Nontechnical Skills for Surgeons as a Framework to Evaluate Cardiopulmonary Bypass Management Skills of Resident Trainees.

BACKGROUND: Nontechnical skills are critical in cardiac surgery but currently there is no formal paradigm to teach these in residency training. We investigated the use of the Nontechnical skills for surgeons (NOTSS) system as a framework to assess and teach nontechnical skills related to cardiopulmonary bypass (CPB) management. METHODS: Single-center retrospective analysis of Integrated and Independent pathway thoracic surgery residents who participated in dedicated nontechnical skills evaluation and training. Two CPB management simulation scenarios were utilized. All residents received a lecture on CPB fundamentals and then individually participated in the first simulation ("Pre-NOTSS"). Immediately following this, nontechnical skills were rated by self-assessment and by a NOTSS trainer. All residents then underwent group NOTSS training followed by the second individual simulation ("Post-NOTSS"). Nontechnical skills were rated as before. NOTSS categories assessed included Situation Awareness, Decision Making, Communication and Teamwork, and Leadership. RESULTS: Nine residents were divided into 2 groups: Junior (n = 4, PGY1-4) and Senior (n = 5, PGY5-8). Pre-NOTSS resident self-ratings were higher for Senior than Junior in the categories of Decision Making, Communication and Teamwork, and Leadership while trainer ratings were similar between the groups. Post-NOTSS, resident self-ratings were higher for Senior than Junior in Situation Awareness and Decision Making while trainer scores were higher for both groups in Communication and Teamwork and Leadership. CONCLUSIONS: The NOTSS framework in conjunction with simulation scenarios provides a practical framework to evaluate and teach nontechnical skills related to CPB management. NOTSS training can lead to improvements in both subjective and objective ratings of nontechnical skills for all PGY levels.

Don't Break My Heart: A Case Report of Takotsubo Syndrome in a Transplanted Heart.

Cardiogenic shock after heart transplant, could be due to acute rejection, cardiac allograft vasculopathy, or myocarditis. Stress cardiomyopathy (CM) in a denervated transplanted heart is unusual. A 56-year-old man with a history of ischemic heart disease and a seizure disorder underwent orthotropic heart transplant. He had breakthrough seizures posttransplant while on levetiracetam (Keppra) and was admitted for status epilepticus. A transthoracic echocardiogram (TTE) was done for hypotension (BP 90/60). TTE showed a severely reduced left ventricular ejection fraction (LVEF) of 15%, hyperkinetic base, and apical ballooning that are consistent with stress CM. Electrocardiogram with T wave inversion in precordial leads. Troponin was elevated to 1.77. The patient had cardiogenic shock and needed an intra-aortic balloon pump and multiple pressors. He was treated for status epilepticus and the LVEF completely recovered in 1 week. The patient had a normal TTE, coronary angiography, and biopsy with no rejection 8 days before admission. Stress CM was the diagnosis of exclusion, confirmed with a complete recovery of the LVEF. There are only 5 case reports of stress CM after heart transplant, with most presenting 9 to 10 years afterwards. We describe an unusual case of cardiogenic shock from stress CM triggered by status epilepticus in a denervated heart only 1 year posttransplant. The mechanism is elusive, and some hypotheses suggest exaggerated sensitivity to a plasma catecholamine surge from parasympathetic denervation. In a denervated heart, autonomic re-innervation can be seen as early as 1 year posttransplant.

Fulminant myocarditis: COVID or not COVID? Reinfection or co-infection?

We describe a unique case of fulminant myocarditis in a patient with presumed SARS-CoV-2 reinfection. Patient had initial infection 4 months backand had COVID-19 antibody at the time of presentation. Endomyocardial biopsy showed lymphocytic myocarditis, that is usually seen in viral myocarditis. The molecular diagnostic testing of the endomyocardial biopsy for cardiotropic viruses was positive for Parvovirus and negative for SARS-CoV-2. Authors highly suspect co-infection of SARS-CoV-2 and Parvovirus, that possibly triggered the immune cascade resulting in fulminant myocarditis. Patient was hemodynamically unstable with ventricular tachycardia and was supported on VA ECMO and Impella CP. There was impressive recovery of left ventricular function within 48 h, leading to decannulation of VA ECMO in 72 h. This unique case was written by the survivor herself.

Computer Based Melanocytic and Nevus Image Enhancement and Segmentation.

Digital dermoscopy aids dermatologists in monitoring potentially cancerous skin lesions. Melanoma is the 5th common form of skin cancer that is rare but the most dangerous. Melanoma is curable if it is detected at an early stage. Automated segmentation of cancerous lesion from normal skin is the most critical yet tricky part in computerized lesion detection and classification. The effectiveness and accuracy of lesion classification are critically dependent on the quality of lesion segmentation. In this paper, we have proposed a novel approach that can automatically preprocess the image and then segment the lesion. The system filters unwanted artifacts including hairs, gel, bubbles, and specular reflection. A novel approach is presented using the concept of wavelets for detection and inpainting the hairs present in the cancer images. The contrast of lesion with the skin is enhanced using adaptive sigmoidal function that takes care of the localized intensity distribution within a given lesion's images. We then present a segmentation approach to precisely segment the lesion from the background. The proposed approach is tested on the European database of dermoscopic images. Results are compared with the competitors to demonstrate the superiority of the suggested approach.

Segmentation of skin lesion using Cohen-Daubechies-Feauveau biorthogonal wavelet.

This paper presents a novel technique for segmentation of skin lesion in dermoscopic images based on wavelet transform along with morphological operations. The acquired dermoscopic images may include artifacts inform of gel, dense hairs and water bubble which make accurate segmentation more challenging. We have also embodied an efficient approach for artifacts removal and hair inpainting, to enhance the overall segmentation results. In proposed research, color space is also analyzed and selection of blue channel for lesion segmentation have confirmed better performance than techniques which utilizes gray scale conversion. We tackle the problem by finding the most suitable mother wavelet for skin lesion segmentation. The performance achieved with 'bior6.8' Cohen-Daubechies-Feauveau biorthogonal wavelet is found to be superior as compared to other wavelet family. The proposed methodology achieves 93.87 % accuracy on dermoscopic images of PH2 dataset acquired at Dermatology Service of Hospital Pedro Hispano, Matosinhos, Portugal.

Penetrating duodenal trauma: A 19-year experience.

BACKGROUND: Multiple techniques are used for repair in duodenal injury ranging from simple suture repair for low-grade injuries to pancreaticoduodenectomy for complicated high-grade injuries. Drains, both intraluminal and extraluminal, are placed variably depending on associated injuries and confidence with the repair. It is our contention that a simplified approach to repair will limit complications and mortality. The major complication of duodenal leak (DL) was the outcome used to assess methods of repair in this study. METHODS: After early deaths from associated vascular injuries were excluded, patients with a penetrating duodenal injury admitted during a 19-year period ending in 2014 constituted the study population. RESULTS: A total of 125 patients with penetrating duodenal injuries were included. Overall, the leak rate was 8% with two duodenal-related mortalities. No differences were seen in patients who had a DL as compared with no leak with respect to demographics, injury severity, or admission variables. Patients with DL were more likely to have a major vascular injury (60% vs. 23%, p = 0.02) and a combined pancreatic injury (70% vs. 31%, p = 0.03). No differences were identified by repair technique, location, or grade of injury. DLs were more likely to have an extraluminal drain (90% vs. 45%, p = 0.008). CONCLUSION: Primary suture repair should be the initial approach considered for most injuries. Major vascular injuries and concomintant pancreatic injuries were associated with most leaks; therefore, adjuncts to repair including intraluminal drainage and pyloric exclusion should be considered on the initial operation. Extraluminal drains should be avoided unless required for associated injuries. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Assessing routing strategies for cognitive radio sensor networks.

Interest in the cognitive radio sensor network (CRSN) paradigm has gradually grown among researchers. This concept seeks to fuse the benefits of dynamic spectrum access into the sensor network, making it a potential player in the next generation (NextGen) network, which is characterized by ubiquity. Notwithstanding its massive potential, little research activity has been dedicated to the network layer. By contrast, we find recent research trends focusing on the physical layer, the link layer and the transport layers. The fact that the cross-layer approach is imperative, due to the resource-constrained nature of CRSNs, can make the design of unique solutions non-trivial in this respect. This paper seeks to explore possible design opportunities with wireless sensor networks (WSNs), cognitive radio ad-hoc networks (CRAHNs) and cross-layer considerations for implementing viable CRSN routing solutions. Additionally, a detailed performance evaluation of WSN routing strategies in a cognitive radio environment is performed to expose research gaps. With this work, we intend to lay a foundation for developing CRSN routing solutions and to establish a basis for future work in this area.