Relax, it's just laparoscopy! A prospective randomized trial on heart rate variability of the surgeon in robot-assisted versus conventional laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic surgery might be beneficial for the patient, but it imposes increased physical and mental strain on the surgeon. Robot-assisted laparoscopic surgery addresses some of the laparoscopic drawbacks and may potentially reduce mental strain. This could reduce the risk of surgeon's fatigue, mishaps and strain-induced illnesses, which may eventually improve the safety of laparoscopic surgical procedures. METHODS: To test this hypothesis, a randomized study was performed, comparing both heart rate and heart rate variability (HRV) of the surgeon as a measure of total and mental strain, respectively, during conventional and robot-assisted laparoscopic cholecystectomy. RESULTS: Both heart rate and HRV (the low-frequency band/high-frequency band ratio) were significantly decreased when using robotic assistance. CONCLUSIONS: These data suggest the use of the daVinci® Surgical System leads to less physical and mental strain of the surgeon during surgery. However, assessing mental strain by means of HRV is cumbersome since there is no clear cutoff point or scale for maximum tolerated strain levels and its related effects on surgeon's health.

A Shot Through the Heart.

We present the case of a patient who was shot through the heart with an air rifle and presented in a stable condition at our emergency department. At the time of presentation, the bullet was still present within the myocardium. Imaging, management, and outcome are discussed in this report.

Quality and process improvement of the multidisciplinary Heart Team meeting using Lean Six Sigma.

INTRODUCTION: The Heart Team is a multidisciplinary meeting for shared decision-making in cardiology and cardiothoracic surgery. A quality improvement project to optimise the Heart Team was initiated after the merger of the cardiac centres of Amsterdam University Medical Centre. METHODS: Lean Six Sigma was applied with the purpose of improving efficiency and quality of care. Qualitative and quantitative analyses supported the multidisciplinary team during quality improvement sessions. Lean Six Sigma tools included process mapping, gemba walks, root cause analysis, line balancing, first time right, standardised work and poka-yoke. INTERVENTIONS: Seven areas of improvement were introduced. Key elements were the improvement of the patient referral process, introduction of a structured agenda, task division and balanced planning of patients, better exchange of information, improved availability of diagnostics and supportive tools and information technology. Work agreements were introduced to support a positive work culture and mutual respect. RESULTS: Lean Six Sigma designed an optimised Heart Team to improve efficiency by better resource utilisation, first time right decision-making, patient selection, complete and better access to information and elimination of waste. It leads to higher quality of decision-making by involving physicians in a more structured preparation, attendance of an imaging cardiologist, meeting duration within limits, installation of standard operating procedures, increased involvement of the referring cardiologists and a better engaged team. CONCLUSIONS: Heart Teams are essential to make evidence-based, patient-centred treatment plans for optimal patient outcomes. However, clinical practice and experience showed that it is challenging to have an efficient and effective discussion with complete patient information and to bring together healthcare professionals. The application of Lean Six Sigma resulted in an optimised Heart Team and created a best practice design for patient-centred, evidence-based decision-making. After implementation and process stability, a postintervention analysis could clarify long-term success and sustainability.

Optimization of a Patient Distribution Framework: Second Wave COVID-19 Preparedness and Challenges in the Amsterdam Region.

To meet surge capacity and to prevent hospitals from being overwhelmed with COVID-19 patients, a regional crisis task force was established during the first pandemic wave to coordinate the even distribution of COVID-19 patients in the Amsterdam region. Based on a preexisting regional management framework for acute care, this task force was led by physicians experienced in managing mass casualty incidents. A collaborative framework consisting of the regional task force, the national task force, and the region's hospital crisis coordinators facilitated intraregional and interregional patient transfers. After hospital admission rates declined following the first COVID-19 wave, a window of opportunity enabled the task forces to create, standardize, and optimize their patient transfer processes before a potential second wave commenced. Improvement was prioritized according to 3 crucial pillars: process standardization, implementation of new strategies, and continuous evaluation of the decision tree. Implementing the novel "fair share" model as a straightforward patient distribution directive supported the regional task force's decisionmaking. Standardization of the digital patient transfer registration process contributed to a uniform, structured system in which every patient transfer was verifiable on intraregional and interregional levels. Furthermore, the regional task force team was optimized and evaluation meetings were standardized. Lines of communication were enhanced, resulting in increased situational awareness among all stakeholders that indirectly provided a safety net and an improved integral framework for managing COVID-19 care capacities. In this article, we describe enhancements to a patient transfer framework that can serve as an exemplary system to meet surge capacity demands during current and future pandemics.

The Search for an Outcome Variable That Measures Both Quality and Processes in Cardiac Surgery: Comparing the Quality Process Index and Mortality.

BACKGROUND: The translation of a large quantity of data into valuable insights for daily clinical practice is underexplored. A considerable amount of information is overwhelming, making it difficult to distill and assess quality and processes at the hospital level. This study contributes to this necessary translation by developing a Quality Process Index that summarizes clinical data to measure quality and processes. METHODS: The Quality Process Index was constructed to enable retrospective analyses of quality and process evolution from 2011 to 2021 for various surgery types in the Amsterdam Cardiosurgical Database (n = 5497). It is presented alongside mortality rates, which are the golden standard for quality measurement. The two outcome variables are compared as quality and process measurement options. RESULTS: Results showed that the mean Quality Process Index appeared rather stable, even though analysis of variance found that the mean Quality Process Index differed significantly over the years (p < 0.001). The 30-day and 120-day mortality rates appeared to fluctuate more, but interestingly, we failed to reject the null hypothesis of equal means. The Quality Process Index and mortality rates were statistically negatively correlated, and the extent of correlation was more pronounced with the 120-day mortality rate, as computed using the Pearson correlation coefficient r (30-day rQPI,30 = -0.07, p < 0.001 and 120-day mortality rates rQPI,120 = -0.12, p < 0.001). CONCLUSIONS: The Quality Process Index seeks to address the need to translate data for quality and process improvement in healthcare. While mortality remains the most impactful outcome measure, the Quality Process Index provides a more stable and comprehensive measurement of quality and process improvement or deterioration in healthcare. Therefore, the Quality Process Index as a quantification reinforces the understanding of the definition of quality and process improvement.

Geometrical models for cardiac MRI in rodents: comparison of quantification of left ventricular volumes and function by various geometrical models with a full-volume MRI data set in rodents.

MRI has been proven to be an accurate method for noninvasive assessment of cardiac function. One of the current limitations of cardiac MRI is that it is time consuming. Therefore, various geometrical models are used, which can reduce scan and postprocessing time. It is unclear how appropriate their use is in rodents. Left ventricular (LV) volumes and ejection fraction (EF) were quantified based on 7.0 Tesla cine-MRI in 12 wild-type (WT) mice, 12 adipose triglyceride lipase knockout (ATGL(-/-)) mice (model of impaired cardiac function), and 11 rats in which we induced cardiac ischemia. The LV volumes and function were either assessed with parallel short-axis slices covering the full volume of the left ventricle (FV, gold standard) or with various geometrical models [modified Simpson rule (SR), biplane ellipsoid (BP), hemisphere cylinder (HC), single-plane ellipsoid (SP), and modified Teichholz Formula (TF)]. Reproducibility of the different models was tested and results were correlated with the gold standard (FV). All models and the FV data set provided reproducible results for the LV volumes and EF, with interclass correlation coefficients ≥0.87. All models significantly over- or underestimated EF, except for SR. Good correlation was found for all volumes and EF for the SR model compared with the FV data set (R(2) ranged between 0.59-0.95 for all parameters). The HC model and BP model also predicted EF well (R(2) ≥ 0.85), although proved to be less useful for quantitative analysis. The SP and TF models correlated poorly with the FV data set (R(2) ≥ 0.45 for EF and R(2) ≥ 0.29 for EF, respectively). For the reduction in acquisition and postprocessing time, only the SR model proved to be a valuable method for calculating LV volumes, stroke volume, and EF.

Systematic Review of Interventions to Reduce Operating Time in Lung Cancer Surgery.

INTRODUCTION: Operating rooms are a scarce resource but often used inefficiently. Operating room efficiency emerges as an important part of maximizing surgical capacity and productivity, minimizing delays, and optimizing lung cancer outcomes. The operative time (time between patient entering and leaving the operating room) is discrete and the one that the surgical team can most directly influence. We performed a systematic review to evaluate the literature and identify methods to improve the efficiency of the intraoperative phase of operations for lung cancer. METHODS: A literature search (in PubMed, Embase, Cochrane, and Scopus) was performed from inception up to March 9, 2020, according to the methodology described in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. RESULTS: We identified 3 articles relevant to the intraoperative phase of lung cancer operating room efficiency. All 3 were consistent in showing clinically relevant time reductions in the intraoperative phase or procedures relevant to this phase. The authors demonstrated that the application of various improvement methodologies resulted in a substantial reduction in operative time, which was associated with a reduction in complications, and improved staff morale. CONCLUSIONS: Our systematic review found that various improvement methodologies have the potential to significantly reduce operative time for lung cancer surgery. This increases the value of lung cancer surgery. These findings are consistent with the wider literature on improving surgical efficiency.

Transition of Macrophages to Fibroblast-Like Cells in Healing Myocardial Infarction.

BACKGROUND: Macrophages and fibroblasts are 2 major cell types involved in healing after myocardial infarction (MI), contributing to myocardial remodeling and fibrosis. Post-MI fibrosis progression is characterized by a decrease in cardiac macrophage content. OBJECTIVES: This study explores the potential of macrophages to express fibroblast genes and the direct role of these cells in post-MI cardiac fibrosis. METHODS: Prolonged in vitro culture of human macrophages was used to evaluate the capacity to express fibroblast markers. Infiltrating cardiac macrophages was tracked in vivo after experimental MI of LysM(Cre/+);ROSA26(EYFP/+) transgenic mice. The expression of Yellow Fluorescent Protein (YFP) in these animals is restricted to myeloid lineage allowing the identification of macrophage-derived fibroblasts. The expression in YFP-positive cells of fibroblast markers was determined in myocardial tissue sections of hearts from these mice after MI. RESULTS: Expression of the fibroblast markers type I collagen, prolyl-4-hydroxylase, fibroblast specific protein-1, and fibroblast activation protein was evidenced in YFP-positive cells in the heart after MI. The presence of fibroblasts after MI was evaluated in the hearts of animals after depletion of macrophages with clodronate liposomes. This macrophage depletion significantly reduced the number of Mac3+Col1A1+ cells in the heart after MI. CONCLUSIONS: The data provide both in vitro and in vivo evidence for the ability of macrophages to transition and adopt a fibroblast-like phenotype. Therapeutic manipulation of this macrophage-fibroblast transition may hold promise for favorably modulating the fibrotic response after MI and after other cardiovascular pathological processes.

Noninvasive molecular imaging of cell death in myocardial infarction using 111In-GSAO.

Acute insult to the myocardium is associated with substantial loss of cardiomyocytes during the process of myocardial infarction. In this setting, apoptosis (programmed cell death) and necrosis may operate on a continuum. Because the latter is characterized by the loss of sarcolemmal integrity, we propose that an appropriately labeled tracer directed at a ubiquitously present intracellular moiety would allow non-invasive definition of cardiomyocyte necrosis. A trivalent arsenic peptide, GSAO (4-(N-(S-glutathionylacetyl)amino)phenylarsonous acid), is capable of binding to intracellular dithiol molecules such as HSP90 and filamin-A. Since GSAO is membrane impermeable and dithiol molecules abundantly present intracellularly, we propose that myocardial localization would represent sarcolemmal disruption or necrotic cell death. In rabbit and mouse models of myocardial infarction and post-infarct heart failure, we employed In-111-labelled GSAO for noninvasive radionuclide molecular imaging. (111)In-GSAO uptake was observed within the regions of apoptosis seeking agent- (99m)Tc-Annexin A5 uptake, suggesting the colocalization of apoptotic and necrotic cell death processes.

Molecular imaging for efficacy of pharmacologic intervention in myocardial remodeling.

OBJECTIVES: Using molecular imaging techniques, we examined interstitial alterations during postmyocardial infarction (MI) remodeling and assessed the efficacy of antiangiotensin and antimineralocorticoid intervention, alone and in combination. BACKGROUND: The antagonists of the renin-angiotensin-aldosterone axis restrict myocardial fibrosis and cardiac remodeling after MI and contribute to improved survival. Radionuclide imaging with technetium-99m-labeled Cy5.5 RGD imaging peptide (CRIP) targets myofibroblasts and indirectly allows monitoring of the extent of collagen deposition post-MI. METHODS: CRIP was intravenously administered for gamma imaging after 4 weeks of MI in 63 Swiss-Webster mice and in 6 unmanipulated mice. Of 63 animals, 50 were treated with captopril (C), losartan (L), spironolactone (S) alone, or in combination (CL, SC, SL, and SCL), 8 mice received no treatment. Echocardiography was performed for assessment of cardiac remodeling. Hearts were characterized histopathologically for the presence of myofibroblasts and thick and thin collagen fiber deposition. RESULTS: Acute MI size was similar in all groups. The quantitative CRIP percent injected dose per gram uptake was greatest in the infarct area of untreated control mice (2.30 +/- 0.14%) and decreased significantly in animals treated with 1 agent (C, L, or S; 1.71 +/- 0.35%; p = 0.0002). The addition of 2 (CL, SC, or SL 1.31 +/- 0.40%; p < 0.0001) or 3 agents (SCL; 1.16 +/- 0.26%; p < 0.0001) demonstrated further reduction in tracer uptake. The decrease in echocardiographic left ventricular function, strain and rotation parameters, as well as histologically verified deposition of thin collagen fibers, was significantly reduced in treatment groups and correlated with CRIP uptake. CONCLUSIONS: Radiolabeled CRIP allows for the evaluation of the efficacy of neurohumoral antagonists after MI and reconfirms superiority of combination therapy. If proven clinically, molecular imaging of the myocardial healing process may help plan an optimal treatment for patients susceptible to heart failure.

Molecular imaging of interstitial alterations in remodeling myocardium after myocardial infarction.

OBJECTIVES: The purpose of this study was to evaluate interstitial alterations in myocardial remodeling using a radiolabeled Cy5.5-RGD imaging peptide (CRIP) that targets myofibroblasts. BACKGROUND: Collagen deposition and interstitial fibrosis contribute to cardiac remodeling and heart failure after myocardial infarction (MI). Evaluation of myofibroblastic proliferation should provide indirect evidence of the extent of fibrosis. METHODS: Of 46 Swiss-Webster mice, MI was induced in 41 by coronary artery occlusion, and 5 were unmanipulated. Of the 41 mice, 6, 6, and 5 received intravenous technetium-99m labeled CRIP for micro-single-photon emission computed tomography imaging 2, 4, and 12 weeks after MI, respectively; 8 received captopril or captopril with losartan up to 4 weeks after MI. Scrambled CRIP was used 4 weeks after MI in 6 mice; the remaining 10 of 46 mice received unradiolabeled CRIP for histologic characterization. RESULTS: Maximum CRIP uptake was observed in the infarct area; quantitative uptake (percent injected dose/g) was highest at 2 weeks (2.75 +/- 0.46%), followed by 4 (2.26 +/- 0.09%) and 12 (1.74 +/- 0.24%) weeks compared with that in unmanipulated mice (0.59 +/- 0.19%). Uptake was higher at 12 weeks in the remote areas. CRIP uptake was histologically traced to myofibroblasts. Captopril alone (1.78 +/- 0.31%) and with losartan (1.13 +/- 0.28%) significantly reduced tracer uptake; scrambled CRIP uptake in infarct area (0.74 +/- 0.17%) was similar to CRIP uptake in normal myocardium. CONCLUSIONS: Radiolabeled CRIP allows for noninvasive visualization of interstitial alterations during cardiac remodeling, and is responsive to antiangiotensin treatment. If proven clinically feasible, such a strategy would help identify post-MI patients likely to develop heart failure.