High-risk Operations Research Articles

Application of risk assessment to improve sustainability in bauxite mining

Uncertainty and risk management are essential for decision-making in the sustainable extraction of mineral resources. Uncertainty in mine planning typically starts with the geostatistical simulation of the variables that influence the decision process, which produces a series of equally probable models. Then a transfer function is applied to each model. The result is a distribution of the response function, which calculates the probability (or risk) that a given area achieves the product quality standards. High-risk operations often fail to achieve the ore quality standards and decrease the mineral resources value. In this context, failure in managing risk may collapse mining operations, leading to unrepairable economic, environmental, and social damages. However, risk assessment is a challenge in the case of multivariate deposits such as bauxite deposits. In these deposits, the response function depends on multiple variables simultaneously. The variables that characterize bauxite deposits also exhibit complex relationships and sum and fraction constraints. The geostatistical simulations should reproduce these peculiarities. This work proposes a workflow to measure risk and uncertainty in complex multivariate deposits aiming at sustainable gains for the mining operations. The workflow starts with a multivariate geostatistical simulation using Projection Pursuit Multivariate Transform. Then these simulated models are combined with the initially planned dig lines and mining scheduling. The results informed the dig lines and periods with the highest risks and uncertainty for all variables, allowing the decision team to take measures focusing on sustainable goals. The methodology is illustrated in a case study of a significant bauxite deposit located in northern Brazil.

Development of an Augmented Reality Concept for Icebreaker Assistance and Convoy Operations

A vessel convoy is a complex and high-risk operation completed during icebreaking operations in the Arctic. Icebreaker navigators need to continuously communicate with their crew while monitoring information such as speed, heading, and distance between vessels in the convoy. This paper presents an augmented reality user interface concept, which aims to support navigators by improving oversight and safety during convoy operations. The concept demonstrates how augmented reality can help to realize a situated user interface that adapts to user’s physical and operational contexts. The concept was developed through a human-centered design process and tested through a virtual reality simulator in a usability study involving seven mariners. The results suggest that augmented reality has the potential to improve the safety of convoy operations by integrating distributed information with heads-up access to operation-critical information. However, the user interface concept is still novel, and further work is needed to develop the concept and safely integrate augmented reality into maritime operations.

Variation in outcomes across surgeons meeting the Leapfrog volume standard for complex oncologic surgery.

A large body of evidence supports regionalization of complex oncologic surgery to high-volume surgeons at high-volume hospitals. However, whether there is heterogeneity of outcomes among high-volume surgeons at high-volume hospitals remains unknown. Patients who underwent esophagectomy, lung resection, pancreatectomy, or proctectomy for primary cancer were identified within the Medicare 100% Standard Analytic File (2013-2017). Mixed-effects analyses assessed the association between Leapfrog annual volume standards for surgeons (esophagectomy ≥7, lung resection ≥15, pancreatectomy ≥10, proctectomy ≥6) and hospitals (esophagectomy ≥20, lung resection ≥40, pancreatectomy ≥20, proctectomy ≥16) relative to postoperative complications and 90-day mortality. Additional analyses using New York's all-payer Statewide Planning and Research Cooperative System (2004-2015) were performed. Among 112,154 Medicare beneficiaries, high-volume surgeons at high-volume hospitals were associated with lower adjusted odds of complications (esophagectomy: odds ratio [OR], 0.73 [95% CI, 0.61-0.86]; lung resection: OR, 0.88 [95% CI, 0.82-0.94]; pancreatectomy: OR, 0.73 [95% CI, 0.66-0.80]; proctectomy: OR, 0.92 [95% CI, 0.85-0.99]) and 90-day mortality (esophagectomy: OR, 0.60 [95% CI, 0.44-0.76]; lung resection: OR, 0.82 [95% CI, 0.73-0.93]; pancreatectomy: OR, 0.66 [95% CI, 0.56-0.76]; proctectomy: OR, 0.74 [95% CI, 0.65-0.85]). For the average patient at the average high-volume hospital, there was a 2-fold difference in the adjusted complication rate between the best-performing and worst-performing high-volume surgeon for all operations (esophagectomy, 28%-55%; lung resection, 7%-21%; pancreatectomy, 16%-35%; proctectomy, 16%-28%). Wide variation was also present in adjusted 90-day mortality for esophagectomy (3.5%-9.3%). Results from New York's all-payer database were similar. Even among high-volume surgeons meeting the Leapfrog volume standards, wide variation in postoperative outcomes exists. These findings suggest that volume alone should not be used as a quality indicator, and quality metrics should be continuously evaluated across all surgeons and hospital systems. Previous studies have demonstrated a surgical volume-outcome relationship for high-risk operations-that is high-volume surgeons and hospitals that perform a specific surgical procedure more frequently have better outcomes for that operation. Although most high-volume surgeons had better outcomes, this study demonstrated that some high-volume surgeons did not have better outcomes. Therefore, volume is an important factor but should not be the only factor considered when assessing the quality of a surgeon and a hospital for cancer surgery.

Survival and quality of life following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) most commonly affects the head of the pancreas. This condition has a dismal prognosis. Patients with early disease may be candidates for pancreaticoduodenectomy (PD). This is a high-risk operation which is associated with considerable morbidity. Whilst perioperative mortality rates have fallen in recent times, the risk remains significant and long-term survival is poor, even in those who make an uncomplicated recovery. Furthermore, PD is known to affect quality of life (QoL) negatively. Most studies suggest it takes up to six months before a patient’s QoL returns to baseline. This is a considerable amount of time for a patient who is unlikely to achieve long-term survival. This short review discusses the recent literature surrounding mortality rates, long-term survival and QoL following PD for PDAC. A comprehensive understanding of these topics will allow clinicians and patients to consider the risks and benefits before surgical resection is considered.

Investigation and Analysis of Sharp Injuries among Health Care Workers from 36 Hospitals in Shandong Province, China.

Background This study investigated and analyzed the current situation of sharp injuries among health care workers (HCWs) in China's Shandong Province. Methods By means of questionnaire survey, the incidence of sharp injuries among HCWs from 36 hospitals in China's Shandong Province in October 2019 was investigated, and the results of this survey were compared with those of October 2012. Results A total of 48165 HCWs were investigated. 549 cases of sharp injuries occurred. The incidence of sharp injuries was 1.14%, which was significantly lower than that in October 2012 (9.71%). In the occupational distribution of sharp injuries among HCWs, the proportion of nurses was 58.65%, doctors 23.32%, and interns 12.02%. Among the distribution of sharp injury departments, general wards, operating rooms, intensive care units, disinfection supply centers, and outpatient clinics were the high-incidence sites of occupational exposure among HCWs. The main instruments causing sharp injuries in HCWs were syringes, scalp steel needles, surgical suture needles, vacuum blood collection needles, and glass slides. Drug administration, double-handed loop needle cap, blood extraction, surgical suture needle, and arteriovenous needle extraction were high-risk operations causing sharp instrument injuries in HCWs. Conclusion The incidence of sharp injuries among HCWs from 36 hospitals in Shandong Province in October 2019 was significantly lower than that in October 2012. Sharp injuries were a common type of occupational exposure for HCWs. The occurrence of sharp injuries should be effectively reduced by changing wrong habitual behavior and implementing standard protective measures.

Update on Metabolic Bariatric Surgery for Morbidly Obese Adolescents

Despite worldwide public attention and intense medical efforts, the prevalence of severe morbid obesity in children and adolescents is still rising. Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways leading to serious co-morbidities such as impaired glucose tolerance or even type 2 diabetes (T2D), dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and hyperuricemia. The management of severe childhood obesity requires a life-long multidisciplinary approach with a combination of lifestyle changes, nutrition, and medications. Standardized life-style intervention programs remain the first-line treatment for morbid obese children and adolescents, but unfortunately reveal limited long-term success. In such cases, metabolic bariatric surgery (MBS) has evolved from being a controversial issue to being included in distinct recommendations. According to the American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee, indications for bariatric surgery in adolescence must follow very strict criteria. Adolescents with class II obesity (BMI > 120% of the 95th percentile) and a diagnosed co-morbidity or with class III obesity (BMI ≥ 140% of the 95th percentile) should be considered for MBS. These interventions represent high-risk operations, and adolescents should be treated in specialized, multidisciplinary high-volume obesity centers with long-term follow-up programs. The Roux-en-Y gastric bypass (RYGB) remains the gold standard of all malabsorptive procedures. Laparoscopic sleeve gastrectomy (LSG), which the authors pioneered as a stand-alone procedure in morbidly obese adolescents in 2008, has become the most commonly performed operation in morbidly obese adolescents at present. Recent literature proves that MBS is safe and effective in morbidly obese adolescents. Mid-term data have revealed significant improvement or even resolution of major co-morbidities. Thus, MBS for the treatment of morbidly obese adolescents has evolved from being a controversial issue to being included in distinct recommendations by several medical societies as a therapeutic strategy to reduce severe co-morbidities potentially causing end-organ damage in adulthood.

Volume-outcome relationship in rectal cancer surgery

IntroductionHospital centralization effect is reported to lower complications and mortality for high risk and complex surgery operations, including colorectal surgery. However, no linear relation between volume and outcome has been demonstrated. Aim of the study was to evaluate the increased surgical volume effect on early outcomes of patient undergoing laparoscopic restorative anterior rectal resection (ARR).MethodsA retrospective analysis of all consecutive patients undergoing ARR with primary anastomosis between November 2016 and December 2020 after centralization of rectal cancer cases in an academic Centre. Short-term outcomes are compared to those of patients operated in the same unit during the previous 10 years before service centralization. The primary outcome was estimated anastomotic leak rate. Mean operative time, need of conversion, postoperative use of blood transfusion, radicality, in-hospital stay, number and type of complications, readmission and reoperation rate, mortality and 1-year and stoma persistence rates were evaluated as secondary outcomes.Results86 patients were operated in the study period and outcomes compared to those of 101 patients operated during the previous ten years. Difference in volume of surgery was significant between the two periods (p 0.019) and the estimated leak rate was significantly lower in the higher volume unit (p 0.047). Mean operative time, need of conversion, postoperative use of blood transfusion and in-hospital stay (p < 0.05) were also significantly reduced in Group A.ConclusionThis study suggests that the shift toward higher volume in rectal cancer surgery is associated to decreased anastomotic leak rate. Potentiation of lower volume surgical units may yield optimal perioperative outcomes.

Research on Automatic Recognition of Pointer Meter Reading Based on Deep Learning Algorithm

With the rapid development of computer technology and intelligent high-performance hardware, deep learning algorithm plays an increasingly important role in society. The development of automatic identification method of instrument and instrument based on deep learning can effectively improve the working efficiency of the basic power grid operation and maintenance personnel, avoid personnel approaching the high-risk operation area, and ensure the continuous monitoring of the readings of key instruments all day. In this paper, a recognition algorithm of pointer types circular instrument based on deep learning algorithm is proposed. Gaussian filter and binary method are used to achieve better recognition effect, which lays a good theoretical foundation for further practical application.

The Status of Occupational Protection During COVID-19 Pandemic: Knowledge, Attitudes, and Practice of Healthcare Workers in Endoscopy Units, China.

Background: SARS-CoV-2 spreads rapidly around the world, and some patients present gastrointestinal symptoms. The existence of the virus in the gastrointestinal tract makes digestive endoscopy a high-risk operation, which associated with an increased risk of infection rate in healthcare workers. This study aimed at exploring current knowledge, practice and attitudes of healthcare workers in endoscopy units in China regarding the status of occupational protection during COVID-19 pandemic.Methods: A cross-sectional study of a national online survey involving 717 healthcare workers in endoscopy units from 94 medical structures in 24 provinces and municipalities around China was conducted online via a questionnaire platform called Wenjuanxing (wjx.cn). The data were analyzed using correlation approaches, Kruskal-Wallis test for independent samples, and linear regression models.Results: Most Chinese healthcare workers in endoscopy units had a good knowledge of COVID-19 (median: 10; range: 7–12), showed a strikingly positive attitude (median: 65; range: 39–65), and carried out good practice (median: 47; range: 14–50) in strengthening the protection, disinfection and management of COVID-19. In terms of attitudes, female staff was more concerned about protection against COVID-19 than male staff (KW = 8.146, P = 0.004). Nurses performed better in both attitude (KW = 2.600, P = 0.009) and practice (KW = 6.358, P < 0.001) than endoscopic physicians when carrying out personal protection, patient care and environmental disinfection against SARS-CoV-2 infection. More positive attitudes in protection were related to better protective behavior in endoscopic daily medical work (r = 0.312; P < 0.001).Conclusion: The findings of this study suggest that Chinese endoscopy healthcare workers have an excellent mastery of knowledge about COVID-19, which is transformed into positive beliefs and attitudes, contributing to good practice during daily endoscopic procedures. Medical staff may benefit from further education. With the gradual normalization amid the ongoing COVID-19 pandemic, protection and management in endoscopy units may be changed accordingly.

High-risk surgery among older adults: Not-quite shared decision-making

BackgroundShared decision-making is critical to optimal patient-centered care. For elective operations, when there is sufficient time for deliberate discussion, little is known about how surgeons navigate decision-making and how surgeons align care with patient preferences. In this context, we sought to explore surgeons’ approaches to decision-making for adults ≥65 years at high-risk of postoperative complications or death. MethodsWe conducted semistructured in-depth interviews with 46 practicing surgeons across Michigan. Transcripts were iteratively analyzed through steps informed by inductive thematic analysis. ResultsFour major themes emerged characterizing how surgeons approach high-risk surgical decision-making for older adults: (1) risk assessment was defined as the process used by surgeons to identify and analyze factors that may negatively impact outcome; (2) expectations and goals described the process of surgeons engaging with patients and families to discuss potential outcomes and desired objectives; (3) external and internal motivating factors outlined extrinsic dynamics (eg, quality metrics, referrals) and intrinsic drivers (eg, surgeons’ personal experiences) that influenced high-risk decision-making; and (4) decision-making approaches and challenges encompassed the roles of patients and surgeons and obstacles to engaging in a true shared decision-making process. ConclusionAlthough shared decision-making is strongly recommended, we found that surgeons who perform high-risk operations among older adults predominantly focused on assessing risk and setting expectations with patients and families rather than inviting them to actively participate in the decision-making process. Surgeons also reported influences on decision-making from quality metrics, referrals, and personal experiences. Patient involvement, however, was seldom discussed suggesting that surgeons may not be engaging in true shared decision-making when benefits should be weighed against a high likelihood of harm.

Impact of left ventricular ejection fraction and preoperative hemoglobin level on perioperative adverse cardiovascular events in noncardiac surgery.

The prediction of a perioperative adverse cardiovascular event (PACE) is an important clinical issue in the medical management of patients undergoing noncardiac surgery. Although several predictors have been reported, simpler and more practical predictors of PACE have been needed. The aim of this study was to investigate the predictors of PACE in noncardiac surgery. We retrospectively analyzed 723 patients who were scheduled for elective noncardiac surgery and underwent preoperative examinations including 12-lead electrocardiography, transthoracic echocardiography, and blood test. PACE was defined as cardiac death, non-fatal myocardial infarction, unstable angina, congestive heart failure, arrhythmia attack that needs emergency treatment (rapid atrial fibrillation, ventricular tachycardia, and bradycardia), acute pulmonary embolism, asystole, pulseless electrical activity, or stroke during 30days after surgery. PACE occurred in 54 (7.5%) of 723 patients. High-risk operation (11% vs. 3%, p = 0.003) was more often seen, left ventricular ejection fraction (LVEF) (55 ± 8% vs. 60 ± 7%, p = 0.001) and preoperative hemoglobin level (11.8 ± 2.2g/dl vs. 12.7 ± 2.0g/dl, p = 0.001) were lower in patients with PACE compared to those without PACE. By multivariate logistic regression analysis, high-risk operation (odds ratio (OR): 7.05, 95% confidence interval (CI) 2.16-23.00, p = 0.001), LVEF (OR 1.06, every 1% decrement, 95% CI 1.03-1.09, p = 0.001), and preoperative hemoglobin level (OR 1.22, every 1g/dl decrement, 95% CI 1.07-1.39, p = 0.003) were identified as independent predictors of PACE. Receiver operating characteristic analysis demonstrated that LVEF of 58% (sensitivity = 80%, specificity = 61%, area under the curve (AUC) = 0.723) and preoperative hemoglobin level of 12.2g/dl (sensitivity = 63%, specificity = 64%, AUC = 0.644) were optimal cut-off values for predicting PACE. High-risk operation, reduced LVEF, and reduced preoperative hemoglobin level were independently associated with PACE in patients undergoing noncardiac surgery.

Enhancing safety in high-risk operations: A multilevel analysis of the role of mindful organising in translating safety climate into individual safety behaviours

Mindful organising is a team level capability that allows teams in high-risk operations to anticipate when something is about to go wrong and quickly act to maintain the stability of the system. The present study aimed to add to our currently limited understanding of the team level conditions that are important for mindful organising to develop as well as broaden our understanding of the impact of mindful organising on individual safety behaviours. To do so, the authors test a multilevel mediation model using data collected from a sample of chemical workers. The model tested whether mindful organising mediates the relationship between team safety climate and individual in-role and extra-role safety behaviour. The findings showed that high levels of priority given to safety over other competing demands in a team is an important prerequisite for mindful organising to develop. The findings also showed that mindful organising leads to increased safety citizenship and compliance with safety protocol.

Preventing Myocardial Injury Following Non-Cardiac Surgery: A Potential Role for Preoperative Antioxidant Therapy with Ubiquinone.

Over 240 million non-cardiac operations occur each year and are associated with a 15–20% incidence of adverse perioperative cardiovascular events. Unfortunately, preoperative therapies that have been useful for chronic ischemic heart diseases, such as coronary artery revascularization, antiplatelet agents, and beta-blockers have failed to improve outcomes. In a pre-clinical swine model of ischemic heart disease, we showed that daily administration of ubiquinone (coenzyme Q10, CoQ10) enhances the antioxidant status of mitochondria within chronically ischemic heart tissue, potentially via a PGC1α-dependent mechanism. In a randomized controlled trial, among high-risk patients undergoing elective vascular surgery, we showed that NT Pro-BNP levels are an important means of risk-stratification during the perioperative period and can be lowered with administration of CoQ10 (400 mg/day) for 3 days prior to surgery. The review provides background information for the role of oxidant stress and inflammation during high-risk operations and the potential novel application of ubiquinone as a preoperative antioxidant therapy that might reduce perioperative adverse cardiovascular outcomes.

Feasibility of re-processing mine tailings to obtain critical raw materials using real options analysis

The re-processing of mine tailings to obtain critical raw materials (CRMs) could reduce the mining of new deposits as well as ensure the profitable use of the waste materials. Though, it requires large scale industrial installations and the development of specialized technologies to obtain CRMs. New investment in mining activities is an operation, engaging for considerable financial resources involved. The scale of such an endeavor makes a new mining activity a high-risk operation due to several uncertainties present. Therefore, there is an acute need to use new tools to assess the risk associated with the planning and development of new mining activities.This study introduces a framework to evaluate the economic risk related to the re-processing of mine tailings to obtain CRMs. The framework, based on real options analysis (ROA), and sensitivity and uncertainty analysis, was applied to analyze the profitability of using mine tailings as a source of CRMs in the Chilean mining industry. The novelty of this approach consists in enabling the investment decision making including the uncertainties related to a novel investment mining project. Resultsshow that tailing storage facilities in Chile have some stocks of CRMs, like scandium, whose extraction could be profitable. For the data used, the results of uncertainty and sensitivity analyses show that capital expenditure has a more significant influence than the other variables. Therefore, for the case of mine tailings re-processing, it is essential to develop processes and technologies that enable lower capital expenses.

Considerations for Laboratory Biosafety and Biosecurity During the Coronavirus Disease 2019 Pandemic: Applying the ISO 35001:2019 Standard and High-Reliability Organizations Principles.

Background: Risk assessment is a critical tool for evaluating emerging pathogens such as severe acute respiratory syndrome coronavirus 2 because of the limited available information about pathogens and the diseases they cause. Industries adopt unique frameworks for risk assessment, for example, the ISO 35001:2019 biorisk management for laboratories and other related organizations provide tools to identify, assess, control, and monitor risks associated with hazardous biological materials. Industries such as aerospace are known as high-reliability organizations (HROs) because these must balance high-risk operations with minimal catastrophic outcomes. HROs focus on five core principles: preoccupation with failure, reluctance to simplify, sensitivity to operations, resilience, and deference to expertise to evaluate and manage risk. Results: In the present discussion, practices described in the ISO 35001 standard and the HRO model are applied to the current challenges faced by laboratories worldwide. Laboratories processing known or unknown coronavirus disease 2019 (COVID-19) samples, testing COVID-19 vaccine candidates, propagating severe acute respiratory syndrome-associated coronavirus-2, or validating diagnostic assays benefit from implementing such practices. Principles extrapolated from the HRO also help illustrate the importance of the end-to-end processes to ensure successful outcomes. Summary: Workplace safety is enhanced by the involvement of all stakeholders, from top leadership to front-line workers. High-quality outcomes as measured by a lack of incidents, accidents, injuries, or near misses are the positive consequences of strictly following standard operating procedures and timely communication of risks and pitfalls. Adopting a systematic framework to identify and manage risks posed by emerging pathogens results in increased workplace safety and higher quality processes and products.

Building demolition risk assessment by applying a hybrid fuzzy FTA and fuzzy CRITIC-TOPSIS framework

PurposeDemolition is a high-risk operation in construction projects that may lead to serious accidents. Risk assessment is a fundamental step in managing demolition risk and preventing casualties and financial losses. The present study aims to provide a framework to identify, analyse and evaluate the risks in building demolition operations.Design/methodology/approachAccording to previous studies and the use of expert knowledge, 10 possible risks of the building demolition operation were identified. Subsequently, these risks were assessed using a combination of fuzzy logic with fault tree analysis (FTA), criteria importance through inter-criteria correlation (CRITIC) and technique for order preference by similarity to ideal solution (TOPSIS). Then, the risks were classified with the help of a risk decision matrix (RDM), and appropriate treatment strategies were presented according to the level of importance of each risk.FindingsConsidering the obtained magnitude for each risk and its rating, building collapse and noise pollution were identified as the most and least significant risks, respectively. The results of this study were in good agreement with the data provided by the Iranian Ministry of Cooperatives, Labour and Social Welfare, as well as obtained results of the previous studies on demolition.Originality/valueThis paper provides a novel framework for assessing the risks in building demolition operations. The findings of this study help demolition project managers to manage the risks in their projects properly.

Open Trans-Catheter Mitral Valve Replacement for Mitral Annular Calcification

Mitral valve replacement in patients with severe mitral annular calcification is a high-risk operation with historically poor outcomes. Percutaneous trans-catheter heart valve (THV) implantation is an alternative therapy to the traditional open surgical approach, but carries significant risks including severe paravalvular leak, left ventricular outflow obstruction, and embolization. To address this, alternative treatment modalities have emerged from the growing experience with THV. Here, we describe an open trans-atrial implantation of a balloon expandable THV. Relative to percutaneous therapies, an open approach permits implanting and expanding the valve under direct visual guidance, with anchoring sutures to precisely position the valve. In comparison to traditional surgical approaches, the risk of left circumflex arterial injury and atrioventricular dissociation is reduced as the annular calcification is left alone and no suture lines are run along the annulus. We illustrate this technique using an Edwards Sapien 3 bioprosthetic valve with an Edwards certitude transthoracic delivery system. Mitral valve replacement in patients with severe mitral annular calcification is a high-risk operation with historically poor outcomes. Percutaneous trans-catheter heart valve (THV) implantation is an alternative therapy to the traditional open surgical approach, but carries significant risks including severe paravalvular leak, left ventricular outflow obstruction, and embolization. To address this, alternative treatment modalities have emerged from the growing experience with THV. Here, we describe an open trans-atrial implantation of a balloon expandable THV. Relative to percutaneous therapies, an open approach permits implanting and expanding the valve under direct visual guidance, with anchoring sutures to precisely position the valve. In comparison to traditional surgical approaches, the risk of left circumflex arterial injury and atrioventricular dissociation is reduced as the annular calcification is left alone and no suture lines are run along the annulus. We illustrate this technique using an Edwards Sapien 3 bioprosthetic valve with an Edwards certitude transthoracic delivery system.

Power-Tool Use in Orthopaedic Surgery: Iatrogenic Injury, Its Detection, and Technological Advances: A Systematic Review.

Background:Power tools are an integral part of orthopaedic surgery but have the capacity to cause iatrogenic injury. With this systematic review, we aimed to investigate the prevalence of iatrogenic injury due to the use of power tools in orthopaedic surgery and to discuss the current methods that can be used to reduce injury.Methods:We performed a systematic review of English-language studies related to power tools and iatrogenic injuries using a keyword search in MEDLINE, Embase, PubMed, and Scopus databases. Exclusion criteria included injuries related to cast-saw use, temperature-induced damage, and complications not clearly related to power-tool use.Results:A total of 3,694 abstracts were retrieved, and 88 studies were included in the final analysis. Few studies and individual case reports looked directly at the prevalence of injury due to power tools. These included 2 studies looking at the frequency of vascular injury during femoral fracture fixation (0.49% and 0.2%), 2 studies investigating the frequency of vertebral artery injury during spinal surgery (0.5% and 0.08%), and 4 studies investigating vascular injury during total joint arthroplasty (1 study involving 138 vascular injuries in 124 patients, 2 studies noting 0.13% and 0.1% incidence, and 1 questionnaire sent electronically to surgeons). There are multiple methods for preventing damage during power-tool use. These include the use of robotics and simulation, specific drill settings, and real-time feedback techniques such as spectroscopy and electromyography.Conclusions:Power tools have the potential to cause iatrogenic injury to surrounding structures during orthopaedic surgery. Fortunately, the published literature suggests that the frequency of iatrogenic injury using orthopaedic power tools is low. There are multiple technologies available to reduce damage using power tools. In high-risk operations, the use of advanced technologies to reduce the chance of iatrogenic injury should be considered.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

COVID-19 smashing the stigma in mental health – a strategic blueprint for change/support

This paper is an update on the article, ‘Smashing the stigma in mental health – a strategic blueprint for change’ (Feringa and Wentzel 2020). The oil and gas industry has endured a significant impact under COVID-19 including economic downturn and growing uncertainty, exposing the effect on human vulnerability. The state of human vulnerability under the pandemic has accelerated mental health from ‘risk’ to ‘critical risk’ in the workplace, particularly in an industry that is underpinned by high-risk operations. Mental health is one of the biggest risks to the oil and gas industry today. The necessary response to this risk is a cohesive, customisable approach that is accessible for organisations to implement, as opposed to the more common experience, which sees a series of individual initiatives put into place in a reactive ad hoc approach.

Benefits of the volume-outcome association in pancreatic cancer surgery depend on patient level risk

Presenter: Sasha Hornock DO | William Beaumont Army Medical Center Background: Research has consistently demonstrated an association between hospital procedural volume and improved perioperative outcomes following high-risk cancer operations. Proponents argue this evidence supports centralization of high-risk surgery. However, concerns exist that centralization may inherently be associated with inequity of care in the US healthcare system. Our objective was to examine patient and hospital-level characteristics of patients undergoing pancreatectomy for cancer at low-, medium- and high-volume hospitals and determine if outcome benefits persist after controlling for differences in patient, administrative and hospital characteristics. Methods: The 2012-2014 Nationwide Inpatient Sample was queried for all patients undergoing pancreatectomy for cancer. Hospitals were stratified by volume proportion based on the annual percentage of hospital discharges for pancreatic surgery. Baseline patient demographics and hospital characteristics were compared. Propensity score matching (PSM) was performed using a generalized boosting model for patient, administrative and hospital-related covariates. Primary outcomes included inpatient mortality, composite morbidity, and length of stay (LOS). Results: 2,748 patients underwent pancreatectomy for cancer. Hospitals with high volumes of pancreatic surgery more commonly treated patients that were white (81% vs 70%) with private insurance (40% vs 31%) and lower Elixhauser Index (EI) comorbidity risk scores (52% vs 37% for EI1) compared to low-volume centers (all p0.05). Though high volume centers do not indicate strong evidence of a reduction in risk of inpatient death (HR 0.40; CI 0.12-1.10; p=0.07), compared to low-volume centers, application of a global model comparison test provides evidence of a statistically significant interaction between the EI and volume that affects mortality (p<0.001), implying that volume effect on mortality depends on patient EI score. Conclusion: Considerable disparities exist among patients treated at high vs low volume centers, with higher-risk and socioeconomically vulnerable patients more commonly treated at lower volume centers. Improvement in inpatient mortality rates appear to be derived from the highest-risk patients receiving treatment at high-volume centers. Development of predictive models to guide selective referrals of high-risk patients to high-volume centers is needed.