Fourth Attempt Research Articles

Video Review Can Measure Surgical Robotic Skill Development in a Resident Robotic Hernia Curriculum: A Retrospective Cohort Study

Background: Hernia repairs are one of the most common general surgery procedures and an essential part of training for general surgery residents. The widespread incorporation of robotic hernia repairs warrants the development of a procedure-specific robotic curriculum to assist novice surgeons in improving technical skills. Objective: To evaluate a robotic hernia simulation-based curriculum for general surgery residents using video review. Methods: Retrospective cohort study of PGY-3 general surgery residents from the University of Chicago from 2019 to 2021. The residents completed inguinal hernia repair (IHR) and ventral hernia repair (VHR) drills as part of a robotic simulation curriculum. The drills were recorded and graded according to the modified objective structured assessment of technical skills (OSATS) and time to completion. The drills were completed by 3 attending surgeons to establish gold-standard benchmarks. Results: In total, 20 residents started the curriculum, 19 completed all IHR drills and 17 completed all VHR drills. Attending surgeon total OSATS scores and time to completion were significantly better than the trainees on the first attempt (P < 0.05). When comparing 1st to 4th attempt, resident OSATS scores improved significantly for IHR (15.5 vs 23.3; P < 0.001) and VHR (16.8 vs 23.3; P < 0.001). Time also improved over 4 attempts (IHR: 28.5 vs 20.5 minutes; P < 0.001 and VHR: 29.6 vs 21.2 minutes; P < 0.001). Residents achieved attending-level OSATS scores by their fourth attempt for VHR, but not for IHR. Residents did not achieve attending-level times for either hernia drills. Conclusions: The robotic hernia curriculum improved resident performance on hernia repair drills and was well-received by the residents.

Association between multiple intubation attempts and complications during emergency department airway management: A national emergency airway registry study

ObjectivePeri-intubation complications are important sequelae of airway management in the emergency department (ED). Our objective was to quantify the increased risk of complications with multiple attempts at emergency airway intubation in the ED. MethodsThis is a secondary analysis of a prospectively collected multicenter registry (National Emergency Airway Registry) consisting of attempted ED intubations among subjects aged >14 years. The primary exposure variable was the number of intubation attempts. The primary outcome measure was the occurrence of peri-intubation major complications within 15 min of intubation including hypotension, hypoxemia, vomiting, dysrhythmias, cardiac arrest, esophageal intubation, and failed airway with cricothyrotomy. We constructed multivariable logistic regression models to determine the associations between complications and the number of intubation attempts while controlling for measured pre-exposure variables. ResultsThere were 19,071 intubations in the NEAR database, of which 15,079 met inclusion for this analysis. Of these, 13,459 were successfully intubated on the first attempt, 1,268 on the second attempt, 269 on the third attempt, 61 on the fourth attempt, and 22 on the fifth or more attempt. A complication occurred in 2,137 encounters (14 %). Major complications accompanied 1,968 encounters (13 %) whereas minor complications affected 315 encounters (2 %). The most common major complication was hypoxia. In our multivariable logistic regression model, odds ratios with 95 % confidence intervals for the occurrence of major complications for multiple attempts compared to first-pass success were 4.4 (3.6–5.3), 7.4 (5.0–10.7), 13.9 (5.6–34.3), and 9.3 (2.1–41.7) for attempts 2–5+ (reference attempt 1), respectively. ConclusionsWe found an independent association between the number of intubation attempts among ED patients undergoing emergency airway intubation and the risk of complications.

Using Engineering Methods (Kaizen and Micromovements Science) to Improve and Provide Evidence Regarding Microsurgical Hand Skills

ObjectiveMicrosurgical interventions involve the interaction of numerous variables, making objective analysis of skill proficiency challenging. This difficulty is even more pronounced in low-resource contexts. Continuous improvement methodologies such as Kaizen-PDCA and Micro-Movements Science can address this issue. This study aimed to demonstrate the advantages of designing and implementing microsurgical training programs using these methodologies. MethodsFollowing an extensive literature review of Kaizen-PDCA and Micro-Movements Science and under the guidance of experienced neurosurgeons and engineers, a microvascular bypass training program was developed using the human placenta. Subsequently, the training program was used to analyze and describe the process of a trainee neurosurgeon in Argentina with no prior experience in microvascular anastomosis, as the operator gained proficiency. ResultsThe trainee required 12 attempts to achieve the program goals. The longest procedural time was during the first attempt (1 h 49 min 05 s with two mistakes), while the shortest time was during the fourth attempt (53 min 29 s with three mistakes). After 12 attempts, the trainee made no mistakes, and the procedural time was reduced to 57 min 37 s. The final learning curve demonstrated a regular pattern and reached a plateau after seven attempts. ConclusionsThe training program and methodology effectively assessed, facilitated, and demonstrated the acquisition of microsurgical skills. Kaizen-PDCA and Micro-Movements Science enabled the effective use of expert experience, detailed evaluation of microsurgical procedures, and integration into a continuous improvement cycle. The program structure could also be valuable for teaching, evaluating, and enhancing similar surgical procedures.

JUSTICE IN THE LIMINAL: THE COUNCIL OF EUROPE AND THE RIGHT TO A HEALTHY ENVIRONMENT

AbstractAs the human right to a healthy environment is codified around the globe, some systems still lag behind. One noticeable straggler is the Council of Europe, which is currently undergoing its fourth attempt to recognize the right. This article examines the proposals tabled within this system in light of overarching debates about climate justice and environmental rights, before focusing specifically on the spatial and temporal limits of the European Convention on Human Rights (ECHR) and the institutional features of its Court. First, the article describes what the author sees as the current liminal moment in the development of human rights law, a time of transition in which established legal concepts can be questioned or reaffirmed. Second, it sketches recent proposals for locating and conceptualizing the right to a healthy environment within the Council of Europe. Evaluating different options, it makes the case for including this right in the ECHR. Third, the article discusses the right's potential to reshape the spatial and temporal limitations on legal subjectivity and Convention protections. These proposals come at a crucial time when the system's ability to protect human rights from environment-related impacts is being tested by climate litigation. The article understands these developments as interrelated and discusses whether current proposals could deliver on demands for climate justice by extending protection to future generations and for extraterritorial environmental impacts.

КЛИНИЧЕСКИЙ СЛУЧАЙ УСПЕШНОЙ РЕАЛИЗАЦИИ РЕПРОДУКТИВНОЙ ФУНКЦИИ У ПАЦИЕНТКИ С ДИСГЕНЕЗИЕЙ ГОНАД

An important problem is the problem of implementing reproductive function in patients with forms of infertility caused by genetic abnormalities. Previously, the prognosis for their reproductive function was considered unfavorable. In modern conditions, by improving IVF techniques using oocyte donation, treatment of infertility in these patients becomes possible. Therefore, studying the features of the tactics of managing such patients at the stage of preconception preparation, the features of IVF protocols, as well as the features of managing pregnancy and labor and delivery is relevant. The purpose of the study is to substantiate the possibility of successful implementation of reproductive function in a patient with gonadal dysgenesis. A clinical case of pregnancy and childbirth in a patient with a typical form of gonadal dysgenesis (karyotype 45 X0) is presented. The diagnosis was made at the age of 15 during a comprehensive examination for primary amenorrhea, and hormone replacement therapy was prescribed. The patient's pregnancy occurred after preparation of the endometrium with estrogens and gestagens as a result of the fourth IVF attempt with the donation of an egg fertilized by her husband's sperm, and was complicated by the threat of termination at 8 and 19 weeks. At 36 weeks, the pregnancy was complicated by severe preeclampsia, which required emergency caesarean section. The course of the postoperative period was uneventful with continuation of therapy for complications of gestation. It is recommended after cessation of lactation - HRT using drugs with an estrogenic component similar in chemical structure to natural ones, gestagenic - metabolically neutral. The study of this clinical case is of undoubted interest, taking into account the peculiarities of management tactics. It is necessary to implement a multidisciplinary approach to the management of such complex patients. Taking into account the peculiarities of the body condition in patients with gonadal dysgenesis and the absence of hormonal ovarian function, it is necessary to ensure optimal preconception preparation, the use of an individual approach to the implementation of the IVF protocol, and the prevention of complications during pregnancy. Fulfillment of these conditions will ensure a positive result of infertility treatment in patients with gonadal dysgenesis who previously did not have the opportunity to realize reproductive function.

Post-activation performance enhancement effect of drop jump on long jump performance during competition

Drop jump is widely used in training sessions, aiming for chronic effects on long jump performance. However, the acute effect of drop jump on long jump performance through its use as a Conditioning Activity (CA) has not been explored. The objective of this study was to verify the Post-activation Performance Enhancement (PAPE) responses induced by successive Drop Jumps (DJ) on competitive long jump performance. Eleven male jumpers (19.0 ± 2.0 years; 178.0 ± 9.0 cm; 73.1 ± 8.9 kg; and personal record 5.78 ± 0.44 m) volunteered for participation. The athletes performed 5 drop jumps 2 min (1′45–2′15 min) before the second, and fourth attempt during official competition of state level, the attempts without the use of CA were considered controls. The performance of the second (5.63 ± 0.43 m), third (5.65 ± 0.46, g = 0.24) and fourth (5.71 ± 0.34 m) jumps performed after activation were higher than the first (5.54 ± 0.45 m) in the control condition, p = 0.02, and p = 0.01 respectively. Differences were also found in the take-off vertical velocity of the jump between the fourth (1.55 ± 0.21) and the first jump (1.30 ± 0.40), p = 0.006. Jump performance showed positive correlation with approach velocity, r = 0.731, vertical take-off velocity, r = 0.412, and take-off duration, r = 0.508. The mean performance in jumping post-activation (5.67 ± 0.38 m) was higher than that without the use of previous CA (5.59 ± 0.44 m), p = 0.02, g = 0.19. The use of DJs as a CA prior to the long jump promotes improvements in the performance of the jump, which can be explained by the increase in the take-off vertical velocity in the athletes.

Animal model of polytrauma for surgical training

Introduction: The aim of this study was to develop a training program for surgeons that would enable them to improve their practical skills using an animal model of polytrauma. Methods: Injury to the stomach, small and large bowel as well as spleen and liver injury were caused laparoscopically, and tension pneumothorax was induced thoracoscopically, in 60 laboratory pigs. A thus obtained polytrauma model was then used for the training of examination processes according to ATLS (advanced trauma life support) principles and of the treatment protocol according to DCS (damage control surgery) principles. Less experienced surgeons (N=10) completed a total of 4 training sessions, and experienced surgeons with postgraduate certification in surgery (N=10) performed 2 treatments. The relative training benefit was subsequently assessed by comparing the first and the last attempt. Furthermore, the absolute benefit of training for the beginners (novice trainees) was evaluated by comparing their last attempt with the first attempt of experienced surgeons. Results: The beginners (less experienced surgeons) showed an improvement (first vs fourth attempt) in all parameters except bowel injury management and laparotomy closure time. Based on the comparison of the experienced surgeons’ first attempt and the beginners’ first attempt, the beginners performed significantly worse in all parameters except the two mentioned above. Average total blood loss was also higher in the beginners’ group – 2531 (±661.1) g vs 1189 (±509.5) g in the experienced surgeons’ group (p<0.001). Conclusion: A novel animal model of polytrauma that can be used for the training of life threatening injury management was developed and validated in the study. The beginners improved significantly in all parameters after the training. However, longer training would be required to achieve results comparable to those of experienced surgeons.

Four nesting attempts of a Great Bustard Otis tarda female in one reproductive season

Abstract A mature Great Bustard (Otis tarda) female tagged with a satellite transmitter in Dévaványa made four breeding attempts in 2019. A total of seven eggs were laid on the four occasions. None of the breeding attempts were successful, and the bird was killed by a predator, presumably a Red Fox (Vulpes vulpes), during the fourth breeding attempt. The four egg-laying attempts are a new experience in the reproductive biology of the species. The failure of the nestings and the death of the bird itself confirm that the conservation measures of the species, as emphasised in international and national conservation plans – controlling predators and egg predator populations, ensuring undisturbed breeding conditions – are important conservation biology actions serving for the protection of the species.

Bleeding during epidural analgesia: case report

BACKGROUND: Bleeding at the puncture site during neuraxial blocks is a potentially dangerous complication, and its risk is significantly increased in patients receiving antithrombotic therapy.
 CLINICAL CASE DESCRIPTION: Patient S. (aged 60 years) was admitted to the department of vascular surgery (Vladivostok). He was diagnosed with Leriches syndrome, for which he took 100 mg of aspirin and 75 mg of clopidogrel. On January 12, 2022, combined spinal-epidural anesthesia was performed, and the epidural space was punctured on the fourth attempt. However, massive bleeding was observed from the puncture site. Intraoperatively, before the great vessels were clamped, 100 units/kg of heparin (8000 units) was administered. After the operation, the epidural puncture site was revised: the sticker was soaked with hemorrhagic discharge and removed, and a new sticker was applied. On January 12, 2022, nadroparin calcium 9500 IU anti-Xa/ml 0.3 mL was given two times a day in the ICU. On the same day, intensive bleeding was noted in the area where the epidural catheter was located. This was treated locally with cold and two doses of fresh frozen plasma. On January 13, 2022, magnetic resonance imaging of the lumbar spine showed the spinal cord without displacement and compression, the puncture area had no signs of bleeding, the epidural catheter was removed, and the patient was discharged for outpatient treatment on day 7.
 CONCLUSION: To reduce bleeding risk in neuraxial blockade, the recommendations for preparing for surgery patients receiving anticoagulant and antiplatelet therapy must be followed, and the pharmacokinetics of antithrombotic drugs must be taken into account. If puncture and catheterization of the epidural space are technically difficult, manipulation should be abandoned.

A New Optimal Method for the Secure Design of Combinational Circuits against Hardware Trojans Using Interference Logic Locking

Effective resistance to intellectual property theft, reverse engineering, and hardware Trojan insertion in integrated circuit supply chains is increasingly essential, for which many solutions have been proposed. Accordingly, strong attacks are also designed in this field. One way to achieve the above goal is obfuscation. The hardware obfuscation method hides the primary function of the circuit and the normal Netlist from the attacker by adding several key gates in the original Netlist. The functionality circuit is correct only if the correct key is applied; otherwise, the circuit is obfuscated. In recent years, various obfuscation methods have been proposed. One is logic locking, the most prominent hardware protection technique since it can protect against untrusted items. Logic locking induces functional and structural changes to a design even before the layout generation. We secured the circuit against hardware Trojan insertion with a secure logic locking method based on the insertion of key gates in interference mode. We call our proposed method Secure Interference Logic Locking, SILL. SILL is based on minimum controllability in paths with maximum fan-out. In this method, we have reduced the number of key gates required for circuit obfuscation and created the maximum Hamming distance between normal and obscure outputs. In addition, the key gates are added to the circuit’s complete interference, and the AES algorithm is used to generate the key. Our proposed method, SILL, was simulated in the Vivado simulation environment; the algorithms used in this method were prepared in VHDL language and designed to allow parallel execution, then applied on the original Netlist of the ISCAS85 benchmark circuits. By analyzing and comparing the results of this simulation to recent works, the amount of hardware consumption has decreased (about 5% space consumption and about a 0.15-nanosecond time delay). Then, the SAT attack algorithm was tested on ISCAS85 benchmark circuits that were obfuscated with SILL. The execution time of the attack in the second attempt was 0.24 nanoseconds longer compared to similar recent works, and it timed out in the fourth attempt. The resistance of our proposed method, having less hardware overhead and higher speed is more effective against SAT attacks than the existing conventional methods.

Robotic Hernia Curriculum Improves Resident Performance on Inguinal and Ventral Hernias

INTRODUCTION: Hernia repairs are one of the most common procedures performed in general surgery. The widespread incorporation of the robotic approach in this procedure warrants the presence of a proficiency-based curriculum to assist novice surgeons in credentialing and safe implementation. This study evaluates the construct validity of a robotic hernia curriculum in a cohort of general surgery residents. METHODS: PGY3 general surgery residents were asked to complete four inguinal hernia (IHR) and four ventral hernia (VHR) drills. These were graded according to the modified objective structured assessment of technical skills (OSATS) by two independent blinded graders in addition to drill time. The hernia drills were completed by three attending surgeons establishing gold standard benchmarks. RESULTS: 20 residents started the curriculum, 19 completed all IHR and 17 completed all VHR. Attending total OSATS scores and times were significantly better than those of the trainees on first attempt (p < 0.05). When comparing the 4th to the 1st attempts for residents, OSATS scores improved significantly for IHR (15.5 vs 23.3, p < 0.001) and VHR (16.8 vs 23.3, p<0.001). Time also improved over 4 attempts (IHR: 28.5 vs 20.5 mins, p < 0.001 and VHR: 29.6 vs 21.2 mins, p < 0.001). Residents were able to achieve attending scores by their fourth attempt for VHR, but not for the IHR (Fig. 1). Residents were not able to achieve attending times for either hernia drill after four attempts.Figure 1CONCLUSION: The robotic hernia curriculum improves resident performance. More procedure specific curricula are needed to better prepare trainees for the operating room.

Revisiting Retake Policy: Analyzing the Success Rates of Examinees With Multiple Attempts on the United States Medical Licensing Examination.

A testing program's decision making on retake policy considers a number of factors, including fairness to examinees, examination security, examination purpose, and classification accuracy. For high-stakes licensure and certification examinations charged with protection of the public, this includes balancing fairness issues inherent in the potential for false negatives with the public protection need to minimize false positives. Since 2012, the United States Medical Licensing Examination (USMLE) has maintained a policy of ≤ 6 attempts on any examination component. The purpose of this study was to empirically examine the appropriateness of existing USMLE retake policy. A sample of over 300,000 examinees who were administered each Step examination between 2008 and 2018 was examined to address how pass rates (per attempt and cumulatively) differed for examinees and examinee subgroups via graphic depictions of pass rates, the impact of restricting the number of attempts on examinees and examinee subgroups via logistic regression analyses, and the impact of restricting the number of attempts on classification error via classification error analyses. Repeaters displayed consistently lower pass rates on subsequent attempts. Regardless of Step, most passing examinees did so by their fourth attempt. Models predicting the log odds of examinees taking ≥ 5 attempts showed a significant effect of gender, race, and medical school status, although the associated sample sizes are small. Misclassification analyses showed that, as attempts increased, the percentage of false passers increased and percentage of false failers decreased. These considerations led to the USMLE's decision to reduce its attempt limit from 6 to 4 on any Step or Step component effective July 2021. This change balances the competing interests of fairness and examination access to the examinee population, while simultaneously maintaining a minimum standard consistent with the mission of the USMLE program to protect the public.

COMPULSORY TRAINING REQUIREMENTS FOR ESTATE AGENTS: THE LEGAL ISSUES

Draft regulations dealing with the training of estate agents were published by GN 971 and 973 in Government Gazette 30160 of 13 August 2007. The regulations, if promulgated, will be government’s fourth attempt to regulate the training of estate agents in South Africa, the first attempt going back to 1983. The purpose of this Note is not to evaluate the educational model encapsulated in the draft regulations, but to focus on the legal ramifications should the regulations become law. To this end it is necessary to sketch thehistory of compulsory training requirements for estate agents in South Africa, and the legislative context within which this was introduced. It is submitted that a number of the provisions of the draft regulations are ultra vires and void, while some may be unenforceable on the ground of vagueness. Others are in conflict with section 22 of the Constitution, in terms of which everycitizen has the right to choose their trade, occupation or profession freely.

MP31-19 REDUCING CATHETER ASSOCIATED-URINARY TRACT INFECTIONS WITH STERILE, CONTINUOUSLY CLOSED DRAINAGE SYSTEMS DOES NOT HAVE TO BE COSTLY

You have accessJournal of UrologyCME1 May 2022MP31-19 REDUCING CATHETER ASSOCIATED-URINARY TRACT INFECTIONS WITH STERILE, CONTINUOUSLY CLOSED DRAINAGE SYSTEMS DOES NOT HAVE TO BE COSTLY Janelle Fox, Christina Jockel, Leslie Konyk, Shaina Thomas, Omar Ayyash, Rajeev Chaudhry, Glenn Cannon, Francis Schneck, Daniel Pelzman, and Lindsay Montoya Janelle FoxJanelle Fox More articles by this author , Christina JockelChristina Jockel More articles by this author , Leslie KonykLeslie Konyk More articles by this author , Shaina ThomasShaina Thomas More articles by this author , Omar AyyashOmar Ayyash More articles by this author , Rajeev ChaudhryRajeev Chaudhry More articles by this author , Glenn CannonGlenn Cannon More articles by this author , Francis SchneckFrancis Schneck More articles by this author , Daniel PelzmanDaniel Pelzman More articles by this author , and Lindsay MontoyaLindsay Montoya More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002580.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Urinary tract infections (UTIs) are the fifth most common hospital-acquired infection. Each foley day increases the risk of UTI by 3-7%, hence the National Healthcare Safety Network (NHSN) has provided hospitals with a means of tracking catheter associated-urinary tract infections (CA-UTIs) and toolkits to help reduce their frequency. One means by which CA-UTIs are reduced is through use of sterile, continuously closed drainage systems. To do so, many hospitals have switched to use of pre-packaged and sealed systems which are more costly. An alternative was proposed in the UPMC Children’s Hospital of Pittsburgh (CHP) Pediatric Intensive Care Unit (PICU) whereby two nurses perform every foley placement to ensure sterile technique. They use a separate foley catheter, sterile insertion kit and urine meter bag which are then treated as a functionally closed system. METHODS: During the 7-month period of April–October 2021, the CHP PICU instituted the two-part, two-person foley insertion protocol and tracked both CA-UTI rates and cost savings compared with the 7-month period using a pre-packaged catheter kit. Closed-system catheter kits cost CHP $198.18 per unit. Two-part, two-person foley insertions cost CHP $68.33 per insertion, with each repeat attempt adding $5.33. RESULTS: A total of 215 patients had indwelling urinary catheters during the study period. Of these, 124 were placed in the PICU and 91 by other services (OR, IR, outside hospitals, Urology). Of the 124 PICU catheterizations, first attempts were successful in 101 patients with 17 second attempts, 5 third attempts and 1 fourth attempt. Costs of using the closed-system catheter kit based on these numbers of attempts would be $30,519. Costs of using a two-part, two-person protocol which remained closed after insertion were $8821.82, translating into a cost savings of $21,679.18 over 7 months or $37,164.30 over 1 year. Among 15 nurses who provided feedback on the new two-person, two-part protocol, 13 of the 15 (87%) preferred this method. There was no statistically significant increase in CA-UTIs after the new protocol was adopted, with CA-UTI rates remaining at 0 throughout the study period. CONCLUSIONS: Switching from pre-packaged closed system catheter kits to a two-part, two-person protocol for foley insertions translates into significant annual cost savings for pediatric acute care facilities, without an increase in CA-UTIs. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e529 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Janelle Fox More articles by this author Christina Jockel More articles by this author Leslie Konyk More articles by this author Shaina Thomas More articles by this author Omar Ayyash More articles by this author Rajeev Chaudhry More articles by this author Glenn Cannon More articles by this author Francis Schneck More articles by this author Daniel Pelzman More articles by this author Lindsay Montoya More articles by this author Expand All Advertisement PDF DownloadLoading ...

A comparison between different endovascular treatment strategies for acute large vessel occlusion due to intracranial artery atherosclerosis: data fromANGEL-ACT Registry.

The aim of our study is to compare the characteristics and clinical outcomes among the different endovascular treatment (EVT) strategies for large vessel occlusion underlying intracranial atherosclerosis (ICAS-LVO) in a recent nationwide registry. Patients with isolated ICAS-LVO were enrolled in our analysis and were categorized into three groups: first-line mechanical thrombectomy (MT) with rescue angioplasty and/or stenting (MT + RS), direct angioplasty and/or stenting without thrombectomy (DA), and MT alone. Baseline and periprocedural characteristics, successful recanalization, and 90-day functional outcomes were compared. Of 396 patients with isolated ICAS-LVO in our study, successful recanalization was achieved in 94.5%, 100%, and 90.9% of patients in the MT + RS, DA, and MT groups, respectively. The 90-day functional independence in the three groups was 50.8%, 59.0%, and 45.1%. The main efficacy and safety outcomes showed no significant differences among the groups. First-pass recanalization (FPR) was more observed in the MT group (43.4%), the recanalization rate per attempt in the MT group gradually decreased until the fourth attempt, and further maneuvers showed recanalization rates of ≈0% per attempt. MT + RS (adjusted odds ratio [aOR] 0.10, p < 0.0001) and DA (aOR 0.18, p = 0.0013) were associated with lower FPR rate than MT alone in the multivariable logistic regression. The technical feasibility and favorable outcomes of several EVT strategies for ICAS-LVO were established in our study. First-line MT with a bailout angioplasty is a reasonable option for ICAS-LVO, and DA is an effective option for the cases when ICAS-LVO is strongly suspected before EVT procedure.

Cotton/Fe3O4@SiO2@H3PW12O40 a magnetic heterogeneous catalyst for biodiesel production: Process optimization through response surface methodology

Use of green alternative sources for energy like biofuels is one of the most important requirements of sustainable development. This research aims to design and prepare a new magnetically recoverable catalyst based on agro-wastes. For this purpose, cotton waste was selected and its application in the preparation of magnetic catalysts (Cotton/Fe3O4@SiO2@ H3PW12O40) used for the production of biodiesel, which is based on heteropoly acid (HPA), was investigated. Magnetic cotton powder with high dispersibility, porosity, and magnetism were prepared by the co-precipitation method and covered by silica using tetraethyl orthosilicate (TEOS) to form Cotton/Fe3O4 @SiO2. Finally, the nanostructured catalyst was prepared by impregnation of phosphotungstic acid (HPW). The proposed catalyst was characterized by X-ray diffraction (XRD), Fourier transform infrared spectroscopy (FT-IR), Field emission scanning electron microscopy (FESEM) equipped with Dispersive Energy X-ray spectroscopy (EDS), Thermo gravimetric analysis (TGA), The Brunauer-Emmett-Teller (BET) surface area analysis, Barrett-Joyner-Halenda (BJH) pore size and volume analysis and vibrating sample magnetometer (VSM). The performance of the proposed core-shell nanocomposite to catalyze transesterification reaction was evaluated and optimized by response surface methodology (RSM). The optimum conditions were found as 3 wt%, 3.5 h, 12:1, and 70 °C, for catalyst dosage, reaction time, the molar ratio of methanol to oil, and reaction temperature, respectively. The production yield was higher than 90% for three runs. On the fourth attempt, the catalyst performance was decreased slightly to 85.5%. The used catalyst was characterized by FT-IR, XRD, EDS, and FESEM for leaching studies. The quality of the biodiesel product was tested according to the standard procedures defined by the American Society for Testing and Materials (ASTM) and European Union (EU).

Трудная ларингоскопия в плановой анестезиологии

Введение. Обеспечение проходимости дыхательных путей — одна из ключевых задач плановой анестезиологии. Почти треть всех случаев анестезиологической смертности связана с трудностями при вентиляции пациентов после индукции в наркоз. Причем большинство из них обусловлены непосредственно интубацией трахеи и трудностями последующей вентиляции. Причиной 80 % закрытых исков Американской ассоциации анестезиологов по поводу повреждения гортани были повторные попытки интубации трахеи во время плановой анестезии. Цель исследования: повышение эффективности и уменьшение частоты осложнений обеспечения проходимости дыхательных путей при трудной ларингоскопии в плановой анестезиологии. Материалы и методы исследования. Нами проанализированы результаты 66 случаев трудной ларингоскопии при плановых оперативных вмешательствах на базе Полтавской областной клинической больницы за 2013–2015 годы. У всех пациентов во время прямой ларингоскопии на фоне миоплегии голосовая щель не визуализировалась. Пациентам I группы применялся клинический протокол оказания медицинской помощи больным с трудной интубацией трахеи, пациентам II группы после неудачной попытки интубации сразу устанавливалась ларингеальная маска соответствующего размера. Исследовалась частота удачных попыток восстановления проходимости дыхательных путей методом интубации трахеи и с помощью ларингеальной маски, частота и причины осложнений. Результаты исследования. У пациентов I группы вторая попытка интубации трахеи была удачной в 43,8 % случаев. Со следующими попытками интубации трахеи эффективность манипуляции прогрессивно уменьшалась до 6,2 % с четвертой попытки. Эффективность последующего использования ларингеальной маски составила 45,4 %; причины несостоятельности: травматизация слизистой, гиперсаливация, бронхорея, ларинго- и бронхоспазм. У пациентов II группы в 91,2 % случаев постановка ларингеальной маски обеспечила герметичность дыхательного контура и адекватную вентиляцию во время оперативного вмешательства. Осложнений практически не наблюдалось. Выводы. Использование клинического протокола оказания медицинской помощи больным с трудной интубацией трахеи в плановой анестезиологии менее эффективно и имеет высокую частоту осложнений, связанных с прямой ларингоскопией, по сравнению с единственной попыткой интубации трахеи и последующим использованием ларингеальной маски.

Simulation and Acquisition of Endotracheal Intubation Skills by Medical Students—A Pilot Study

Introduction: Endotracheal intubation is a vital life-saving skill required by physicians in life-threatening situations in and out of the hospital. Medical students are exposed to these procedures mainly as they rotate through the department of Anaesthesia, in their subspecialty posting in Surgery. In this study, we sought to assess the ease of learning endotracheal intubation by medical students in the skills laboratory using an adult-sized (Laerdal Medical) manikin. Methods: This was a prospective descriptive study assessing the ability of medical students at endotracheal intubation during their 12-week rotation in the Anaesthesia Department during their subspecialty posting from August to October 2019 in the Skills Laboratory. An adult-sized manikin (Laerdal Medical) intubating head was used for the study. This was preceded by a detailed lecture and demonstration in the skills laboratory after successful passage of the endotracheal tube and connected to a self-inflating ventilation (Ambou) bag. Adequate chest movement meant proper placement, while the fullness of the stomach meant oesophageal intubation. Results: All the 500 level (45) students in the class were recruited for this prospective study. 30 (66%) had successful endotracheal intubation at the first attempt, 7 (14.4%) at the second attempt, 5 (11.1%) at the third attempt, 2 (4.4%) students at the fourth attempt and 1 (2.2%) had successful endotracheal intubation at the fifth attempt. Attempts were made to reinforce information on the practical procedure by a repeat performance by the instructor after each set of successful attempts was separated from the pack of unsuccessful candidates. In the end, however, we had 100% successful endotracheal intubation, but after 5 attempts by the last medical student. Conclusion: Endotracheal intubation skills can be learned with some level of ease when done after detailed information and training of medical students. More so when not under undue stress and life-threatening situations in the skills laboratory. By extension, this increases the confidence of medical students in the live patients in the Operating Theatre, after repeated attempts in the skills laboratory. This has the benefit of improving the chances of acquisition of endotracheal intubation in real-life situations.

Comment to the Article by O.A. Kaplunov et al. “Hypotrophic Clavicle Pseudoarthrosis Treatment: A Case Report”

In the comment on the article Treatment of Hypotrophic Nonunion of the Clavicle: A Clinical Case, the reasons for the failure of primary and refixation of the clavicle closed fracture are analyzed in detail. A 70-year-old patient got a fracture of the middle third of the left clavicle diaphysis as a result of a fall. He underwent four surgical treatment options: plate osteosynthesis; plate osteosynthesis + bone autoplasty; plate osteosynthesis + vascularized fibular flap reconstruction; external osteosynthesis. A month after the fourth attempt of surgical treatment, fusion, improvement of the function of the right upper limb and the quality of life of the patient were achieved. Technological inaccuracy, namely, the lack of the fragments fixation stability due to the incorrectly chosen length of the plate, as well as an incomplete assessment of the anamnesis and the identified cognitive behavioral features of the patient, are considered as possible reasons for the treatment failure. The author of the comment highlights modern approaches to the treatment of clavicle fractures, and also briefly dwells on the theory of fracture fixation in general. He pays special attention to biological and mechanical factors affecting fractures healing. The author considers the compliance with the basic principles of osteosynthesis to be the main factor in achieving good results in fracture treatment.

Referendum on early elections: The case of Slovakia in the European context

Summary The referendum initiative of 2021 is the fourth attempt in Slovakia to call a referendum on early parliamentary elections in less than 30 years. The aim of this article is to answer the question of whether the shortening of the parliamentary term by referendum is in accordance with the Slovak Constitution. Since the shortening of parliamentary term by referendum is a constitutional issue which is a question of identity common to all European democracies, the authors analyse the existence of such direct democracy instrument in the Council of Europe member states and compare the relevant constitutional framework with the Slovak Constitution. The authors’ opinion is that the referendum on early elections contradicts not only several constitutional provisions, but also the overall philosophy of the Slovak Constitution and Western-type democracy.