Validation of 3D printed MAYO tubes and stethoscope in simulated medical environment - Tools fabricated with additive manufacturing for emergency care.

Emergency and disaster medical care often face resource or equipment shortages. 3D printing technology has been proven to be effective in cases with insufficient supply chains. MAYO tubes and stethoscopes are essential components of ABCDE patient examinations; however, 3D-printed variants have not been fully tested. These 3D-printed instruments were substituted and validated in a simulated pre-hospital environment. In total, 26 participants were included in this study. Fifteen clinicians or paramedics with at least 3 years of professional experience and 10 medical students. One student was excluded because he had relevant experience with emergency care. As basic tasks, the placement of MAYO tubes and auscultation with stethoscopes were performed using medical simulators. 3D printed instruments were compared with conventional clinical devices by measuring the time required for the intervention, success rate, and user satisfaction. In the study FFF (Fused Filament Fabrication (FFF), SLS (Selective Laser Sintering (SLS), and SLA (stereolithography) 3D printing were used in this study. The times required for implementation and auscultation were examined for each instrument. There was no significant difference between the MAYO tube (p = 0.798) and the stethoscope (p = 0.676). In the case of stethoscopy, the study investigated the correct diagnosis, and no significant difference was found (p = 0.239), although an interesting trend was observed. Regarding the MAYO tube, the study found no significant difference in correct position formation (p = 0.163). The experience levels of the groups did not influence these factors. However, significant differences in user satisfaction were found in both cases in favour of the conventional versions (p < 0.001). Overall, the results of this study suggest that 3D-printed devices could be suitable replacements for clinic-based devices in emergency situations. The 3D-printed devices did not perform inferiorly at any of the indicated points compared to their classical counterparts. However, the practical applicability of the devices used in this study requires further investigation.

Can we predict critical care mortality with non-conventional inflammatory markers in SARS-CoV-2 infected patients?

BACKGROUND: Severe COVID-19 disease is associated with multiple organ involvement,then failure and often fatal outcomes.In addition,inflammatory mechanisms and cytokine storms,documented in many COVID-19 patients,are responsible for the progression of the disease and high mortality rates.Inflammatory parameters,such as procalcitonin(PCT) and C-reactive protein(CRP), are widely used in clinical practice. OBJECTIVE: To evaluate the predictive power of non-conventional inflammatory markers regarding mortality risk. METHODS: In our prospective study 52 patients were followed for 5 days after admission to an intensive care unit immediately with severe SARS-CoV-2 infection.We compared leukocyte-,platelet antisedimentation rate (LAR, PAR),neutrophil lymphocyte ratio(NLR), CRP, PCT levels. RESULTS: In non-surviving(NSU) patients LAR remained largely constant from D1 to D4 with a statistically significant drop(p < 0.05) only seen on D5.The NSU group showed statistically significant(p < 0.05) elevated LAR medians on D4 and D5, compared to the SU group.NLR values were continually higher in the non-survivor group.The difference between the SU and NSU groups were statistically significant on every examined day.PAR, CRP and PCT levels didn't show any significant differences between the SU and NSU groups. CONCLUSIONS: In conclusion, this study suggests that LAR and NLR are especially worthy of further investigation as prognostic markers.LAR might be of particular relevance as it is not routinely obtained in current clinical practice.It would seem beneficial to include LAR in data sets to train prognostic artificial intelligence.

The Effects of Rapamycin on the Intestinal Graft in a Rat Model of Cold Ischemia Perfusion and Preservation.

Attenuating the rheological and structural consequences of intestinal ischemia-reperfusion-injury (IRI) is important in transplant proceedings. Preconditioning is an often-proposed remedy. This technique uses physical or pharmacological methods to manipulate key ischemia pathways, such as oxidation, inflammation, and autophagy, prior to ischemia. This study determined the time-dependent effects of Rapamycin preconditioning on small-bowel grafts undergoing cold ischemia perfusion and preservation. Our main parameters were mucosa and cell injury and autophagy. A total of 30 male Wistar rats were divided into 5 groups: sham, preservation-control, and 3 treated groups (Rapamycin administered either 0, 30, or 60 min prior to perfusion). After perfusion, the intestines were placed in chilled IGL-1 solution for 12 h. Thereafter, they were reperfused. Histology and bioanalysis (LDH and lactate) were used to ascertain intestinal injury while immunohistochemistry was used for measuring changes in autophagy markers (Beclin-1, LC3B, and p62 proteins). The results show no significant difference amongst the groups after vascular perfusion. However, intestinal injury findings and autophagy changes demonstrate that administering Rapamycin 30 min or 60 min prior was protective against adverse cold ischemia and reperfusion of the intestinal graft. These findings show that Rapamycin is protective against cold ischemia of the small intestine, especially when administered 30 min before the onset.

Comparison of VividTrac, King Vision and Macintosh laryngoscopes in normal and difficult airways during simulated cardiopulmonary resuscitation among novices.

INTRODUCTION: Early endotracheal intubation improves neurological outcomes in cardiopulmonary resuscitation, although cardiopulmonary resuscitation is initially carried out by personnel with limited experience in a significant proportion of cases. Videolaryngoscopes might decrease the number of attempts and time needed, especially among novices. We sought to compare videolaryngoscopes with direct laryngoscopes in simulated cardiopulmonary resuscitation scenarios. MATERIALS AND METHODS: Forty-four medical students were recruited to serve as novice users. Following brief, standardized training, students executed endotracheal intubation with the King Vision®, Macintosh and VividTrac® laryngoscopes, on a cardiopulmonary resuscitation trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma and user satisfaction. RESULTS: In the normal airway scenario, significantly shorter intubation times were achieved using the King Vision® than the Macintosh laryngoscope. In the difficult airway scenario, we found that the VividTrac® was superior to the King Vision® and Macintosh laryngoscopes in the laryngoscopy time. In both scenarios, we noted no difference in the first-attempt success rate, but the best view of the glottis and dental trauma, esophageal intubation and bougie use were more frequent with the Macintosh laryngoscope than with the videolaryngoscopes. The shortest tube insertion times were achieved using the King Vision® in both scenarios. CONCLUSION: All providers achieved successful intubation within three attempts, but we found no device superior in any of our scenarios regarding the first-attempt success rate. The King Vision® was superior to the Macintosh laryngoscope in the intubation time in the normal airway scenario and noninferior in the difficult airway scenario for novice users. We noted significantly less esophageal intubation using the videolaryngoscopes than using the Macintosh laryngoscope in both scenarios. Based on our results, the KingVision® might be recommended over the VividTrac® and Macintosh laryngoscopes for further evaluation.

Changes of pituitary adenylate cyclase activating polypeptide (PACAP) level in polytrauma patients in the early post-traumatic period.

In polytrauma patients who survive the primary insult, the imbalance between the pro- and anti-inflammatory processes seems to be responsible for life-threatening complications such as sepsis or multiple organ dysfunction syndrome. Measurement of C-reactive protein (CRP) and procalcitonin (PCT) is a standard way for differentiating between infectious (bacterial) and non-infectious inflammation. Monitoring of immune cell functions, like leukocyte anti-sedimentation rate (LAR) can also be useful to diagnose infectious complications. Pituitary adenylate cyclase activating polypeptide (PACAP) is a neuropeptide with well-known immunomodulatory and anti-inflammatory effects. The aim of our study was to determine the changes of PACAP38 levels in polytrauma patients in the early post-traumatic period in intensive care unit and analyse possible correlation of its level with conventional (CRP, PCT) and unconventional (LAR) laboratory parameters. Twenty polytrauma patients were enrolled. Blood samples were taken daily for five days. We observed significant correlation between PACAP38 and CRP levels on day 4 and 5 as well as between PACAP38 and LAR levels all of the days. This could be due to the anti-inflammatory and cytoprotective functions of PACAP38 as part of an endogenous response to the trauma induced systemic inflammatory response syndrome. These significant correlations could have clinical importance in monitoring the dynamic balance of pro- and anti-inflammatory processes in case of polytraumatic patients.

Manufacturing a First Upper Molar Dental Forceps Using Continuous Fiber Reinforcement (CFR) Additive Manufacturing Technology with Carbon-Reinforced Polyamide.

3D printing is an emerging and disruptive technology, supporting the field of medicine over the past decades. In the recent years, the use of additive manufacturing (AM) has had a strong impact on everyday dental applications. Despite remarkable previous results from interdisciplinary research teams, there is no evidence or recommendation about the proper fabrication of handheld medical devices using desktop 3D printers. The aim of this study was to critically examine and compare the mechanical behavior of materials printed with FFF (fused filament fabrication) and CFR (continuous fiber reinforcement) additive manufacturing technologies, and to create and evaluate a massive and practically usable right upper molar forceps. Flexural and torsion fatigue tests, as well as Shore D measurements, were performed. The tensile strength was also measured in the case of the composite material. The flexural tests revealed the measured force values to have a linear correlation with the bending between the 10 mm (17.06 N at 5000th cycle) and 30 mm (37.99 N at 5000th cycle) deflection range. The findings were supported by scanning electron microscopy (SEM) images. Based on the results of the mechanical and structural tests, a dental forceps was designed, 3D printed using CFR technology, and validated by five dentists using a Likert scale. In addition, the vertical force of extraction was measured using a unique molar tooth model, where the reference test was carried out using a standard metal right upper molar forceps. Surprisingly, the tests revealed there to be no significant differences between the standard (84.80 N ± 16.96 N) and 3D-printed devices (70.30 N ± 4.41 N) in terms of extraction force in the tested range. The results also highlighted that desktop CFR technology is potentially suitable for the production of handheld medical devices that have to withstand high forces and perform load-bearing functions.

Effectivity of near-peer teaching in training of basic surgical skills - a randomized controlled trial.

BACKGROUND: Near-peer teaching (NPT) is a special way of teaching where the tutor is one or more academic years ahead of the person being tutored. The literature agrees on the benefits of the method, but there are only a few publications examining its effectiveness using objective methods. The aim of our study was to examine the effectiveness of NPT in the training of basic surgical skills. METHODS: We included 60 volunteer students who participated in a 20 × 45 min long surgical skills course. Based on the results of a pre-course test, we randomly divided the students into six equal groups. All groups completed the same curriculum, with three groups being assisted by a NPT tutor. After the course, they completed the same test as at the beginning. The exams were recorded on anonymized videos and were blindly evaluated. The students' satisfaction was monitored using a self-administered online anonymous questionnaire. Statistical analysis was performed using the Mann-Whitney and Wilcoxon tests. RESULTS: Overall, student performance improved with completion of the course (from 119.86 to 153.55 points, p <  0.01). In groups where a NPT tutor assisted, students achieved a significantly better score (37.20 vs. 30.18 points improvement, p = 0.036). The difference was prominent in surgical knotting tasks (14.73 vs. 9.30 points improvement, p <  0.01). In cases of suturing (15.90 vs. 15.46 points) and laparoscopy (7.00 vs. 4.98 points), the presence of the NPT tutor did not significantly affect development. Based on student feedback, although students positively assessed the presence of NPT, it did not significantly improve students' overall satisfaction since it was already 4,82 on a scale of 5 in the control group. CONCLUSIONS: Overall, involving a NPT tutor had a positive impact on student development. An outstanding difference was observed in connection with knotting techniques.

An Overview on Personal Protective Equipment (PPE) Fabricated with Additive Manufacturing Technologies in the Era of COVID-19 Pandemic.

Different additive manufacturing technologies have proven effective and useful in remote medicine and emergency or disaster situations. The coronavirus disease 2019 (COVID-19) disease, caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus, has had a huge impact on our society, including in relation to the continuous supply of personal protective equipment (PPE). The aim of the study is to give a detailed overview of 3D-printed PPE devices and provide practical information regarding the manufacturing and further design process, as well as describing the potential risks of using them. Open-source models of a half-face mask, safety goggles, and a face-protecting shield are evaluated, considering production time, material usage, and cost. Estimations have been performed with fused filament fabrication (FFF) and selective laser sintering (SLS) technology, highlighting the material characteristics of polylactic acid (PLA), polyamide, and a two-compound silicone. Spectrophotometry measurements of transparent PMMA samples were performed to determine their functionality as goggles or face mask parts. All the tests were carried out before and after the tetra-acetyl-ethylene-diamine (TAED)-based disinfection process. The results show that the disinfection has no significant effect on the mechanical and structural stability of the used polymers; therefore, 3D-printed PPE is reusable. For each device, recommendations and possible means of development are explained. The files of the modified models are provided. SLS and FFF additive manufacturing technology can be useful tools in PPE development and small-series production, but open-source models must be used with special care.

The present and the future of medical simulation education in Hungary / Az egészségügyi szimulációs oktatás jelene és jövoje Magyarországon

Simulation-based medical education aims to model clinical situations and tasks using simulators, computers or even human beings. By using this system, the students are able to learn and master technical, also non-technical skills in lifelike situations. This publication contains a historical review of simulation-based education system, and its actualities in Hungary. Simulation has an unquestionable role in medical education. It is beneficial for the students, for the teachers, and for the teaching hospitals as well, since it saves clinical equipment and reduces the human burden. Its main purpose is to establish connection between theoretical and practical competencies, preparing the students for real medical challenges. Simulation has been a known teaching method for centuries, but only the 21st century brought real breakthrough due to the sudden development of technology. As a result of the recent years' innovative development and accepted innovative solutions, the modeling of complex medical procedures turned into more realistic. In Hungary, 3D-printed tools, virtual reality and augmented reality approaches are already adopted for education purposes. The national simulation network contains 3 universities and 16 hospitals. The initial developments are shown to be successful, as simulation-based training is progressively involved in undergraduate and post-graduate education, and the overall feedback is positive from the involved students. The evolvement of comprehensive national methodology for education has started also, by publishing reference books. This review is about the state of the national simulation education and offers development possibilities. Orv Hetil. 2020; 161(26): 1078-1087.

A national survey of videolaryngoscopes and alternative intubation devices in Hungary.

INTRODUCTION: Videolaryngoscopy (VL) as a new airway management technique has evolved in recent decades, and a large number of videolaryngoscopes are now available on the market. Most recent major guidelines already recommend the immediate availability and use of VL in difficult airway management scenarios. However, national data on the availability of VL, introduction into practice and patterns of use are rarely published. Therefore, the current study aimed to provide data on VL in Hungary. MATERIALS AND METHODS: An electronic survey was designed and popularized with the help of the Hungarian Society of Anaesthesiology and Intensive Therapy to explore the availability, use, and practice of and attitudes toward VL among Hungarian anesthesiologists. The survey was conducted between 01.01.2018 and 31.12.2018. RESULTS: In total, 324 duly completed forms were returned and analyzed. Responders were mainly males (58%), specialists (80%) and those involved mainly in anesthesia practice (68%) in the public sector. Two hundred and ten (65%) responders had access to various videolaryngoscopes and were mainly from surgery, intensive care and traumatology units. No responders reported the availability of eight videolaryngoscopes out of the eighteen listed devices, and 32% of the responders had never used any videolaryngoscope in clinical settings. The most commonly available devices were KingVision, MacGrath Mac and Airtraq. Most of the responders reported using videolaryngoscopes mainly for difficult airway management and reported using a fiberscope as the first alternative device. Popular methods for selecting videolaryngoscopes included the following: short clinical trial (n = 67/324), decision of the departmental lead (n = 65/324) and price (n = 54/324). The majority of responders had some training prior to clinical application, but training was mainly voluntary. Overall, 98% of the responders considered videolaryngoscopes beneficial. CONCLUSIONS: Approximately two-thirds of Hungarian anesthesiologists have immediate access to videolaryngoscopes, which are used mainly for difficult airway management. The overall attitude towards VL is positive, and many videolaryngoscopes are known and have been used by Hungarian anesthesiologists. However, only a few devices on the market are used commonly. Based on the results, further improvement might be recommended regarding VL training and availability.

Pulmonary contusion.

Lung contusion resulting from chest trauma may be present various clinical pictures. It quite often remains unrecognized and is only suspected later when severe complications have developed. Lung contusion may present in association with chest trauma but may also occur alone. It has to be emphasized, that lung contusion as a clinical identity does not necessarily require a blunt or penetrating chest to be in the background. Nowadays, as a result of traffic accidents, following high energy deceleration, lung contusion may present without an actual tissue damage in the chest wall as a condition initiating an independent, life-threatening generalised process. Although lung contusion shows similarities to blast injury of the lung with respect to clinical consequences, other factors play a role in its aetiology and pathology. Its description and recognition as an independent pathology is not simple. Several approaches exist: thoracic trauma, pulmonary contusion, pulmonary laceration, lung contusion; although these may show similar clinical signs, manifest in different pathologies. Pathologies with similar meaning and possibly similar clinical course cannot, actually, be differentiated; they may accompany other injuries to the trunk, skull or extremities, which, alone, are associated with high morbidity and mortality. Generally, it can be declared that besides high energy, blunt injuries affecting the trunk, lung contusion, has been an often neglected additional radiological finding attached to the main report, despite the fact, that its late consequences crucially determine the prospects of the injured.

[Actor as a simulated patient in medical education at the University of Pécs]. / A színész mint szimulált páciens az oktatásban a Pécsi Tudományegyetemen.

INTRODUCTION: Medical training in the 21st century faces simulation-based education as one of the challenges that efficiently contributes to clinical skills development while moderating the burden on the clinicians and patients alike. AIM: The University of Pécs, Medical School has launched a simulation program in the MediSkillsLab based on history taking with actors to improve patient interviewing communication skills. METHOD: This new program was inspired by experiences gathered in previous medical language teaching and integrates the method of the "Standardized Patient Program". The method has been applied in America since the 1960s. RESULTS: This is the first time the program has been introduced in Hungary and implemented in an interdisciplinary design, where medical specialists, linguists, actor-patients and medical students collaborate to improve professional, language and communicative competence of the students. CONCLUSION: A course like this has its pivotal role in the medical training, and as a result more efficient and patient-oriented communication may take place at the clinical setting. Orv Hetil. 2017; 158(26): 1022-1027.

Comparison of VividTrac®, Airtraq®, King Vision®, Macintosh Laryngoscope and a Custom-Made Videolaryngoscope for difficult and normal airways in mannequins by novices.

BACKGROUND: Direct laryngoscopy remains the gold standard for endotracheal intubation and is preferred by experienced operators. However, an increasing number of reports currently support videolaryngoscopy, particularly for novice users. The widespread use of videolaryngoscopy may be limited due to financial limitations, especially in low-income countries. Therefore, affordable single-use scopes are now becoming increasingly popular. We sought to compare these new scopes with direct laryngoscopes and the previously tested videolaryngoscopes in mannequins by novices. METHODS: Fifty medical students were recruited to serve as novice users. Following brief, standardized training, students were asked to execute endotracheal intubation with each of the devices, including the Airtraq®, a custom-made videolaryngoscope, the King Vision®, the Macintosh laryngoscope and the VividTrac®, on an airway trainer (Laerdal Airway Management Trainer®) in normal and difficult airway scenarios. We evaluated the time to and the proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma and user satisfaction. RESULTS: We observed no differences in esophageal intubation. However, intubation-related times, the view of the glottis and operator satisfaction were significantly better throughout the study with the commercial videolaryngoscopes. In comparison, the custom-made videolaryngoscope performance proved to be similar to that of the Macintosh laryngoscope. The VividTrac® performance was similar (P > 0.05) or significantly better than that of the King Vision® in both scenarios. CONCLUSIONS: Based upon our results, the Airtraq®, King Vision® and VividTrac® were superior to the Macintosh laryngscope in both normal and difficult airway scencarios for novice users. In particular, our study is the first to report that the VividTrac® shows promise for further clinical evaluation.

Dynamic changes of matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 after burn injury.

PURPOSE: Severe burn is a life-threatening condition. Many trials discuss the role of matrix metalloproteinases and tissue inhibitor of metalloproteinases in diseases generating systemic inflammatory response syndrome, and in some, their prognostic importance has been established. We aimed to describe the time courses of the aforementioned system and to evaluate the difference between survivors and nonsurvivors in burns. MATERIALS: Thirty-one patients were enrolled. Blood samples were collected on admission and on the 5 consecutive days. Circulating matrix metalloproteinase 9 (MMP-9) and tissue inhibitor of metalloproteinase 1 (TIMP-1) have been measured. Healthy individuals were invited as controls. RESULTS: Tissue inhibitor of metalloproteinase 1 increased in the burn group (P < .001) by day 2 and remained elevated thereafter. Plasma MMP-9 and MMP-9/TIMP-1 were already elevated on admission (P < .001) and decreased in tendency thereafter. In burned patients, significantly lower MMP-9 were noted on days 4 to 6 as MMP-9/TIMP-1 were also lower on days 3 to 6 (P < .01) compared with controls. We experienced difference regarding survival on days 5 and 6 by TIMP-1 (P < .05). CONCLUSIONS: Our research is the first follow-up study elucidating the dynamic changes of MMP-9-TIMP-1 system in severe burns. Alteration of MMP-9-TIMP-1 balance might influence systemic inflammatory response and related mortality. Matrix metalloproteinase 9 might be a good injury marker in burns after an extensive trial.

Time course of CD marker expression in patients with burns and its prognostic value.

INTRODUCTION: Due to immune suppression sepsis has remained the leading cause of mortality after burns. CD marker expression in circulating blood has not been fully examined in humans. The aim of our study was to asses CD marker expression after burns and to compare it between survivors and non-survivors. PATIENTS AND METHODS: Blood samples from all patients (n = 35) receiving intensive care treatment with more than 20% burned surface area were collected on admission and 5 consecutive days thereafter. Expressions of CD11a, CD11b, CD18, CD49d, CD97 and CD14 were measured on granulocytes, lymphocytes and monocytes. RESULTS: Expressions of granulocytes CD11a (days 1-2), CD18 (day 1), lymphocytes CD11a (days 1-5), CD11b (days 2-4), CD18 (days 1-6), CD49d (days 1-6), CD97 (day 1), monocytes CD11a (days 1-6), CD11b (day 2 and 5-6), CD18 (days 1-6), CD49d (days 1-6), CD97 (days 1-2), and CD14 (days 4-6) were significantly lower in patients than in healthy controls. Expressions of granulocyte CD11a (days 3-6), lymphocytes CD11a (days 3-6), CD11b (days 4-6), CD18 (days 4-6), monocyte CD97 (days 3-6) were significantly higher in survivors (n = 20) than in non-survivors (n = 15). CONCLUSION: These results suggest that burns is associated with immunosuppression and overwhelming anti-inflammatory processes may be signs of bad prognosis.

First steps in the management of pericardial effusion: who was first to relieve the pericardial sac--Larrey or Romero?

Early reports told us that the first pericardiotomy was performed by Baron Dominique Jean Larrey, Napoleon's chief military surgeon. In this article, we reveal a previous operation of that kind and its publication by Francisco Romero, who had a 9-year head start over Larrey's performance. The aim of this article was to briefly review the two-century-old history of pericardial fenestration.

Improvement of air tightness of stapled lung parenchyma using fascia lata.

Postoperative air leakage, a seemingly minor complication following procedures on emphysaematosus lung parenchyma can lead to very serious consequences. It is best treated if prevented. We report a technical modification of buttressing stapled resection line using autologous fascia lata.