Instrument and Supply Variability: An Opportunity to Reduce the Carbon Footprint of the Operating Room.

INTRODUCTION: Reducing costs and carbon footprints are important, parallel priorities for the US health-care system. Within surgery, reducing the number of instruments that are sterilized and disposable supplies that are used for each operation may help achieve both goals. We wanted to measure the existing variability in surgical instrument and supply choices and assess whether standardization could have a meaningful cost and environmental impact. METHODS: We analyzed surgeon preference cards for common general surgery operations at our hospital to measure the number of sterilizable instrument trays and supplies used by each surgeon for each operation. From this data, we calculated supply costs, carbon footprint, and median operative time and studied the variability in each of these metrics. RESULTS: Among the ten operations studied, variability in sterilizable instrument trays requested on surgeon preference cards ranged from one to eight. Variability in disposable supplies requested ranged from 17 to 45. Variability in open supply costs ranged from $104 to $4184. Variability in carbon footprint ranged from 17 to 708 kg CO2e. If the highest-cost surgeon for each operation switched their preference card to that of the median-cost surgeon, $245,343 in open supply costs and 41,708 kg CO2e could be saved. CONCLUSIONS: There is significant variability in the instrument and supply choices of surgeons performing common general surgery operations. Standardizing this variability may lead to meaningful cost savings and carbon footprint reduction, especially if scaled across the entire health system.

Design of Dust-Filtering Algorithms for LiDAR Sensors Using Intensity and Range Information in Off-Road Vehicles.

Although the LiDAR sensor provides high-resolution point cloud data, its performance degrades when exposed to dust environments, which may cause a failure in perception for robotics applications. To address this issue, our study designed an intensity-based filter that can remove dust particles from LiDAR data in two steps. In the first step, it identifies potential points that are likely to be dust by using intensity information. The second step involves analyzing the point density around selected points and removing them if they do not meet the threshold criterion. To test the proposed filter, we collected experimental data sets under the existence of dust and manually labeled them. Using these data, the de-dusting performance of the designed filter was evaluated and compared to several types of conventional filters. The proposed filter outperforms the conventional ones in achieving the best performance with the highest F1 score and removing dust without sacrificing the original surrounding data.

Intelligent Tire Sensor-Based Real-Time Road Surface Classification Using an Artificial Neural Network.

Vehicles today have many advanced driver assistance control systems that improve vehicle safety and comfort. With the development of more sophisticated vehicle electronic control and autonomous driving technology, the need and effort to estimate road surface conditions is increasing. In this paper, a real-time road surface classification algorithm, based on a deep neural network, is developed using a database collected through an intelligent tire sensor system with a three-axis accelerometer installed inside the tire. Two representative types of network, fully connected neural network (FCNN) and convolutional neural network (CNN), are learned with each of the three-axis acceleration sensor signals, and their performances were compared to obtain an optimal learning network result. The learning results show that the road surface type can be classified in real-time with sufficient accuracy when the longitudinal and vertical axis acceleration signals are trained with the CNN. In order to improve classification accuracy, a CNN with multiple input that can simultaneously learn 2-axis or 3-axis acceleration signals is suggested. In addition, by analyzing how the accuracy of the network is affected by number of classes and length of input data, which is related to delay of classification, the appropriate network can be selected according to the application. The proposed real-time road surface classification algorithm is expected to be utilized with various vehicle electronic control systems and makes a contribution to improving vehicle performance.

Outcomes for Prenatally Diagnosed Right Congenital Diaphragmatic Hernia.

BACKGROUND: Right congenital diaphragmatic hernia (CDH) occurs less frequently than left CDH. Therefore, prognostic indicators for right CDH are not as well studied as for left CDH. METHODS: A retrospective review from a single, tertiary referral center (from 1994 until July 2013) of patients with unilateral right CDH was conducted. Prenatal characteristics were evaluated and correlated with survival to discharge and need for extracorporeal membranous oxygen (ECMO). RESULTS: In total, 34 patients were identified. There were 12 postnatal deaths and 2 fetal demises (6%), representing an overall mortality of 41%. Six patients required ECMO. Nine patients underwent fetal intervention and were analyzed separately. For patients not undergoing fetal intervention, the survival rate was 52% and a higher mean (±SD) lung-to-head ratio (LHR) was associated with survival (1.1 ± 0.4 vs. 0.8 ± 0.2, p = 0.03). There were no deaths or need for ECMO in any patient with an LHR ≥1.0. Of the 9 patients who underwent fetal intervention, survival was 78% and only 1 patient required ECMO. Fetal intervention was primarily tracheal occlusion (n = 8). CONCLUSIONS: An LHR <1.0 is associated with worse survival for right CDH and may also reflect the need for ECMO.

Effect of Prenatal Repair of Myelomeningocele on Urological Outcomes at School Age.

PURPOSE: We investigated longer term urological outcomes in patients enrolled in the Management of Myelomeningocele Study (MOMS). MATERIALS AND METHODS: Women who participated in the original trial were asked for consent for followup for their child at age 6 years or older in a single comprehensive study visit to a MOMS center. Participating children underwent urological and radiologic procedures to provide objective evidence of current bladder functioning. Primary urological outcome was defined as any among need for clean intermittent catheterization, vesicostomy, urethral dilatation or augmentation cystoplasty. RESULTS: A total of 156 children were evaluated, with a mean age of 7.4 years. Overall 62% vs 87% in the prenatal and postnatal surgery groups, respectively, were placed on clean intermittent catheterization (RR 0.71, 95% CI 0.58-0.86, p <0.001). Voiding status was significantly different between the groups (p <0.001) as 24% in the prenatal group vs 4% in the postnatal group (RR 5.8, 95% CI 1.8-18.7) were reported to be voiding volitionally. Augmentation cystoplasty, vesicostomy and urethral dilation did not differ between the 2 groups. Aside from a larger post-void residual urodynamic catheterization volume, there were no other statistical differences in videourodynamic data or findings on renal/bladder ultrasound. CONCLUSIONS: Prenatal closure of myelomeningocele resulted in less reported clean intermittent catheterization at school age and the mechanism for this is unclear. Although most children are in diapers or on clean intermittent catheterization, parental reports showed children who underwent prenatal closure may be more likely to void volitionally than the postnatal group. Despite these findings, urological outcomes alone should not be the sole impetus to perform in utero closure in children with spina bifida.

Fetal Congenital Pulmonary Airway Malformation: The Role of an Objective Measurement of Cardiomediastinal Shift.

OBJECTIVE: To examine the relationship between cardiomediastinal shift angle (CMSA) and adverse perinatal outcomes and hydrops in cases of congenital pulmonary airway malformation (CPAM). STUDY DESIGN: This retrospective study evaluated CPAM cases referred to our institution from 2008 to 2015. The primary outcome was a composite score for adverse perinatal outcome. CMSA was measured for each case and evaluated for its association with the primary outcome. The prediction accuracy of CMSA for adverse perinatal outcome was assessed using receiver operator characteristic (ROC) curves. RESULTS: Eighteen (21.2%) of the 85 cases experienced an adverse perinatal outcome. Increases in CMSA were associated with adverse perinatal outcomes and hydrops in bivariate analyses. Adjusted analyses found each 10-degree increase in CMSA to be associated with increased odds of an adverse perinatal outcome (adjusted odds ratio [aOR] 2.2, 95% confidence interval [CI]: 1.4-3.3) and hydrops (aOR 3.0, 95% CI: 1.5-6.1). CMSA performed well and was comparable to CPAM volume ratio in predicting adverse perinatal outcomes (area under the curve 0.81 and 0.84, respectively). CONCLUSION: We describe a novel measurement of mediastinal shift in cases of CPAM and its relationship with adverse perinatal outcomes and hydrops. These findings may shape the evaluation and management of CPAMs, improve our understanding of their prognosis, and influence patient counseling.

Esophagoesophagopexy technique for assisted fistulization of esophageal atresia.

PURPOSE: We describe our experience using a modified suture fistula technique for addressing tension in longer gap esophageal atresia (EA). Esophagoesophagopexy (EEP) is the tacking of the proximal and distal ends of esophageal pouches without formal anastomosis. In this retrospective cohort, we review the outcomes of patients with EA after EEP. METHODS: We reviewed the operative reports of EA cases treated at our institution from 1997 to 2016 and identified all patients described as having EEP. RESULTS: Of 129 EA cases, five patients underwent EEP. Formal anastomosis was not done due to patient's instability, prematurity, or long gap. Median birth weight was 1.4 kg (0.6-2.2 kg), and median gestational age at birth was 29 weeks (25-34 weeks). Age at time of EEP ranged 0-5 months. Esophagoesophageal fistula was confirmed in three patients. All three had strictures requiring weekly dilations. One of these patients died. The two surviving patients underwent fundoplication. CONCLUSION: We describe an alternative technique for esophageal anastomosis in patients for whom a standard anastomosis is not possible. EEP can lead to a functional anastomosis through fistulization and avoid the morbidity of multiple thoracotomies and lengthening procedures. Families should be educated on the potential need for dilations and antireflux procedures.

Closer Look at the Nutritional Outcomes of Patients After Primary Repair of Congenital Diaphragmatic Hernia.

OBJECTIVES: We hypothesize that the patients after primary repair of congenital diaphragmatic hernia (CDH) can have poor nutritional outcomes and plan to identify risk factors to further stratify these patients. METHODS: Retrospective cohort of patients who had primary repair of CDH between 2000 and 2014 and had follow-up at our institution. Z scores (weight for age and weight for length) were calculated using the World Health Organization and Centers for Disease Control and Prevention growth standards. RESULTS: For the 67 patients in the cohort, the median age at the time of repair was 3 days (interquartile range 2-5) and at the time of discharge was 20.5 days (interquartile range 16-30). Fifteen percent of the patients required supplemental tube feeding for inadequate oral intake and 69% required fortified feedings for inadequate growth at discharge (4 patients subsequently needed gastrostomy tube placement). The median z scores at discharge were -1.0 (-2.1 to -0.3) and -1.2 (-2.3 to -0.5) in weight for age and weight for length, respectively. The risk factors for low z scores included open repair and longer periods of postoperative intubation or hospitalization. The z scores were similar at 6 months of age compared to discharge, but then statistically improved at 12 months of age. CONCLUSIONS: Patients with primary repair of CDH are at risk for poor nutritional outcomes at the time of hospital discharge and require follow-up to ensure adequate growth. Patients at highest risk are those who had an open repair and had prolonged intubation or hospitalization.

Sacrococcygeal teratoma: late recurrence warrants long-term surveillance.

BACKGROUND: Sacrococcygeal teratoma (SCT) is a rare childhood malignancy. Although overall survival is favorable, recurrent tumors are associated with poor outcomes. As most recurrences occur within 3 years of presentation, the utility of long-term surveillance is uncertain. METHODS: Patients with SCTs evaluated and managed by our pediatric surgery department between 1986 and 2013 were included. Details pertaining to laboratory values, operative findings, tumor histology, management, recurrence, and outcomes were recorded and analyzed. RESULTS: During the study period, 40 children with the diagnosis of SCT were managed by our practice. Five (13%) developed a recurrence. The median age at the initial resection was day of life two (range day of life 0-2.5 years). The median time to recurrence was 5 years (range 5 months-15 years). Among those with recurrences, mature teratoma was the most common histological type on the initial resection (n = 3), with yolk sac and immature teratomas comprising the other two. At the time of recurrence, three patients had mature teratomas, and all are alive and well following resection. Two patients had yolk sac tumors at the time of recurrence and both died. CONCLUSION: SCT can recur many years after the initial resection. Our findings suggest that all patients with SCT should be closely followed into adulthood.

Amniotic band syndrome: a single-institutional experience.

INTRODUCTION: Amniotic band syndrome (ABS) is uncommon. We review our single-institutional experience to define its natural history and outcomes. MATERIALS AND METHODS: We conducted a retrospective analysis from a single, tertiary referral center of patients evaluated for and confirmed to have ABS from 1997 to 2012. RESULTS: Twenty-eight patients had confirmed ABS. The mean ± SD maternal age was 27.9 ± 5.9 years, and the mean gestational age at diagnosis was 20.7 ± 3.8 months. Oligohydramnios was reported in 4 patients. Eleven patients had membrane disruption, of whom 4 had undergone a prior percutaneous intervention. Extremities were the most common site affected (n = 20), followed by the umbilical cord (n = 7), abdomen (n = 5), limb-body wall complex (n = 5), head (n = 1), and chest (n = 1). Nine patients were felt to be candidates for fetal intervention; 5 underwent fetoscopic amniotic band lysis with 4 survivors. Overall survival, excluding 3 terminations, was 74%. There were 5 fetal demises and one neonatal death. Cord involvement was higher in nonsurvivors (67%) compared to survivors (19%, p = 0.05). DISCUSSION: ABS most commonly involves the extremities. Membrane disruption is not always present. Fetoscopic lysis is appropriate for select patients, and special consideration should be given for cord involvement, which is associated with a worse outcome.

Surgical site infections in neonates and infants: is antibiotic prophylaxis needed for longer than 24 h?

PURPOSE: The purpose is to determine whether use of perioperative antibiotics for more than 24 h decreases the incidence of SSI in neonates and infants. METHODS: We studied neonates and infants who had clean-contaminated or contaminated gastrointestinal operations from 1996 to 2006. Patient- and operation-related variables, duration of perioperative antibiotics, and SSI within 30 days were ascertained by retrospective chart review. In assessing the effects of antibiotic duration, we controlled for confounding by indication using standard covariate adjustment and propensity score matching. RESULTS: Among 732 operations, the incidence of SSI was 13%. Using propensity score matching, the odds of SSI were similar (OR 1.1, 95% CI 0.6-1.9) in patients who received ≤24 h of postoperative antibiotics compared to >24 h. No difference was also found in standard covariate adjustment. This multivariate model identified three independent predictors of SSI: preoperative infection (OR 3.9, 95% CI 1.4-10.9) and re-operation through the same incision, both within 30 days (OR 3.5, 95% CI 1.7-7.4) and later (OR 2.3, 95% CI 1.4-3.8). CONCLUSION: In clean-contaminated and contaminated gastrointestinal operations, giving >24 h of postoperative antibiotics offered no protection against SSI. An adequately powered randomized clinical trial is needed to conclusively evaluate longer duration antibiotic prophylaxis.

Teach Design to Surgical Trainees: One Small Step for Surgeons, One Giant Leap for Surgery.

The field of surgery faces complex, systemic challenges that will require new academic frameworks. In this paper, we propose design thinking as a useful problem-solving technique to apply to such challenges. We define design thinking and provide a brief history of this practice. Finally, we offer suggestions to introduce design thinking to surgical trainees, drawing from the experience of innovation programs that have incorporated this technique.

Evaluating Health Literacy in Families of Injured Children: A Prospective Observational Cohort Study at a Level One Pediatric Trauma Center.

BACKGROUND: Low health literacy (HL) has been associated with poor health outcomes in children. Optimal recovery after pediatric injury requires caregiver participation in complicated rehabilitative and medical aftercare. We aimed to quantify HL among guardians of injured children and identify factors associated with low HL of guardians. METHODS: A prospective observational cohort study was conducted to evaluate the HL using the Newest Vital Sign™ of guardians of injured children (≤18 years) admitted to a level 1 pediatric trauma center. Patient and guardian characteristics were compared across levels of HL using univariate statistics. We conducted multivariable logistic regression to identify factors independently-associated with low HL. RESULTS: A sample of 95 guardian-child dyads were enrolled. The majority of guardians had low HL (n = 52, 55%), followed by moderate HL (n = 36, 38%) and high HL (n = 7, 7%). Many families received public benefits (n = 47, 49%) and 12 guardians (13%) had both housing and employment insecurity. Guardians with low HL were significantly more likely to have insecure housing and not have completed any college. CONCLUSION: The majority of injured children had a primary guardian with low HL. Pediatric trauma centers should consider screening for low HL to ensure that families have adequate post-discharge support. LEVEL OF EVIDENCE: Level 3.

A novel ergonomic simulator for laparoscopic surgery.

Despite the importance of laparoscopic skill development to General Surgery trainees, current laparoscopic simulators are either too expensive or suffer from poor portability or low video quality. Moreover, several trainers without height adjustable platforms and screens do not promote optimal ergonomics. In this paper, we present the design process and initial prototype of a novel ergonomic laparoscopic simulator that addresses these limitations.

Anesthesia for in utero repair of myelomeningocele.

Recently published results suggest that prenatal repair of fetal myelomeningocele is a potentially preferable alternative when compared to postnatal repair. In this article, the pathology of myelomeningocele, unique physiologic considerations, perioperative anesthetic management, and ethical considerations of open fetal surgery for prenatal myelomeningocele repair are discussed. Open fetal surgeries have many unique anesthetic issues such as inducing profound uterine relaxation, vigilance for maternal or fetal blood loss, fetal monitoring, and possible fetal resuscitation. Postoperative management, including the requirement for postoperative tocolysis and maternal analgesia, are also reviewed. The success of intrauterine myelomeningocele repair relies on a well-coordinated multidisciplinary approach. Fetal surgery is an important topic for anesthesiologists to understand, as the number of fetal procedures is likely to increase as new fetal treatment centers are opened across the United States.

Fetal production of growth factors and inflammatory mediators predicts pulmonary hypertension in congenital diaphragmatic hernia.

BACKGROUND: Congenital diaphragmatic hernia (CDH) represents a spectrum of lung hypoplasia, and consequent pulmonary hypertension (PH) is an important cause of postnatal morbidity and mortality. We studied biomarkers at the maternal-fetal interface to understand factors associated with the persistence of PH. METHODS: Maternal and cord blood samples from fetuses with CDH and unaffected controls were analyzed using a human 39plex immunoassay kit. Cellular trafficking between the mother and the fetus was quantified using quantitative real-time PCR for nonshared alleles. Biomarker profiles were then correlated with CDH severity on the basis of the degree of PH. RESULTS: Cord blood levels of epidermal growth factor, platelet-derived growth factor, and several inflammatory mediators increased significantly as the severity of CDH increased, whereas maternal levels of growth factors and mediators decreased significantly with CDH severity. Maternal cells were increased in fetuses with severe CDH as compared with controls, with elevated levels of the CXC chemokine ligand-10 in patients with the highest trafficking. CONCLUSION: Patients with CDH demonstrate proinflammatory and chemotactic signals in fetal blood at the time of birth. Because some of these molecules have been implicated in the development of PH, prenatal strategies targeting specific molecular pathways may be useful adjuncts to current fetal therapies.

The North American Fetal Therapy Network Registry data on outcomes of radiofrequency ablation for twin-reversed arterial perfusion sequence.

OBJECTIVE: To report the North American Fetal Therapy Network (NAFTNet) Registry data on the outcomes of using radiofrequency ablation to treat twin-reversed arterial perfusion (TRAP). METHODS: This was a retrospective review of the records of all patients who underwent percutaneous radiofrequency ablation of an acardiac twin after referral to 12 NAFTNet institutions between 1998 and 2008. Maternal, fetal and neonatal data were analyzed. The primary outcome was neonatal survival to 30 days of age. All participating sites conducted this study under institutional review board approval. RESULTS: Of the 98 patients identified, there were no maternal deaths and no women required blood transfusions. Most women (76 of 98; 78%) stayed in the hospital for ≤1 day after the procedure. Mean gestational age at delivery was 33.4 weeks overall and 36.0 weeks for survivors. Median gestational age at delivery was 37.0 weeks. Survival of the pump twin to 30 days was 80% in the overall cohort. CONCLUSION: The NAFTNet registry data suggest that radiofrequency ablation of the acardiac twin is an effective treatment for TRAP sequence.

Congenital high airway obstruction sequence (CHAOS): a new case and a review of phenotypic features.

Congenital high airway obstruction sequence (CHAOS) has traditionally been defined as airway obstruction with ultrasound evidence of distal airway dilatation, expanded lungs, ascites, and hydrops. It can result from aplasia or intrinsic obstruction to the formation of the upper airway (larynx and trachea) during development. CHAOS is commonly sporadic and there is no known causative gene. In this comprehensive review on CHAOS, we examined 117 reported cases of this sequence and describe a new case. Malformations in addition to high airway obstruction were present in 64/118 (54.2%) of patients. The most frequent anomalies affected the digits and musculoskeletal system, but there was no distinct phenotype or characteristic dysmorphic appearance associated with CHAOS. The ex utero intrapartum therapy (EXIT) procedure has greatly improved survival for these patients and 36/118 (30.5%) were alive at the time of reporting. Only 2 patients out of 12 who underwent laryngotracheoplasty were tracheostomy-free at the time of their reporting. Six out of 13 were able to produce some speech. Our review provides valuable information on associated anomalies and survival in this complex sequence. The phenotypic variability seen in this review of patients makes it likely that the causes of CHAOS are genetically heterogeneous.

Non-Invasive Chromosomal Evaluation (NICE) Study: results of a multicenter prospective cohort study for detection of fetal trisomy 21 and trisomy 18.

OBJECTIVE: We sought to evaluate performance of a noninvasive prenatal test for fetal trisomy 21 (T21) and trisomy 18 (T18). STUDY DESIGN: A multicenter cohort study was performed whereby cell-free DNA from maternal plasma was analyzed. Chromosome-selective sequencing on chromosomes 21 and 18 was performed with reporting of an aneuploidy risk (High Risk or Low Risk) for each subject. RESULTS: Of the 81 T21 cases, all were classified as High Risk for T21 and there was 1 false-positive result among the 2888 normal cases, for a sensitivity of 100% (95% confidence interval [CI], 95.5-100%) and a false-positive rate of 0.03% (95% CI, 0.002-0.20%). Of the 38 T18 cases, 37 were classified as High Risk and there were 2 false-positive results among the 2888 normal cases, for a sensitivity of 97.4% (95% CI, 86.5-99.9%) and a false-positive rate of 0.07% (95% CI, 0.02-0.25%). CONCLUSION: Chromosome-selective sequencing of cell-free DNA and application of an individualized risk algorithm is effective in the detection of fetal T21 and T18.