Constrained numerical deconvolution using orthogonal polynomials.

In this article, we present an enhanced version of Cutler's deconvolution method to address the limitations of the original algorithm in estimating realistic input and output parameters. Cutler's method, based on orthogonal polynomials, suffers from unconstrained solutions, leading to the lack of realism in the deconvolved signals in some applications. Our proposed approach incorporates constraints using a ridge factor and Lagrangian multipliers in an iterative fashion, maintaining Cutler's iterative projection-based nature. This extension avoids the need for external optimization solvers, making it particularly suitable for applications requiring constraints on inputs and outputs. We demonstrate the effectiveness of the proposed method through two practical applications: the estimation of COVID-19 curves and the study of mavoglurant, an experimental drug. Our results show that the extended method presents a sum of squared residuals in the same order of magnitude of that of the original Cutler's method and other widely known unconstrained deconvolution techniques, but obtains instead physically plausible solutions, correcting the errors introduced by the alternative methods considered, as illustrated in our case studies.

[Patient simulation for hand therapy in an anesthesiologist after an occupational injury: A case study]. / Simulación clínica para la rehabilitación de la mano en un anestesiólogo después de una lesión ocupacional: un estudio de caso.

We described the use of clinical simulation for hand therapy in an anesthesiologist that accidentally suffered from entrapment with the surgical table in the right thumb and underwent a partial toe-to-hand autograft. At week 14 after surgery, the patient practiced anesthetic tasks and clinical scenarios using a patient simulator instead undergoing a regular occupational therapy regimen. Quantifiable physical, functional and psychological measures improved during and after the simulation intervention, and there was no decline one month after the patient returned to work. The use of clinical simulation as part of the rehabilitation process of an anesthesiologist after hand injury contributed to improving the range of motion, strength, sensibility, and functional tests. Overall, it played an important role in determining the worker's potential to withstand the demands of anesthesia practice.

[Bringing clinical simulation into anesthesiology and postoperative recovery care residency training]. / Integración de la simulación clínica en el programa formativo de la especialidad de anestesiología y reanimación.

This article describes the use of clinical simulations for training residents in anesthesiology and postoperative recovery care at Hospital Universitario Marqués de Valdecilla. A working group defined criteria for the competencies residents would acquire by means of simulation training, designed the scenarios to be used, and took responsibility for coordinating and funding the program. We used the platform of the Critical Events Training Center of the Marcelino Botin Foundation, now part of our center's virtual hospital. The simulation-based training modules include 4 activities in the residents' first year, 3 in each of the second and third years, and 4 in the fourth year; all center on acquisition of the identified competencies and take into consideration the time availability of residents and instructors and the budget. We have concluded that integrating clinical simulations into residency training is a challenge for educators, given that a large part of the benefit derived from this tool comes from complementing it with other instructional resources and adapting it to the syllabus. More studies are required to establish criteria to guide the integration of this tool into the curriculum in those areas of the specialty where it can work most efficiently; the effectiveness of the approach also needs to be assessed. Simulations facilitate training without putting patients at risk and provide residents with early exposure to situations that might otherwise be difficult to observe. This tool also encourages the practice of reflective clinical decision-making.

Role of 3D printing for the protection of surgical and critical care professionals in the COVID-19 pandemic. / Papel de la impresión 3D para la protección de los profesionales del área quirúrgica y críticos en la pandemia de COVID-19.

BACKGROUND AND OBJECTIVE: There is a shortage of supplies for the protection of professionals during the COVID-19 pandemic. 3D printing offers the possibility to compensate for the production of some of the equipment needed. The objective is to describe the role of 3D printing in a health service during the COVID-19 pandemic, with an emphasis on the process to develop a final product ready to be implemented in the clinical environment. METHODS: A working group was formed between the healthcare administration, clinicians and other public and private institutions in Cantabria, Spain coordinated by the Valdecilla Virtual Hospital. The process included receiving the printing proposals, learning about the printing resources in the region, selecting the devices, creating a team for each project, prototyping, evaluation and redesign, manufacturing, assembly and distribution. RESULTS: The following supplies are produced: 1) devices that help protect providers: face protection screens (2,400 units), personalized accessories for photophores (20 units) and ear-protection forks for face-masks (1,200 units); 2) products related to the ventilation of infected patients: connectors for non-invasive ventilation systems; and 3) oral and nasopharyngeal swabs (7,500 units) for the identification of coronavirus carriers with the aim of designing action protocols in clinical areas. CONCLUSIONS: 3D printing is a valid resource for the production of protective material for professionals whose supply is reduced during a pandemic.

[Simulation as a tool to facilitate change in healthcare organisations]. / La simulación como herramienta para facilitar el cambio en las organizaciones sanitarias.

OBJECTIVE: To describe the use of simulation as a tool to support the strategic management of change in the Cantabrian Regional Health Service in Spain. METHODS: A working group was created to: 1) define the strategic areas of innovation and change; 2) establish criteria for the selection of proposals that can be addressed with simulation; 3) analyse and select the proposals; 4) design and implement the simulation programs, and 5) evaluate results. RESULTS: The constantly changing needs of the regional health system enabled 6 strategic areas to be identified during 2017-208: 1) efficient use of resources; 2) implementation of health plans of interest in the community; 3) patient safety improvement; 4) management of health personnel; 5) development of new professional skills, and 6) selection and implementation of new technology. CONCLUSIONS: Clinical simulation is a useful tool to promote innovation strategies in healthcare, facilitating the adaptation of professionals and patients to change.

Emotional response to a high-fidelity trauma simulation: An observational study. / Respuesta emocional a una simulación de alta fidelidad en trauma: Un estudio observacional.

INTRODUCTION: The emotional environment created during a simulation session can influence learning. Positive emotions improve perceptual processing and facilitate learning, while negative emotions can reduce working memory, resulting in poorer learning outcomes. OBJECTIVES: The aim of this study was to investigate the impact of simulation training on emotions during all phases of a high-fidelity simulation using standard prebriefing and «good judgement debriefing ¼ techniques. METHODS: This was an observational study that included 74 anesthesiologists participating in a simulation-based training. A standardized prebriefing was followed by «good judgement debriefing¼. In order to assess emotions, we used the circumplex model of emotion, and asked participants to complete the affect grid scale before prebriefing (Stage 1), before starting the simulation (Stage 2), before debriefing (Stage 3) and following debriefing (Stage 4). RESULTS: The affect grid scores obtained from 67 participants were analyzed. Following debriefing, the experience of the polytrauma patient simulation was significantly more pleasant compared to previous stages (P<0.01). In addition, participants perceived the activity as becoming increasingly active as it progressed (P<0.01). CONCLUSIONS: High-fidelity trauma simulation creating a safe environment using a standardized prebriefing and «good judgement debriefing¼ is experienced as a pleasant and active activity at all stages of the simulation. Further investigation is needed to assess the impact of these results on learning.

Learning outcomes evaluation of a simulation-based introductory course to anaesthesia. / Evaluación de los resultados de aprendizaje de un curso de introducción a la anestesiología basado en simulación clínica.

OBJECTIVE: An increased number of errors and reduced patient safety have been reported during the incorporation of residents, as this period involves learning new skills. The objectives were to evaluate the learning outcomes of an immersive simulation boot-camp for incoming residents before starting the clinical rotations. Airway assessment, airway control with direct laryngoscopy, and epidural catheterization competencies were evaluated. MATERIAL AND METHOD: Twelve first-year anaesthesiology residents participated. A prospective study to evaluate transfer of endotracheal intubation skills learned at the simulation centre to clinical practice (primary outcome) was conducted. A checklist of 28 skills and behaviours was used to assess the first supervised intubation performed during anaesthesia induction in ASA I/II patients. Secondary outcome was self-efficacy to perform epidural catheterization. A satisfaction survey was also performed. RESULTS: Seventy-five percent of residents completed more than 21 out of 28 skills and behaviours to assess and control the airway during their first intubation in patients. Twelve items were performed by all residents and 5 by half of them. More than 83% of participants reported a high level of self-efficacy in placing an epidural catheter. All participants would recommend the course to their colleagues. CONCLUSIONS: A focused intensive simulation-based boot-camp addressing key competencies required to begin anaesthesia residency was well received, and led to transfer of airway management skills learned to clinical settings when performing for first time on patients, and to increased self-reported efficacy in performing epidural catheterization.

[Innovation in healthcare processes and patient safety using clinical simulation]. / Innovando en procesos asistenciales y seguridad del paciente mediante simulación clínica.

OBJECTIVE: Many excellent ideas are never implemented or generalised by healthcare organisations. There are two related paradigms: thinking that individuals primarily change through accumulating knowledge, and believing that the dissemination of that knowledge within the organisation is the key element to facilitate change. As an alternative, a description and evaluation of a simulation-based inter-professional team training program conducted in a Regional Health Service to promote and facilitate change is presented. MATERIAL AND METHODS: The Department of Continuing Education completed the needs assessment using the proposals presented by clinical units and management. Skills and behaviors that could be learned using simulation were selected, and all personnel from the units participating were included. Experiential learning principles based on clinical simulation and debriefing, were used for the instructional design. The Kirkpatrick model was used to evaluate the program. RESULTS: Objectives included: a) decision-making and teamwork skills training in high prevalence diseases with a high rate of preventable complications; b) care processes reorganisation to improve efficiency, while maintaining patient safety; and, c) implementation of new complex techniques with a long learning curve, and high preventable complications rate. Thirty clinical units organised 39 training programs in the 3 public hospitals, and primary care of the Regional Health Service during 2013-2014. Over 1,559 healthcare professionals participated, including nursing assistants, nurses and physicians. CONCLUSION: Simulation in healthcare to train inter-professional teams can promote and facilitate change in patient care, and organisational re-engineering.

Stock management in hospital pharmacy using chance-constrained model predictive control.

One of the most important problems in the pharmacy department of a hospital is stock management. The clinical need for drugs must be satisfied with limited work labor while minimizing the use of economic resources. The complexity of the problem resides in the random nature of the drug demand and the multiple constraints that must be taken into account in every decision. In this article, chance-constrained model predictive control is proposed to deal with this problem. The flexibility of model predictive control allows taking into account explicitly the different objectives and constraints involved in the problem while the use of chance constraints provides a trade-off between conservativeness and efficiency. The solution proposed is assessed to study its implementation in two Spanish hospitals.

Enhancement of opiate analgesia by nimodipine in cancer patients chronically treated with morphine: a preliminary report.

The ability of nimodipine, a calcium-channel blocker, to enhance morphine analgesia and/or modify the development of tolerance was studied in patients with cancer pain who had needed successive increments of morphine for periods ranging from 21 to 780 days. Assessment of daily morphine consumption was the primary effect parameter. Nimodipine succeeded in reducing the daily dose of morphine in 16 of 23 patients (oral, n = 13; intrathecal, n = 3), and failed to modify it in 2 patients. Total oral daily dose was reduced by nimodipine (120 mg/day) from 282.6 +/- 47.7 mg to 158.7 +/- 26.2 mg (n = 15, P < 0.001). Intrathecal morphine was also reduced by 1-5 mg/day. Nimodipine was withdrawn in 5 patients during the first week of treatment due to intolerance (n = 3) or aggravation of the disease (n = 2). These preliminary results support experimental findings showing that pharmacological interference with Ca(2+)-related events may modify chronic opioid effects, including the expression of tolerance.

Could the piggyback operation in liver transplantation be routinely used?

OBJECTIVE: To determine if orthotopic liver transplantation with inferior vena cava preservation, performed without using caval cross clamping or venovenous bypass, can minimize hemodynamic instability and low renal perfusion pressure. DESIGN: A prospective case series of 44 consecutive adult orthotopic liver transplantations, with a maximum follow-up of 30 months. SETTING: An institutional university referral center. PATIENTS: Between November 1990 and May 1993, 39 consecutive adult liver transplant recipients underwent transplantation with the following primary diagnoses: alcoholic cirrhosis (n = 23), viral cirrhosis (n = 9), primary biliary cirrhosis (n = 2), Wilson's disease (n = 2), primary sclerosing cholangitis (n = 1), fulminant hepatic failure (n = 1), and secondary hepatic malignant neoplasm (n = 1); five had repeated orthotopic liver transplantation. INTERVENTION: Orthotopic liver transplantations were performed using the piggyback technique, but with placement of the vascular clamp on the inferior vena cava laterally instead of across it so that it remained patent throughout the anhepatic stage. Favorable anatomic conditions in the recipients were not considered; venovenous bypass was not used. MAIN OUTCOME MEASURES: Intraoperative hemodynamic profile, blood loss and replacement, surgical time and complications, and patient survival. RESULTS: No significant hemodynamic changes with lateral clamping and no increases in surgical complications, rate of retransplantation, blood product requirements, or survival rate compared with the standard procedure. CONCLUSION: The piggyback operation could be routinely used in orthotopic liver transplantation.

[Heart rupture following thoracic blunt trauma]. / Rotura cardíaca tras traumatismo torácico cerrado.

We describe a 39-year-old woman who suffered rupture of the left auricula as a result of a non-penetrating chest wound received in a traffic accident. Rupture of the heart chambers after trauma is not infrequent, but survival is extremely rare. The patient was released from care and has suffered no subsequent complications.

[Endoscopic anterior commissurotomy (EAC) versus TUR as the treatment for the neck obstruction syndrome. Our experience. The results]. / La comisurotomía anterior endoscópica (CAE) versus RTU como tratamiento del síndrome obstructivo cervical. Experiencia. Resultados.

OBJECTIVE: 30 patients were included over a 5-year period in a protocol divided into two uniform cohorts (age, surgical risk, prostatic volume, etc.). Both groups are compared based on morphological effectiveness, functionality, quality of life parameters, etc. Also a comparison on the efficacy of anterior commissurotomy vs. conventional TUR is carried out. METHOD: After 12 hours, a cohort of 15 patients had a Collins' loop section of the vesical neck anterior aspect, a technique described by Keitzer (1969). RESULTS: Results were optimal and superior to those obtained with TUR. We conclude this technique is effective, and emphasize the validity of the concepts described by Gil Vernet in 1956.

[Usefulness of posterior capsulectomy in the treatment of bladder neck disease]. / Utilidad de la capsulectomía posterior como tratamiento de la enfermedad de cuello vesical.

RATIONALE: Presentation of 12-year experience accrued in the surgical treatment of the acquired bladder neck disease. Based on Riches' experience (1961), posterior capsulotomy, although exceptional in terms of indication, was effective in the treatment of 26 patients with early failure of standard endoscopic techniques. MATERIALS AND METHOD: Over a 12-year period, 945 prostatectomies were entered in a protocol, 305 (32.2%) open surgery and 640 (67.8%) transurethral resections. Incidence of sclerosis was 5.03% (48 patients). Treatment of second group with TUR and/or cervicotomy failed in 26 (45-58%) patients. Posterior capsulotomy was effective in 100% patients. RESULTS: Mean follow-up has been productive, and exceeds 4 years based on clinical, radiologic, endoscopic and urodynamic parameters.

[Bilateral synchronous renal cell carcinoma. Report of a case]. / Carcinoma de células renales bilateral sincrónico. Presentación de un caso.

The radical nephrectomy is considered to be the optional treatment for renal carcinoma. In the last years, the good results with partial resection shows conservadora surgery the most suitable treatment for well-localized bilateral renal tumours. In this cases dialysis is avoided, and the subsequent risk of immunological deficit and the higher possibility of metastasic illness are minimized. Nowadays, however, there seems to be some controversy over conservative surgery, concerning applications and technique of surgery to practice (partial resection vs. enucleation). We have a case of bilateral synchronic renal cell carcinoma where radical surgery on the left kidney was put into practice, as it presented a great tumour with multiples points corticals confirmed by PAAF and conservative surgery on the right kidney with enucleation of localized mass in the lower renal. The patient held normal renal function with a good quality of life for five years, finding out then, in one of the radiological tests, carcinoma relapse in the only kidney, that forced to radical surgery and to his inclusion in dialysis programme.

[Vestibular approach in urinary incontinence in women. Original technic. Experience. Results]. / La vía de abordaje vestibular en la incontinencia de orina en la mujer. Técnica original. Experiencia. Resultados.

Presentation of an original technique to treat S.U.I. in women. This technique contains in itself many others, both in terms of the conceptual anatomical base on which it is inspired, and in the possibilities of its surgical application. Lisfranc's approach, supra-meatic and infra-clitoridean, allows to section both the pubo-urethral ligament and Colles fascia thus reaching into the Retzius. It makes possible the use of solid anatomical elements (pelvian fascia, elevator, urethro-vaginal septum, etc...) thus allowing to suspend the pelvian base from fascia ligaments or from the abdominal wall muscles. Sixty patient who had simple S.U.I. received treatment, with a 95% efficacy index based on the evaluation of the urodynamic, bacteriological and clinical studies. We conclude with an evaluation on the validity of the results obtained by emphasizing the high efficacy index, simplicity, low morbidity and short hospital stay.

[Cerebrospinal fluid drainage to protect the spinal cord during surgical repair of thoracoabdominal aortic aneurysm]. / Drenaje de líquido cefalorraquídeo como protección de la médula espinal durante la reparación quirúrgica de un aneurisma aórtico toracoabdominal.

Spinal cord injury is a serious complication of aortic cross-clamping during thoracoabdominal aortic surgery. We report the case of a 59-year-old man whose mycotic pseudoaneurysm in the thoracoabdominal aorta was repaired surgically. Cerebrospinal fluid pressure was monitored and the fluid was drained to protect the spinal cord while the aorta was clamped. A 19-G epidural catheter was inserted into the subarachnoid space using a paramedian approach form L2-L3. The aorta was clamped at the thoracic level in the descending distal portion and at the abdominal level above the kidney, for a period of 61 minutes. A total of 65 ml of cerebrospinal fluid was drained. The early postoperative period was uneventful and tubes were removed 40 hours after surgery. The results of neurological examination were normal. One week later the patient developed a respiratory infection, which was followed by multi-organ failure and died 22 days after the operation. We discuss the case and review the various alternatives available for protecting the spinal cord during surgery on the thoracoabdominal aorta.

[Major ambulatory surgery in otorhinolaryngology]. / Cirugía mayor ambulatoria en otorrinolaringología.

In the last years we have witnessed a great increase of major ambulatory surgery procedures in our specialty. Some of them are very common as adenoidectomies, tonsillectomies and also the insertion of transtympanic tubes. Nevertheless there is no agreement about which of the procedures should be realized through AMS. The aim of this work is to do a review on the most important features involved in AMS entlightening what kind of operations can be included i such programmes.