Integrating Smartphone Applications and Wearable Devices for Postoperative Rehabilitation in Total Knee Arthroplasty: A Critical Review.

BACKGROUND: Smartphone and wearable technologies offer innovative methods for monitoring postoperative recovery in total knee arthroplasty (TKA) patients. This review assessed the benefits of these technologies in postoperative care, focusing on (1) smartphone applications, (2) wearable devices, and (3) their combination. METHODS: A systematic search identified studies on smartphone applications and wearables for post-TKA monitoring. The review analyzed 2,119 studies, with 58 meeting criteria: 25 on applications, 25 on wearables, and 8 on both. Studies were rated with a methodology index as well as by levels of evidence. They were then analyzed by categorizing them by adherence and patient satisfaction, functional outcomes and pain scores, gait analyses and ranges of motion, and measurement and comparison tools. RESULTS: A review of 24 of 25 publications related to smartphone applications used for postoperative recovery in TKA showed the potential for improved patient's satisfaction, gait recovery, pain medication scheduling guidance with improved pain management, cost savings, and functional outcomes. Wearable technologies used in postoperative recovery demonstrated monitoring accuracy in 25 studies. These devices also showed effectiveness in gait and motion analysis. Other demonstrated benefits of the wearables were improved outcomes, return to function, cost reduction, and again, better management of pain due to patient interaction and guidance. Studies that combined applications and wearables demonstrated the individual findings with the addition of adherence, patient's satisfaction, and overall mobility improvement at 3 months. CONCLUSIONS: Smartphone applications and wearables can enhance postoperative rehabilitation for TKA patients. Smartphone applications and wearables have been shown in randomized trials to be accurate, effective, and useful in the postoperative rehabilitation of TKA patients. A recurring theme in the review was improved adherence to care plans and medication schedules that ultimately result in improved functional outcomes. These technologies and the data that they generate offer direct patient benefits and the potential for future cost savings.

Manuka Honey: Feasibility and Safety in Postoperative Neurosurgical Wound Care.

OBJECTIVE: To date, no reports have been published on active Leptospermum manuka honey (ALH) feasibility as a postoperative topical wound supplement in neurosurgical patients. The objective of the study is to present the authors' initial experience with using ALH in postoperative neurosurgical patients. METHODS: A single-surgeon retrospective case series review of cranial and spinal operations between 2018 and 2020 was performed in patients with nonhealing wounds or wounds deemed "at risk" as defined by grade 1 Sandy surgical wound dehiscence grading classification. An ALH gel or ointment was applied to these incisions once a day for 2 to 4 weeks. Patients were followed up in the clinic every 2 weeks until incisions had healed. RESULTS: Twenty-five postoperative patients (12 cranial, 13 spinal) were identified to be at high risk of operative debridement. All 25 patients were prescribed a topical application of ALH, which was easily adopted without patient-related adverse events. Seven (four cranial, three spinal) patients required operative debridement and treatment with long-term antibiotic therapy. CONCLUSIONS: In this small case series of neurosurgical patients who were at risk of poor wound healing, the application of medical-grade ALH was well tolerated without patient-reported adverse events. The ALH may have prevented the need for operative debridement in the majority of patients. Further prospective studies are necessary to establish its efficacy in wound healing in the neurosurgical population.

Wireless implantable and biodegradable sensors for postsurgery monitoring: current status and future perspectives.

In in vivo postsurgery monitoring, the use of wireless biodegradable implantable sensors has gained and is gaining a lot of interest, particularly in cases of monitoring for a short period of time. The employment of biodegradable materials allows the circumvention of secondary surgery for device removal. Additionally, the use of wireless communication for data elaboration avoids the need for transcutaneous wires. As such, it is possible to prevent possible inflammation and infections associated with long-term implants which are not wireless. It is expected that microfabricated biodegradable sensors will have a strong impact in acute or transient biomedical applications. However, the design of such high-performing electronic systems, both fully biodegradable and wireless, is very complex, particularly at small scales. The associated technologies are still in their infancy and should be more deeply and extensively investigated in animal models and, successively, in humans, before being clinically implemented. In this context, the present review aims to provide a complete overview of wireless biodegradable implantable sensors, covering the vital signs to be monitored, the wireless technologies involved, and the biodegradable materials used for the production of the devices, as well as designed devices and their applications. In particular, both their advantages and drawbacks are highlighted, and the key challenges faced, mainly associated with fabrication techniques, and control over degradation kinetics and biocompatibility of the device, are reported and discussed.

Fully automated postoperative ventilation in cardiac surgery patients: a randomised clinical trial.

BACKGROUND: Ensuring that lung-protective ventilation is achieved at scale is challenging in perioperative practice. Fully automated ventilation may be more effective in delivering lung-protective ventilation. Here, we compared automated lung-protective ventilation with conventional ventilation after elective cardiac surgery in haemodynamically stable patients. METHODS: In this single-centre investigator-led study, patients were randomly assigned at the end of cardiac surgery to receive either automated (adaptive support ventilation) or conventional ventilation. The primary endpoint was the proportion of postoperative ventilation time characterised by exposure to predefined optimal, acceptable, and critical (injurious) ventilatory parameters in the first three postoperative hours. Secondary outcomes included severe hypoxaemia (Spo2 <85%) and resumption of spontaneous breathing. Data are presented as mean (95% confidence intervals [CIs]). RESULTS: We randomised 220 patients (30.4% females; age: 62-76 yr). Subjects randomised to automated ventilation (n=109) spent a 29.7% (95% CI: 22.1-37.4) higher mean proportion of postoperative ventilation time receiving optimal postoperative ventilation after surgery (P<0.001) compared with subjects receiving conventional postoperative ventilation (n=111). Automated ventilation also reduced the proportion of postoperative ventilation time that subjects were exposed to injurious ventilatory settings by 2.5% (95% CI: 1-4; P=0.003). Severe hypoxaemia was less likely in subjects randomised to automated ventilation (risk ratio: 0.26 [0.22-0.31]; P<0.01). Subjects resumed spontaneous breathing more rapidly when randomised to automated ventilation (hazard ratio: 1.38 [1.05-1.83]; P=0.03). CONCLUSIONS: Fully automated ventilation in haemodynamically stable patients after cardiac surgery optimised lung-protective ventilation during postoperative ventilation, with fewer episodes of severe hypoxaemia and an accelerated resumption of spontaneous breathing. CLINICAL TRIAL REGISTRATION: NCT03180203.

Novel, digital, chest drainage system in cardiac surgery.

BACKGROUND: A new, self-contained, digital, continuous pump-driven chest drainage system is compared in a randomized control trial to a traditional wall-suction system in cardiac surgery. METHODS: One hundred and twenty adult elective cardiac patients undergoing coronary artery bypass graft and/or valve surgery were randomized to the study or control group. Both groups had similar pre/intra-operative demographics: age 67.8 vs 67.0 years, Euroscore 2.3 vs 2.2, and body surface area 1.92 vs 1.91 m2 . Additionally, a satisfaction assessment score (0-10) was performed by 52 staff members. RESULTS: Given homogenous intra-operative variables, total chest-tube drainage was comparable among groups (566 vs 640 mL; ns), but the study group showed more efficient fluid collection during the early postoperative phase due to continuous suction (P = .01). Blood, cell saver transfusions and postoperative hemoglobin values were similar in both groups. The study group experienced drain removal after 29.8 vs 38.4 hours in the control group (ns). Seven crossovers from the Study to the Control group were registered but no patient had drain-related complications. The Personnel Satisfaction Assessment scored above 5 for all questions asked. CONCLUSIONS: The new, digital, chest drainage system showed better early drainage of the chest cavity and was as reliable as conventional systems. Quicker drain removal might impact on intensive care unit (ICU) stay and reduce costs. Additional advantages are portable size, battery operation, patient mobility, noiseless function, digital indications and alarms. The satisfaction assessment of the new system by the staff revealed a higher score when compared to the traditional wall suction chest drainage system.

Variation in Drain Management After Pancreatoduodenectomy: Early Versus Delayed Removal.

OBJECTIVE: The objectives are to report practice patterns and management of operatively placed drains and to compare outcomes in patients with early versus delayed drain removal after pancreatoduodenectomy. BACKGROUND: Early drain removal after pancreatoduodenectomy, when guided by postoperative day (POD) 1 drain fluid amylase (DFA-1), is associated with reduced rates of clinically relevant postoperative pancreatic fistula (CR-POPF). However, whether surgeons have altered their management based on this strategy is unknown. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2014 Participant Use File was queried to identify patients having undergone pancreatoduodenectomy (n = 3093). Patients with intraoperatively placed drains were stratified according to measurement of DFA-1 and day of drain removal. Patients with POD 1 DFA-1 of ≤5000 U/L whose drains were removed by POD 3 were propensity score-matched with patients whose drains were removed after POD 3. RESULTS: Of 2698 patients, 580 (21.5%) had a DFA-1 recorded. Measurement of DFA-1 was associated with earlier time to drain removal and shorter postoperative length of stay (P < 0.01). Propensity score matching revealed that early drain removal when DFA-1 was ≤5000 U/L was associated with significant (P < 0.05) reductions in overall morbidity (35.3% vs 52.3%), CR-POPF (0.9% vs 7.9%), and length of stay (6 vs 8 days). CONCLUSIONS: Significant variation exists in the use of drain fluid amylase in the management and timing of surgical drain removal after pancreatoduodenectomy. Clinical outcomes are best when drain fluid amylase is low and operatively placed drains are removed by POD 3.

Immediate versus delayed removal of urinary catheter after laparoscopic hysterectomy: a randomised controlled trial.

OBJECTIVE: To evaluate if immediate catheter removal (ICR) after laparoscopic hysterectomy is associated with similar retention outcomes compared with delayed removal (DCR). STUDY DESIGN: Non-inferiority randomised controlled trial. POPULATION: Women undergoing laparoscopic hysterectomy in six hospitals in the Netherlands. METHODS: Women were randomised to ICR or DCR (between 18 and 24 hours after surgery). PRIMARY OUTCOME: The inability to void within 6 hours after catheter removal. RESULTS: One hundred and fifty-five women were randomised to ICR (n = 74) and DCR (n = 81). The intention-to-treat and per-protocol analysis could not demonstrate the non-inferiority of ICR: ten women with ICR could not urinate spontaneously within 6 hours compared with none in the delayed group (risk difference 13.5%, 5.6-24.8, P = 0.88). However, seven of these women could void spontaneously within 9 hours without additional intervention. Regarding the secondary outcomes, eight women from the delayed group requested earlier catheter removal because of complaints (9.9%). Three women with ICR (4.1%) had a urinary tract infection postoperatively versus eight with DCR (9.9%, risk difference -5.8%, -15.1 to 3.5, P = 0.215). Women with ICR mobilised significantly earlier (5.7 hours, 0.8-23.3 versus 21.0 hours, 1.4-29.9; P ≤ 0.001). CONCLUSION: The non-inferiority of ICR could not be demonstrated in terms of urinary retention 6 hours after procedure. However, 70% of the women with voiding difficulties could void spontaneously within 9 hours after laparoscopic hysterectomy. It is therefore questionable if all observed urinary retention cases were clinically relevant. As a result, the clinical advantages of ICR may still outweigh the risk of bladder retention and it should therefore be considered after uncomplicated laparoscopic hysterectomy. TWEETABLE ABSTRACT: The advantages of immediate catheter removal after laparoscopic hysterectomy seem to outweigh the risk of bladder retention.

Rigid dressings versus soft dressings for transtibial amputations.

BACKGROUND: Dressings are part of the routine postoperative management of people after transtibial amputation. Two types of dressings are commonly used; soft dressings (e.g. elastic bandages, crepe bandages) and rigid dressings (e.g. non-removable rigid dressings, removable rigid dressings, immediate postoperative protheses). Soft dressings are the conventional dressing choice as they are cheap and easy to apply, while rigid dressings are costly, more time consuming to apply and require skilled personnel to apply the dressings. However, rigid dressings have been suggested to result in faster wound healing due to the hard exterior providing a greater degree of compression to the stump. OBJECTIVES: To assess the benefits and harms of rigid dressings versus soft dressings for treating transtibial amputations. SEARCH METHODS: In December 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, EBSCO CINAHL Plus, Ovid AMED and PEDro to identify relevant trials. To identify further published, unpublished and ongoing studies, we also searched clinical trial registries, the grey literature, the reference lists of relevant studies and reviews identified in prior searches. We used the Cited Reference Search facility on ThomsonReuters Web of Science and contacted relevant individuals and organisations. There were no restrictions with respect to language, date of publication or study setting. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs that enrolled people with transtibial amputations. There were no restrictions on the age of participants and reasons for amputation. Trials that compared the effectiveness of rigid dressings with soft dressings were the main focus of this review. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles, abstracts and full-text publications for eligible studies. Two review authors also independently extracted data on study characteristics and outcomes, and performed risk of bias and GRADE assessments. MAIN RESULTS: We included nine RCTs and quasi-RCTs involving 436 participants (441 limbs). All studies recruited participants from acute and/or rehabilitation hospitals from seven different countries (the USA, Australia, Indonesia, Thailand, Canada, France and the UK). In all but one study, it was clearly stated that amputations were secondary to vascular conditions.Primary outcomes Wound healing We are uncertain whether rigid dressings decrease the time to wound healing compared with soft dressings (MD -25.60 days; 95% CI -49.08 to -2.12; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is not clear whether rigid dressings increase the proportion of wounds healed compared with soft dressings (RR 1.14; 95% CI 0.74 to 1.76; one study, 51 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Adverse events It is not clear whether rigid dressings increase the proportion of skin-related adverse events compared with soft dressings (RR 0.65; 95% CI 0.32 to 1.32; I2 = 0%; six studies, 336 participants (340 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision.It is not clear whether rigid dressings increase the proportion of non skin-related adverse events compared with soft dressings (RR 1.09; 95% CI 0.60 to 1.99; I2 = 0%; six studies, 342 participants (346 limbs)); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. In addition, we are uncertain whether rigid dressings decrease the time to no pain compared with soft dressings (MD -0.35 weeks; 95% CI -2.11 to 1.41; one study of 23 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision.Secondary outcomesWe are uncertain whether rigid dressings decrease the time to walking compared with soft dressings (MD -3 days; 95% CI -9.96 to 3.96; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and twice for very serious imprecision. We are also uncertain whether rigid dressings decrease the length of hospital stay compared with soft dressings (MD -30.10 days; 95% CI -49.82 to -10.38; one study, 56 participants); very low-certainty evidence, downgraded twice for very high risk of bias and once for serious imprecision. It is also not clear whether rigid dressings decrease the time to readiness for prosthetic prescription and swelling compared with soft dressings, as results are based on very low-certainty evidence, downgraded twice for very high risk of bias and once/twice for serious/very serious imprecision. None of the studies reported outcomes on patient comfort, quality of life and cost. AUTHORS' CONCLUSIONS: We are uncertain of the benefits and harms of rigid dressings compared with soft dressings for people undergoing transtibial amputation due to limited and very low-certainty evidence. It is not clear if rigid dressings are superior to soft dressings for improving outcomes related to wound healing, adverse events, prosthetic prescription, walking function, length of hospital stay and swelling. Clinicians should exercise clinical judgement as to which type of dressing they use, and consider the pros and cons of each for patients (e.g. patients with high risk of falling may benefit from the protection offered by a rigid dressing, and patients with poor skin integrity may have less risk of skin breakdown from a soft dressing).

Electrical Stimulation and Recovery of Gastrointestinal Function Following Surgery: A Systematic Review.

OBJECTIVES: Postoperative ileus occurs in approximately 5-15% of patients following major abdominal surgery, and poses a substantial clinical and economic burden. Electrical stimulation has been proposed as a means to aid postoperative gastrointestinal (GI) recovery, but no methods have entered routine clinical practice. A systematic review was undertaken to assess electrical stimulation techniques and to evaluate their clinical efficacy in order to identify promising areas for future research. MATERIALS AND METHODS: Literature was searched using MEDLINE, EMBASE, Google Scholar and by assessing relevant clinical trial databases. Studies investigating the use of electrical stimulation for postoperative GI recovery were included, regardless of methods used or outcomes measured. A critical review was constructed encompassing all included studies and evaluating and synthesizing stimulation techniques, protocols, and clinical outcomes. RESULTS: A broad range of neuromodulation strategies and protocols were identified and assessed. Improved postoperative GI recovery following electrical stimulation was reported by 55% of studies (10/18), most commonly those assessing transcutaneous electrical nerve stimulation and electroacupuncture therapy (7/10). Several studies reported shorter time to first flatus and stool, shorter duration of hospital stay, and reduced postoperative pain. However, inconsistent reporting and limitations in trial design were common, compromising a definitive determination of electrical stimulation efficacy. CONCLUSIONS: Electrical stimulation appears to be a promising methodology to aid postoperative GI recovery, but greater attention to mechanisms of action and clinical trial quality is necessary for progress. Future research should also aim to apply validated and standardized gut recovery outcomes and consistent neuromodulation methodologies.

Modulating Portal Hemodynamics With Vascular Ring Allows Efficient Regeneration After Partial Hepatectomy in a Porcine Model.

OBJECTIVE: To investigate safety and efficacy of temporary portal hemodynamics modulation with a novel percutaneously adjustable vascular ring (MID-AVR) onto a porcine model of 75% hepatectomy. BACKGROUND: Postoperative liver failure is a leading cause of mortality after major hepatectomy. Portal flow modulation is an increasingly accepted concept to prevent postoperative liver failure. Nonetheless, the current strategies have shortcomings. METHODS: Resection was performed under hemodynamic monitoring in 17 large, white pigs allocated into 2 groups. Eight pigs had ring around the portal vein for 3 days with the aim of reducing changes in hemodynamics due to hepatectomy. Analysis of hemodynamics, laboratory, and histopathological parameters was performed. RESULTS: Percutaneous inflation, deflation, and removal of the MID-AVR were safe. Two (25%) pigs in the MID-AVR group and 4 (45%) controls died before day 3 (P = NS). A moderate increase of portal flow rate per liver mass after resection was associated with better survival (P = 0.017). The portocaval pressure gradient was lower after hepatectomy in the MID-AVR group (P = 0.001). Postoperative serum bilirubin levels were lower in the MID-AVR group (P = 0.007 at day 5). In the MID-AVR group, the Ki67 index was significantly higher on day 3 (P = 0.043) and the architectural derangement was lower (P < 0.05). Morphometric quantification of the bile canaliculi revealed a significantly lower number of intersection branches (P < 0.05) and intersection nodes (P < 0.001) on day 7 compared with the preoperative specimen, in the control group. These differences were not found in the ring group. CONCLUSIONS: MID-AVR is safe for portal hemodynamics modulation. It might improve liver regeneration by protecting liver microarchitecture.

Laser treatments in early wound healing improve scar appearance: a randomized split-wound trial with nonablative fractional laser exposures vs. untreated controls.

BACKGROUND: In recent years, various lasers have increasingly been applied during wound healing to minimize scar formation. However, no consensus regarding treatment procedures exists. OBJECTIVES: To assess scar formation clinically after three nonablative fractional laser (NAFL) exposures, targeting the inflammation, proliferation and remodelling wound healing phases in patients vs. untreated controls. METHODS: A randomized controlled trial was performed using a split-wound design to assess excisional wound halves treated with 1540-nm NAFL vs. no laser treatment. Three NAFL exposures were provided: immediately before surgery, at suture removal and 6 weeks after surgery. NAFL exposures were applied using two handpieces, sequentially distributing energy deeply and more superficially in the skin (40-50 mJ per microbeam). Evaluated at 3 months of follow-up, the primary outcome was blinded, on-site evaluation using the Patient Observer Scar Assessment Scale (POSAS total; range from 6, normal skin to 60, worst imaginable scar). Secondary outcomes comprised blinded evaluation on the Vancouver Scar Scale (VSS) and standardized assessment comparing scar sides, carried out by blinded on-site, photo and patient assessments. This trial was registered with ClinicalTrials.gov (NCT03253484). RESULTS: Thirty of 32 patients completed the trial. At the 3-month follow-up, the NAFL-treated scar halves showed improvement compared with the untreated control halves on POSAS total: NAFL treated, median 11, interquartile range (IQR) 9-12 vs. control, median 12, IQR 10-16; P = 0·001. The POSAS subitems showed that the NAFL-treated halves were significantly less red and more pliable, and presented with smoother relief than the untreated controls. VSS total correspondingly revealed enhanced appearance in the NAFL-treated halves: median 2, IQR 1-2·5 vs. control, median 2, IQR 1·75-3, P = 0·007. The standardized assessment comparing appearance of scar halves demonstrated a low degree of correspondence between on-site, photo and patient assessments. NAFL-treated scars were rated as superior to untreated scars by 21 of 29 patients. CONCLUSIONS: NAFL-treated scars showed subtle improvement compared with untreated control scars.

Use of a web-based app to improve postoperative outcomes for patients receiving gynecological oncology care: A randomized controlled feasibility trial.

OBJECTIVE: Nearly 1 in 5 patients hospitalized for ovarian cancer surgery are readmitted for complications that may have been prevented with monitoring. We conducted a randomized controlled feasibility trial to evaluate a postoperative web-based app intervention to provide real-time symptom monitoring among patients diagnosed or with suspected gynecological cancer who had open bilateral salpingo-oophorectomy surgery. METHODS: Participants were randomized into two groups: (1) App + Reminder: had access to the app, and use was encouraged with daily and/or weekly reminders; (2) app: had access to the app but received no reminders. The app displayed discharge instructions and queried symptoms. Patients' self-reported health information was integrated into their electronic health records. Outcomes above a predetermined threshold triggered alerts that indicated a patient may need medical intervention. Participants completed a questionnaire at baseline and 30-day follow-up. They were also invited to provide qualitative, post-intervention feedback. RESULTS: We screened 35 patients, with high rates of recruitment (74%, N = 26) and completion (93%, N = 24). Participants in the App + Reminder group had more frequent app use relative to the app group (p = 0.05). Using differences-in-differences (DID) analysis for quality of life, the App + Reminder group had relative increase in the mental health score (DID = 7.51, p = 0.15) but decrease in the physical health score (DID = -7.49, p = 0.13). Participant feedback suggested the relative decrease in physical quality of life was attributable to the app activating patients' focus on physical symptoms, not the intervention. CONCLUSION: The pilot established feasibility, acceptability, and some potential benefits of a new web-based app intervention for gynecological oncology postoperative care.

Perioperative management of obese patient.

PURPOSE OF REVIEW: The volume of bariatric and nonbariatric surgical procedures on obese patients is dramatically increasing worldwide over the past years. In this review, we discuss the physiopathlogy of respiratory function during anesthesia in obese patients, the stratification of perioperative risk to develop intraoperative and postoperative pulmonary complications, the optimization of airway management, and perioperative ventilation, including postoperative respiratory assistance. RECENT FINDINGS: Scores have been proposed to stratify the risk of surgical patients, some of which were specifically developed for obese patients. Most scores identify obstructive sleep apnea and elevated BMI as independent risk factors. Obese patients might be at risk of difficult intubation and mask ventilation, and also of developing postoperative pulmonary complications. Intraoperative ventilation settings affect clinical outcome, but the optimal ventilation strategy is still to be determined. Opioid-free regimens are being widely investigated. Postoperative monitoring and respiratory assistance are necessary in selected patients. Early mobilization and physiotherapy are mandatory. SUMMARY: Obese patients are at higher risk of perioperative complications, mainly associated with those related to the respiratory function. An appropriate preoperative evaluation, intraoperative management, and postoperative support and monitoring is essential to improve outcome and increase the safety of the surgical procedure.

Pulmonary vein re-mapping after cryoballoon ablation for atrial fibrillation.

Aims: Establishment of pulmonary vein isolation (PVI) during cryoballoon (CB) ablation is generally confirmed by use of an octapolar inner-lumen mapping catheter (Achieve®). The aim of this study is to evaluate the residual PV potential (PVP) using the conventional circular catheter after CB-PVI. Methods and results: A total of 105 consecutive patients (418 PVs) with paroxysmal AF who underwent the initial CB-PVI were prospectively included in this study. Of those, 305 (73%) PVs with real-time recordings of PVP elimination by Achieve® catheter during successful PVI were included. After isolation of all 4 PVs, PV antral remapping by conventional circular mapping catheter was performed. After CB-PVI, residual PVP was detected in 4.3% (13/305) of PVs (1.2% of left-superior PV, 2.5% of left-inferior PV, none of right-superior PV, and 20% of right-inferior PV). Almost 60% of residual PV potential was located around the bottom portion of the right-inferior PV. In PVs with residual potential, PV trunk was shorter (12.7 ± 5.7 mm vs. 18.7 ± 7.9, P = 0.001), minimal balloon temperature was higher (-46.6 ± 5.9 °C vs. -50.9 ± 8.2, P = 0.02), and balloon warming time was shorter (35.6 ± 17.8 s vs. 50.0 ± 22.8, P = 0.006) than those without. All residual potentials were eliminated by additional touch up ablation. After the initial ablation procedure, 1-year AF-free rate was 79.5%. Conclusion: PV remapping after CB-PVI revealed residual antral PVP in 4.3% of PVs and in 20% of RIPVs in particular. The Achieve® catheter sometimes fails to detect complete PV antral isolation.

Accuracy of remote continuous respiratory rate monitoring technologies intended for low care clinical settings: a prospective observational study.

PURPOSE: Altered respiratory rate (RR) has been identified as an important predictor of serious adverse events during hospitalization. Introduction of a well-tolerated continuous RR monitor could potentially reduce serious adverse events such as opioid-induced respiratory depression. The purpose of this study was to investigate the ability of different monitor devices to detect RR in low care clinical settings. METHODS: This was a prospective method-comparison study with a cross-sectional design. Thoracic impedance pneumography (IPG), frequency modulated continuous wave radar, and an acoustic breath sounds monitor were compared with the gold standard of capnography for their ability to detect RR in breaths per minute (breaths·min-1) in awake postoperative patients in the postanesthesia care unit. The Bland and Altman method for repeated measurements and mixed effect modelling was used to obtain bias and limits of agreement (LoA). Furthermore, the ability of the three devices to assist with correct treatment decisions was evaluated in Clarke Error Grids. RESULTS: Twenty patients were monitored for 1,203 min, with a median [interquartile range] of 61 [60-63] min per patient. The bias (98.9% LoA) were 0.1 (-7.9 to 7.9) breaths·min-1 for the acoustic monitor, -1.6 (-10.8 to 7.6) for the radar, and -1.9 (-13.1 to 9.2) for the IPG. The extent to which the monitors guided adequate or led to inadequate treatment decisions (determined by Clarke Error Grid analysis) differed significantly between the monitors (P = 0.011). Decisions were correct 96% of the time for acoustic, 95% of the time for radar, and 94% of the time for IPG monitoring devices. CONCLUSIONS: None of the studied devices (acoustic, IPG, and radar monitor) had LoA that were within our predefined (based on clinical judgement) limits of ± 2 breaths·min-1. The acoustic breath sound monitor predicted the correct treatment more often than the IPG and the radar device.

Current trends and pitfalls in endoscopic treatment of urolithiasis.

Current development of endoscopic technology, lithotripters, and stone-retrieval devices has expanded the indications for retrograde and antegrade endoscopic therapy in the management of urolithiasis. This technology has also resulted in minimally invasive therapy. As surgeons' experience of endourological procedures with the newer instruments has become integrated, the surgical technique and indications for urolithiasis have also changed in the past few years. The present review provides an overview of endourological procedures for upper urinary tract stones and the key points related to surgical techniques.

Gauze Impregnated With Quaternary Ammonium Salt Reduces Bacterial Colonization of Surgical Drains After Breast Reconstruction.

Surgical site infection after breast reconstruction is associated with increased length of hospital stay, readmission rates, cost, morbidity, and mortality. Identifying methods to reduce surgical site infection without the use of antibiotics may be beneficial at reducing antimicrobial resistance, reserving the use of antibiotics for more severe cases. Quaternary ammonium salts have previously been shown to be a safe and effective antimicrobial agent in the setting of in vitro and in vivo animal experiments. A retrospective study was conducted to investigate the antimicrobial properties of a quaternary ammonium salt, 3-trimethoxysilyl propyldimethyloctadecyl ammonium chloride (QAS-3PAC; Bio-spear), at reducing surgical drain site colonization and infection after breast reconstruction (deep inferior epigastric perforator flap reconstruction or tissue expander placement). Twenty patients were enrolled, with 14 surgical drains covered with nonimpregnated gauze and 17 surgical drains covered with QAS-3PAC impregnated gauze, for the purposes of investigating bacterial colonization. Antibiotic sensitivity analysis was also conducted when bacterial cultures were positive. The overall incidence of bacterial colonization of surgical drains was lower in the treatment group compared with the control group (17.6% vs 64.3%, respectively; P = 0.008). QAS-3PAC impregnated gauze reduced the incidence of bacterial colonization of surgical drains during the first (0.0% vs 33.3%) and second (33.3% vs 87.5%; P = 0.04) postoperative week. Furthermore, no enhanced antibiotic resistance was noted on drains treated with QAS-3PAC impregnated gauze. The results of this study suggest that QAS-3PAC impregnated gauze applied over surgical drains may be an effective method for reducing the incidence of bacterial colonization.

Variation in Use of Postoperative Precautions and Equipment Following Total Hip Arthroplasty: A Survey of the AAHKS and CAS Membership.

BACKGROUND: A traditional method to reduce dislocation risk following total hip arthroplasty involves prescribing postoperative precautions and ambulatory equipment to patients. The purpose of this study was to determine the prevalence of postoperative precaution and equipment use among North American arthroplasty surgeons for patients undergoing primary total hip arthroplasty. METHODS: We conducted a survey of American Association of Hip and Knee Surgeons and Canadian Arthroplasty Society members using an electronic questionnaire format to determine how often precautions and equipment were prescribed, and whether their use was associated with surgical approach and other surgeon demographics. RESULTS: Of the respondents, 44% universally prescribed precautions while 33% never prescribed precautions. Use of the posterolateral approach, surgeon experience, and larger head size use were significantly associated (P < .01) with precaution and equipment use. Direct anterior approach surgeons were significantly less likely to prescribe precautions (P < .0001) and significantly less likely to prescribe equipment (P < .0001). CONCLUSION: Although postoperative precautions continue to be used to some degree by the majority of members, their consumption of healthcare resources through utilization of additional care providers and purchasing of equipment, known association with reduced patient satisfaction, and lack of supporting evidence make them a target for future scrutiny.

[Patient Positioning after Intraocular Surgery]. / Postoperative Lagerung nach intraokularen Operationen.

Gas tamponades are widely used during intraocular surgery. The high surface tension at the intraocular liquid to gas interface is used in retinal detachment and macular surgery, as well as in lamellar corneal transplant surgery. The patient's postoperative posture determines the position of the gas bubble inside the eye. The article describes the development, physical laws and methods for postoperative positioning after intraocular surgery.

[Customized external nasal splint after rhinoplasty, introduction to the "tissu-modelage"]. / Attelle nasale externe sur-mesure après rhinoplastie, introduction au concept de « tissu-modelage ¼.

The authors report their experience of 2 years (43 patients) using a customized splint consists of thermoplastic which is molded on the new nose after rhinoplasty, according to a process comparable to that used by dentists to make the gutters. This splint will be applied several weeks to guide healing in a desired direction. The molding of the nose can be re-sculpted to guide the scarring to a better result. Lightweight, washable, discreet, our splint works to the advantage to be worn without discomfort for several weeks in order to improve the efficiency of contention.