Self-contained image mapping of placental vasculature in 3D ultrasound-guided fetoscopy.

BACKGROUND: Surgical navigation technology directed at fetoscopic procedures is relatively underdeveloped compared with other forms of endoscopy. The narrow fetoscopic field of views and the vast vascular network on the placenta make examination and photocoagulation treatment of twin-to-twin transfusion syndrome challenging. Though ultrasonography is used for intraoperative guidance, its navigational ability is not fully exploited. This work aims to integrate 3D ultrasound imaging and endoscopic vision seamlessly for placental vasculature mapping through a self-contained framework without external navigational devices. METHODS: This is achieved through development, integration, and experimentation of novel navigational modules. Firstly, a framework design that addresses the current limitations based on identified gaps is conceptualized. Secondly, integration of navigational modules including (1) ultrasound-based localization, (2) image alignment, and (3) vision-based tracking to update the scene texture map is implemented. This updated texture map is projected to an ultrasound-constructed 3D model for photorealistic texturing of the 3D scene creating a panoramic view of the moving fetoscope. In addition, a collaborative scheme for the integration of the modular workflow system is proposed to schedule updates in a systematic fashion. Finally, experiments are carried out to evaluate each modular variation and an integrated collaborative scheme of the framework. RESULTS: The modules and the collaborative scheme are evaluated through a series of phantom experiments with controlled trajectories for repeatability. The collaborative framework demonstrated the best accuracy (5.2 % RMS error) compared with all the three single-module variations during the experiment. Validation on an ex vivo monkey placenta shows visual continuity of the freehand fetoscopic panorama. CONCLUSIONS: The proposed developed collaborative framework and the evaluation study of the framework variations provide analytical insights for effective integration of ultrasonography and endoscopy. This contributes to the development of navigation techniques in fetoscopic procedures and can potentially be extended to other applications in intraoperative imaging.

Ultrahigh sensitivity endoscopic camera using a new CMOS image sensor: providing with clear images under low illumination in addition to fluorescent images.

BACKGROUND: We developed a new ultrahigh-sensitive CMOS camera using a specific sensor that has a wide range of spectral sensitivity characteristics. The objective of this study is to present our updated endoscopic technology that has successfully integrated two innovative functions; ultrasensitive imaging as well as advanced fluorescent viewing. METHODS: Two different experiments were conducted. One was carried out to evaluate the function of the ultrahigh-sensitive camera. The other was to test the availability of the newly developed sensor and its performance as a fluorescence endoscope. In both studies, the distance from the endoscopic tip to the target was varied and those endoscopic images in each setting were taken for further comparison. RESULTS: In the first experiment, the 3-CCD camera failed to display the clear images under low illumination, and the target was hardly seen. In contrast, the CMOS camera was able to display the targets regardless of the camera-target distance under low illumination. Under high illumination, imaging quality given by both cameras was quite alike. In the second experiment as a fluorescence endoscope, the CMOS camera was capable of clearly showing the fluorescent-activated organs. CONCLUSIONS: The ultrahigh sensitivity CMOS HD endoscopic camera is expected to provide us with clear images under low illumination in addition to the fluorescent images under high illumination in the field of laparoscopic surgery.

Oncology and Palliative Care Integration Model: A Cost Analysis Study in a Brazilian Hospital Setting.

Background: In 2019, the São Paulo State Cancer Institute (ICESP) implemented a novel model integrating Oncology with Palliative Care specialists. We evaluated the impact of this model on healthcare resource utilization and costs. Methods: We analyzed data from all patients who passed away in February (1 month prior to implementation) and November (8 months after model implementation group) at ICESP, Brazil. Healthcare utilization data, including emergency department visits, hospital and intensive care unit admissions, chemotherapy, and radiotherapy use, were retrieved from Electronic Medical Records. Unit cost values were obtained from the administrative database. Results: A total of 198 patients who died in February and 196 in November were included in the analysis. Groups exhibited similarities in sex, age, ECOG, cancer type, previous outpatient palliative care consultations, and place of death (ward: 56.6% pre-intervention, 50% post-intervention). The mean cost per patient was US$13,226.29 pre-intervention and US$11,445.82 post-intervention (P = .007). Statistically significant differences were noted in days hospitalized in the surgical ward (227 vs 115), emergency department visits (233 vs 45), chemotherapy sessions (140 vs 26), and radiotherapy sessions (146 vs 10). Excluding outpatient treatments, the total costs for chemotherapy and radiotherapy in the last 30 days of life were US$16,924.45 pre-intervention and US$7851.65 post-intervention. Reductions were more pronounced in patients with ECOG 3-4 (P = .039). Conclusion: Our data suggests that the integration model was associated with a reduction in potentially inappropriate treatments during the last month of life, leading to decreased healthcare utilization and costs.

3-D endoscope using a single CCD camera and pneumatic vibration mechanism.

BACKGROUND: During endoscopic surgical procedures, surgeons must manipulate an endoscope inside the body cavity to observe a surgical area while estimating the distance between that area and the surgical instruments by reference to a monitor on which the movement and size of the surgical instruments are displayed in 2-D endoscopic images. Therefore, there is a risk of the endoscope or instruments physically damaging body tissues. To overcome this problem, we developed a Ø5-mm, 3-D endoscope using a single 1/10-inch CCD camera and pneumatic vibration mechanism. METHODS: The 3-D endoscope proposed in this paper consists of an outer and inner sleeve, a 1/10-inch CCD camera attached to its distal end, and a pneumatic vibration mechanism attached to its proximal end. This endoscope can acquire left and right endoscopic images for stereovision in synchrony with the periodical motion generated by the vibration mechanism. We measured the displacement at the proximal and distal end of the 3-D endoscope simultaneously, and evaluated the feasibility of its use in vivo. RESULTS: The displacement at the distal end of the endoscope to which the CCD camera is attached was approximately ±0.25 mm. The timing when the displacement of the CCD camera was at maximal amplitude coincided with the timing when the displacement of its proximal end was at maximal amplitude. In the in vivo experiment, this 3-D endoscope can provide clear 3-D images of the surgical area. CONCLUSIONS: The developed 3-D endoscope that uses a single CCD camera and pneumatic vibration mechanism can successfully visualize internal organs inside the body even though the CCD camera is moved by the vibration. Therefore, the risk of damage to fragile body tissues can be significantly decreased.

Palliative cancer care: costs in a Brazilian quaternary hospital.

Palliative care (PC) improves the quality of life of patients with diseases such as cancer, and several studies have shown a reduction in costs among patients who use PC services when compared with those receiving standard oncological treatments. Most studies on PC costs are carried out in high-income countries. There is a lack of these types of studies in middle-income and low-income countries and of better evidence about this intervention. OBJECTIVE: To describe resource utilisation and costs among patients with cancer in a Brazilian quaternary hospital by cancer localisation and per month of treatment before death. METHODS: This study is a description of retrospective costs to estimate the costs of formal healthcare sector associated with PCs, from the perspective of a public quaternary cancer hospital. Unit costs were estimated using microcosting and macrocosting approaches. SETTING/PARTICIPANTS: Patients older than 18 years old who died from 2010 to 2013 and who had at least two visits in PC and/or made use of hospice care. RESULTS: Among the 2985 patients included in the study, the average cost per patient was US$12 335, ranging from US$8269 for patients with pancreatic cancer to US$19 395 for patients with brain cancer. The main costing item was hospital admission (47.6% of the total cost), followed by hospice care (29.5%) and medical and other supplies (11.1%). CONCLUSIONS: The study clarified the direct medical costs and the profile and use of resources of patients with cancer who need PC, and can help in the planning and allocation of resources in cancer care.

A novel ultrasmall composite optical fiberscope.

BACKGROUND: Accurately aiming laser energy at a target from a two-dimensional endoscopic view is difficult during endoscopic laser surgery, particularly when the endoscope and the laser fiber are misaligned. We developed a composite optical fiberscope (COF) that can simultaneously visualize a target area and perform laser irradiation. The identical orientation of the endoscope and the laser fiber allows intuitive aiming at a target, even from a two-dimensional endoscopic view. METHODS: We developed an ultrasmall COF (1.1-mm diameter) with a central cauterizing laser fiber surrounded by imaging and illumination fibers as a tool for various surgical applications. Porcine mesenteric blood vessels were laser irradiated in vivo and the procedure was filmed using ultrahigh-speed (max 1,000,000 frames per second) and thermographic cameras. Blood flow and vessel diameters were measured before and after laser irradiation. RESULTS: The target vessels were highly visible and laser energy was delivered to the center of the view. Images from the ultrahigh-speed camera showed the blocking of the target vessel by the laser irradiation. The irradiated point initially became constricted, then discolored, and then decreased in size. Blood flow was decreased by 81.7% after laser irradiation and the diameter of the vessels at the irradiated point was approximately 46-48% smaller than that of the unirradiated vessels. Medical doctors also confirmed that the blood vessel was blocked after the experiments. CONCLUSIONS: Our new laser surgery device may be useful for many surgical applications because it allows simultaneous diagnosis and treatment as well as intuitive aiming at a target despite its ultrasmall 1.1-mm diameter.

A novel ultralow-illumination endoscope system.

BACKGROUND: Endoscopic surgery has become an accepted major type of minimally invasive surgery. However, complications arising from heat generated by sources of endoscopic illumination can include surgical fire or burns, and intense illumination during ob-gyn/fetoscopic surgery might damage fetal ocular development. Fiber-optic bundles for illumination within the endoscope essentially double the outer diameter of the endoscope, which is a major obstacle to miniaturization and decreasing costs. Light cables also decrease the maneuverability of the endoscope METHODS: We developed a novel endoscope with ultralow illumination to visualize dark body cavities and investigated its feasibility in vivo. An adaptor was created to connect a conventional endoscope to an ultrahigh-sensitivity camera developed by the Japan Broadcasting Corporation (NHK) for broadcasting. The ability to visualize rabbit visceral blood vessels in vivo by the new prototype and by a current endoscope under ultralow illumination provided by a standard light source was compared. In addition, the performance of the two endoscopes was compared using only an extracorporeal flashlight without any specific light source placed within body cavities. RESULTS: The new endoscope could visualize the target under ultralow illumination of approximately 100 lx. Very little could be visualized using the current endoscope, whereas the prototype generated clear images of the rabbit blood vessels under both ultralow illumination and extracorporeal illumination provided by a flashlight. CONCLUSIONS: The potential for damage caused by a light source can be minimized using our new endoscope, which results in safer and less invasive procedures. Further studies are under way to develop a nonilluminated endoscope without a light cable or source and to miniaturize the camera to decrease costs and improve the maneuverability of the entire endoscope system.

Validity and reliability of the Brazilian version of the Patient Dignity Inventory (PDI - Br).

OBJECTIVE: to perform the psychometric validation of the Brazilian version of the Patient Dignity Inventory (PDI - Br) in patients with advanced diseases in palliative care. METHOD: a methodological study to verify the psychometric properties of the Patient Dignity Inventory (PDI - Br) instrument, through validity and reliability tests. RESULTS: the exploratory factor analysis showed a factorial solution with three factors, responsible for 40.9% of the explained variance, with adequate internal consistency for the Presence of Symptoms (α=0.859), Dependence (α=0.871), and Existential Suffering (α=0.759) domains. The test-retest was performed and indicated moderate to strong correlations. Convergent validity demonstrated a positive correlation between the Presence of Symptoms and the sadness (r=0.443) and anxiety (r=0.464) variables. Weak negative correlations were observed between the PDI - Br domains and functionality, spiritual well-being and quality of life. CONCLUSION: composed of three domains and 25 items, the PDI - Br instrument presented satisfactory psychometric properties for its use in our environment, through the evidence of validity and reliability.

The development of a composite-type optical fiberscope system for fetoscopic laser photocoagulation of chorionic plate anastomosing vessels (FLPC).

We developed a new laser device using a composite-type optical fiberscope for laser surgery to treat twin-twin transfusion syndrome. The composite-type optical fiberscope (2.2 mm in external diameter) consists of a centrally located single fiber for laser treatment (0.1 mm in diameter) and its surrounding fibers for diagnosis. This fiberscope enables transmission of 40-W Yb fiber laser. The Yb fiber laser can be focused to 10mm focal length using two lenses on the tip of the fiberscope. In this research, we emitted the laser to in vivo porcine mesenteric vessel with blood flow both with an established laser fiber of 0.6-mm diameter (0.6-mm normal fiber) and with our composite-type optical fiberscope to compare the cautery performance of those devices. According to the experimental results, the composite-type optical fiberscope has a cautery efficiency equal to that of a 0.6-mm normal fiber, and it can contract the vein diameter about 35% as compared to the vein diameter before laser irradiation.

Prospects of future measures for persons with dementia in Japan.

In May 2008, the Japanese government launched the 'Emergency Project for Improvement of Medical Care and Quality of Life for People with Dementia' under the idea that it is necessary to build a society, without delay, where people can live life safely without anxiety even after being affected by dementia, where they can be supported by appropriate and integrated services of medical care, long-term care and community care. We would like to introduce our future dementia policy standing on the outcome of this project, which was published as a report on 10 July 2008. The measures for people with dementia in Japan have gradually achieved good results. For example, public understanding and awareness of dementia has increased through renaming the term for dementia in Japanese from 'Chiho' to 'Ninchi-sho' in 2004, and the comprehensive care system was founded focusing on the importance of providing community based long-term care while maintaining the person's familiar human relationships and residential circumstances. However, case reports show that there are yet some cases that fail to deliver appropriate treatment or long-term care service as a result of a lack of timely definite diagnosis in an early stage or a lack of coordination between medical care and long-term care. Therefore, the future dementia policy should be designed by envisaging the flow of the measures that would support the life of the person and his/her family, and improve their quality of life; starting with measures that link early notice of the patient, his/her family or neighbor to early diagnosis, and then measures to develop well-designed comprehensive care planning that provides appropriate medical and long-term care services through good coordination, while promoting research and development of diagnosis/treatment technology. In addition, in regard to early-onset dementia, comprehensive self-support measures including employment assistance should be promoted.

Palliative care consultation team: symptom relief in first 48 hours of hospitalization.

OBJECTIVE: To compare the relief of symptoms provided by palliative care consultation team (PCCT) compared to the traditional care team (TC), in patients with advanced cancer in the first 48 hours of hospitalization. METHOD: Allocated to PCCT Group and TC Group, this study assessed 290 patients according to the Edmonton Symptom Assessment System (ESAS) within the first 48 hours of hospitalization. The main outcome was a minimum 2-point reduction in symptom intensity. RESULTS: At 48 hours, the PCCT Group had a 2-point reduction in the mean differences (p <0.001) in pain, nausea, dyspnea, and depression; and TC Group, on nausea and sleep impairment (p <0.001). Multiple Logistic Regression found for the PCCT Group a greater chance of pain relief (OR 2.34; CI 1.01-5.43; p = 0.049). CONCLUSION: There was superiority of the PCCT Group for pain relief, dyspnea and depression. There is a need for more studies that broaden the understanding of team modalities.

Fast image mapping of endoscopic image mosaics with three-dimensional ultrasound image for intrauterine fetal surgery.

This paper describes a fast image mapping system that integrates endoscopic image mosaics with three-dimensional (3-D) ultrasound images for assisting intrauterine laser photocoagulation treatment. Endoscopic laser photocoagulation treatment has a good survival rate and a low complication rate for twins. However, the small field of view and lack of surrounding information makes the identification of vessel anastomosis difficult. We have developed an extended visualization system with the fusion of endoscopic image mosaics with a 3-D ultrasound-image model. Fully automatic and fast calibration is used for endoscope calibration in fluid. The 3-D spatial position of the endoscopic images and the ultrasound image are tracked by a 3-D position tracking device. The mosaiced endoscope images are registered to the surface of the 3-D ultrasound placenta model by using a fast GPU-based image rendering method and a seamless multi-images processing. Experimental results show that the system may provide an improved and efficient way of planning and guidance in laser photocoagulation treatment.

Blood flow measurement system for fetoscopic laser photocoagulation of chorionic plate anastomosing vessels (FLPC).

Fetoscopic laser photocoagulation of chorionic plate anastomosing vessels (FLPC) applies to the treatment of previable fetuses with severe twin-twin transfusion syndrome (TTTS). The ultimate goal of FLPC is selective blood flow interruption of anastomotic communicating vessels on the placenta fetoscopically. However, there has not been an established method to confirm that the blood flow is blocked, thus, it depends on the operator's experience or intuition to evaluate whether the FLPC was performed successfully or not. For this issue, we have developed a composite-type optical fiberscope (2.2 mm in diameter), which has centrally-located cautery laser fiber and surrounding located fiberglasses for viewing. This fiberscope enables transmission of 50 W Yb fiber laser which can be focused to 10 mm focal length using two lenses on the fiberscope tip. In this study, we combined the fiberscope and a laser blood-flow meter, and irradiated cautery laser to porcine mesenteric vein with measuring blood flow at the same time. From the experimental results, we could quantitatively measure the blood flow before and after laser irradiation, and confirm the blood flow blocking with our system.

ICG fluorescence endoscope for visualization of the placental vascular network.

Intrauterine laser photocoagulation for twin-twin transfusion syndrome (TTTS) needs accurate in-situ recognition of placental vascular anastomosis. Because the conventional procedure is highly dependent upon the operators' skill and experience, we developed a new way to visualize the placental vascular network by a rigid-type fluorescence endoscope coupled with intravenous administration of Indocyanine green (ICG). The feasibility of the fluorescence endoscope was examined with monkey placentas and pregnant rats. The ICG fluorescence endoscope can visualize the placental vascular network in detail even in the presence of turbid amniotic fluid. Thus, this method is potentially useful for in-situ definition of the placental vascular anastomoses during the treatment for TTTS. In addition, our rigid-type fluorescence endoscope will also be a useful tool for lymph node dissection using ICG by endoscopic surgery.

Unshielded fetal magnetocardiography system using two-dimensional gradiometers.

We developed a fetal magnetocardiography (fMCG) system that uses a pair of two-dimensional gradiometers to achieve high signal-to-noise ratio. The gradiometer, which is based on a low-Tc superconducting quantum interference device, detects the gradient of a magnetic field in two orthogonal directions. Gradiometer position is easy to adjust by operating the gantry to drive the cryostat in both the swinging and axial directions. As a result, a fMCG waveform for 25 weeks' gestation was measured under an unshielded environment in real time. Moreover, the P and T waves for 25 and 34 weeks' gestation, respectively, were obtained by averaging. These results indicate that this two-dimensional gradiometer is one of the most promising techniques for measuring fetal heart rate and diagnosing fetal arrhythmia.

Endoscopic fetal urethrotomy for anterior urethral valves: a preliminary report.

Anterior urethral valves are a rare congenital anomaly associated with distal urethral obstruction, which can result in a poor prognosis. We report on the endoscopic creation of a fetal urethrotomy for obstructive uropathy resulting from anterior urethral valves. A 33-year-old woman was evaluated at 17 weeks gestation due to fetal megacystis. The diagnosis of anterior urethral valves was confirmed by the characteristic sonographic feature of a dilated membranous penile urethra. Oligohydramnios with normal-appearing kidneys and favorable urinary electrolytes led to fetal intervention. Ablation on the ventral site of the fetal penis for a cutaneous urethrotomy was performed using a YAG laser under a 1-mm fetoscope at 19 weeks gestation. Urine was drained from the incision and the dilated penis and the distended bladder shrunk with an increase in amniotic fluid. However, the fetus died unexpectedly on postoperative day 3, and chorioamnionitis was suspected as the etiology. While the outcome was unfavorable, our preliminary experience shows that fetal urethrotomy for obstructive uropathy can be achieved in utero using an endoscopic laser approach. Further experience will be required to evaluate the therapeutic value of this new procedure in the management of fetal anterior urethral valves.

8K ultra-high-definition microscopic camera for ophthalmic surgery.

BACKGROUND: We have developed a new compact lightweight 8K ultra-high-definition (UHD; 7,680×4,320 pixels) camera and started medical application with an ophthalmic surgical microscope which is interchangeable with the conventional high-definition (1,920×1,080 pixels)/4K UHD (3,840×2,160 pixels) microscopic camera. METHODS: We did a feasibility study to apply our 8K UHD microscope in cataract surgery, glaucoma surgery and vitreous surgery using pig cadaver eyes. The 8K UHD microscope comprises a surgical microscope, a camera adaptor with relay lenses, an 8K UHD camera and an 8K UHD LCD to share the 8K UHD images with all surgical staff in real time. RESULTS: In ophthalmic surgeries, higher resolution images than conventional microscopic cameras were obtained with 8K UHD LCD equivalent to the observation through the microscopic eye pieces. CONCLUSION: Based on the results of this feasibility study, clinical trials on human ophthalmic surgery using the new 8K UHD microscopic camera should be conducted in the near future.

Early Palliative Care and Its Impact on End-of-Life Care for Cancer Patients in Brazil.

BACKGROUND: Integrating palliative care into standard oncology care has been recommended for cancer patients. Early palliative care is associated with less aggressive treatment at the end of life. OBJECTIVE: To describe cancer patients receiving palliative care in Brazil, determining the time from entry into palliative care to death, and investigating whether late referral to palliative care is associated with aggressive end-of-life treatment. DESIGN: This was a cross-sectional study of cancer patients receiving palliative care in Brazil. SETTING/SUBJECTS: Subjects were 2985 cancer patients ≥18 years of age who received at least two palliative care visits at the São Paulo State Cancer Institute, in the city of São Paulo, Brazil, and died between 2010 and 2013. MEASUREMENTS: We evaluated the time from the first palliative care consult to death, stratifying cases by the timing of entry into palliative care (≥3 or <3 months before death). The associations between early palliative care and indicators of aggressive treatment were assessed by Pearson's chi-square test and Fisher's exact test. RESULTS: The overall median time between entry into palliative care and death was 34 days (mean, 72 days) and was significantly shorter in 2013 than in 2010 (p < 0.001). The number of emergency department visits was significantly lower among the patients who entered palliative care earlier (p < 0.001). CONCLUSIONS: Among cancer patients in Brazil, late referral to palliative care is common. Patients who enter palliative care earlier appear to receive less aggressive end-of-life treatment.

Effect of an 8K ultra-high-definition television system in a case of laparoscopic gynecologic surgery.

Various endoscopic devices have been developed for advanced minimally invasive surgery. We recently applied a new 8K ultra-high-definition television system during laparoscopic treatment of endometriosis. The procedure, which is described in detail, stands as the first reported application of an 8K ultra-high-definition system for laparoscopic gynecologic surgery. Comparison is made between depiction of the lesion by the new system and depiction by a full high-definition system. Improved diagnostic accuracy resulted from the increased image resolution, and we believe that this and other advantages will lead to widespread acceptance and further application of 8K ultra-high-definition systems in the field of gynecologic surgery.