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.

Improving Inclusivity in Robotics Design: An Exploration of Methods for Upstream Co-Creation.

Disabled people are often involved in robotics research as potential users of technologies which address specific needs. However, their more generalised lived expertise is not usually included when planning the overall design trajectory of robots for health and social care purposes. This risks losing valuable insight into the lived experience of disabled people, and impinges on their right to be involved in the shaping of their future care. This project draws upon the expertise of an interdisciplinary team to explore methodologies for involving people with disabilities in the early design of care robots in a way that enables incorporation of their broader values, experiences and expectations. We developed a comparative set of focus group workshops using Community Philosophy, LEGO® Serious Play® and Design Thinking to explore how people with a range of different physical impairments used these techniques to envision a "useful robot". The outputs were then workshopped with a group of roboticists and designers to explore how they interacted with the thematic map produced. Through this process, we aimed to understand how people living with disability think robots might improve their lives and consider new ways of bringing the fullness of lived experience into earlier stages of robot design. Secondary aims were to assess whether and how co-creative methodologies might produce actionable information for designers (or why not), and to deepen the exchange of social scientific and technical knowledge about feasible trajectories for robotics in health-social care. Our analysis indicated that using these methods in a sequential process of workshops with disabled people and incorporating engineers and other stakeholders at the Design Thinking stage could potentially produce technologically actionable results to inform follow-on proposals.

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.

Extremely High-Throughput Parallel Microfluidic Vortex-Actuated Cell Sorting.

We demonstrate extremely high-throughput microfluidic cell sorting by making a parallel version of the vortex-actuated cell sorter (VACS). The set-up includes a parallel microfluidic sorter chip and parallel cytometry instrumentation: optics, electronics and control software. The result is capable of sorting lymphocyte-sized particles at 16 times the rate of our single-stream VACS devices, and approximately 10 times the rate of commercial cell sorters for an equivalent procedure. We believe this opens the potential to scale cell sorting for applications requiring the processing of much greater cell numbers than currently possible with conventional cell sorting.

From discovery to delivery: public sector development of the rVSV-ZEBOV Ebola vaccine.

The discovery and development of the Ebola rVSV-ZEBOV vaccine challenge the common assumption that the research and development for innovative therapeutic products and vaccines is best carried out by the private sector. Using internal government documents obtained through an access to information request, we analyze the development of rVSV-ZEBOV by researchers at Canada's National Microbiology Laboratory beyond its patenting and licensing to a biotech company in the United States in 2010. According to government documentation, the company failed to make any progress toward a phase 1 clinical trial until after the WHO Public Health Emergency of International Concern freed substantial donor and public funds for the vaccine's further development. The development of rVSV-ZEBOV, from sponsoring early stage research through to carrying out clinical trials during the epidemic, was instead the result of the combined efforts of the Canadian government, its researchers, and other publicly funded institutions. This case study of rVSV-ZEBOV underscores the significant public contribution to the R&D of vaccines even under conditions of precarity, and suggests that an alternative approach to generating knowledge and developing interventions, such as open science, is required in order to fully realize the public sector's contribution to improved global health.

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.

Grief, poetry, and the sweet unexpected.

This paper explains the healing benefits, the "sweet unexpected" of the title, which results from using poetry to engage trauma, including traumatic grief. The benefits of poetry are presented alongside a discussion of a 22-year-old nonprofit called The Pongo Poetry Project. The sweet unexpected includes the ease with which trauma survivors engage their trauma narrative, the critical insights that emerge in poetry, the beneficial social context of sharing poetry, and the healing benefits of poetry for writers, care providers, and readers alike. The paper concludes by providing resources that can help people use poetry in their own work.

Examining radiographic outcomes over time.

Statistical analysis plays a critical role in data interpretation in all fields and particularly so for clinical data where important treatment decisions are made. We provide here an in-depth and illustrative analysis to examine patterns and radiographic scores in an early disease rheumatoid arthritis cohort over a 3-year follow-up period. The total Sharp radiographic scores were interpolated from the rates at 6 months, 1, 2, and 3 years and were transformed to count data after rounding. The generalized estimating equations approach and two-part models were applied to analyze the longitudinal radiographic scores using the clinical, demographic, and therapeutic characteristics of the patients after adjusting for the pattern outcomes. Total Sharp scores were modeled, assuming that they were Poisson distributed or had a negative binomial distribution with either an AR(1) working correlation matrix or an exchangeable working correlation matrix. To account for the excessive zero counts, we used two-part models that include the zero-inflated Poisson and the zero-inflated negative binomial to fit the data. This is an innovation because two-part models have not been used in rheumatology even though they are highly appropriate for analyzing data from rheumatic studies. In addition, we analyzed data using generalized estimating equations and compared results from different models using formal statistical goodness-of-fit criteria and arrive at the best model for predicting purposes.

Patterns of radiographic outcomes in early, seropositive rheumatoid arthritis: a baseline analysis.

We examine radiographic profile patterns using clustering algorithms to assess progression rates at set time intervals in a rheumatoid arthritis (RA) observational study. Hands/feet radiographic scores were analyzed for 190 early, seropositive RA patients with ≥ 3 radiographic observations from a prospective cohort. Assessments at 6 months, 1 year, and yearly thereafter were requested for demographic, therapeutic, functional, laboratory, radiographic, and clinical data. Progression rates for the total sharp scores [erosion (E)+joint space narrowing (JSN)] were interpolated for intervals of 0 to 6 months, 6 month-1 year, 1-2 years, and 2-3 years past first radiographic observation. Patients were grouped on their sets of rates by K-median clustering algorithms, and categorical group membership was regressed onto baseline characteristics using multinomial models. The number of clusters was determined using one-way MANOVA, and baseline differences across clusters by Kruskal-Wallis tests. The median RA duration was 6.1 months, mean age 52 years, median disease activity score (DAS) 4.6, mean radiographic observations 4.6 (range 3-8) for this mostly female (77%), Caucasian (78%) sample. 3 patterns were determined: increasing (n = 41; 22%), increasing then decreasing (n = 41; 22%), and flat (n = 108; 57%). High baseline C-reactive protein was associated with a worsening radiographic progression (p < 0.005), as were HAQ-DI (p = 0.07), JSN (p < 0.01), and E (p = 0.03). Our conclusions are that radiographic progression patterns graphically supplement traditional linear rates, and are flexible to use in both clinical and observational studies. The identified clusters and rates may correspond better with clinical status and treatment over the disease course than linear progression rates alone.

Equivalent responses to disease-modifying antirheumatic drugs initiated at any time during the first 15 months after symptom onset in patients with seropositive rheumatoid arthritis.

OBJECTIVE: To evaluate responses by time to initiation of nonbiologic disease-modifying antirheumatic drugs (DMARD) in a DMARD-naive cohort of patients with early seropositive rheumatoid arthritis (RA). METHODS: Subjects were categorized by the time from symptom onset to the first DMARD use (median 5.7 months, range 0.6-15.9). Subjects who started their first DMARD within 5 months of symptom onset were compared to subjects who started after 5 months. Disease Activity Scores (DAS-44) and total Sharp Score (TSS) progression rates were analyzed using Wilcoxon rank-sum and chi-square tests; multiple linear regression analysis adjusted for potential covariates. The slope of the least-squares regression line was calculated to estimate the annualized TSS progression rates. RESULTS: Of 233 RA patients, 76% were female and mean age was 50 (SD 13) years. At DMARD start, DAS-44 was similar in all subsets within the 0.6 to 15 months' duration between symptom onset and DMARD initiation. Erosion scores tended to be higher in those who started DMARD later, but Health Assessment Questionnaire-Disability Index (HAQ-DI) scores were higher in those who started DMARD earlier. During the 2 years after DMARD initiation, improvements in HAQ-DI and DAS-44 were similar in the various duration subsets, with about 25% ever achieving DAS remission (DAS < 1.6). Radiographic progression tended to be numerically but not statistically more rapid in the earlier subsets. CONCLUSION: Following initiation of nonbiologic DMARD therapy at various times within 15 months of symptom onset, improvements of DAS-44, HAQ-DI, remission rate, and radiographic progression rate were similar, although higher baseline erosion scores were present in those with later initiation of DMARD.

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.

Comparison of composite measures of disease activity in an early seropositive rheumatoid arthritis cohort.

OBJECTIVE: To evaluate concordance and agreement of the original DAS44/ESR-4 item composite disease activity status measure with nine simpler derivatives when classifying patient responses by European League of Associations for Rheumatology (EULAR) criteria, using an early rheumatoid factor positive (RF+) rheumatoid arthritis (RA) patient cohort. METHODS: Disease-modifying anti-rheumatic drug-naïve RF+ patients (n = 223; mean duration of symptoms, 6 months) were categorised as ACR none/20/50/70 responders. One-way analysis of variance and two-sample t tests were used to investigate the relationship between the ACR response groups and each composite measure. EULAR reached/change cut-point scores were calculated for each composite measure. EULAR (good/moderate/none) responses for each composite measure and the degree of agreement with the DAS44/ESR-4 item were calculated for 203 patients. RESULTS: Patients were mostly female (78%) with moderate to high disease activity. A centile-based nomogram compared equivalent composite measure scores. Changes from baseline in the composite measures in patients with ACRnone were significantly less than those of ACR20/50/70 responders, and those for ACR50 were significantly different from those for ACR70. EULAR reached/change cut-point scores for our cohort were similar to published cut-points. When compared with the DAS44/ESR-4 item, EULAR (good/moderate/none) percentage agreements were 92 with the DAS44/ESR-3 item, 74 with the Clinical Disease Activity Index, and 80 with the DAS28/ESR-4 item, the DAS28/CRP-4 item and the Simplified Disease Activity Index. CONCLUSION: The relationships of nine different RA composite measures against the DAS44/ESR-4 item when applied to a cohort of seropositive patients with early RA are described. Each of these simplified status and response measures could be useful in assessing patients with RA, but the specific measure selected should be pre-specified and described for each study.

Classifying radiographic progression status in early rheumatoid arthritis patients using propensity scores to adjust for baseline differences.

Various methods are used to measure radiographic joint damage in patients with rheumatoid arthritis (RA), but determining proportions of responsive patients is difficult. A key problem in observational studies when assessing damage outcomes is incorporating time to treatment initialization and adjusting for observed baseline differences. We examined five different definitions to select an appropriate index to classify radiographic damage in RA patients as progressive or nonprogressive. In addition, we compared different times from symptom onset to treatment and their effects on patient radiographic categorization. Propensity scores to adjust for baseline differences, including time since symptom onset, were used to match those treated early with those treated later using the stratification, radius, nearest neighbor and kernel methods. The mean effect of treatment on the treated was computed for each matching method. Observational data were analyzed for 185 early RA patients from the Western Consortium study followed six to sixty months (mean thirty-one months). For the selected index, 75 patients were categorized as nonprogressors; they had significantly lower disease activity, more clinical improvement and were treated earlier than the progressors. Of those treated within three months of symptom onset, 57% were classified as radiographically progressive versus 35% of those treated later (P = 0.0058). However, after propensity score adjustment for baseline differences, we noticed nonsignificant (P > 0.05) nonprogression in patients given earlier treatment. We conclude that propensity score analysis reduced but did not remove all bias.