Is pronator quadratus muscle repair required after anterior plate fixation for distal radial fractures? A prospective randomized comparative study.

In this prospective, randomized comparative study in patients with distal radial fractures, we aimed to determine whether surgical repair of the superficial head after anterior locking plate fixation of the radius improves clinical or functional outcomes or both, and distal radioulnar joint stability. One hundred patients were randomized to undergo distal radial fixation with or without repair of the superficial head. Twenty-one patients were lost to follow-up, leaving a final sample of 79 patients. No differences were observed between the groups in functional scores or complication after operation. Surgical repair of the superficial head of the pronator quadratus muscle after osteosynthesis with an anterior locking plate for distal radial fractures does not appear to substantially contribute to preserving distal radioulnar joint stability or improving the consolidation process.Level of evidence: II.

Design and Evaluation of Deep Learning Models for Continuous Acute Pain Detection Based on Phasic Electrodermal Activity.

The current method for assessing pain in clinical practice is subjective and relies on self-reported scales. An objective and accurate method of pain assessment is needed for physicians to prescribe the proper medication dosage, which could reduce addiction to opioids. Hence, many works have used electrodermal activity (EDA) as a suitable signal for detecting pain. Previous studies have used machine learning and deep learning to detect pain responses, but none have used a sequence-to-sequence deep learning approach to continuously detect acute pain from EDA signals, as well as accurate detection of pain onset. In this study, we evaluated deep learning models including 1-dimensional convolutional neural networks (1D-CNN), long short-term memory networks (LSTM), and three hybrid CNN-LSTM architectures for continuous pain detection using phasic EDA features. We used a database consisting of 36 healthy volunteers who underwent pain stimuli induced by a thermal grill. We extracted the phasic component, phasic drivers, and time-frequency spectrum of the phasic EDA (TFS-phEDA), which was found to be the most discerning physiomarker. The best model was a parallel hybrid architecture of a temporal convolutional neural network and a stacked bi-directional and uni-directional LSTM, which obtained a F1-score of 77.8% and was able to correctly detect pain in 15-second signals. The model was evaluated using 37 independent subjects from the BioVid Heat Pain Database and outperformed other approaches in recognizing higher pain levels compared to baseline with an accuracy of 91.5%. The results show the feasibility of continuous pain detection using deep learning and EDA.

Health and Socioeconomic Determinants of Abuse among Women with Disabilities.

The double vulnerability of women with disabilities places them at the center of this research paper. Intersectionality is key in research on gender-based violence. This study analyzes the perspective of the victims and non-victims themselves on this issue, through a comparative analysis between women with and without disabilities, at two levels of analysis: quantitative, through the adaptation of various scales (Assessment Screen-Disability/AAS-D, and the Woman Abuse Screening Tool/WAST), and qualitative, with semi-structured interviews (open scripts and different themes), and focus groups with experts from the associative network. The results obtained indicate that the most frequent type of violence is physical, followed by psychological and sexual, mainly perpetrated by partners. The higher their level of education, the more they defend themselves; receiving public aid can be a risk factor for domestic and sexual violence, and belonging to the associative movement and having paid work outside the home act as preventive measures. In conclusion, it is necessary to establish strategic protection measures and effective detection and intervention systems to make victims visible and care for them.

Guidewire type and prior use affects ureteral stent insertion force.

INTRODUCTION: To improve the success rate and safety of ureteral stent insertion, we sought to identify the effect of guidewire type and prior use upon the force needed to advance a 6Fr ureteral stent over various guidewires. MATERIALS AND METHODS: Two-hundred forty stent insertion trials were performed in an ex vivo porcine urinary tract model. Ten trials were randomly performed over 12 new and 12 used guidewires. For each trial, the force required to advance a 6Fr Cook double-pigtail ureteral stent was recorded. Guidewires included the Olympus Glidewire, Cook Fixed Core, and Boston Scientific Amplatz Super Stiff, Sensor, ZIPwire, and Zebra wire. RESULTS: The mean force needed for stent advancement was the lowest for the new Glidewire (0.18N) and ZIPwire (0.22N), with no significant difference to each other (p = 0.90). The following new wires required increasingly higher stent insertion forces compared to the Glidewire, the Zebra (0.60N; p < 0.01), Fixed Core (1.25N; p < 0.01), Sensor (1.43N; p < 0.01), and Amplatz Super Stiff wires (2.03N; p < 0.01). There was no statistical difference between new and used Glidewires (0.18N versus 0.29N; p = 0.14) and Zebra wires (0.59N versus 0.60N; p = 0.88). All other used wires required a significantly greater advancement force than their new counterparts (p < 0.01). CONCLUSIONS: For the same stent, the force required for stent advancement varies greatly between guidewire types. In addition, used guidewires typically required more force compared to new guidewires. In long or difficult cases, switching to a new wire may improve the ease of stent placement and reduce potential complications.

Age-dependent carry-over effects in a long-distance migratory bird.

Migratory birds usually respond to climate change by modifying breeding and/or wintering areas, as well as by reproducing earlier. In addition, changes in winter habitat use or breeding phenology could have important carry-over effects on subsequent breeding success. Here, we studied age- and sex-dependent carry-over effects from wintering to the breeding stage of a small aerial insectivorous long-distance migratory bird, the barn swallows (Hirundo rustica) breeding in Denmark during 1984-2013. First, we used stable isotope analyses combined with ringing recoveries to identify wintering areas. Second, we found that environmental conditions as inferred by Normalized Differential Vegetation Index (NDVI) have deteriorated at the wintering grounds. Third, we used confirmatory path analysis to quantify the indirect effect of winter conditions on subsequent breeding success. Females advanced onset of breeding, laid more eggs and raised more fledglings in the first brood when ecological conditions during the previous winter improved. This response was age dependent, since yearlings did not respond to this environmental cue but the response was increasingly stronger as females aged. Males showed a similar response to winter conditions, although not statistically significant. These results highlight the importance of studying carry-over effects within the context of climate change, especially in relation to age of individuals.

Evaluation of a Chitosan Hemostat in a Porcine Laparoscopic Partial Nephrectomy Model: A Pilot Study.

Background and Objective: The ideal hemostatic agent for laparoscopic partial nephrectomy (LPN) would provide complete hemostasis and sealing of the collecting system at a low cost. Chitosan (CS) is an established topical hemostatic agent, but standard sterilization techniques affect its functional and biologic properties, thereby preventing parenteral uses. This study sought to characterize the safety and efficacy of an implanted CS hemostat sterilized with either a standard technique, electron beam (e-beam) irradiation, or a novel technique, nonthermal nitrogen plasma, in a porcine LPN model. Methods: Laparoscopic partial nephrectomies were performed on six farm pigs and hemostasis achieved using only a CS hemostatic agent (Clo-Sur P.A.D.) that was e-beam (n = 3) or plasma sterilized (PS) (n = 3). Number of pads needed to achieve hemostasis, estimated blood loss, operative time, mass of kidney resection, and warm ischemia time were measured. Animals were monitored for 14 weeks and at harvest, retrograde ureteropyelography and histologic analysis were performed. Results: Complete hemostasis and collection system sealing were achieved in both groups. There was a trend toward less pads required for hemostasis (p = 0.056) and reduced blood loss (p = 0.096) with PS pads, although this did not achieve statistical significance. No complications were observed for 14 weeks and gross examination showed the implanted CS was encapsulated in a fibrous capsule. Histologic analysis revealed a healed nephrectomy site with residual CS and associated chronic inflammation, reactive fibrosis, and foreign body giant cell formation. Importantly, the adjacent renal tissue was intact and viable with no residual parenchymal inflammation or cytologic damage. Conclusion: CS pads alone provided safe and effective hemostasis in a porcine LPN model. PS may enhance hemostatic efficacy and resorption compared with e-beam.

High-Frequency Dusting Versus Conventional Holmium Laser Lithotripsy for Intrarenal and Ureteral Calculi.

INTRODUCTION: The efficiency of holmium laser lithotripsy for urolithiasis depends upon several factors, including laser pulse energy and frequency and stone composition and retropulsion. This study investigates the complex interplay between these factors and quantifies lithotripsy efficiency using different laser settings in a benchtop kidney and ureter model. MATERIALS AND METHODS: In vitro caliceal and ex vivo porcine ureteral models were constructed. Calcium oxalate monohydrate stones were fragmented using a 200-µm laser fiber. In the caliceal model, stone fragmentation and vaporization rates at settings of 0.6 J/5 Hz, 0.2 J/15 Hz, and 0.2 J/50 Hz were compared. In the ureteral model, fragmentation time, retropulsion rate, fragmentation rate, and fragmented stone weight were compared at settings of 0.6 J/5 Hz and 0.2 J/15 Hz. Retropulsive forces generated at 0.6 J/5 Hz, 0.2 J/15 Hz, and 0.2 J/50 Hz settings were compared. Analysis was performed using Student's t-test and one-way ANOVA. RESULTS: In the caliceal model, the 0.6 J/5 Hz setting fragmented and vaporized stones at a higher rate than the 0.2 J/15 Hz setting (0.072 vs. 0.049 mg/s; p < 0.001). However, when the 0.2 J energy setting was combined with the 50 Hz frequency, the fragmentation rate (0.069 mg/s) was similar to the fragmentation rate at 0.6 J/5 Hz (0.072 mg/s; p = 0.677). In the ureteral model, the 0.6 J/5 Hz setting produced higher fragmentation rates (0.089 vs. 0.049 mg/s; p < 0.001), but resulted in significantly lower fragmented stone weight overall (16.815 vs. 25.485 mg; p = 0.009) due to higher retropulsion rates (0.732 vs. 0.213 mm/s; p < 0.001). Retropulsive forces decreased significantly when pulse energy decreased from 0.6 to 0.2 J (0.907 vs. 0.223 N; p < 0.001). Frequency did not affect retropulsive force at 15 and 50 Hz settings (0.223 vs. 0.288 N; p = 0.509). CONCLUSIONS: Laser lithotripsy of calcium oxalate monohydrate stones in the ureter should be performed using the low-energy, moderate-frequency dusting setting to minimize retropulsion and maximize efficiency. In the renal calix, the low-energy high-frequency setting performed similarly to the high-energy low-frequency setting.

Bench-Top Feasibility Testing of a Novel Percutaneous Renal Access Technique: The Laser Direct Alignment Radiation Reduction Technique (DARRT).

INTRODUCTION: Traditional techniques for obtaining percutaneous renal access utilize continuous fluoroscopy. In an attempt to minimize radiation exposure, we describe a novel laser direct alignment radiation reduction technique (DARRT) for percutaneous access and test it in a bench-top model. METHODS: In this randomized-controlled bench-top study, 20 medical personnel obtained renal accesses using both the conventional bullseye technique and the laser DARRT. The primary endpoint was total fluoroscopy time. Secondary endpoints included insertion time, puncture attempts, course corrections, and subjective procedural difficulty. In the laser DARRT, fluoroscopy was used with the C-arm positioned with the laser beam at a 30° angle. The access needle and hub were aligned with the laser beam. Effective caliceal puncture was confirmed with fluoroscopy and direct vision. The Paired samples Wilcoxon signed rank test was used for statistical analysis with significance at p < 0.05. RESULTS: A total of 120 needle placements were recorded. Fluoroscopy time for needle access using the laser DARRT was significantly lower than the bullseye technique in all groups as follows: attendings (7.09 vs 18.51 seconds; p < 0.001), residents (6.55 vs 13.93 seconds; p = 0.001), and medical students (6.69 vs 20.22 seconds; p < 0.001). Students rated the laser DARRT easier to use (2.56 vs 4.89; p < 0.001). No difference was seen in total access time, puncture attempts, or course corrections between techniques. CONCLUSION: The laser DARRT reduced fluoroscopy time by 63%, compared with the conventional bullseye technique. The least experienced users found the laser DARRT significantly easier to learn. This novel technique is promising and merits additional testing in animal and human models.

Kidney, Ureter, and Bladder (KUB): A Novel Grading System for Encrusted Ureteral Stents.

OBJECTIVE: To introduce a grading system (kidney, ureter, and bladder [KUB]) to identify encrusted stents that may require multiple surgeries, multimodal surgery, and operative time > 180 minutes for successful removal. METHODS: One hundred ten retained encrusted ureteral stents were retrospectively scored using the KUB grading system and this score was correlated with operative time, need for multiple surgeries or multimodal surgery, and stone-free rate. Data analysis was performed with t test, Mann-Whitney U test, and chi-square tests. A P value of <0.05 was considered statistically significant. RESULTS: Average indwelling stent time was 17.2 months (0.7-139.0). There were 83.6% of stents removed in a single surgery, with 63.0% of these requiring multimodal surgery. K score ≥ 3 was associated with multiple surgeries (odds ratio [OR] 3.59, P = .006), multimodal surgery (OR 2.44, P = .04), operative time > 180 minutes (OR 3.80, P = .001), and lower stone-free rate (OR 0.23, P = .02). U score ≥ 3 was associated with operative time > 180 minutes (OR 3.28, P = .003). B score ≥ 3 was associated with lower stone-free rate (OR 0.23, P = .020). Total score ≥ 9 was associated with multiple surgeries (OR 4.19, P = .001), operative time > 180 minutes (OR 3.45, P = .002), and lower stone-free rate (OR 0.13, P = .001). CONCLUSION: The KUB system identifies stents at risk for requiring multiple surgeries, multimodal surgery, and operative time > 180 minutes. It also correlates with stone-free rate. This grading system can help surgeons manage patient expectations and predict surgical complexity.

Direct Endoscopic Visualization Combined with Ultrasound Guided Access during Percutaneous Nephrolithotomy: A Feasibility Study and Comparison to a Conventional Cohort.

PURPOSE: Percutaneous nephrolithotomy access may be technically challenging and result in significant radiation exposure. In an attempt to reduce percutaneous nephrolithotomy radiation exposure, a novel technique combining ultrasound and direct ureteroscopic visualization was developed and reviewed. MATERIALS AND METHODS: Ureteroscopy without fluoroscopy was used to determine the optimal calyx for access, which was punctured with a Chiba needle under percutaneous ultrasound guidance. Next a wire was passed into the collecting system and ureteroscopically pulled into the ureter using a basket. Tract dilation and sheath and nephrostomy tube placement were performed under direct ureteroscopic visualization. Twenty consecutive patients undergoing this novel technique were reviewed and compared to 20 matched patients treated with conventional percutaneous nephrolithotomy. Mann-Whitney U and Pearson chi-square tests were used for comparisons with p <0.05 considered significant. RESULTS: Using this novel technique mean fluoroscopy access time was 3.5 seconds (range 0 to 27.9) and mean total fluoroscopic time was 8.8 seconds (range 0 to 47.1). Mean operative time was 232 minutes (range 87 to 533), estimated blood loss was 111 ml, the stone-free rate was 65% and the complication rate was 25%. Compared to 20 matched conventional percutaneous nephrolithotomy cases, there was no difference in operative time (p=0.76), estimated blood loss (p=0.64), stone-free rate (p=0.50) or complications (p=1.00). However, the novel technique resulted in a significant reduction in fluoroscopy access time (3.5 vs 915.5 seconds, p <0.001) and total fluoroscopy time (8.8 vs 1,028.7 seconds, p <0.001). CONCLUSIONS: This study demonstrates the feasibility of combined ultrasound and ureteroscopic assisted access for percutaneous nephrolithotomy. A greater than 99% reduction in fluoroscopy time was achieved using this technique.

Percutaneous Externally Assembled Laparoscopic Instruments: Creation of a New Surgical Paradigm.

OBJECTIVES: Laparoendoscopic single-site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) produce excellent cosmetic outcomes, but are technically challenging. The objective of this study was to test the functionality and feasibility of a novel minimally invasive surgical paradigm, which maintains triangulation but uses special externally assembled instruments to minimize the postoperative cosmetic impact. METHODS: Percutaneous Externally Assembled Laparoscopic (PEAL) instruments have specialized 2.96-mm shafts with interchangeable 5-mm working tips that are assembled externally. First, 5-mm laparoscopic, PEAL, and 2-mm needlescopic instruments were tested to determine piercing force on fresh human cadaver organs. In a bench-top study, 20 subjects assembled and used PEAL instruments in five different skills tests that were also compared with the same tasks using conventional laparoscopic instruments. Finally, PEAL instrument functionality was tested in a four-porcine nephrectomy feasibility study. RESULTS: PEAL (2.80 lbF) and 5-mm laparoscopic instruments (2.28 lbF) had a significantly higher mean organ piercing perforation force compared with needlescopic instruments (1.39 lbF, p < 0.05). Average assembly time of PEAL instruments was 31.08 seconds (range: 19.83-43.85). There were no significant differences in the amount of time needed for completion of the bench-top tasks between laparoscopic and PEAL instruments (p > 0.05 for all tasks). Four-porcine PEAL nephrectomies were completed with no complications and minimal blood loss (mean 7.5 mL). Mean operative time was 98.25 minutes (range 79-116). CONCLUSION: PEAL tools are easily assembled, have similar safety and efficacy compared with standard laparoscopic tools, and are less likely to injure organs compared with needlescopic instruments. They function well during laparoscopic nephrectomy and may decrease the invasiveness of conventional laparoscopic instrumentation.

Renal Vascular Clamp Placement: A Potential Cause of Incomplete Hilar Control during Partial Nephrectomy.

PURPOSE: Previous benchtop studies have shown that robotic bulldog clamps provide incomplete vascular control of a Penrose drain. We determined the efficacy of robotic and laparoscopic bulldog clamps to ensure hemostasis on the human renal artery. The effect of clamp position on vascular control was also examined. MATERIALS AND METHODS: Fresh human cadaveric renal arteries were used to determine the leak point pressure of 7 bulldog clamps from a total of 3 manufacturers. Five trials were performed per clamp at 4 locations, including the fulcrum, proximal, middle and distal positions. Comparison was done using the Kruskal-Wallis test with p <0.05 considered significant. RESULTS: None of the bulldog clamps leaked at a pressure less than 215 mm Hg when applied at the proximal, middle or distal position. In general leak point pressure decreased as the artery was positioned more distal along the clamp. The exception was when the vessel was placed at the fulcrum position. At that position 80% to 100% of trials with the Klein laparoscopic, 100% with the Klein robotic (Klein Robotic, San Antonio, Texas) and 60% to 80% with the Scanlan robotic (Scanlan International, Saint Paul, Minnesota) clamp leaked at pressure below 215 mm Hg. CONCLUSIONS: Each vascular clamp adequately occluded flow at physiological pressure when placed at the proximal, middle or distal position. Furthermore, these results demonstrate that there is leakage at physiological pressure when the artery is placed at the fulcrum of certain clamp types. These results suggest that applying a bulldog clamp at the fulcrum could potentially lead to inadequate vessel occlusion and intraoperative bleeding.

Techniques for Minimizing Radiation Exposure During Evaluation, Surgical Treatment, and Follow-up of Urinary Lithiasis.

Patients receive significant radiation exposure during the diagnosis, treatment, and follow-up of urinary stone disease. This radiation exposure may result in patient harm and is believed to contribute to the risk for malignancy. This review will present current information to allow surgeons to optimize their diagnostic, treatment, and follow-up regimens to allow optimal care of stone disease patients at the lowest radiation dose possible.

Ureteroscopy Without Fluoroscopy: A Feasibility Study and Comparison with Conventional Ureteroscopy.

INTRODUCTION AND OBJECTIVES: Patients with urolithiasis are exposed to significant amounts of radiation during their initial work-up, surgical treatment, and follow-up. The purpose of this study was to determine the feasibility of performing ureteroscopy without fluoroscopy. In addition, we compared patients treated using a completely fluoroless ureteroscopic technique with a cohort of conventional ureteroscopies performed using fluoroscopy. MATERIALS AND METHODS: A retrospective review of 50 consecutive patients undergoing fluoroless ureteroscopy was performed. These procedures were performed by inserting guidewires and instruments using tactile feedback, direct visualization, and external visual cues to substitute for fluoroscopy. In addition, this cohort was compared with 50 conventional, fluoroscopy-guided ureteroscopies performed in the same time period. RESULTS: Fifty ureteroscopies were performed without image guidance. For this cohort, the mean operative time was 59.2 minutes, overall stone burden was 91.53 mm(2), complication rate was 4%, and repeat procedure rate was 8%. Compared with conventional ureteroscopy the fluoroless ureteroscopy patients had a larger stone burden (p=0.042; 91.53 vs 56.58 mm(2)), but similar age, gender, American Society of Anesthesiologists (ASA) score, body-mass index, operative time, complication rate, and repeat procedure rate. CONCLUSIONS: This study demonstrates the feasibility and efficacy of the completely fluoroless ureteroscopic treatment of calculi throughout the entire upper urinary tract while completely removing radiation exposure to the patients and staff. Although this fluoroless technique may be most applicable in patients at highest risk for radiation exposure, such as pregnant women, children, and recurrent stone formers, it offers an alternative for reduction of radiation in all patients.

Trapezio-metacarpal arthrodesis: procedure and results.

The high prevalence of trapezio-metacarpal joint (TMJ) osteoarthritis leads to develop techniques to improve surgical outcomes when conservative treatment has failed. We have evaluated 18 patients with Eaton III TMJ osteoarthritis, who underwent an arthrodesis. Using a dorsal-radial curved shaped skin incision the TMJ was exposed through the space between the abductor pollicis longus and the extensor pollicis brevis muscles. The articular capsule was divided and the TMJ was opened. Neat curettage was then performed in both joint surfaces by removing all the articular cartilage until some cancellous bone hints appeared underneath. The joint was then fixed in the optimal position by a 1.6 mm Kirschner wire and a 1.1 mm guide wire. A cannulated drill for the guide wire was used and matched to a cannulated lag screw. Then, a cylinder-shaped cancellous bone autograft harvested from the distal radius by a percutaneous approach was applied in the hole by drilling backwards in order to spread the bone about onto the hole walls. The joint was then definitively fixed by the cannulated lag screw. The K wires were removed by that time. DASH score changed from an average of 68 in the preoperative assessment to 39.4 at the end of the evolution time. The evolution of pain has decreased from 9.2 points preoperatively to 3.9 points in the postoperative using the visual analogue scale. In terms of mobility, it has decreased from 4 points preoperatively to 3.9 postoperatively, 14 patients got opposition of the thumb to the fifth finger, two of them to the head of the fifth metacarpal bone, one patient to the fourth finger, and one to the third. This slight decrease of mobility had no effect on performing activities of daily life, as expressed by the patients. The grip strength increased from 17 to 21.7 kg and the thumb opposition from 7.8 to 11.2 kg. All patients, except one, would have the operation again after knowing the final results. This patient said that results did not meet previous expectations. On the radiographic evaluation, consolidation has been achieved in 17 patients. When thumb carpo-metacarpal arthrodesis is indicated, the procedure provides a reliable and lasting treatment with satisfactory results. The development of new implants and the possibility of introducing autologous graft percutaneously as is described using this technique leads to improve the results.

Computer modeling and ex vivo experiments with a (saline-linked) irrigated electrode for RF-assisted heating.

BACKGROUND: Externally irrigated radiofrequency (RF) electrodes have been widely used to thermally ablate tumors in surface tissue and to thermally coagulate the transection plane during a surgical resection. As far as we know, no mathematical model has yet been developed to study the electrical and thermal performance of these electrodes, especially the role of the saline layer that forms around the electrode. METHODS: Numerical models of a TissueLink device model DS3.0 (Salient Surgical Technologies, Portsmouth, NH, USA) were developed. Irrigation was modeled including a saline layer and a heat convection term in the governing equation. Ex vivo experiments based on fragments of bovine hepatic tissue were conducted to obtain information which was used in building the numerical model. We compared the 60°C isotherm of the computer results with the whitening contour in the heated samples. RESULTS: Computer and experimental results were in fine agreement in terms of lesion depth (2.4 mm in the simulations and 2.4 ± 0.6 mm in the experiments). In contrast, the lesion width was greater in the simulation (9.6 mm vs. 7.8 ± 1.8 mm). The computer simulations allowed us to explain the role of the saline layer in creating the thermal lesion. Impedance gradually decreased as heating proceeded. The saline was not observed to boil. In the proximity of the electrode (around 1 mm) the thermal lesion was mainly created by the RF power in this zone, while at a further distance the thermal lesion was created by the hot saline on the tissue surface by simple thermal conduction. Including the heat convection term associated with the saline velocity in the governing equation was crucial to verifying that the saline layer had not reached boiling temperature. CONCLUSIONS: The model reproduced thermal performance during heating in terms of lesion depth, and provided an explanation for: 1) the relationship between impedance, electrode insertion depth, and saline layer, and 2) the process of creating thermal lesions in the tissue with this type of electrode.