1.05-5.81, p = 0.037), and preoperative narcotic use (OR 3.27, CI 1.41-7.60, p = 0.006) were associated with higher opioid requirement. CONCLUSION: Patients who were aged 20-39, males, and those with prior narcotic exposure used the highest doses of narcotics postoperatively. Knowledge of the factors predictive of high narcotic usage may allow better preoperative management of patient expectations and more effective postoperative care to prevent the complications of high narcotic usage.

Profile of metabolic and infectious stone-formers in a contemporary PCNL cohort.

INTRODUCTION: To identify factors associated with stone composition in patients undergoing percutaneous nephrolithotomy (PCNL). MATERIAL AND METHODS: A retrospective analysis of patients who underwent PCNL at two academic institutions between 2002 and 2014. Stone composition, stone characteristics based on non-contrast computer tomography (NCCT), patient demographics, and the S.T.O.N.E nephrolithometry scores were compared. Stones were characterized as either infection or metabolic. Metabolic stones were classified as calcium phosphate-containing and all others. RESULTS: A total of 192 renal units underwent PCNL. Retrieved stones were found to be 75% (144) metabolic and 25% (48) infection by stone analysis. Of the metabolic stones, 51% (73) were phosphate-containing calculi. Overall, infection stones were found to have a significantly higher S.T.O.N.E nephrolithometry score than metabolic stones (9.2 versus 8.1, p < 0.001). Average Hounsfield units (HU) were significantly lower in infection stones (765 versus 899, p < 0.05). Sixty-three percent of patients with infection stones were female as compared to 46% of patients with metabolic stones. Patients with phosphate-containing stones in the metabolic group were significantly more likely to be female (56% versus 35%, p < 0.01), younger (mean 49 versus 60 years of age, p < 0.02), and have lower BMI's (30 versus 32, p < 0.02) compared with other metabolic stones. CONCLUSIONS: Patient demographics including age, sex and BMI differ between patients with phosphate and non-phosphate containing metabolic stones. Higher S.T.O.N.E nephrolithometry scores were found in infection stones. These findings may serve as useful tools in the identification of stone compositions that are being seen more frequently in large and complicated stones undergoing PCNL.

Pulmonary nodules and CT screening: the past, present and future.

Lung cancer screening has come a long way since the early studies with chest X-ray. Advancing technology and progress in the processing of images have enabled low dose CT to be tried and tested, and evidence suggests its use can result in a significant mortality benefit. There are several issues that need refining in order to successfully implement screening in the UK and elsewhere. Some countries have started patchy implementation of screening and there is increased recognition that the appropriate management of pulmonary nodules is crucial to optimise benefits of early detection, while reducing harm caused by inappropriate medical intervention. This review summarises and differentiates the many recent guidelines on pulmonary nodule management, discusses screening activity in other countries and exposes the present barriers to implementation in the UK.

UK Lung Cancer RCT Pilot Screening Trial: baseline findings from the screening arm provide evidence for the potential implementation of lung cancer screening.

BACKGROUND: Lung cancer screening using low-dose CT (LDCT) was shown to reduce lung cancer mortality by 20% in the National Lung Screening Trial. METHODS: The pilot UK Lung Cancer Screening (UKLS) is a randomised controlled trial of LDCT screening for lung cancer versus usual care. A population-based questionnaire was used to identify high-risk individuals. CT screen-detected nodules were managed by a pre-specified protocol. Cost effectiveness was modelled with reference to the National Lung Cancer Screening Trial mortality reduction. RESULTS: 247 354 individuals aged 50-75 years were approached; 30.7% expressed an interest, 8729 (11.5%) were eligible and 4055 were randomised, 2028 into the CT arm (1994 underwent a CT). Forty-two participants (2.1%) had confirmed lung cancer, 34 (1.7%) at baseline and 8 (0.4%) at the 12-month scan. 28/42 (66.7%) had stage I disease, 36/42 (85.7%) had stage I or II disease. 35/42 (83.3%) had surgical resection. 536 subjects had nodules greater than 50 mm(3) or 5 mm diameter and 41/536 were found to have lung cancer. One further cancer was detected by follow-up of nodules between 15 and 50 mm(3) at 12 months. The baseline estimate for the incremental cost-effectiveness ratio of once-only CT screening, under the UKLS protocol, was £8466 per quality adjusted life year gained (CI £5542 to £12 569). CONCLUSIONS: The UKLS pilot trial demonstrated that it is possible to detect lung cancer at an early stage and deliver potentially curative treatment in over 80% of cases. Health economic analysis suggests that the intervention would be cost effective-this needs to be confirmed using data on observed lung cancer mortality reduction. TRIAL REGISTRATION: ISRCTN 78513845.

Renal Vascular Clamp Placement: A Potential Cause of Incomplete Hilar Control during Partial Nephrectomy.

PURPOSE: Previous benchtop studies have shown that robotic bulldog clamps provide incomplete vascular control of a Penrose drain. We determined the efficacy of robotic and laparoscopic bulldog clamps to ensure hemostasis on the human renal artery. The effect of clamp position on vascular control was also examined. MATERIALS AND METHODS: Fresh human cadaveric renal arteries were used to determine the leak point pressure of 7 bulldog clamps from a total of 3 manufacturers. Five trials were performed per clamp at 4 locations, including the fulcrum, proximal, middle and distal positions. Comparison was done using the Kruskal-Wallis test with p <0.05 considered significant. RESULTS: None of the bulldog clamps leaked at a pressure less than 215 mm Hg when applied at the proximal, middle or distal position. In general leak point pressure decreased as the artery was positioned more distal along the clamp. The exception was when the vessel was placed at the fulcrum position. At that position 80% to 100% of trials with the Klein laparoscopic, 100% with the Klein robotic (Klein Robotic, San Antonio, Texas) and 60% to 80% with the Scanlan robotic (Scanlan International, Saint Paul, Minnesota) clamp leaked at pressure below 215 mm Hg. CONCLUSIONS: Each vascular clamp adequately occluded flow at physiological pressure when placed at the proximal, middle or distal position. Furthermore, these results demonstrate that there is leakage at physiological pressure when the artery is placed at the fulcrum of certain clamp types. These results suggest that applying a bulldog clamp at the fulcrum could potentially lead to inadequate vessel occlusion and intraoperative bleeding.

Direct Endoscopic Visualization Combined with Ultrasound Guided Access during Percutaneous Nephrolithotomy: A Feasibility Study and Comparison to a Conventional Cohort.

PURPOSE: Percutaneous nephrolithotomy access may be technically challenging and result in significant radiation exposure. In an attempt to reduce percutaneous nephrolithotomy radiation exposure, a novel technique combining ultrasound and direct ureteroscopic visualization was developed and reviewed. MATERIALS AND METHODS: Ureteroscopy without fluoroscopy was used to determine the optimal calyx for access, which was punctured with a Chiba needle under percutaneous ultrasound guidance. Next a wire was passed into the collecting system and ureteroscopically pulled into the ureter using a basket. Tract dilation and sheath and nephrostomy tube placement were performed under direct ureteroscopic visualization. Twenty consecutive patients undergoing this novel technique were reviewed and compared to 20 matched patients treated with conventional percutaneous nephrolithotomy. Mann-Whitney U and Pearson chi-square tests were used for comparisons with p <0.05 considered significant. RESULTS: Using this novel technique mean fluoroscopy access time was 3.5 seconds (range 0 to 27.9) and mean total fluoroscopic time was 8.8 seconds (range 0 to 47.1). Mean operative time was 232 minutes (range 87 to 533), estimated blood loss was 111 ml, the stone-free rate was 65% and the complication rate was 25%. Compared to 20 matched conventional percutaneous nephrolithotomy cases, there was no difference in operative time (p=0.76), estimated blood loss (p=0.64), stone-free rate (p=0.50) or complications (p=1.00). However, the novel technique resulted in a significant reduction in fluoroscopy access time (3.5 vs 915.5 seconds, p <0.001) and total fluoroscopy time (8.8 vs 1,028.7 seconds, p <0.001). CONCLUSIONS: This study demonstrates the feasibility of combined ultrasound and ureteroscopic assisted access for percutaneous nephrolithotomy. A greater than 99% reduction in fluoroscopy time was achieved using this technique.

Techniques for Minimizing Radiation Exposure During Evaluation, Surgical Treatment, and Follow-up of Urinary Lithiasis.

Patients receive significant radiation exposure during the diagnosis, treatment, and follow-up of urinary stone disease. This radiation exposure may result in patient harm and is believed to contribute to the risk for malignancy. This review will present current information to allow surgeons to optimize their diagnostic, treatment, and follow-up regimens to allow optimal care of stone disease patients at the lowest radiation dose possible.

Treatment decisions and survival for people with small-cell lung cancer.

BACKGROUND: Chemotherapy improves survival for many patients with SCLC, and hence it is important to understand variations in practice and outcomes for this treatment strategy. METHODS: We used the National Lung Cancer Audit and Hospital Episodes Statistics to determine the proportion of patients who received chemotherapy for SCLC, and assess the effects of patient and organisational factors on the odds of receiving chemotherapy and of completing four cycles. We calculated median survival and used Cox regression to determine factors that predicted survival. RESULTS: Of 15 091 cases of SCLC, 70% received at least one cycle of chemotherapy. More deprived people were less likely to receive chemotherapy, but patients were more likely to receive chemotherapy, and to complete ≥ four cycles, if they were referred to the lung cancer team by their GP. Median survival for those treated with chemotherapy was 12.9 months for limited and 7.3 months for extensive stage disease. CONCLUSIONS: The Linked NLCA and HES data provide real-life measures of survival in people treated with chemotherapy and show how this is influenced by patient and tumour characteristics. These data show the characteristics of patients who are less likely to complete a full course of treatment, an adverse predictor of survival.

Does Blacklight Illumination Improve Speed and Accuracy of Foot Pedal Activation in the Low-Light Operating Room?

Background: Urologists frequently activate foot pedals in a low-light operating room (OR). Pedal activation in low-light conditions poses the potential for incorrect pedal activation, potentially leading to increased radiation exposure, patient burns, or OR fires. This study compares speed, accuracy, dark adaptation, and surgeon preference for pedal activation in 4 lighting conditions. Materials and Methods: During a simulated percutaneous nephrolithotomy (PCNL), pedals for C-arm, laser, and ultrasonic lithotripter (USL) were randomized to 3 different positions. Urology attendings, residents, and medical students activated pedals in a randomized order in 4 settings: a dark OR with no illumination, an OR with overhead illumination, a dark OR with glowstick illumination, and a dark OR with blacklight illumination. Endpoints included pedal activation time; number of attempted, incomplete, and incorrect activations; dark adaptation; and subjective pedal preference. ANOVA was used for analysis with p < 0.05 considered significant. Results: In our study with 20 participants, the mean pedal activation times were significantly faster when using glowstick illumination (6.77 seconds) and blacklight illumination (5.34 seconds) compared with the no illumination arm (8.47 seconds, p < 0.001). Additionally, individual pedal activations for the C-arm, laser, and USL were significantly faster with glowstick and blacklight illumination compared with a dark OR (p < 0.001 for all). The blacklight illumination arm demonstrated decreased attempted (0.30 vs. 3.45, p < 0.001), incomplete (1.25 vs. 7.75, p < 0.001), and incorrect activations (0.35 vs. 1.25, p < 0.001) compared with the dark setting, while demonstrating no difference compared with having room lights on. Dark adaptation was significantly improved with blacklight illumination compared with having the room lights on (134.5 vs. 140.5 luminance, p < 0.001). All participants (100%) preferred illuminated pedals compared with the dark OR, with 90% favoring the blacklight illumination. Conclusions: During a simulated PCNL, blacklight illumination significantly improved accuracy and efficiency of pedal activation compared with the conventional dark OR, while maintaining the surgeon's dark adaptation.

Is Bigger Better? Comparison of 150 µm and 200 µm Thulium Fiber for In Situ Lower-Pole Lithotripsy.

Introduction: The thulium fiber laser (TFL) generates a focused beam, which can be transmitted to laser fibers with small core diameters and may facilitate in situ lower-pole lithotripsy. This study compares lithotripsy performance of the 150 and 200 µm TFL in a lower pole benchtop kidney model. Materials and Methods: Using a 3D model printed from an actual kidney, in situ laser lithotripsy was performed on 1 cm lower-pole BegoStones (calcium oxalate monohydrate consistency) using four different settings (all 20W) and two fiber sizes (150 and 200 µm). Procedure time, laser time, total pulse energy, and fiber stripping were compared between the two fibers using an ANOVA or independent t-test. Results: The 150 µm fiber at 0.2 J × 100 Hz had the shortest lasing and procedure time (17.3 and 18.5 minutes) and lowest total pulse energy (20.75 kJ) compared with other study arms (p < 0.001). Overall procedure time, lasing time, and total pulse energy were significantly different between the 8 settings (p < 0.001 for all). At higher frequency (100 and 200 Hz), lasing time was significantly faster compared with 20 and 50 Hz (19.9 vs 27.3 minutes; p < 0.001). Furthermore, the average total procedure time was shorter with 150 µm compared with 200 µm regardless of settings (23.2 vs 29.8 minutes; p < 0.001). Conclusion: The 150 µm fiber results in shorter procedure and lasing time at lower total energy levels during lower-pole in situ lithotripsy. Overall, the fastest setting was 0.2 J and 100 Hz with the 150 µm fiber. Smaller laser fibers can potentially allow more efficient in situ laser lithotripsy with better irrigation and visibility at higher deflection angles.

Effects of mindfulness-based interventions on symptoms and interoception in trauma-related disorders and exposure to traumatic events: Systematic review and meta-analysis.

Interoception is defined as the sense of the internal state of the body. Dysfunctions in interoception are found in several mental disorders, including trauma-related conditions. Mindfulness-Based Interventions (MBIs) have been shown to influence interoceptive processes. Randomised controlled trials (RCTs) have investigated whether MBIs impact symptoms and interoception in patients with trauma-related disorders. We undertook a systematic review and meta-analysis to synthesize these data. We included RCTs with an MBI arm which enrolled adult patients with trauma related-disorders or exposure to a traumatic experience, and addressed changes in interoception and trauma-related symptoms. A random-effects multivariate meta-analytic model was performed to quantify group differences in score change from baseline to follow-up. Twelve studies were included in the systematic review, and eleven in the meta-analysis. Overall, MBIs showed small to moderate positive effects on both interoception and symptoms. Despite a high heterogeneity in results, sensitivity analyses confirmed the robustness of the findings. We conclude that the efficacy of MBIs on trauma-related symptoms and interoception is supported by randomised evidence. However, further research is needed to understand whether changes in interoception might underpin the effectiveness of MBIs in trauma-related disorders.

Do Flat Panel Detector C-Arms Decrease Radiation Exposure Compared to Conventional Image Intensifiers?

OBJECTIVE: To compare the radiation dose and image quality between flat panel detector (FPD) and traditional image intensifier (II) C-arms at their lowest radiation settings. METHODS: In a ureteroscopy simulation using a cadaver model, the radiation exposure was compared between FPD and II at 4 pulses-per-second (pps) using both low dose and automatic exposure control (AEC) settings. Additionally, the lowest dose settings for each machine were compared (4 pps with low dose in the FPD and 1 pps with low dose in the II). Five trials of 5 minutes were conducted for each setting. Four new optically stimulated luminescent dosimeters were used in each trial to record radiation exposure. Ten blinded urologists completed a survey rating image quality for each setting. RESULTS: When comparing the FPD and II at their lowest possible settings, the FPD produced significantly more radiation (P <.05). Using both machines at 4 pps in low dose mode resulted in no significant difference between C-arms (P >.05). Conversely, operating the C-arms at 4 pps and AEC resulted in significantly higher radiation exposure from the FPD compared to the II (P <.05). There was no significant difference in image quality at each setting. CONCLUSION: FPDs produce significantly more radiation at the lowest settings compared to IIs. Surgeons should employ IIs when reducing radiation exposure as low as possible is imperative, such as when operating on pediatric and pregnant patients.