Retrospective Multicenter Observational Study of Immediate Voiding at End of Urinary Sphincter Surgery (REMOVE).

PURPOSE: Patients may remain catheterized after artificial urinary sphincter surgery to prevent urinary retention, despite a lack of evidence to support this practice. Our study aims to evaluate the feasibility of outpatient, catheter-free continence surgery using a multi-institutional database. We hypothesize that between catheterized controls and patients without a catheter, there would be no difference in the rate of urinary retention or postoperative complications. MATERIALS AND METHODS: We conducted a retrospective review of patients undergoing first-time artificial urinary sphincter placement from 2009-2021. Patients were stratified by postoperative catheter status into either no-catheter (leaving the procedure without a catheter) or catheter (postoperative indwelling catheter for ∼24 hours). The primary outcome, urinary retention, was defined as catheterization due to subjective voiding difficulty or documented postvoid residual over 250 mL. RESULTS: Our study identified 302 catheter and 123 no-catheter patients. Twenty (6.6%) catheter and 9 (7.3%) no-catheter patients developed urinary retention (P = .8). On multivariable analysis, controlling for age, cuff size, radiation history and surgeon, there was no statistically significant association between omitting a catheter and urinary retention (OR: 0.45, 95% CI: 0.13-1.58; P = .2). Furthermore, at 30 months follow-up, Kaplan-Meier survival analysis revealed that device survival was 70% (95% CI: 62%-76%) vs 69% (95% CI: 48%-82%) for the catheter and no-catheter group, respectively. CONCLUSIONS: In our multi-institutional cohort, overall retention rates were low (7%) in groups with a catheter and without. Obviating postoperative catheterization facilitates outpatient incontinence surgery without altering reoperation over medium-term follow-up.

Effects of air blower and pump failures on the performance of A2O processes for wastewater treatment.

The unexpected failure of equipment such as pumps and fans in wastewater treatment plants can reduce wastewater treatment efficiency, leading to direct leakage of untreated wastewater into the environment. It is hence important to predict the possible consequences of equipment failure to minimize the leakage of harmful substances. This study examines the impacts of equipment shutdown on the performance and recovery time of a laboratory-scale anaerobic/anoxic/aerobic system with regard to reactor conditions and water quality. Two days after the air blowers are stopped, the concentrations of the soluble chemical oxygen demand, NH4-N, and PO4-P in the effluent of the settling tank increase to 122 mg/L, 23.8 mg/L, and 46.6 mg/L, respectively. These concentrations return to their initial values after 12, 24, and 48 h of restarting the air blowers. The concentrations of PO4-P and NO3-N in the effluent increase to 58 mg/L and 20 mg/L, respectively, about 24 h after stopping the return activated sludge and mixed liquor recirculation pumps, owing to the release of phosphates in the settling tank and inhibition of denitrification.

Association between Previous Pelvic Radiation and All-Cause and Cause-Specific Failure of Replacement Artificial Urinary Sphincters.

PURPOSE: In order to accurately characterize how a history of radiation therapy affects the lifespan of replacement artificial urinary sphincters (AUSs), all possible sources of device failure must be considered. We assessed the competing risks of device failure based on radiation history in men with replacement AUSs. MATERIALS AND METHODS: We identified men who had a replacement AUS in a single institutional, retrospective database. To assess survival from all-cause device failure based on radiation history and other factors, we conducted Kaplan-Meier, Cox proportional-hazards and competing risks analyses. RESULTS: Among 247 men who had a first replacement AUS, men with a history of radiation had shorter time to all-cause device failure (median 1.4 vs 3.5 years for men with radiation vs without radiation history, p=0.02). On multivariable Cox-proportional hazards analysis, previous radiation was associated with increased risk of all-cause device failure (HR: 2.12, 95% CI: 1.30-3.43, p=0.002). On multivariable cause-specific hazards analysis, prior radiation was associated with a higher risk of erosion/infection (HR: 7.57, 95% CI: 2.27-25.2, p <0.001), but was not associated with risk of urethral atrophy (p=0.5) or mechanical failure (p=0.15). CONCLUSIONS: Among men with a replacement AUS, a history of pelvic radiation was associated with shorter time to device failure of any cause. Radiation was also specifically associated with a sevenfold increase in the risk of erosion or infection of replacement AUS, but not with urethral atrophy or mechanical failure. Patients with a replacement AUS should be appropriately counseled on how radiation history may impact outcomes of future revisions.

Factors Influencing Incidence of Wheelchair Repairs and Consequences Among Individuals with Spinal Cord Injury.

OBJECTIVE: To investigate the frequency and consequences of wheelchair repairs, looking at the relationship to usage, components, out-of-pocket costs, number of days affecting the user, and factors associated with the need for repairs or consequences. DESIGN: Survey, cross-sectional. SETTING: Nine spinal cord injury (SCI) Model Systems centers. PARTICIPANTS: Wheelchair users with SCI (N=533). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Cost and incidence of wheelchair repairs and consequences and wheelchair usage within the past 6 months. RESULTS: A total of 310 participants (56%) reported repairs, 127 (42%) of whom experienced at least 1 adverse consequence lasting a median of 5 days (interquartile range [IQR], 2-17.3 days). Repair rates were highest for the seating system, electronics, and tires. Participants were most often stranded at home or forced to use a backup chair. Median out-of-pocket costs were $150 (IQR, $50-$620). Active users, based on type of mobility and terrain, experienced more repairs and consequences than less active users. Repairs were more common among those who were Black (odds ratio [OR], 2.42) or power wheelchair (PWC) users (OR, 1.84), whereas consequences were more common among those who were Black (OR, 2.27), PWC (OR, 2.08) or power assist users (OR, 2.76), and those who had public insurance (OR, 1.70). CONCLUSIONS: Wheelchair repairs continue to affect more than 50% of wheelchair users with significant financial and personal cost. High repair rates limited participation inside and outside of the home. Consequences lasted longer than 2 weeks for many and may be minimized by a working backup chair. Disparities exist based on participant and wheelchair factors; repairs and adverse consequences appear to hit those most vulnerable with the least financial resources. Costs may be a barrier to repair completion for some individuals. This ongoing problem of high repair rates and their associated effects requires action such as higher standards, access to quicker service, and better training of users on wheelchair maintenance and repair.

Factors associated with deficiencies in packaging of surgical instrument by staff at a single center in China.

BACKGROUND: Surgical instrument packaging quality directly affects the safety and performance of surgery. We aimed to investigate the factors causing defects in surgical instrument packaging and recommend strategies to prevent defects in surgical instrument packaging. METHODS: We collected surgical instrument packaging data regarding age, gender, length of service, educational background, number of staff dealing with packaging, time period of packaging, instrument specification, where the wrap was intact, whether the wrap reached the required quality of cleaning, and whether the instruments were satisfactorily cleaned in compliance with guidelines from 5000 surgical instrument packages during June-December 2018 at Central Sterile Supply Department of the West China Second University Hospital, Sichuan University. Meanwhile, a questionnaire survey completed by the operating room staff using surgical instruments was used to measure the level of their satisfaction with the instruments in the packages. We utilized single-factor analysis to investigate possible factors that might cause defects in surgical instrument packaging, and conducted multivariate logistic regression analysis of the factors associated with defects in packaging. RESULTS: Length of service, educational background, number of staff dealing with packaging, time period of packaging, instrument structure, whether the wrap was intact, whether the wrap reached the required quality of cleaning, and whether the surgical instruments were satisfactorily cleaned in compliance with guidelines were the factors significantly (P < 0.05) associated with defects in surgical instrument packaging. CONCLUSION: This study reveals that various factors are associated with defects in surgical instrument packaging. Recommendations for reducing incidences of defects include improved scheduling of packaging workload, greater provision of training in packaging skills, and standardization of packaging procedure.

Spontaneous resolution of asymptomatic alumina matrix composite ceramic liner dissociation: a case report.

BACKGROUND: Total hip arthroplasty(THA)is widely used to treat end-stage hip disorders. Ceramic-on-ceramic total hip prostheses are widely used because of their durability. Alumina matrix composite (AMC), known as the fourth-generation ceramics, reduces implant fracture and wear rate compared to their predecessors. However, ceramic acetabular liner dissociation is a complication that necessitates revision of the AMC prostheses. To date, only few cases of AMC liner dissociation have been reported and all of which have been treated with revision surgery. Therefore, the prognosis of non-operated AMC liner dissociation remains unknown so far. CASE PRESENTATION: A 57-year-old man with avascular necrosis of the femoral head was treated with THA, wherein a Pinnacle® (DePuy, J&J, Warsaw, IN) acetabular cup and AMC liner were implanted. Intraoperative examination confirmed proper seating of the liner, whereas the initial postoperative radiograph revealed liner dissociation. The patient refused surgical revision due to the absence of symptoms and was discharged and followed-up. The patient made an uneventful recovery, and radiographic follow-up at 6-month post-operation showed that the liner was re-seated to its right position. No clinical or radiographic anomaly was found at the 15-month of postoperative follow-up. CONCLUSIONS: Here, we report an unprecedented case of AMC ceramic liner dissociation with spontaneous resolution. This case shows that ceramic liner dissociation could be asymptomatic, and careful postoperative examination of the patient is important. Spontaneous resolution is possible, but the underlying mechanism and the eligible patient to benefit from it must be investigated. Before clarifying these questions, revision surgery should be the first-line treatment.

Development of a Wheelchair Repair Registry.

OBJECTIVE: To describe the development of a wheelchair repair registry from large datasets to attain an understanding of wheelchair failures and service repairs. DESIGN: Guidelines for registry development were applied and anchored around Labor-Tracker, a web-based information management system for wheelchair suppliers to manage and track wheelchair repairs. The registry was designed using online analytical processing, allowing for rapid data queries from multiple dimensions that enable complex data analysis and discovery. SETTING: The Wheelchair Repair Registry (WRR) was developed through an industry and academic collaboration whereby repair data were collected in the field, entered into the Labor-Tracker system, deidentified, and then transferred to the registry and made available for analyses. PARTICIPANTS: Wheelchair supplier service technicians reported data from repair services provided to individuals who use power wheelchairs, manual wheelchairs, and scooters. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Wheelchair failure and repair data, including variables related to scheduling, equipment information (eg, manufacturer, model, serial number, purchase date), labor, parts, and reasons for repairs. RESULTS: The WRR was developed to analyze wheelchair repairs and failures from the Labor-Tracker system. Currently, the registry has more than 60,000 repairs conducted on more than 5000 wheelchair devices from 25 manufacturers. The devices include 60% power wheelchairs, 35% manual wheelchairs, and 5% scooters. CONCLUSIONS: The WWR creates opportunities to apply large-data analytical methodologies that will serve to inform quality standards, practice, equipment selection, preventative maintenance routines, product design, and policy.

The Effect of Measured Radiotherapy Dose on Intrathecal Drug Delivery System Function.

OBJECTIVES: Radiation therapy (RT) and intrathecal drug delivery systems (IDDS) are often used concurrently to optimize pain management in patients with cancer. Concern remains among clinicians regarding the potential for IDDS malfunction in the setting of RT. Here we assessed the frequency of IDDS malfunction in a large cohort of patients treated with RT. MATERIALS AND METHODS: Cancer patients with IDDS and subsequent RT at our institution from 2011 to 2019 were eligible for this study. Patients were excluded in the rare event that their IDDS was managed by an outside clinic and follow-up documentation was unavailable. Eighty-eight patients aged 22-88 years old (43% female, 57% male) representing 106 separate courses of RT were retrospectively identified. Patients received varying levels of radiation for treatment of cancer and cumulative dose to the IDDS was calculated. IDDS interrogation was subsequently performed by a pain specialist. Malfunction was recorded as deviation from the expected drug volume and/or device errors reported upon interrogation as defined by the manufacturer. RESULTS: Total measured RT dose to the IDDS ranged from 0 to 18.0 Gy (median = 0.2 Gy) with median dose of 0.04 Gy/fraction (range, 0-3.2 Gy/fraction). Ten pumps received a total dose >2 Gy and three received ≥5 Gy. Eighty-two percentage of patients had follow-up with a pain specialist for IDDS interrogation and all patients underwent follow-up with a healthcare provider following RT. There were zero incidences of IDDS malfunction related to RT. No patient had clinical evidence of radiation related pump malfunction at subsequent encounters. CONCLUSIONS: We found no evidence that RT in patients with IDDS led to device failure or dysfunction. While radiation oncologists and pain specialists should coordinate patient care, it does not appear that RT dose impacts the function of the IDDS to warrant significant clinical concern.

Low-cost equipment for the evaluation of reach and grasp in post-stroke individuals: a pilot study.

BACKGROUND: Reach-grasp movements are motor components commonly affected after stroke and directly related to the independence of these individuals. Evaluations of these activities can be performed using clinical instruments and assessed by detailed and costly kinematic analyses. The aim of this study was to develop an analysis of reach-grasp movements in post-stroke patients using a simple, inexpensive, and manageable instrument. RESULTS: A Mann-Whitney test was used to compare paretic and non-paretic limb motor performance. A statistically significant difference was found between the variables of total time (p = 0.02) and speed to reach target 3 (p = 0.04) for task 1, while in task 2 significance was found only in the aspect of speed to reach target 2 (p = 0.04). The correlation between clinical tests and variables of tasks was then performed using Spearman's rank correlation coefficient. At task 1, when compared with the REACH instrument, the close target sub-item; there was a high positive correlation between the parameters of total time (p = 0.028), target velocity 3 (p = 0.028), and target acceleration 3 (p = 0.028). Another instrument that showed a high positive correlation with the target time 3 (p = 0.01) and target acceleration 3 (p = 0.028) variables was the Box and Block Test. When correlated, the data between the task 2 variables and clinical instruments did not present statistically significant data. CONCLUSION: Our instrument-the Temporal Data Acquisition Instrument-TDAI-fulfilled the expected objectives and can be used as an option to evaluate the movements of reach and grasp of upper limb post-stroke, using an easy and fast application, without the need for calibration. Trial registration Trial Registration: Research Ethics Committee of the Trairi School of Health Sciences-Number 2.625.609, approved on April 13, 2018; Brazilian Registry of Clinical Trials-RBR-4995cr approved on July 4, 2019 retrospectively registered (http://www.ensaiosclinicos.gov.br/rg/RBR-4995cr/).

The Impact of Endourological Experience on Flexible Ureteroscopy Outcomes and Performance at Different Levels of Expertise: Retrospective Multifactorial Analysis.

INTRODUCTION: The aim of this study was to analyze the influence of residents' participation in flexible ureteroscopy (fURS) on intra- and postoperative outcomes. MATERIALS AND METHODS: Intra- and postoperative parameters were compared in a retrospective monocentric setting between 3 groups: "resident group" (47 cases) for surgeries performed by experienced residents alone, "consultant group" (245 cases) for surgeries performed by consultants alone, "resident plus consultant group" (124 cases) for training surgeries between September 2013 and June 2017. RESULTS: Patients operated by residents alone had a significantly smaller median kidney stone diameter (5.0 vs. 7.0 mm for "consultant group" and 6.0 mm for "resident plus consultant group," p = 0.011), shorter operating time (median 47.0 vs. 63.0 and 77.0 min, p < 0.001) and fluoroscopy time (median 39.0 vs. 69.5 and 89.0 s, p < 0.001), as well as shorter postoperative hospital stay (p = 0.013). The laser application rate was the smallest in the "resident group" (10.64 vs. 31.43 and 29.84%, p = 0.009). Univariate analysis revealed no relevant differences regarding flexible ureteroscope defect rate, postoperative stone-free rate, or ≥2 Clavien-Dindo classification complications between the groups (p > 0.05). CONCLUSION: A proper case selection of less complicated cases, especially without laser application, could balance the experience deficit of the residents. fURS can be incorporated as a part of residents' training without an impact on fURS device defect rate or clinical outcomes.

An Unusual Pattern of Dyssynchronous Breathing due to Expiratory Flow Obstruction in the Scavenging System Caused by the Weight of Water Condensate.

BACKGROUND: Patient-ventilator dyssynchrony is commonly due to patient pathophysiologic factors and imprecise ventilator settings. In unusual circumstances, such dyssynchrony can also be due to faults within the equipment preventing from its normal operation during assisted mechanical ventilation. CASE DESCRIPTION: We report a patient showing an unusual pattern of dyssynchronous breathing related to a blocked scavenging system caused by the failure of its rod valve to open. Collection of water condensate inside its reservoir bag leading to a weight drag and deformation of its shape was found to be the cause. Specifically, our patient manifested as failure to trigger with the development of high positive end-expiratory pressure (PEEP) and paradoxical pressure changes during pressure support ventilation. CONCLUSION: Water condensation distal to the ventilator exhaust gas outlet may not be immediately apparent. Clinicians should remain alert with patient-ventilator dyssynchrony, especially with an unusual pattern, as it may signify equipment faults, such as expiratory gas flow obstruction within the scavenging system. HOW TO CITE THIS ARTICLE: Chan KM, Ng YC, So HY. An Unusual Pattern of Dyssynchronous Breathing due to Expiratory Flow Obstruction in the Scavenging System Caused by the Weight of Water Condensate. Indian J Crit Care Med 2020;24(11):1128-1131.

Is loss of power output due to laser fiber degradation still an issue during prostate vaporization using the 180 W GreenLight XPS laser?

PURPOSE: To investigate whether heat-induced fiber degradation and loss of power output, which occurred during GreenLight laser vaporization (LV) of the prostate using the first- and second-generation 80 and 120 W laser, are still an issue during LV using the upgraded third generation 180 W GreenLight XPS™ laser. METHODS: Laser beam power output of 53 laser fibers was measured at baseline and after every 25 kJ of delivered energy during routine 180 W GreenLight XPS™ LV in 47 patients with prostatic bladder outflow obstruction. After the procedures, the fiber tips were microscopically examined. RESULTS: The median applied energy per patient was 178 kJ [interquartile range (IQR): 106-247]. Loss of power output during the procedure was detectable in all fibers. After the application of 25, 150, and 250 kJ, the median power output decreased to 77% (IQR 59-87), 57% (IQR 32-71), and 51% (IQR 37-64) of the baseline value. Nine fibers (17%) remained on a relatively high power output level (> 80% of the initial output), while 13 fibers (25%) showed an end-of-procedure power output of less than 20%. Microscopy of the fiber tip revealed mild-to-moderate overall degradation and increasing degradation with higher energy delivered. CONCLUSION: Despite changes in fiber design, heat-induced fiber damage and loss of power output remain an issue during 180 W GreenLight XPS™ LV. Whether modifications of the surgical technique can prevent impairment of fiber performance needs to be further evaluated.

Retained entrapped coronary stent appearing like an aortic flap.

Entrapment of coronary angioplasty hardware is a rare but serious complication of coronary interventions which may be managed percutaneously or surgically. We described a case of an entrapped coronary stent in a patient with a history of failed coronary intervention with no documents available. In transesophageal echocardiography, there was a linear echo density in the ascending aorta stuck in the right coronary artery resembling a dissection flap but based on the history of failed coronary intervention, this odd structure was supposed to be a retained angioplasty device. The patient underwent surgical removal of the entrapped device which was a fractured stent.

CIED malfunction in patients receiving radiation is a rare event that could be detected by remote monitoring.

INTRODUCTION: An increasing number of patients with cardiac devices require radiation therapy for treatment of a variety of cancers. This study aimed to identify the incidence and predictors of cardiac implantable electronic devices (CIED) malfunction in a real-world population that has received radiation therapy. METHODS: This retrospective cohort study included 109 adult patients who received radiation therapy at the University of Rochester Medical Center, Radiation Oncology Department, between 2000 and 2015. Sixty patients had pacemakers and 49 had automatic implantable cardioverter defibrillators. Subjects received either high energy (16 MV) and/or low energy (6 MV) photon beams with or without electron beams (6-16 MeV). We included interrogations done from first day of radiation and up to 3 months' postradiation therapy. Outcomes analyzed were device-related malfunctions and device-related clinical events. Fisher's exact, Wilcoxon, and Kruskall-Wallis tests were used for bivariate analysis. Logistic regression with robust adjustment was used for multivariate analysis. RESULTS: We identified six device-related malfunctions. All events were minor and included partial settings reset leading to loss of historical data, pacing thresholds changes, lead impedance changes, and LV output increase. Two patients had device-related clinical events, including dyspnea and diaphragmatic-stimulation. In bivariate analysis, CIED malfunction was associated with CIED duration in situ. In multivariate analysis, there was no significant statistical association between adverse events and beam energy type, CIED location, or dose of radiation delivered to the target. CONCLUSIONS: CIED malfunctions are uncommon in real-world patients and associated with minor clinical events. In our cohort, remote CIED monitoring would have identified all events.

Risk factors for complications in cochlear implant surgery.

PURPOSE: The objective of this study was to achieve uniform reporting of complications and failures in cochlear implantation, to analyze complications and failures and to identify risk factors for complications in a series of over 1300 cochlear implantations. METHODS: In a retrospective chart review and observational study, data from all cochlear implantations from 1987 to 2015 were entered in a custom-made database. Complications were classified using the contracted form of the Clavien-Dindo system and risk factors were identified by statistical analysis. RESULTS: A complication rate of 18.4% and a device failure rate of 2.9% were found. There was a higher rate of hematoma in patients with a clotting disorder and when a subtotal petrosectomy was performed, a higher rate of wound infections in patients who were not vaccinated against Streptococcus pneumoniae and a higher rate of meningitis in patients with an inner ear malformation. CONCLUSIONS: The use of a strict definition of a medical complication and device failure-in combination with the Clavien-Dindo classification system-enables uniform and objective registration of adverse events and prevents any tendency to downgrade complications. Complication and failure rates in this series are comparable to those reported in the literature. These results stress the need for pneumococcal vaccination, which may prevent general wound infections, but is especially important for patients with inner ear malformation, who have an increased risk of (postoperative) meningitis.

Stability of L-shaped and inverted triangle fixation assemblies in treating Pauwels type II femoral neck fracture: a comparative mechanical study.

PURPOSE: The aim of our study is to compare the mechanical resistance of two screw configurations in fixating type II Pauwels femoral neck fractures. METHODS: Fifteen synthetic models of femur bones in young adults were divided into three equal groups: intact (G1), models with fixation of a 5.0-mm failure zone created in the posterior cortex of the femoral neck using an L-shaped screw arrangement (G2, n = 5), and models with an identical failure zone fixated using an inverted triangle assembly (G3, n = 5). Model strength (axial loading) and rotational deviation of the fragments were load-tested until a 5.0-mm displacement was reached (step 1) and then until failure, here considered as 10.0 mm displacement in G2 and G3 or femoral neck fracture in G1 (step 2). RESULTS: In step 1, the mean resistance in G1 was 1593 N (standard deviation [SD] of 62 N); this value in G2 was 1261 N (SD 49 N) and in G3 was 1074 N (SD 153 N). During step 2, the value for G1 was 2247 N (SD 84 N), for G2 was 1895 N (SD 69 N), and for G3 was 1523 N (SD 280 N). G3 (the inverted triangle assembly) showed a significantly lower maximum load than the group using the L-shaped assembly (G2) and the control group (G1), which was significant using Kruskal-Wallis analysis of variance (p = 0.002). CONCLUSION: Under test conditions in synthetic bone, fixation using a L-shaped screw assembly provides greater mechanical resistance than an inverted triangle assembly.

A Systematic Approach to the Evaluation and Management of the Failed Artificial Urinary Sphincter.

In men with post-prostatectomy incontinence, persistent or recurrent urinary leakage following artificial urinary sphincter placement is a frustrating complaint. Surgical failure can be classified as occurring early in the post-operative period vs. late-following a period of established continence-and should be managed according to the time course and severity of urinary leakage. We present a systematic approach for the evaluation and treatment of the failed artificial urinary sphincter. After considering the patient's individualized treatment goals and impact on quality of life, the clinician can more appropriately advise patients on a management strategy for their recurrent or persistent urinary incontinence following artificial urinary sphincter placement.

Cardiac Perforation by Migrated Fractured Strut of Inferior Vena Cava Filter Mimicking Acute Coronary Syndrome.

We present a rare late complication after inferior vena cava filter (IVC) placement. A 52-year-old woman with an IVC presented with sudden onset of chest pain. Cardiac catheterisation and echocardiography revealed an embolised IVC filter strut penetrating the right ventricle. Endovascular retrieval was considered but deemed unsafe due to proximity to the right coronary artery and concern for migration to pulmonary circulation. Urgent removal of the strut was performed via sternotomy. The postoperative course was uneventful. Two weeks later, she was asymptomatic. Minimally invasive approaches have been described for retrieval of intact IVC filters that have migrated to the right heart but not for embolised filter fragments. We recommend traditional sternotomy as the preferred method of retrieval as it limits the likelihood of further migration or trauma.