Brain and brain-heart Granger causality during wakefulness and sleep.

In this exploratory study we apply Granger Causality (GC) to investigate the brain-brain and brain-heart interactions during wakefulness and sleep. Our analysis includes electroencephalogram (EEG) and electrocardiogram (ECG) data during all-night polysomnographic recordings from volunteers with apnea, available from the Massachusetts General Hospital's Computational Clinical Neurophysiology Laboratory and the Clinical Data Animation Laboratory. The data is manually annotated by clinical staff at the MGH in 30 second contiguous intervals (wakefulness and sleep stages 1, 2, 3, and rapid eye movement (REM). We applied GC to 4-s non-overlapping segments of available EEG and ECG across all-night recordings of 50 randomly chosen patients. To identify differences in GC between the different sleep stages, the GC for each sleep stage was subtracted from the GC during wakefulness. Positive (negative) differences indicated that GC was greater (lower) during wakefulness compared to the specific sleep stage. The application of GC to study brain-brain and brain-heart bidirectional connections during wakefulness and sleep confirmed the importance of fronto-posterior connectivity during these two states, but has also revealed differences in ipsilateral and contralateral mechanisms of these connections. It has also confirmed the existence of bidirectional brain-heart connections that are more prominent in the direction from brain to heart. Our exploratory study has shown that GC can be successfully applied to sleep data analysis and captures the varying physiological mechanisms that are related to wakefulness and different sleep stages.

Surgical Hand Gesture Recognition Utilizing Electroencephalogram as Input to the Machine Learning and Network Neuroscience Algorithms.

Surgical gestures detection can provide targeted, automated surgical skill assessment and feedback during surgical training for robot-assisted surgery (RAS). Several sources including surgical videos, robot tool kinematics, and an electromyogram (EMG) have been proposed to reach this goal. We aimed to extract features from electroencephalogram (EEG) data and use them in machine learning algorithms to classify robot-assisted surgical gestures. EEG was collected from five RAS surgeons with varying experience while performing 34 robot-assisted radical prostatectomies over the course of three years. Eight dominant hand and six non-dominant hand gesture types were extracted and synchronized with associated EEG data. Network neuroscience algorithms were utilized to extract functional brain network and power spectral density features. Sixty extracted features were used as input to machine learning algorithms to classify gesture types. The analysis of variance (ANOVA) F-value statistical method was used for feature selection and 10-fold cross-validation was used to validate the proposed method. The proposed feature set used in the extra trees (ET) algorithm classified eight gesture types performed by the dominant hand of five RAS surgeons with an accuracy of 90%, precision: 90%, sensitivity: 88%, and also classified six gesture types performed by the non-dominant hand with an accuracy of 93%, precision: 94%, sensitivity: 94%.

Association between Functional Brain Network Metrics and Surgeon Performance and Distraction in the Operating Room.

OBJECTIVE: The aim of this work was to examine (electroencephalogram) EEG features that represent dynamic changes in the functional brain network of a surgical trainee and whether these features can be used to evaluate a robot assisted surgeon's (RAS) performance and distraction level in the operating room. MATERIALS AND METHODS: Electroencephalogram (EEG) data were collected from three robotic surgeons in an operating room (OR) via a 128-channel EEG headset with a frequency of 500 samples/second. Signal processing and network neuroscience algorithms were applied to the data to extract EEG features. The SURG-TLX and NASA-TLX metrics were subjectively evaluated by a surgeon and mentor at the end of each task. The scores given to performance and distraction metrics were used in the analyses here. Statistical test data were utilized to select EEG features that have a significant relationship with surgeon performance and distraction while carrying out a RAS surgical task in the OR. RESULTS: RAS surgeon performance and distraction had a relationship with the surgeon's functional brain network metrics as recorded throughout OR surgery. We also found a significant negative Pearson correlation between performance and the distraction level (-0.37, p-value < 0.0001). CONCLUSIONS: The method proposed in this study has potential for evaluating RAS surgeon performance and the level of distraction. This has possible applications in improving patient safety, surgical mentorship, and training.

Functional outcomes after robot-assisted radical cystectomy: A review of literature.

Robot-assisted radical cystectomy has steadily gained wider acceptance among urologists compared with open and laparoscopic approaches. Robot-assisted radical cystectomy has shown comparable perioperative and oncologic outcomes compared with open radical cystectomy. Nevertheless, data about the functional outcomes and quality of life after robot-assisted radical cystectomy remain limited. We sought to review the literature and describe urinary, sexual and bowel functions after robot-assisted radical cystectomy in addition to mental health and health-related quality of life. Despite limitations of the available literature, data suggests that functional outcomes after robot-assisted radical cystectomy are comparable to open radical cystectomy. However, more studies utilizing standardized definitions are required.

Investigating the association between the urinary microbiome and bladder cancer: An exploratory study.

INTRODUCTION: We sought to investigate the association between the urinary microbiome and bladder cancer, including the difference between nonmuscle-invasive (NMIBC) and muscle-invasive (MIBC) bladder cancer, and Bacillus Calmette Guerin (BCG) responsive vs. BCG-refractory NMIBC. METHODS: Urine specimens were collected from consecutive patients with bladder cancer and healthy volunteers. Urine samples were analyzed using 16S rRNA sequencing to identify and compare any present bacteria. Alteration in the urinary microbiome was described in terms of alpha (diversity of populations within a sample) and beta diversities (differences between populations among different samples). Analyses were corrected for age, sex, method of sample preservation, and method of collection (mid-stream catch vs. catheterized urine). RESULTS: Fifty-three samples (43 patients with bladder cancer, and 10 controls) were included. For bladder cancer patients, mean age was 70 years, 7 (16%) were females; and 29 (67%) had NMIBC. Among patients with NMIBC, 11 (38%) patients received BCG, 6 of which had recurrence or progression after a median follow up of 13 months. Comparing the microbiome of bladder cancer patients vs. healthy controls, beta-diversity was significantly different, with Actinomyces, Achromobacter, Brevibacterium, and Brucella significantly more abundant in urine samples of bladder cancer patients. Comparing NMIBC and MIBC, Hemophilus and Veillonella were significantly more abundant in urine of MIBC patients, while Cupriavidus was significantly more abundant in NMIBC patients. Among NMIBC patients, Serratia and Brochothrix, Negativicoccus, Escherichia-Shigella, and Pseudomonas were significantly more abundant in patients who responded to BCG in comparison to those who did not. CONCLUSION: Urinary microbiome varied between patients with bladder cancer and healthy controls. Moreover, urinary microbial profiles differed among patient with NMIBC vs. MIBC, and among BCG responsive vs. BCG refractory NMIBC.

Prevalence and Predictors of Venous Thromboembolism After Robot-Assisted Radical Cystectomy.

OBJECTIVE: To describe incidence and variables associated with venous thromboembolism (VTE) after robot-assisted radical cystectomy (RARC). METHODS: A retrospective review of the prospectively maintained departmental database was performed. Extended thromboprophylaxis (for 4 weeks postoperatively) was implemented November 2017. Patients were divided into VTE (deep venous thrombosis [DVT] and/or pulmonary embolism [PE]) and non-VTE groups. Baseline demographics, disease characteristics and perioperative outcomes were compared. Cochran-Armitage trend test was used to assess trends of VTE. Multivariate logistic regression was used to identify variables associated with VTE. The Kaplan-Meier method was used to depict recurrence free survival (RFS), disease specific survival (DSS), and overall survival (OS). RESULTS: Twenty nine patients (5%) developed VTE (14 developed DVT and 15 developed PE). Median time to DVT was 28 days and to PE was 23 days after RARC. The rate of VTE remained stable between 2005 and 2020 (P= .99). Patients who developed VTE had significantly higher BMI (31 vs 29, P = .04), had COPD more often (34% vs 14%, P < .01) and had longer median hospital stay (8 vs 7 days, P = .01). Multivariate analysis showed that BMI (odds ratio [OR] 1.05; 95% confidence interval [CI] 1.005-1.10; P = .03), COPD (OR 3.24; 95% CI 1.43-7.30; P < .01),and non-organ confined disease (OR 2.73; 95% CI 1.22-6.11; P = 0.01) were associated with VTE. Kaplan-Meier curves showed that patients who developed VTE exhibited similar RFS (79% vs 64%, P = .28), DSS (90% vs 76%, P = .17), and OS (54% vs 52%, P = .76) at 5 years compared to those who did not develop VTE. CONCLUSION: VTE remains a significant complication after RARC. Higher BMI, COPD, and non-organ confined disease were significantly associated with VTE.

Development and Cross-Validation of a Nomogram for Chronic Kidney Disease Following Robot-Assisted Radical Cystectomy.

Introduction: We sought to identify the factors associated with deterioration of renal functions after robot-assisted radical cystectomy, and to develop a nomogram to detect the probability of progression to chronic kidney disease (CKD). Materials and Methods: A retrospective review of our prospectively maintained database. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-Epidemiology Collaboration creatinine formula utilizing all follow-up creatinine values. CKD was defined as stage 3b (eGFR <45 mL/minute/1.73 m2) based on the National Kidney Foundation classification. Kaplan-Meier curves were used to depict CKD-free survival. A multivariate Cox regression model was used to determine predictors for CKD and to build the perioperative nomogram. Results: The data set comprised 442 patients with a median follow-up of 25 months (12-59). Thirty-seven percent developed CKD at a median of 9 months (4-18). CKD-free survival rates at 1, 3, and 5 years were 75%, 58%, and 50%, respectively. CKD was significantly associated with preoperative eGFR (hazards ratio [HR]: 0.96, 95% confidence interval [CI]: 0.95-0.97, p < 0.01), body mass index (HR: 1.03, 95% CI: 1.01-1.05, p = 0.03), Charlson Comorbidity Index ≥3 (HR: 2.20, 95% CI: 1.35-3.58, p < 0.01), diabetes (HR: 1.59, 95% CI: 1.09-2.31, p = 0.02), 90 days postoperative strictures (HR: 4.04, 95% CI: 1.76-9.30, p < 0.01), 90 days postoperative hydronephrosis (HR: 2.26, 95% CI: 1.34-3.79, p < 0.01), 90 days recurrent urinary tract infection (HR: 1.84, 95% CI: 1.08-3.14, p = 0.02), 90 days acute kidney injury (HR: 1.70, 95% CI: 1.19-2.43, p < 0.01), and node positive disease (HR: 1.94, 95% CI: 1.31-2.86, p < 0.01). A 5-year CKD-free survival nomogram was developed. Conclusion: We have developed and cross-validated a nomogram for detecting CKD-free survival. This nomogram may have a role in counseling and follow up of patients. This study was done after the approval of the IRB committee (I-79606).

A High Throughput Approach to Reconstruct Partial-Body and Neutron Radiation Exposures on an Individual Basis.

Biodosimetry-based individualized reconstruction of complex irradiation scenarios (partial-body shielding and/or neutron + photon mixtures) can improve treatment decisions after mass-casualty radiation-related incidents. We used a high-throughput micronucleus assay with automated scanning and imaging software on ex-vivo irradiated human lymphocytes to: a) reconstruct partial-body and/or neutron exposure, and b) estimate separately the photon and neutron doses in a mixed exposure. The mechanistic background is that, compared with total-body photon irradiations, neutrons produce more heavily-damaged lymphocytes with multiple micronuclei/binucleated cell, whereas partial-body exposures produce fewer such lymphocytes. To utilize these differences for biodosimetry, we developed metrics that describe micronuclei distributions in binucleated cells and serve as predictors in machine learning or parametric analyses of the following scenarios: (A) Homogeneous gamma-irradiation, mimicking total-body exposures, vs. mixtures of irradiated blood with unirradiated blood, mimicking partial-body exposures. (B) X rays vs. various neutron + photon mixtures. The results showed high accuracies of scenario and dose reconstructions. Specifically, receiver operating characteristic curve areas (AUC) for sample classification by exposure type reached 0.931 and 0.916 in scenarios A and B, respectively. R2 for actual vs. reconstructed doses in these scenarios reached 0.87 and 0.77, respectively. These encouraging findings demonstrate a proof-of-principle for the proposed approach of high-throughput reconstruction of clinically-relevant complex radiation exposure scenarios.

Reoperations following Robot-Assisted Radical Cystectomy: A Decade of Experience.

PURPOSE: There is a paucity of data regarding the operative management of complications after robot-assisted radical cystectomy. We reviewed operative management of robot-assisted radical cystectomy specific complications during our 10-year experience with this procedure and assessed the feasibility, safety and outcomes of robot-assisted reoperations. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent surgical interventions for robot-assisted radical cystectomy specific complications between 2005 and 2015. Univariable and multivariable logistic regression models were fit to evaluate predictors of surgical intervention after robot-assisted radical cystectomy. Kaplan-Meier curves were used to describe time to surgical interventions. RESULTS: A total of 92 patients (23%) underwent surgical intervention after robot-assisted radical cystectomy. Mean followup was 27 months. Average time to any surgical intervention after cystectomy was 14 months. The reoperation rate was 5%, 2% and 16% at 30, 31 to 90 and greater than 90 days, respectively. Using the Kaplan-Meier method surgical interventions occurred at a rate of 30% at 2 years and 46% at 5 years. Interventions for ureteroileal complications were the most common (48 cases) followed by interventions for bowel obstruction, fistulas and abdominal wall related complications (11 cases). Clavien 3 or greater complications and neoadjuvant chemotherapy were associated with surgical intervention. CONCLUSIONS: Even in experienced hands the long-term complications of robot-assisted radical cystectomy are notable. Of our patients 23% required surgical interventions after the procedure. Our initial experience with robot-assisted management of robot-assisted radical cystectomy complications appears safe and feasible, although the decision to proceed is determined primarily by surgeon experience.

Simulation-based training in robot-assisted surgery: current evidence of value and potential trends for the future.

Robot-assisted surgery has changed the landscape of surgery. Implementation of robotics into most surgical specialties has left many educators challenged to develop the tools necessary to train and credential surgeons. Advances in robot-assisted surgery have led to the development of simulators and tools to assess skills that transfer to surgical practice. We report on current trends in robot-assisted surgical training, focus on simulation-based education, and anticipate future developments.

Frequency of class B carbapenemases (MbetaL) in enterobacteriacae.

OBJECTIVE: To determine the frequency of Metallo- -lactamase producing Enteriobacteriaceae species. METHOD: The descriptive cross-sectional study was carried out from January to December 2011 in the Department of Microbiology, Basic Medical Sciences Institute, Jinnah Postgraduate Medical Centre, Karachi. A total of 500 specimens were initially collected. The culture positive samples were analysed for further identification, and antimicrobial sensitivity was done according to Clinical and Laboratory Standards Institute guidelines 2009. The Carbapenemases Producing Enterobacteriaceae strains were screened by the Modified Hodge Test, and Metallo-beta-Lactamase production was confirmed by the EDTA combined disc test. RESULT: From amongst 402 organisms detected, 200 (49.75%) were Enterobacteriaceae, while Escherichia coli was the leading pathogen (65%). Only 6% were identified as Carbapenemases Producing Enterobacteriaceae and 9 (75%) of them were Metallo-beta-Lactamase producing strains, while 3 (25%) contained other enzymes. CONCLUSION: Metallo-beta-Lactamase producing Enterobacteriaceae species are causing problems in tertiary care hospitals.

Results of type-III supracondylar fracture humerus with open reduction and internal fixation in children after failed closed reduction.

BACKGROUND: Supracondylar fracture of humerus is the second most common fracture in children which account for 60-75% of all fractures around the elbow. There are various treatment modalities for type-III fracture, i.e., closed reduction and casting, skeletal traction, close reduction and percutaneous pinning and open reduction and internal fixation. This study was conducted to see the outcome of open reduction and internal fixation after failed closed reduction. METHODS: This study was conducted in the Orthopaedics Departments of Khyber Teaching Hospital Peshawar and Ayub Teaching Hospital Abbottabad from February 2007 to Nov 2007 on 30 children. Patients included were of either gender with age range from 5-12 years with displaced supracondylar fracture (type-III) after failed closed reduction. All fractures were fixed with two cross K-wires by open reduction and internal fixation. The patients were assessed both clinically and radiologically and results were tabulated according to Flynn criteria. RESULTS: Twenty-eight patients had excellent results while two had good results according to Flynn criteria. None of the patients had either fair or poor result. CONCLUSION: Open reduction and internal fixation is a good and reliable method after failed closed reduction and gives stable fixation with anatomical alignment.