Real-time laser speckle contrast imaging for intraoperative neurovascular blood flow assessment: animal experimental study.

The use of various blood flow control methods in neurovascular interventions is crucial for reducing postoperative complications. Neurosurgeons worldwide use different methods, such as contact Dopplerography, intraoperative indocyanine videoangiography (ICG) video angiography, fluorescein angiography, flowmetry, intraoperative angiography, and direct angiography. However, there is no noninvasive method that can assess the presence of blood flow in the vessels of the brain without the introduction of fluorescent substances throughout the intervention. The real-time laser-speckle contrast imaging (LSCI) method was studied for its effectiveness in controlling blood flow in standard cerebrovascular surgery cases in rat common carotid arteries, such as proximal occlusion, trapping, reperfusion, anastomosis, and intraoperative vessel thrombosis. The real-time LSCI method is a promising method for use in neurosurgical practice. This approach allows timely diagnosis of intraoperative disturbance of blood flow in vessels in cases of clip occlusion or thrombosis. Additionally, LSCI allows us to reliably confirm the functioning of the anastomosis and reperfusion after removal of the clips and thrombolysis in real time. An unresolved limitation of the method is noise from movements, but this does not reduce the value of the method. Additional research is required to improve the quality of the data obtained.

Comparing laser speckle contrast imaging and indocyanine green angiography for assessment of parathyroid perfusion.

Accurate intraoperative assessment of parathyroid blood flow is crucial to preserve function postoperatively. Indocyanine green (ICG) angiography has been successfully employed, however its conventional application has limitations. A label-free method overcomes these limitations, and laser speckle contrast imaging (LSCI) is one such method that can accurately detect and quantify differences in parathyroid perfusion. In this study, twenty-one patients undergoing thyroidectomy or parathyroidectomy were recruited to compare LSCI and ICG fluorescence intraoperatively. An experimental imaging device was used to image a total of 37 parathyroid glands. Scores of 0, 1 or 2 were assigned for ICG fluorescence by three observers based on perceived intensity: 0 for little to no fluorescence, 1 for moderate or patchy fluorescence, and 2 for strong fluorescence. Speckle contrast values were grouped according to these scores. Analyses of variance were performed to detect significant differences between groups. Lastly, ICG fluorescence intensity was calculated for each parathyroid gland and compared with speckle contrast in a linear regression. Results showed significant differences in speckle contrast between groups such that parathyroids with ICG score 0 had higher speckle contrast than those assigned ICG score 1, which in turn had higher speckle contrast than those assigned ICG score 2. This was further supported by a correlation coefficient of -0.81 between mean-normalized ICG fluorescence intensity and speckle contrast. This suggests that ICG angiography and LSCI detect similar differences in blood flow to parathyroid glands. Laser speckle contrast imaging shows promise as a label-free alternative that overcomes current limitations of ICG angiography for parathyroid assessment.

Real-time laser speckle contrast imaging measurement during normothermic machine perfusion in pretransplant kidney assessment.

OBJECTIVES: Normothermic machine perfusion (NMP) provides a platform for pre-transplant kidney quality assessment that is essential for the use of marginal donor kidneys. Laser speckle contrast imaging (LSCI) presents distinct advantages as a real-time and noncontact imaging technique for measuring microcirculation. In this study, we aimed to assess the value of LSCI in visualizing renal cortical perfusion and investigate the additional value of dual-side LSCI measurements compared to single aspect measurement during NMP. METHODS: Porcine kidneys were obtained from a slaughterhouse and then underwent NMP. LSCI was used to measure one-sided cortical perfusion in the first 100 min of NMP. Thereafter, the inferior renal artery branch was occluded to induce partial ischemia and LSCI measurements on both ventral and dorsal sides were performed. RESULTS: LSCI fluxes correlated linearly with the renal blood flow (R2 = 0.90, p < 0.001). After renal artery branch occlusion, absence of renal cortical perfusion could be visualized and semiquantified by LSCI. The overall ischemic area percentage of the ventral and dorsal sides was comparable (median interquartile range [IQR], 38 [24-43]% vs. 29 [17-46]%, p = 0.43), but heterogenous patterns between the two aspects were observed. There was a significant difference in oxygen consumption (mean ± standard deviation [SD], 2.57 ± 0.63 vs. 1.83 ± 0.49 mLO2 /min/100 g, p < 0.001), urine output (median [IQR], 1.3 [1.1-1.7] vs. 0.8 [0.6-1.3] mL/min, p < 0.05), lactate dehydrogenase (mean ± SD, 768 ± 370 vs. 905 ± 401 U/L, p < 0.05) and AST (mean ± SD, 352 ± 285 vs. 462 ± 383 U/L, p < 0.01) before and after renal artery occlusion, while no significant difference was found in creatinine clearance, fractional excretion of sodium, total sodium reabsorption and histological damage. CONCLUSIONS: LSCI fluxes correlated linearly with renal blood flow during NMP. Renal cortical microcirculation and absent perfusion can be visualized and semiquantified by LSCI. It provides a relative understanding of perfusion levels, allowing for a qualitative comparison between regions in the kidney. Dual-side LSCI measurements are of added value compared to single aspect measurement and renal function markers.

Comprehensive assessment of systemic arteriosclerosis in relation to the ocular resistive index in acute coronary syndrome patients.

This study aimed to investigate the relationship between ocular vascular resistance parameters, evaluated by laser speckle flowgraphy (LSFG), and systemic atherosclerosis, renal parameters and cardiac function in acute coronary syndrome (ACS) patients. We evaluated 53 ACS patients between April 2019 and September 2020. LSFG measured the mean blur rate (MBR) and ocular blowout time (BOT) and resistivity index (RI). 110 consequent patients without a history of coronary artery disease who visited ophthalmology as a control group. Significant positive correlations were observed between ocular RI and systemic parameters in ACS patients, including intima-media thickness (r = 0.34, P = 0.015), brachial-ankle pulse-wave velocity (r = 0.41, P = 0.002), cystatin C (r = 0.32, P = 0.020), and E/e' (r = 0.34, P = 0.013). Ocular RI was significantly higher in the ACS group than in the control group in male in their 40 s (0.37 ± 0.02 vs. 0.29 ± 0.01, P < 0.001) and 50 s (0.36 ± 0.02 vs. 0.30 ± 0.01, P = 0.01). We found that the ocular RI was associated with systemic atherosclerosis, early renal dysfunction, and diastolic cardiac dysfunction in ACS patients, suggesting that it could be a useful non-invasive comprehensive arteriosclerotic marker.

Blood Perfusion of Random Skin Flaps in Humans-In Vivo Assessment by Laser Speckle Contrast Imaging.

BACKGROUND: The viability of random skin flaps (RSFs) depends on an adequate perfusion pressure to avoid necrosis. Laser speckle contrast imaging is a new method to monitor skin flap microcirculation. OBJECTIVE: The authors aimed to use laser speckle contrast imaging in evaluating the correlation between the perfusion pressure and the length-to-width ratio (LTWR) of RSFs. MATERIALS AND METHODS: Sixty patients submitted to flaps were included: 20 advancement, 20 rotation, and 20 transposition flaps. Laser speckle contrast imaging measurements of perfusion were obtained-after the flaps were planned, dissected, and sutured-from the base to the tip of the flaps, allowing the creation of plot charts and calculation of linear regression equations. RESULTS: Perfusion consistently and significantly decreased with the dissection of all flaps. A significant correlation between LTWR and perfusion was observed in undermined and sutured stages; a mathematical model was then delineated, explaining objectively the drop of perfusion along LTWR, with statistical significance, in all flaps. CONCLUSION: Laser speckle contrast imaging allows accurate, rapid, reproducible, and noncontact measurements of skin blood perfusion over RSF, ultimately leading to an optimization of skin flap planning. This study proves that variation of perfusion pressure along the flap is dependent on the LTWR in a linear decreasing function.

Laser Speckle Contrast Imaging for the Objective Assessment of Blood Perfusion in Keloids Treated With Dual-Wavelength Laser Therapy.

BACKGROUND: Most of the widely used methods for the assessment of keloid treatment are subjective grading scales based on the opinion of an individual clinician or patient. There is a growing need for objective methods to evaluate keloid treatment. OBJECTIVE: This study aimed to evaluate the value of laser speckle contrast imaging (LSCI) as an objective method for the assessment of dual-wavelength laser therapy for keloids. METHODS: This prospective study included 21 patients with 54 keloids. All patients were treated with a combined 585-nm pulsed dye laser and 1,064 nm neodymium-doped yttrium aluminum garnet dual-wavelength laser at 4 weeks to 6 weeks intervals. Keloids were assessed using the Vancouver Scar Scale (VSS) and LSCI. RESULTS: The total VSS score significantly decreased after 4 sessions of treatment (p < .05). Blood perfusion in keloids as measured by LSCI was significantly reduced after treatment (p < .05). The improvement of chest keloids in terms of the total VSS score and blood perfusion was significantly greater than that of scapular keloids (p < .05). There was a positive correlation between decreased perfusion and reduced total VSS score (R2 = 0.84). CONCLUSION: Blood perfusion in keloids significantly decreased after dual-wavelength laser therapy. Laser speckle contrast imaging is a promising objective method for assessing the improvement of keloids treated with laser therapy.

Evidence Based Burn Depth Assessment Using Laser-Based Technologies: Where Do We Stand?

Early clinical assessment of burn depth and associated healing potential (HP) remains extremely challenging, even for experienced surgeons. Inaccurate diagnosis often leads to prolonged healing times and unnecessary surgical procedures, resulting in incremental costs, and unfavorable outcomes. Laser Doppler imaging (LDI) is currently the most objective and accurate diagnostic tool to measure blood flow and its associated HP, the main predictor for a patient's long-term functional and aesthetic outcome. A systematic review was performed on non-invasive, laser-based methods for burn depth assessment using skin microcirculation measurements to determine time to healing: Laser Doppler flowmetry (LDF), LDI and laser speckle contrast imaging (LSCI). Important drawbacks of single point LDF measurements are direct contact with numerous small points on the wound bed and the need to carry out serial measurements over several days. LDI is a fast, "non-contact," single measurement tool allowing to scan large burned areas with a 96% accuracy. LDI reduces the number of surgeries, improves the functional and aesthetic outcome and is cost-effective. There is only limited evidence for the use of LSCI in burn depth assessment. LSCI still needs technical improvements and scientific validation, before it can be approved for reliable burn assessment. LDI has proven to be invaluable in determining the optimal treatment of a burn patient. For unclear reasons, LDI is still not routinely used in burn centers worldwide. Additional research is required to identify potential "barriers" for universal implementation of this evidence-based burn depth assessment tool.

Using blood flow pulsatility to improve the accuracy of laser speckle contrast imaging in the assessment of burns.

OBJECTIVES: Measurement of perfusion is an established method to evaluate the depth of burns. However, high accuracy is only achievable >48 h after injury. The aim of the study was to investigate if measurement of blood flow pulsatility, combined with perfusion measurement, can improve early assessment of burn depth using laser speckle contrast imaging (LSCI). METHODS: Perfusion and pulsatility were measured with LSCI in 187 regions of interest in 32 patients, between 0 and 5 days after injury. The reproducibility of pulsatility was tested for recording durations between 1 and 12 s. The most reproducible duration was chosen, and receiver operator characteristics were created to find suitable pulsatility cut-offs to predict surgical need. RESULTS: A measurement duration of 8 s resulted in a good reproducibility of the pulsatility (%CV: 15.9%). Longer measurement durations resulted in a small improvement of the accuracy of the assessment. A pulsatility of <1.45 (Perfusion Units)2 on day 0-2 after injury predicted surgical need with a sensitivity of 100% (95% CI: 83.2-100%), specificity of 100% (95% CI: 95.2-100%), a positive predictive value of 100%, and a negative predictive value of 100%. Pulsatility was not significantly different when comparing measurements done day 0-2 to day 3-5. Perfusion was however significantly higher day 3-5 compared to day 0-2 for wounds healing within 3 weeks. CONCLUSION: Measurement of pulsatility improves the accuracy of the assessment of burns with LSCI and makes it possible to predict the need for surgery during day 0-2 after injury with a high accuracy.

Global diastolic strain rate for the assessment of left ventricular diastolic dysfunction in young peritoneal dialysis patients: a case control study.

BACKGROUND: Left ventricular (LV) myocardial longitudinal diastolic strain rate measured by two-dimensional speckle tracking imaging (2D-STI) was proved to have a better correlation with the LV diastolic function. We aimed to use this sensitive tool to predict LV myocardial diastolic dysfunction in young peritoneal dialysis (PD) patients with preserved LV ejection fraction (LVEF). METHODS: We enrolled 30 PD patients aged ≤60 with LVEF ≥54% and classified as normal LV diastolic function by conventional echocardiography, and 30 age- and sex-matched healthy people as the control group. The left atrial maximum volume index (LAVI), LV mass index (LVMI), LVEF, LV posterior wall thickness (LVPWT), interventricular septal thickness (IVST), peak velocity of tricuspid regurgitation (TR), peak early diastolic velocity/late diastolic velocity (by Pulsed Doppler) (E/A) and E/peak velocity of the early diastolic wave (by Pulsed-wave tissue Doppler) (E/e') were recorded by conventional echocardiographic. Next, the average LV global longitudinal systolic strain (GLS avg) and the average LV global longitudinal diastolic strain rate (DSr avg) during early diastole (DSrE avg), late diastole (DSrA avg) and isovolumic relaxation period (DSrIVR avg) were obtained from 2D-STI. Combined them with E, the new noninvasive indexes (E/DSrE avg., E/DSrA avg. and E/DSrIVR avg) were derived. RESULTS: The PD group 's LVEF, E/e', TR and LAVI were in the normal range compared with the controls, and only e' (p < 0.001) was decreased. The LVMI (p < 0.001), LVPWT (p < 0.001), IVST (p < 0.001) increased while E/A (p < 0.001) decreased. The GLS avg. (p = 0.008) was significantly decreased in PD patients compared with the controls. DSrA avg. (p = 0.006) and E/DSrE avg. (p = 0.006) were increased, while DSrE avg. (p < 0.001), DSrIVR avg. (p = 0.017) and E/DSrA avg. (p < 0.001) decreased. After the multivariable regression analysis, the correlation between DSrE and the conventional parameters including LVPWT (p < 0.001), E/A (p < 0.001) still remained significant. CONCLUSIONS: Young PD patients with preserved LVEF already exhibited myocardial diastolic dysfunction. Global diastolic strain rate indexes were valuable parameters to evaluate diastolic dysfunction. Additionally, LVPWT was highly correlated with DSrE, such parameter should be taken into account for predicting the early LV diastolic dysfunction in clinical practice.

Impacto en costos por embarazos adolescentes 15 a 18 años en un hospital del departamento del Atlántico 2013 a 2017 / Impact on costs for adolescent pregnancies 15 to 18 years in a hospital in the department of Atlantic 2013 to 2017

Introduction: Adolescence is the transition between childhood and adulthood. The beginning of reproductive sexual life in this phase means to 1 in 5 adolescents becoming pregnant. 64% of these pregnancies are not planned, which entails high costs in health institutions. Objective: Show by proportional analysis the costs of care for pregnant adolescents in a hospital in the Atlantic department in 2013 and 2017. Materials and methods: Cross-sectional descriptive study, by means of proportional analysis, estimated costs of vaginal delivery by caesarean section and ICU care in 2013 and 2017 periods. Results: It was found that the costs of patients attended in 2013 and 2017, the 2013 proportion is lower (chi-square: 2,287; P> 0.05). In the costs of patients attended by vaginal delivery in 2013 and 2017, the proportion of 2013 is lower (chi-square: 17,340; P <0.05). The costs of patients attended by Cesarean in 2013 and 2017, the proportion of 2013 is lower (chi-square: 5,771; P <0.05). The costs of patients cared for by Caesarean section and patients referred to the ICU for the year 2013, the proportion of patients referred to the ICU is lower. (chi-square: 5,771; P = 0.00 for Cesarean section in 2013 and a chi-square value: 2,276; P = 0.03 for ICU referral in 2013). Conclusions: adolescent pregnancy is a public health problem with an increasing trend that leads to obstetric complications that can occur during this period, plus the high rate of caesarean sections, which therefore increases costs in the provision of health services.

Introducción: La adolescencia marca la separación entre la infancia y la vida adulta, con el inicio de la vida sexual reproductiva conlleva a que 1 de cada 5 adolescentes quede embarazada. El 64% de estos embarazos no sean planeados, generando altos costos en las instituciones de salud. Objetivo: Determinar mediante análisis de proporciones los costos de la atención en embarazadas adolescentes en un hospital del Departamento del Atlántico en los periodos 2013 y 2017. Materiales y métodos: Estudio descriptivo transversal, mediante análisis de proporciones se estimaron costos de parto vaginal cesárea y atención en uci en periodos 2013 y 2017. Resultados: se encontró que los costos de pacientes atendidas en los años 2013 y 2017, la proporción 2013 es menor (chi ­ cuadrado: 2,287; P > 0,05). Los costos de pacientes atendidas por parto vaginal en los años 2013 y 2017, la proporción del 2013 es menor (chi ­ cuadrado: 17,340; P < 0,05). Los costos de pacientes atendidas por Cesárea en los años 2013 y 2017, la proporción del 2013 es menor (chi ­ cuadrado: 5,771; P < 0,05). Los costos de pacientes atendidas por Cesárea y las pacientes remitidas a UCI para el año 2013, la proporción de pacientes remitidas a UCI es menor. (chi ­ cuadrado: 5,771; P = 0,00 para Cesárea en 2013 y un valor de chi ­ cuadrado: 2,276; P = 0,03 para remisión a UCI en 2013). Conclusiones: el embarazo adolescente es un problema de salud pública con tendencia al aumento que acarrea complicaciones obstétricas que pueden presentarse en el transcurso de este periodo más el índice elevado de cesáreas que por ende aumenta los costos en la prestación de los servicios de salud.

Atención en salud basada en el valor: retos y oportunidades / Value-based health care: challenges and opportunities / Assistência médica baseada em valor: desafios e oportunidades

La atención en Salud Basada en el Valor es un modelo de atención re-ciente, innovador, dirigido a garantizar mejores resultados en salud para la población atendida, paralelo a un uso óptimo de los recursos. Para su implementación, dicho modelo propone una serie de principios, los cua-les son analizados dentro del presente documento. Para esto, se tiene en cuenta no sólo sus características fundamentales, sino también, su facti-bilidad, posibles barreras y oportunidades. Los principios revisados son: unidades integradas de atención, medición de resultados en salud y cos-tos, plataformas tecnológicas, modelos de pago centrados en la atención, sistemas integrados de atención y expansión geográfica. Adicionalmente, se incluyen la atención centrado en el paciente y el trabajo en equipo co-mo componentes fundamentales de este modelo también

Value-based Health Care is a recent, innovative delivering healthcare model which has emerged as a cost-effective alter-native to provide superior health outcomes for patients while decreasing inefficiencies in the system. For its successful im-plementation this model provides a set of principles which are revised in the present article, providing insights on their feasibility, challenges and opportunities. The principles revised here are: Integrated Practice Units, Health Outcomes and Cost Measurement, Value-based Payments, enabling health systems platforms, and efficient allocation of resources. Along with the-se, a person-centered approach and stakeholders' participation and engagement have been also revised as key components of the model.

A assistência médica baseada em valor é um modelo de assis-tência inovador que visa garantir melhores resultados de saúde para a população atendida e o uso ideal dos recursos. Para sua implementação, propõe-se uma série de princípios anali-sados neste documento, uma análise na qual são levadas em consideração as características fundamentais, viabilidade, pos-síveis barreiras e oportunidades que esse modelo pode gerar. Os princípios revisados são: unidades de atendimento integra-das, mensuração de resultados de saúde e custo, plataformas tecnológicas, modelos de pagamento focados na geração de valor, sistemas / redes de atendimento integrados e expansão geográfica. Além disso, o atendimento centrado no paciente e o trabalho em equipe são incluídos como componentes funda-mentais deste modelo.

Projeto de intervenção: fortalecimento da educação permanente na atenção básica no município de Serrita-PE / Projeto de intervenção: fortalecimento da educação permanente na atenção básica no município de Serrita-PE

Introdução: A educação permanente em saúde é um instrumento transformador dos processos de trabalho, visando a melhoria no atendimento à população e a qualificação dos profissionais. Objetivo Geral: Elaborar um plano de intervenção para fortalecimento da educação permanente na atenção básica no município de Serrita - PE, visando o fortalecimento das ações em saúde pública e a redução dos encaminhamentos desnecessários aos serviços especializados. Método: estudo descritivo com abordagem qualitativa. Os dados foram obtidos a partir da coleta de dados para o projeto de intervenção (P.I) onde foi realizada através de pesquisa qualitativa e quantitativa nos sistemas de informações da Secretaria Municipal de Saúde do município, através do sistema de regulação, como também os sistemas do Ministério da Saúde. Para a análise das entrevistas, foi utilizada a técnica de análise de conteúdo. Resultados: a partir da análise dos dados emergiram duas categorias: a educação permanente em saúde como estratégia para discussão e resolução de problemas e a educação permanente contribuindo para a consolidação das Equipes de Saúde da Família (ESF). Conclusão: a educação permanente em saúde contribui para um processo de reorientação das práticas dos trabalhadores, pela capacitação, qualificação dos profissionais da saúde, favorecendo a melhoria da qualidade da assistência.(AU)

Serie de protocolos de manejos clínicos para atención primaria de la salud: módulo introductorio / Series of clinical management protocols for primary health care: introductory module

Esta serie de Protocolos de Manejo Clínico para la Atención Primaria de la Salud ­APS- nace con la intención de ser una ayuda práctica en el consultorio para el manejo de las patologías prevalentes en las comunidades donde los equipos de salud de la familia ­ ESF- desarrollan su tarea. Serán igualmente de ayuda a los profesionales que se desenvuelven en el ámbito de la atención primaria en otros establecimientos de salud. Pretenden, sin reemplazar al estudio cuidadoso de la bibliografía pertinente, servir de guía de fácil acceso para la toma de decisiones clínicas en las que consideramos tareas esenciales, situaciones, problemas o condiciones prevalentes y prioritarias en APS.