Use of multidisciplinary positive deviance seminars to improve efficiency in a high-volume arthroplasty practice: a pilot study.

BACKGROUND: Positive deviance (PD) seminars, which have shown excellent results in improving the quality of surgical practices, use individual performance feedback to identify team members who outperform their peers; the strategies from those with exemplary performance are used to improve team members' practices. Our study aimed to use the PD approach with arthroplasty surgeons and nurses to identify multidisciplinary strategies and recommendations to improve operating room (OR) efficiency. METHODS: We recruited 5 surgeons who performed high-volume primary arthroplasty and had participated in 4-joint rooms since 2012, and 29 nurses who had participated in 4-joint rooms and in at least 16 cases in our data set. Three 1-hour PD sessions were held in February and March 2021: 1 with surgeons, 1 with nurses, and 1 with both surgeons and nurses to select recommendations for implementation. The sessions were led by a member of the nonorthopedic surgical faculty who was familiar with the subjects discussed and with PD seminars. To determine the success of the recommendations, we compared OR efficiency before and after implementation. We defined success as performance of 4 joint procedures within 8 hours. RESULTS: Eleven recommendations were recorded from the session with nurses and 7 from the session with surgeons, of which 11 were selected for implementation. During the month after implementation, there were great improvements across all time intervals of surgical procedures, with the greatest improvements seen in mean anesthesia preparation time in the room (4.51 min [26.3%]), mean procedure duration (9.75 min [14.0%]) and mean anesthesia finish time (5.78 min [44.0%]) (all p < 0.001). The total time saved per day was 49.84 minutes; this led to a success rate of 69.0%, a relative increase of 73.8% from our 2012-2020 success rate of 39.7% (p < 0.001). CONCLUSION: The recommendations and increased motivation owing to the individualized feedback reduced time spent per case, allowing more days to finish on time. Positive deviance seminars offer an inexpensive, efficient and collegial means for process improvement in the OR.

Artificial intelligence-driven prescriptive model to optimize team efficiency in a high-volume primary arthroplasty practice.

PURPOSE: We aimed to improve OR efficiency using machine learning (ML) to find relevant metrics influencing surgery time success and team performance on efficiency to create a model which incorporated team, patient, and surgery-related factors. METHODS: From 2012 to 2020, five surgeons, 44 nurses, and 152 anesthesiologists participated in 1199 four joint days (4796 cases): 1461 THA, 1496 TKA, 652 HR, 242 UKA, and 945 others. Patients were 2461f:2335 m; age, 64.1; BMI, 29.93; and ASA, 2.45. Surgical Success was defined as completing four joints within an eight hour shift using one OR. Time data was recorded prospectively using Surgical Information Management Systems. Hospital records provided team, patient demographics, adverse events, and anesthetic. Data mining identified patterns and relationships in higher dimensions. Predictive analytics used ML ranking algorithm to identify important metrics and created decision tree models for benchmarks and success probability. RESULTS: Five variables predicted success: anaesthesia preparation time, surgical preparation time, time of procedure, anesthesia finish time, and type of joint replacement. The model determined success rate with accuracy of 72% and AUC = 0.72. Probability of success based on mean performance was 77-89% (mean-median) if APT 14-15 minutes, PT 68-70 minutes, AFT four to five minutes, and turnover 25-27 minutes. With the above benchmarks maintained, success rate was 59% if surgeon exceeded 71.5-minutes PT or 89% if 64-minutes procedure time or 66% when anesthesiologist spent 17-19.5 minutes on APT. CONCLUSION: AI-ML predicted OR success without increasing resources. Benchmarks track OR performance, demonstrate effects of strategic changes, guide decisions, and provide teamwork improvement opportunities.

Smart Technology and Orthopaedic Surgery: Current Concepts Regarding the Impact of Smartphones and Wearable Technology on Our Patients and Practice.

PURPOSE OF REVIEW: While limited to case reports or small case series, emerging evidence advocates the inclusion of smartphone-interfacing mobile platforms and wearable technologies, consisting of internet-powered mobile and wearable devices that interface with smartphones, in the orthopaedic surgery practice. The purpose of this review is to investigate the relevance and impact of this technology in orthopaedic surgery. RECENT FINDINGS: Smartphone-interfacing mobile platforms and wearable technologies are capable of improving the patients' quality of life as well as the extent of their therapeutic engagement, while promoting the orthopaedic surgeons' abilities and level of care. Offered advantages include improvements in diagnosis and examination, preoperative templating and planning, and intraoperative assistance, as well as postoperative monitoring and rehabilitation. Supplemental surgical exposure, through haptic feedback and realism of audio and video, may add another perspective to these innovations by simulating the operative environment and potentially adding a virtual tactile feature to the operator's visual experience. Although encouraging in the field of orthopaedic surgery, surgeons should be cautious when using smartphone-interfacing mobile platforms and wearable technologies, given the lack of a current academic governing board certification and clinical practice validation processes.

Correlation of 68Ga-DOTATATE uptake on PET/CT with pathologic features of cellular proliferation in neuroendocrine neoplasms.

OBJECTIVE: 68Ga-DOTATATE positron emission tomography/computed tomography (PET/CT) is a useful tool for diagnosing and staging neuroendocrine neoplasms (NEN). Unlike other PET tracers like FDG, the meaningfulness and use of standardized uptake values (SUVs) of 68Ga-DOTATATE is not well-established. This study aimed to determine if a correlation exists between intensity of 68Ga-DOTATATE uptake and markers of cellular proliferation. METHODS: This retrospective study included 79 patients with positive 68Ga-DOTATATE PET/CT and Ki-67 and/or mitotic index (MI) available on pathology report. SUVmax of the most intense lesion and the most intense organ-matched lesion were determined. Demographics and pathology results for Ki-67 and MI were collected from the electronic medical record. Correlations and trends for correlations of SUVmax to Ki-67 and MI were performed using Kruskal-Wallis and Cuzick trend tests. RESULTS: A trend for an association between SUVmax and Ki-67 grade was found; median SUVmax of Ki-67 < 3%, 3-20%, and > 20% was 35.2, 31.8, and 12.8 (p = 0.077), respectively. There was also a trend between SUVmax and Ki-67 categories in organ-matched lesions (p = 0.08). The median organ-matched SUVmax of MI < 2, 2-20, and > 20 lesions was 34.2, 18, and 21.7, respectively, (Cuzick trend test p = 0.066). The median SUVmax for small bowel, pancreatic, and other primary locations was 27.6, 46.9, and 9.3 (p < 0.01), respectively. CONCLUSIONS: The association between 68Ga-DOTATATE SUVmax, histologic grade, and primary site of NEN demonstrates its potential use for prognostication, or potentially as a surrogate for histologic grading when biopsy is not possible.

Cell sorting actuated by a microfluidic inertial vortex.

The sorting of specific cell populations is an established tool in biological research, with new applications demanding greater cell throughput, sterility and elimination of cross-contamination. Here we report 'vortex-actuated cell sorting' (VACS), a new technique that deflects cells individually, via the generation of a transient microfluidic vortex by a thermal vapour bubble: a novel mechanism, which is able to sort cells based on fluorescently-labelled molecular markers. Using in silico simulation and experiments on beads, an immortal cell line and human peripheral blood mononuclear cells (PBMCs), we demonstrate high-purity and high-recovery sorting with input rates up to 104 cells per s and switching speeds comparable to existing techniques (>40 kHz). A tiny footprint (1 × 0.25 mm) affords miniaturization and the potential to achieve multiplexing: a crucial step in increasing processing rate. Simple construction using biocompatible materials potentially minimizes cost of fabrication and permits single-use sterile cartridges. We believe VACS potentially enables parallel sorting at throughputs relevant to cell therapy, liquid biopsy and phenotypic screening.

Metastatic Gallbladder Melanoma Presenting as Acute Emphysematous Cholecystitis.

Malignant melanoma is an aggressive tumor with a high potential for distant metastases, including spread to the gallbladder where it represents more than half of all metastases detected at autopsy. Yet, it is rarely symptomatic in life and is a rare cause of acute cholecystitis. Emphysematous cholecystitis is a rare, potentially fatal variant of acute cholecystitis characterized by the presence of gas in the gallbladder lumen or wall. We report a 77-year-old woman with acute emphysematous cholecystitis as the initial feature of recurrent melanoma metastatic to the gallbladder. This exceptional association highlights the need to consider a relapse of malignancy when assessing unexplained abdominal symptoms in any patient with a prior history of melanoma.

CT of rib lesions.

OBJECTIVE: This article discusses how ribs are involved in a variety of traumatic, metabolic, inflammatory, neoplastic, and congenital disorders. CONCLUSION: We review the normal anatomy pertinent to rib imaging and illustrate the key features of a variety of rib lesions, emphasizing the diagnostic value of CT.

Association of tumor necrosis factor alpha polymorphism, but not the shared epitope, with increased radiographic progression in a seropositive rheumatoid arthritis inception cohort.

OBJECTIVE: To determine whether the tumor necrosis factor alpha (TNFA) -308 guanine-to-adenosine polymorphism and/or the shared epitope (SE) is associated with radiographic damage in patients with early rheumatoid arthritis (RA). METHODS: The cohort consisted of 189 patients with early seropositive RA (median 5.6 months since symptom onset) who had active disease, no previous disease-modifying antirheumatic drug treatment, and >or=2 sets of scored radiographs of the hands/wrists and forefeet. TNFA -308 polymorphism was analyzed by polymerase chain reaction pyrosequencing. The SE was defined as presence of any 1 of the following HLA-DRB1 alleles: *0101, *0102, *0401, *0404, *0405, *0408, *0410, *1001, *1402, or *1406. Radiographic progression was assessed by the total Sharp score. RESULTS: Using a weighted least-squares regression analysis, patients with the -308 TNFA AA plus AG genotypes (n=49) had significantly higher rates of progression in erosion scores (median 0.84 versus 0.48 units/year), joint space narrowing (JSN) scores (0.42 versus 0.04), and total Sharp scores (1.70 versus 0.61) compared with patients with the TNFA GG genotype (n=140). Presence of the SE (n=137) was associated with significantly lower progression rates (per year) for total Sharp scores (median 0.9 versus 1.25 units/year) and JSN scores (0.04 versus 0.41), but not for erosion scores (0.50 versus 0.61) compared with patients without the SE (n=52). In a least-squares multiple linear regression model, the presence of the AA plus AG genotypes was associated with a significantly higher progression rate after adjusting for the presence of the SE, interaction between the SE and the AA plus AG genotypes, baseline log C-reactive protein level, Health Assessment Questionnaire Disability Index, total Sharp score, swollen joint count, and presence of osteophytes (osteoarthritis). There was a strong linkage disequilibrium between DRB1*0301 and TNFA polymorphism (D'=0.84, r2=0.45, P<0.001). CONCLUSION: This study showed an association between the TNFA -308 polymorphism and progression of radiographic damage in patients with early seropositive RA. This association appeared to be independent of the SE, but might be dependent on other genetic variants in linkage disequilibrium with the -308 TNFA A allele and DRB1*0301. Further studies should be conducted to validate these results in both longitudinal observational cohorts and randomized clinical trials.