Robotic surgery: financial impact of surgical trays optimization in bariatric and thoracic surgery.

The incorporation of new technologies in the surgical field, such as the robotic da Vinci System, has made it possible to offer a series of advantages to the patient and the surgeon, with important benefits for both. However, cost continues to be a limiting factor to the adoption of this technology. The development of strategies to maximize the measures that can lead to reduced expenses is a key factor to improve cost-benefit ratio. According to some studies, more than 50% of the costs of a surgical procedure are related to materials and medical supplies, which is why any measure aimed at optimizing their use is pertinent. Our institution, the Orlando Regional Medical Center (ORMC), created a working group whose main purpose is to optimize the Robotic OR process. Their first step was to optimize the surgical trays, and this was carried out in four stages: observation, modification, trial period, and cost analysis. The specialties involved in this initiative were Bariatric and Thoracic Surgeries. Once the optimization process ended, the number of laparoscopic/thoracoscopy instruments in the trays decreased by 63 and 87% for bariatric and thoracic surgery, respectively; and the number of conventional surgery instruments was also reduced by 47 and 64%, for the same specialties, respectively. The financial analysis concluded that implementing this measure will lead to an estimated six-figure savings per year.

High-Resolution Hyperspectral Imaging Using Low-Cost Components: Application within Environmental Monitoring Scenarios.

High-resolution hyperspectral imaging is becoming indispensable, enabling the precise detection of spectral variations across complex, spatially intricate targets. However, despite these significant benefits, currently available high-resolution set-ups are typically prohibitively expensive, significantly limiting their user base and accessibility. These limitations can have wider implications, limiting data collection opportunities, and therefore our knowledge, across a wide range of environments. In this article we introduce a low-cost alternative to the currently available instrumentation. This instrument provides hyperspectral datasets capable of resolving spectral variations in mm-scale targets, that cannot typically be resolved with many existing low-cost hyperspectral imaging alternatives. Instrument metrology is provided, and its efficacy is demonstrated within a mineralogy-based environmental monitoring application highlighting it as a valuable addition to the field of low-cost hyperspectral imaging.

A Review of Direct Oral Anticoagulants in Patients With Stage 5 or End-Stage Kidney Disease.

OBJECTIVE: To evaluate the role of oral anticoagulation in patients with stage 5 chronic kidney disease (CKD-5) or end-stage kidney disease (ESKD). DATA SOURCES: A literature search of PubMed (January 2000 to July 1, 2021), the Cochrane Library, and Google Scholar databases (through April 1, 2021) was performed with keywords DOAC (direct-acting oral anticoagulant) OR NOAC or dabigatran OR rivaroxaban OR apixaban OR edoxaban AND end-stage kidney disease combined with atrial fibrillation (AF) or venous thromboembolism (VTE) OR pulmonary embolism OR deep-vein thrombosis. STUDY SELECTION AND DATA EXTRACTION: Case-control, cohort, and randomized controlled trials comparing DOACs to an active control for AF or VTE in patients with CKD-5 or ESKD and reporting outcomes of stroke, recurrent thromboembolism, or major bleeding were included. DATA SYNTHESIS: Nine studies were included. Efficacy data supporting routine use of warfarin or DOACs in CKD-5 or ESKD are limited. Rivaroxaban and apixaban may provide enhanced safety compared to warfarin in patients with AF. Data for VTE are limited to 1 retrospective study. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Because of the paucity of rigorous, prospective studies in CKD-5 or ESKD, OACs should not be broadly used in this population. It is clear that data regarding efficacy of DOACs cannot be reliably and safely extrapolated from the non-ESKD population. Therefore, use of OACs in this population should be individualized. CONCLUSIONS: If OACs for stroke prevention with AF are deemed necessary, apixaban or rivaroxaban can be considered. DOACs cannot currently be recommended over warfarin in patients with CKD-5 or ESKD and VTE.

Low-Cost Hyperspectral Imaging with A Smartphone.

Recent advances in smartphone technologies have opened the door to the development of accessible, highly portable sensing tools capable of accurate and reliable data collection in a range of environmental settings. In this article, we introduce a low-cost smartphone-based hyperspectral imaging system that can convert a standard smartphone camera into a visible wavelength hyperspectral sensor for ca. £100. To the best of our knowledge, this represents the first smartphone capable of hyperspectral data collection without the need for extensive post processing. The Hyperspectral Smartphone's abilities are tested in a variety of environmental applications and its capabilities directly compared to the laboratory-based analogue from our previous research, as well as the wider existing literature. The Hyperspectral Smartphone is capable of accurate, laboratory- and field-based hyperspectral data collection, demonstrating the significant promise of both this device and smartphone-based hyperspectral imaging as a whole.

Efficacy and Safety of Nonvitamin K Oral Anticoagulants following Cardiac Valve Replacement.

OBJECTIVE: To compare the efficacy and safety of nonvitamin K oral anticoagulants (NOACs) and vitamin K antagonists (VKAs) following bioprosthetic cardiac valve replacement. METHODS: This was a retrospective analysis conducted at a community teaching hospital in the southeastern United States between August 2015 and August 2018. Patients 18 years of age and older who underwent cardiac valve replacement and were prescribed oral anticoagulation were screened for inclusion. Patients were excluded if they had a mechanical valve replacement, experienced a venous thromboembolism, cerebrovascular accident, or acute coronary syndrome within 1 month before valve replacement, changed oral anticoagulation during the study period, were lost to follow-up, or declined to participate in the follow-up survey. The primary outcome was a composite of thromboembolic events within 90 days following bioprosthetic cardiac valve replacement. The safety outcome was major bleeding within 180 days of bioprosthetic cardiac valve replacement. RESULTS: The primary outcome of a composite of thromboembolic events within 90 days following bioprosthetic cardiac valve replacement occurred in 1 patient (4.3%) in the VKA group and 4 patients (7.4%) in the NOAC group. Major bleeding occurred in 2 patients (8.7%) in the VKA group and 0 patients in the NOAC group. CONCLUSION: Our study is the first to report the efficacy and safety of NOACs compared with VKA therapy following bioprosthetic cardiac valve replacement irrespective of an atrial fibrillation diagnosis. Notably, two of the thromboembolic events in the NOAC group occurred while therapy was held or inappropriately dosed; when these events are removed, the rate of thromboembolism is 3.8%. This rate is consistent with the VKA group. Our study adds to a small pool of literature regarding the use of NOACs following bioprosthetic cardiac valve replacement and suggests that NOACs may have similar efficacy and improved safety as compared with VKA therapy. Large randomized controlled trials are warranted to confirm our observations.

Low-Cost Hyperspectral Imaging System: Design and Testing for Laboratory-Based Environmental Applications.

The recent surge in the development of low-cost, miniaturised technologies provides a significant opportunity to develop miniaturised hyperspectral imagers at a fraction of the cost of currently available commercial set-ups. This article introduces a low-cost laboratory-based hyperspectral imager developed using commercially available components. The imager is capable of quantitative and qualitative hyperspectral measurements, and it was tested in a variety of laboratory-based environmental applications where it demonstrated its ability to collect data that correlates well with existing datasets. In its current format, the imager is an accurate laboratory measurement tool, with significant potential for ongoing future developments. It represents an initial development in accessible hyperspectral technologies, providing a robust basis for future improvements.

Hyperspectral Imaging in Environmental Monitoring: A Review of Recent Developments and Technological Advances in Compact Field Deployable Systems.

The development and uptake of field deployable hyperspectral imaging systems within environmental monitoring represents an exciting and innovative development that could revolutionize a number of sensing applications in the coming decades. In this article we focus on the successful miniaturization and improved portability of hyperspectral sensors, covering their application both from aerial and ground-based platforms in a number of environmental application areas, highlighting in particular the recent implementation of low-cost consumer technology in this context. At present, these devices largely complement existing monitoring approaches, however, as technology continues to improve, these units are moving towards reaching a standard suitable for stand-alone monitoring in the not too distant future. As these low-cost and light-weight devices are already producing scientific grade results, they now have the potential to significantly improve accessibility to hyperspectral monitoring technology, as well as vastly proliferating acquisition of such datasets.

Adaptive Physical Activity for Stroke: An Early-Stage Randomized Controlled Trial in the United States.

Background. As stroke survival improves, there is an increasing need for effective, low-cost programs to reduce deconditioning and improve mobility. Objective. To conduct a phase II trial examining whether the community-based Italian Adaptive Physical Activity exercise program for stroke survivors (APA-Stroke) is safe, effective, and feasible in the United States. Methods. In this single-blind, randomized controlled trial, 76 stroke survivors with mild to moderate hemiparesis >6 months were randomized to either APA-Stroke (N = 43) or Sittercise (N = 33). APA-Stroke is a progressive group exercise regimen tailored to hemiparesis that includes walking, strength, and balance training. Sittercise, a seated, nonprogressive aerobic upper body general exercise program, served as the control. Both interventions were 1 hour, 3 times weekly, in 5 community locations, supervised by exercise instructors. Results. A total of 76 participants aged 63.9 ± 1.2 years, mean months poststroke 61.8 ± 9.3, were included. There were no serious adverse events; completion rates were 58% for APA-Stroke, 70% for Sittercise. APA-Stroke participants improved significantly in walking speed. Sample size was inadequate to demonstrate significant between-group differences. Financial and logistical feasibility of the program has been demonstrated. Ongoing APA classes have been offered to >200 participants in county Senior Centers since study completion. Conclusion. APA-Stroke shows great promise as a low-cost, feasible intervention. It significantly increased walking speed. Safety and feasibility in the US context are demonstrated. A pivotal clinical trial is required to determine whether APA-Stroke should be considered standard of care.

Stroke survivors with severe mental illness: Are they at-risk for increased non-psychiatric hospitalizations?

BACKGROUND: This study examined outcomes for two groups of stroke survivors treated in Veteran Health Administration (VHA) hospitals, those with a severe mental illness (SMI) and those without prior psychiatric diagnoses, to examine risk of non-psychiatric medical hospitalizations over five years after initial stroke. METHODS: This retrospective cohort study included 523 veterans who survived an initial stroke hospitalization in a VHA medical center during fiscal year 2003. The survivors were followed using administrative data documenting inpatient stroke treatment, patient demographics, disease comorbidities, and VHA hospital admissions. Multivariate Poisson regression was used to examine the relationship between patients with and without SMI diagnosis preceding the stroke and their experience with non-psychiatric medical hospitalizations after the stroke. RESULTS: The study included 100 patients with SMI and 423 without SMI. Unadjusted means for pre-stroke non-psychiatric hospitalizations were higher (p = 0.0004) among SMI patients (1.47 ± 0.51) compared to those without SMI (1.00 ± 1.33), a difference which persisted through the first year post-stroke (SMI: 2.33 ± 2.46; No SMI: 1.74 ± 1.86; p = 0.0004). Number of non-psychiatric hospitalizations were not significantly different between the two groups after adjustment for patient sociodemographic, comorbidity, length of stay and inpatient stroke treatment characteristics. Antithrombotic medications significantly lowered risk (OR = 0.61; 95% CI: 0.49-0.73) for stroke-related readmission within 30 days of discharge. CONCLUSIONS: No significant differences in medical hospitalizations were present after adjusting for comorbid and sociodemographic characteristics between SMI and non-SMI stroke patients in the five-year follow-up. However, unadjusted results continue to draw attention to disparities, with SMI patients experiencing more non-psychiatric hospitalizations both prior to and up to one year after their initial stroke. Additionally, stroke survivors discharged on antithrombotic medications were at lower risk of re-admission within 30 days suggesting the VHA should continue to focus on effective stroke management irrespective of SMI.

Fulvestrant 500 mg versus anastrozole 1 mg for hormone receptor-positive advanced breast cancer (FALCON): an international, randomised, double-blind, phase 3 trial.

BACKGROUND: Aromatase inhibitors are a standard of care for hormone receptor-positive locally advanced or metastatic breast cancer. We investigated whether the selective oestrogen receptor degrader fulvestrant could improve progression-free survival compared with anastrozole in postmenopausal patients who had not received previous endocrine therapy. METHODS: In this phase 3, randomised, double-blind trial, we recruited eligible patients with histologically confirmed oestrogen receptor-positive or progesterone receptor-positive, or both, locally advanced or metastatic breast cancer from 113 academic hospitals and community centres in 20 countries. Eligible patients were endocrine therapy-naive, with WHO performance status 0-2, and at least one measurable or non-measurable lesion. Patients were randomly assigned (1:1) to fulvestrant (500 mg intramuscular injection; on days 0, 14, 28, then every 28 days thereafter) or anastrozole (1 mg orally daily) using a computer-generated randomisation scheme. The primary endpoint was progression-free survival, determined by Response Evaluation Criteria in Solid Tumors version 1·1, intervention by surgery or radiotherapy because of disease deterioration, or death from any cause, assessed in the intention-to-treat population. Safety outcomes were assessed in all patients who received at least one dose of randomised treatment (including placebo). This trial is registered with ClinicalTrials.gov, number NCT01602380. FINDINGS: Between Oct 17, 2012, and July 11, 2014, 524 patients were enrolled to this study. Of these, 462 patients were randomised (230 to receive fulvestrant and 232 to receive anastrozole). Progression-free survival was significantly longer in the fulvestrant group than in the anastrozole group (hazard ratio [HR] 0·797, 95% CI 0·637-0·999, p=0·0486). Median progression-free survival was 16·6 months (95% CI 13·83-20·99) in the fulvestrant group versus 13·8 months (11·99-16·59) in the anastrozole group. The most common adverse events were arthralgia (38 [17%] in the fulvestrant group vs 24 [10%] in the anastrozole group) and hot flushes (26 [11%] in the fulvestrant group vs 24 [10%] in the anastrozole group). 16 (7%) of 228 patients in in the fulvestrant group and 11 (5%) of 232 patients in the anastrozole group discontinued because of adverse events. INTERPRETATION: Fulvestrant has superior efficacy and is a preferred treatment option for patients with hormone receptor-positive locally advanced or metastatic breast cancer who have not received previous endocrine therapy compared with a third-generation aromatase inhibitor, a standard of care for first-line treatment of these patients. FUNDING: AstraZeneca.

Inhibition of EGFR, HER2, and HER3 signaling with AZD8931 in combination with anastrozole as an anticancer approach: Phase II randomized study in women with endocrine-therapy-naïve advanced breast cancer.

PURPOSE: AZD8931 is an orally bioavailable, reversible tyrosine kinase inhibitor of EGFR, HER2, and HER3 signaling. The Phase II MINT study (ClinicalTrials.gov NCT01151215) investigated whether adding AZD8931 to endocrine therapy would delay development of endocrine resistance in patients with hormone-sensitive advanced breast cancer. METHODS: Patients were randomized 1:1:1 to receive daily anastrozole (1 mg) in combination with AZD8931 20 mg twice daily (bid), AZD8931 40 mg bid, or placebo. The primary objective was evaluation of progression-free survival (PFS) in patients treated with combination AZD8931 and anastrozole versus anastrozole alone. Secondary objectives included assessment of safety and tolerability, objective response rate, and overall survival. RESULTS: At the interim analysis, 359 patients were randomized and received anastrozole in combination with AZD8931 20 mg (n = 118), 40 mg (n = 120), or placebo (n = 121); 39 % of patients (n = 141) had a progression event. Median PFS (HR; 95 % CI vs placebo) in the AZD8931 20, 40 mg, and placebo arms was 10.9 (1.37; 0.91-2.06, P = 0.135), 13.8 (1.16; 0.77-1.75, P = 0.485), and 14.0 months, respectively. No indication of clinical benefit was observed following treatment with AZD8931 for the secondary endpoints. Safety findings showed a greater incidence of diarrhea (40, 51, and 12 % for AZD8931 20, 40 mg, and placebo, respectively), rash (32, 48, and 12 %), dry skin (19, 25, and 2 %), and acneiform dermatitis (16, 28, and 2 %) in patients treated with AZD8931 versus placebo. CONCLUSIONS: AZD8931, in combination with endocrine therapy, does not appear to enhance endocrine responsiveness and is associated with greater skin and gastrointestinal toxicity.

Effectiveness of adaptive physical activity combined with therapeutic patient education in stroke survivors at twelve months: a non-randomized parallel group study.

BACKGROUND: Adaptive physical activity (APA) is a community-based exercise program for chronic stroke survivors that proved to be effective in improving physical functioning and psychological well-being in the short term. AIM: The aim of the present paper is to determine the effectiveness at twelve months of an intervention of APA combined with therapeutic patient education (TPE) in stroke survivors. DESIGN: This study is a non-randomized parallel group study comparing APA-TPE intervention with treatment as usual (TAU). SETTING: Patients were recruited after discharge from two Physical Medicine and Rehabilitation Units, 3 to 18 months after the stroke event. The APA-TPE intervention was conducted in local gymnasiums. POPULATION: The study population includes consecutive adult stroke survivors with mild to moderate hemiparesis who were able to walk 25 m independently and had no need of physical therapy. METHODS: The experimental group (N.=126) underwent 16 biweekly sessions of APA and 3 TPE sessions and controls (N.=103) underwent TAU. Twelve-month outcomes included the Modified Barthel Index, the Caregiver Strain Index, SF-12 health-related quality of life, medical complications and health services use. RESULTS: At twelve months, the ability to perform daily living activities, assessed using Modified Barthel Index, was decreased in the TAU group and improved in the APA-TPE group. The physical and mental components of quality of life were significantly improved in both groups. The risk of fractures (OR=0.09, 95% CI 0.01-0.79) and recourse to rehabilitation treatments (OR=0.24, 95% CI 0.08-0.77) were lower in the APA-TPE compared with the TAU group. No difference was found between groups concerning the caregiver burden. CONCLUSION: APA-TPE is an effective intervention to maintain and improve activities of daily living, reduce falls and recourse to rehabilitation treatments at twelve months. CLINICAL REHABILITATION IMPACT: Structured physical activity programs that can be performed also at home, when combined with therapeutic education focused on benefits of physical activity, will encourage stroke survivors to continue exercising. Therefore, it fulfills an essential requirement to the maintenance of lasting health benefits and the prevention of physical and psychological deterioration.

A phase II clinical trial of a natural formulation containing tea catechins for xerostomia.

OBJECTIVE: Previous animal studies indicated catechins from the tea plant (Camellia sinensis) may modulate salivary function and possess a therapeutic effect for xerostomia. The objective of this study was to evaluate a natural formulation containing tea catechins in 60 patients with xerostomia, including patients with Sjögren syndrome. STUDY DESIGN: This study used a double-blind, placebo-controlled, randomized design. The functional placebo contained all natural formulation ingredients and 500 mg xylitol, but without the key plant extracts. RESULTS: After 8 weeks of therapy, the xylitol-containing placebo failed to modulate saliva output. In comparison, the catechin-containing natural formulation resulted in a statistically significant increase in unstimulated (3.8-fold) and stimulated (2.1-fold) saliva output vs baseline. The quality of life score showed a significant improvement in both groups but no significant difference between groups. CONCLUSIONS: The catechin-containing natural formula partially restored salivary function in patients with xerostomia and provided an objective improvement in saliva output, which warrants large-scale clinical trials.

Community-based exercise for chronic disease management: an Italian design for the United States?

Although only a small proportion of older adults in the United States engage in recommended amounts of physical exercise, the health benefits of exercise for this population and the potential for lowering health care costs are substantial. However, access to regular exercise programs for the frail elderly and individuals with disabilities remains limited. In the context of health reform and emerging opportunities in developing integrated systems of care, the experience in Tuscany in implementing a community-based program of exercise for the elderly should be of interest.

Impact of adapted physical activity and therapeutic patient education on functioning and quality of life in patients with postacute strokes.

OBJECTIVE: The aim of this study was to assess whether the combination of Adapted Physical Activity (APA) and Therapeutic Patient Education (TPE) improves function and quality of life in survivors of strokes. METHODS: This nonrandomized controlled study enrolled patients with mild to moderate hemiparesis referred to 2 physical medicine and rehabilitation units in Emilia-Romagna, Italy, 3 to 18 months after a single unilateral mild to moderate stroke. The experimental group (n = 126) received 16 APA sessions and 3 sessions of TPE, and the control group (n = 103) received usual care; 86.9% completed treatment. The main outcome measure was a 4-month change in gait endurance (that corresponds to 2 months after intervention in the experimental group), and secondary outcomes included the Short Physical Performance Battery, Berg Balance Scale, Barthel Index, Geriatric Depression Scale, 12-item Short-Form Health Survey, and Caregiver Strain Index. Changes in scores at 4 months were compared between groups using analysis of variance and controlling for group imbalance by means of the propensity score. RESULTS: Gait endurance, physical performance, balance, and the physical component of the quality of life score increased significantly at 4 months in the APA group and remained stable in the control group. The propensity-adjusted between-group change was significant for these scores at P < .01. CONCLUSIONS: Our results confirm that it is feasible and potentially effective to implement APA programs for elderly patients with complex clinical conditions as early as 3 months after a stroke and suggest that, when combined with TPE, the effects of a postrehabilitation APA program are relatively enduring.

Community-based exercise for upper limb paresis: a controlled trial with telerehabilitation.

BACKGROUND: Arm paresis remains a major impairment after stroke despite the best conventional rehabilitation. Randomized, controlled trials of intensive exercise programs have demonstrated improvements in arm function for patients with chronic stroke. However, the gains achieved have been relatively modest for the large investments in patient and therapist time. OBJECTIVE: To evaluate the safety, acceptance, adherence, and effectiveness of a community-based exercise program for upper limb paresis in patients with chronic stroke and the effects of telerehabilitation monitoring in kiosks distributed through the community. METHODS: Longitudinal cohort with geographic control group. The experimental group received devices needed for a home exercise program based on the Carr and Shepherd "Motor Learning Program" and were instructed to practice the exercises at least twice a week at the kiosk and at least 3 more days a week at home. The control group received usual care. RESULTS: Compared with the control group, patients in the experimental group demonstrated significant gains in arm function as measured by the Wolf Motor Function Test, 9-Hole Peg Test, Motricity Index, and Nottingham Extended Activities of Daily Living Questionnaire. The intervention received high satisfaction ratings and produced no adverse events. Only 30% of the subjects attended kiosks regularly. Outcomes for this group did not differ significantly from those who only practiced at home. CONCLUSIONS: Home- and community-based exercise for arm paresis is safe and effective. Telerehabilitation interventions will need additional enhancements to improve effectiveness. The optimal upper extremity exercise prescription poststroke remains to be established.

The effects of 3,3',4,4'-tetrabromobiphenyl on rats fed diets containing a constant level of copper and varying levels of molybdenum.

Copper (Cu) metabolism is altered in rats fed diets high in molybdenum (Mo) and low in Cu. This 10-week study was carried out to examine the effects of supplemental Mo (7.5-240 µg/g diet) on male Sprague-Dawley rats fed diets adequate in Cu (5 µg/g diet) and to determine the susceptibility of Mo-treated animals to the environmental pollutant 3,3',4,4'-tetrabromobiphenyl (TBB). After 7 weeks of dietary treatment, half of the rats in each group received a single IP injection of TBB (150 µM/kg bw), while the other half received the corn oil vehicle. Rats sacrificed at 10 weeks showed no effects of Mo on growth, feed efficiency, or selected organ or tissue weights. Dose-dependent effects on plasma Mo (0-5.1 µg/mL), plasma Cu (0.95-0.20 µg/mL), and bone Cu (3.4-10 µg/g) in control through the high dose were found. Cu sequestration in the bone of Mo-treated rats is a new finding. TBB treatment resulted in dramatic weight loss and loss of absolute organ mass. Relative organ weights were increased, except for the thymus. TBB altered the concentrations of certain amino acids. Compared to control rats, this polybrominated biphenyl congener significantly decreased plasma Cu and ceruloplasmin at higher concentrations of dietary Mo and promoted the process of plasma Cu decrease by Mo, suggesting a combined effect.

New knowledge, innovations, and improvement in a Magnet® Children's Hospital Cardiac Center.

Bedside nurses involved in research and evidence-based practice (EBP) have the ability to change policies, patient care, and outcomes. This article describes the journey of a research committee using the Magnet® component of new knowledge, innovation, and improvements. Using several tools, the unit-based committee developed skills in meeting management, nursing research methods, and EBP. Focusing to improve family and nurse communication about the plan of care, the committee recommended changes in the existing Plan of Care tool, including family input and recommendations for families to view and add to the sheet and participate in daily rounds, which was not the standard practice. Since this intervention was implemented, patient satisfaction has increased, as well as nurse engagement and intent to stay. This project exemplifies how nurse-driven innovations and family partnership led to new knowledge, innovations in learning about research, applying it to practice, and improving practice.