Improve Success Rates Research Articles

Surprise is inevitable: How do we train and prepare to make our critical infrastructure more resilient?

While current practices for infrastructure currently follow principles of reliability and risk, these are—by necessity—based on knowledge of past events. They are not suited to adapt infrastructure to dramatic change and/or future surprises. In this paper, we propose a research agenda for the development of novel training exercises that complement current approaches by drawing upon a theory of resilience that emphasizes adaptive response to surprise. We argue that experience with surprise in ‘realistic, yet fictitious’ infrastructure systems simulations can improve the capacity of infrastructure managers to sense, anticipate, adapt to, and learn from surprise in virtual crises gaming scenarios when trainees successfully integrate their experiences from simpler to more complex stages of expertise. Virtual platforms that are shareable and extensible to classroom and operational settings might speed this process of integration of experience, and improve success rates among infrastructure managers confronted with surprise.

A COMPARATIVE STUDY ON HRM POLICIES AND PRACTICES IN NATIONALIZED AND PRIVATE SECTOR BANKS

A study of understanding the aspects which drive Information Technology services start-ups to effectively manage to start up, sustain and grow the business in India is explored in this study. After the initial 2 years of the venture formation, start-up saga continues to the growth stages and understanding the challenges of sustaining and growing the Information Technology Services start-up organizations in India, which has been a major contributor to Indian Exports and GDP growth has been the core research area of this study. The business challenges faced during initial set up years (0-2 years) may vary from business challenges faced during growth years (2-10 years). Research Objectives focus on studying initial years as well as growth years of the Information Technology Services start-ups to understand the similarities, differences in the attributes needed during various lifecycle stages of the organization. The qualitative study addresses understanding the characteristics of success factors in Information technology services start-up and the specific problem in the lack of understanding the various business challenges and reasons behind various aspects that leads to the success or failure of technology start-ups. Key words: Job satisfaction, achievement, training development, HRM an improved success rate for start-ups may help to attract investors, might retain existing jobs. Success Rate may attract many new entrepreneurs to come forward to build on their dream ideas into businesses and contribute more to economic growth through creation of jobs, sustenance of jobs with successful business growth and innovative solutions to the society at large domestically as well as globally. KEYWORDS: Management Challenges, IT Services Startups, Information Technology Services Startups, Start-up Initial Years, Start-up Growth Years, Success Factors

Detecting Blastocyst Components by Artificial Intelligence for Human Embryological Analysis to Improve Success Rate of In Vitro Fertilization.

Morphological attributes of human blastocyst components and their characteristics are highly correlated with the success rate of in vitro fertilization (IVF). Blastocyst component analysis aims to choose the most viable embryos to improve the success rate of IVF. The embryologist evaluates blastocyst viability by manual microscopic assessment of its components, such as zona pellucida (ZP), trophectoderm (TE), blastocoel (BL), and inner cell mass (ICM). With the success of deep learning in the medical diagnosis domain, semantic segmentation has the potential to detect crucial components of human blastocysts for computerized analysis. In this study, a sprint semantic segmentation network (SSS-Net) is proposed to accurately detect blastocyst components for embryological analysis. The proposed method is based on a fully convolutional semantic segmentation scheme that provides the pixel-wise classification of important blastocyst components that help to automatically check the morphologies of these elements. The proposed SSS-Net uses the sprint convolutional block (SCB), which uses asymmetric kernel convolutions in combination with depth-wise separable convolutions to reduce the overall cost of the network. SSS-Net is a shallow architecture with dense feature aggregation, which helps in better segmentation. The proposed SSS-Net consumes a smaller number of trainable parameters (4.04 million) compared to state-of-the-art methods. The SSS-Net was evaluated using a publicly available human blastocyst image dataset for component segmentation. The experimental results confirm that our proposal provides promising segmentation performance with a Jaccard Index of 82.88%, 77.40%, 88.39%, 84.94%, and 96.03% for ZP, TE, BL, ICM, and background, with residual connectivity, respectively. It is also provides a Jaccard Index of 84.51%, 78.15%, 88.68%, 84.50%, and 95.82% for ZP, TE, BL, ICM, and background, with dense connectivity, respectively. The proposed SSS-Net is providing a mean Jaccard Index (Mean JI) of 85.93% and 86.34% with residual and dense connectivity, respectively; this shows effective segmentation of blastocyst components for embryological analysis.

Systematic review and meta-analysis of arterial embolization compared with traditional management on outcomes of traumatic massive facial haemorrhage.

Maxillofacial trauma accounts for ~10% of trauma presentations to most centres, with massive haemorrhage occurring in 1.2-4.5% of cases. Despite its infrequent presentation, there is significant associated morbidity and mortality. Transcatheter arterial embolization (TAE) is playing an increasingly prominent role in trauma presentations. The aim of this article was to compare outcomes of TAE with more traditional management methods for the treatment of massive facial haemorrhage following maxillofacial trauma. A database and Google Scholar search was performed, with articles discussing massive facial haemorrhage secondary to maxillofacial trauma and its management included. Twenty-seven articles were found that met inclusion criteria, encompassing 384 patients. Statistical testing comparing mortality between TAE and non-TAE groups did not find a significant difference, with a mortality rate of 30.2% in the TAE group and 38.9% in the non-TAE group. Assessment of morbidity directly related to interventions was difficult, as many of the included participants had significant associated injuries which contributed an indeterminate degree to morbidity. There was a 10% rate of adverse events associated with TAE, most commonly puncture site haematomas and soft tissue swelling, with more significant adverse events including cerebrovascular accidents and blindness. Embolization was correlated with increased rates of haemorrhage control when compared with other interventions. Overall, despite no significant impact on mortality, embolization is recommended in the management of massive haemorrhage following maxillofacial trauma due to improved success rates at haemorrhage control and a low rate of significant adverse events.

Supraclavicular Brachial Plexus Block by Nerve Stimulator or Ultrasound: An Observational Cross-sectional Study

Introduction: Supraclavicular approach to the brachial plexus block is considered to be one of the most effective anaesthetic procedures for upper limb surgeries. Peripheral Nerve Stimulation (PNS) has traditionally been used as the gold standard technique for nerve location. More recently, Ultrasound (USG)-guided single injection supraclavicular block is used which allows direct visualisation of nerve, but its use is limited by cost constraints and the level of expertise needed. Aim: To compare the efficacy of USG and PNS in supraclavicular brachial plexus block especially the onset of motor block in orthopaedic forearm surgeries. Materials and Methods: An observational cross-sectional analytical study was conducted from January 2019 to January 2020 on 60 patients attending emergency operation theatre for orthopaedic forearm surgeries. They were allocated alternatively to one of the two groups (30 in each group) based on the technique of nerve block, either using USG or PNS. Block execution time (puncture time), the number of needle passes, time of onset of sensory block, time of onset of motor block, quality of sensory block, quality of motor block, the intraoperative requirement of opioids, complications, success, and failure were the exposure variables. The qualitative data were compared using Chi-square test and for comparison of the continuous variable, the student’s t-test and Fisher’s exact test were used. The p-value<0.05 was considered statistically significant. Results: Patients in both groups were comparable concerning demographic parameters like age, sex, and American Society of Anaesthesiologists (ASA) physical status. The mean time of onset of a motor block using the USG-guided technique was 8.6±1.0 minutes, and using a PNS was 11.1±1.0 minutes (p-value<0.01). There was a 93.3% success rate in the USG- guided technique, compared to an 83.3% success rate in the PNS method (p-value of 0.222). No complications were seen in the USG-guided group. In the PNS-guided group, four complications were noted among 30 patients, the most common being vascular puncture (2 cases). Conclusion: USG-guided supraclavicular block was superior to PNS technique in terms of rapid onset motor and sensory block, block quality, improved success rate, and fewer complications.

Deep anterior lamellar keratoplasty for keratoconus

Advanced keratoconus may require keratoplasty when the patient can no longer achieve functional vision with glasses and contact lenses. Deep anterior lamellar keratoplasty (DALK) has become the surgical treatment of choice due to its undisputed advantages over penetrating keratoplasty including the reduced risk of intraoperative complications, the absence of endothelial immune rejection, and the longer graft survival. Albeit “big-bubble” DALK still represents the most popular surgical method, several modifications have been developed over the years. This allowed standardization of the technique, with improved success rates and clinical outcomes. This review presents an overview on the literature on DALK surgery for keratoconus. We discuss state-of-the art surgical techniques, current evidence on the clinical outcomes and complications as well as possible future directions.

Enhanced Periodontal Debridement with Periodontal Endoscopy (Perioscopy) for Diagnosis and Treatment in Periodontal Therapy

The perioscope, which was only recently introduced, has greatly improved the removal of subgingval calculus during periodontal therapy. A fibre-optic periodontal endoscope was created to aid in the imaging of subgingival tissues and to improve periodontal disease diagnosis and treatment. Scaling and root planing have the goal of completely removing plaque and calculus from root surfaces. While this is unachievable, the agreed end-point during periodontal instrumentation is a smooth, glassy root surface. This has frequently led in over instrumentation and excessive cementum removal. Cement removal has been judged unnecessary in most cases. The removal of plaque, calculus, and endotoxin adhered to the root surface is critical. The easiest way to clean root surfaces is to use powered instruments sparingly. Due to a lack of visibility, excessive cementum removal occurs during hand instrumentation. The ability to visibly debride roots using endoscopic technology can improve success rates in a more conservative and minimally invasive manner. The perioscopy device was created to visualise the subgingival region for diagnosis, but it has since been altered to help with periodontitis therapy. The perioscope is a small camera that is encased in a sleeve and inserted under the gingival sulcus or pocket for subgingivally visualisation and instrumentation. This technique gives the greatest conservative approach to non surgical and surgical periodontal care because it enables superb magnified visualisation of the root surface and ensures the total or near complete elimination of the bacterial infection. The aim of this brief review was to provide knowledge about periodontal endoscopy, its implementation in day today practice.

Single-phase Scan Using Trapezoidal Cross-injection Method in 3D-CT before Pulmonary Segmentectomy

We performed three-dimensional computed tomography (3D-CT) with pulmonary artery (PA) and pulmonary vein (PV) segmentation for image support in patients undergoing pulmonary segmentectomy. Automatic segmentation of PA and PV is possible with single-phase scan by the use of SYNAPSE VINCENT (Fujifilm) image integration module. However, there are limitations to this automatic segmentation with many cases of segmentation errors and failures. Therefore, we examined the CT value and automatic extraction of PA and PV using a contrast-enhanced protocol in which the chest is included in the imaging range. As a result of a retrospective study, a new protocol using the trapezoidal cross-injection method in which the CT value of PA and PV is 200 Hounsfield unit (HU) or more and the CT value difference of PA and PV is 50 HU or more is desirable. The amount of contrast used was decreased to about 60% with the new protocol. CT value and difference in density were enough for imaging the PA and PV. The automatic image integration with SYNAPSE VINCENT had tendency for improved success rate with the new protocol, suggesting the usefulness of the new protocol.

Endoscopic management of recurrent tracheoesophageal fistula with trichloroacetic acid in pediatric patients.

Surgical repair of recurrent tracheoesophageal fistula has a high risk of complications. Therefore, various endoscopic techniques have been used to avoid complications. To understand the usefulness of trichloroacetic acid endoscopic application for the treatment of recurrent tracheoesophageal fistula. An observational, descriptive, retrospective, case-series-based study was carried out in a tertiary pediatric hospital. Records of patients with recurrent tracheoesophageal fistula from 2015 to 2021 were reviewed. All patients within this period underwent brushing and trichloroacetic acid application. Mean time of recurrent tracheoesophageal fistula occurrence was 4.8 months (range: 1-19.2). Two patients had a small fistula (less than 4 mm), three patients had a medium fistula (4 mm), and two patients had a large fistula (more than 4 mm). Mean sessions for fistula closure were 2.2 (range: 1-4). Mean time between procedures was 22 days (range: 14-30). Mean follow-up since fistula closure confirmation was 33 months (range: 9-72), during which no recurrences were noted. Endoscopic management of recurrent transesophageal fistula with trichloroacetic acid is a safe and effective procedure. Brushing and trichloroacetic acid combined improve success rates. Fistulas over 4 mm in diameter require more procedures. However, a larger patient cohort and a longer follow-up period are needed to confirm this.

Silk-Based Bioengineered Diaphyseal Cortical Bone Unit Enclosing an Implantable Bone Marrow toward Atrophic Nonunion Grafting.

Postnatal fracture healing of atrophic long bone diaphyseal nonunions remains a challenge for orthopedic surgeons. Paucity of autologous spongiosa has potentiated the use of tissue engineered bone grafts to improve success rates of bone marrow engraftment used in plate reosteosynthesis. Herein, the development and in vitro validation of a "sandwich-type" biofabricated diaphyseal cross-sectional unit, with an outer mechanically robust bioprinted cortical bone shell, encompassing an engineered bone marrow, are reported. Channelized silk fibroin blend sponges derived from Bombyx mori and Antheraea assama help in developing compartmentalized endosteum, exhibiting specialized osteoblasts (endosteal niche) and discontinuous endothelium (vascular niche). The cellular cross-talk between these two niches triggered via integrin-mediated cell adhesion, enables in preserving quiescence state of CD34+ /CD38- hematopoietic stem cells and their recycling in the engineered marrow. The outer cortical bone strut is developed through multimaterial microextrusion bioprinting strategy. Osteogenically primed mesenchymal stem cells-laden silk fibroin-nano-hydroxyapatite bioink is bioprinted alongside paramagnetic Fe-doped bioactive glass-polycaprolactone blend thermoplastic ink, reinforcing it for mechanical stability. Pulsed magnetic field actuation positively influences the osteogenic commitment and maturation of the bioprinted constructs via mechanotransductory route. Therefore, the assembled engineered marrow and bioprinted cortical shell hold promise as potential orthobiologic substitutes toward atrophic nonunion repairs.

High-flow nasal cannula therapy, factors affecting effective inspired oxygen fraction: an experimental adult bench model

Oxygenation through High Flow Delivery Systems (HFO) is described as capable of delivering accurate FiO2. Meanwhile, peak inspiratory flow dot{V}_{{text{I}}} ) of patients with acute hypoxemic respiratory failure can reach up to 120 L/min, largely exceeding HFO flow. Currently, very few data on the reliability of HFO devices at these high dot{V}_{{text{I}}} are available. We sought to evaluate factors affecting oxygenation while using HFO systems at high dot{V}_{{text{I}}} in a bench study. Spontaneous breathing was generated with a mechanical test lung connected to a mechanical ventilator Servo-i®, set to volume control mode. Gas flow from a HFO device was delivered to the test lung. The influence on effective inspired oxygen fraction of three parameters (FiO2 0.6, 0.8, and 1, dot{V}_{{text{I}}} from 28 to 98.1 L/min, and HFO Gas Flows from 40 to 60 L/min) were analyzed and are reported. The present bench study demonstrates that during HFO treatment, measured FiO2 in the lung does not equal set FiO2 on the device. The substance of this variation (ΔFiO2) is tightly correlated to dot{V}_{{text{I}}} (Pearson’s coefficient of 0.94, p-value < 0.001). Additionally, set FiO2 and Flow at HFO device appear to significatively affect ΔFiO2 as well (p-values < 0.001, adjusted to dot{V}_{{text{I}}} ). The result of multivariate linear regression indicates predictors (dot{V}_{{text{I}}} , Flow and set FiO2) to explain 92% of the variance of delta FiO2 through K-Fold Cross Validation. Moreover, adjunction of a dead space in the breathing circuit significantly decreased ΔFiO2 (p < 0.01). The present bench study did expose a weakness of HFO devices in reliability of delivering accurate FIO2 at high dot{V}_{{text{I}}} as well as, to a lesser extent, at dot{V}_{{text{I}}} below equivalent set HFO Flows. Moreover, set HFO flow and set FIO2 did influence the variability of effective inspired oxygen fraction. The adjunction of a dead space in the experimental set-up significantly amended this variability and should thus be further studied in order to improve success rate of HFO therapy.

Modified long-axis in-plane ultrasound-guided radial artery cannulation in adult patients: A randomized controlled trial

IntroductionFor adults with small radial arteries, ultrasound-guided radial artery cannulation remains challenging and the relevant data is currently lacking. The study aimed to test the hypothesis that modified long-axis in-plane ultrasound guidance (M-LAIP) would improve success rates of radial artery cannulation in this population. Patients and methodsThis was a prospective, randomised, and controlled clinical study that enrolled 201 adult patients with diameters of the radial artery less than 2.2 mm. Patients were randomised to M-LAIP, short-axis out-of-plane (SAOP), or conventional palpation (C-P) group according to different approaches of radial artery cannulation (M-LAIP, SAOP, and C-P). Outcome measurements included the success rate, cannulation time, and cannulation-related adverse events. ResultsThe cannulation success rate was significantly higher in the M-LAIP group than in the SAOP or C-P groups (first success rate: 80.3% vs. 53.8% or 33.8%; P < 0.001; total success rate: 93.9% vs. 78.5% or 50.8%; P < 0.001). Total cannulation time in the M-LAIP group was shorter than that in the SAOP group (P = 0.002) or the C-P group (P < 0.001). The rates of posterior wall puncture and haematoma in the M-LAIP group were lower than that in the SAOP group or C-P group (P < 0.008). ConclusionThe use of the M-LAIP approach significantly improved the success rate of radial artery cannulation, shortened procedure time, and lowered the rates of posterior wall puncture and haematoma in adults with radial artery diameters less than 2.2 mm, compared with that achieved by the SAOP or C-P approach.

Generating Predictable and Adaptive Dialog Policies in Single- and Multi-domain Goal-oriented Dialog Systems

Most existing commercial goal-oriented chatbots are diagram-based; i.e. they follow a rigid dialog flow to fill the slot values needed to achieve a user’s goal. Diagram-based chatbots are predictable, thus their adoption in commercial settings; however, their lack of flexibility may cause many users to leave the conversation before achieving their goal. On the other hand, state-of-the-art research chatbots use Reinforcement Learning (RL) to generate flexible dialog policies. However, such chatbots can be unpredictable, may violate the intended business constraints, and require large training datasets to produce a mature policy. We propose a framework that achieves a middle ground between the diagram-based and RL-based chatbots: we constrain the space of possible chatbot responses using a novel structure, the chatbot dependency graph, and use RL to dynamically select the best valid responses. Dependency graphs are directed graphs that conveniently express a chatbot’s logic by defining the dependencies among slots: all valid dialog flows are encapsulated in one dependency graph. Our experiments in both single-domain and multi-domain settings show that our framework quickly adapts to user characteristics and achieves up to 23.77% improved success rate compared to a state-of-the-art RL model.

Improving IUI success by performing modified slow-release insemination and a patient-centred approach in an insemination programme with partner semen: a prospective cohort study.

Pregnancy rates after in vitro fertilisation (IVF) treatment continue to improve, while intrauterine insemination (IUI) programmes show no such trend. There is a need to improve success rates with IUI to retain it as a viable option for couples who prefer avoiding IVF as a first line treatment. To investigate if a modified slow-release insemination (SRI) increases the clinical pregnancy rate (CPR) after intrauterine insemination (IUI) with partner semen. This was a prospective cohort study in a Belgian tertiary fertility centre. Between July 2011 and December 2018, we studied data from an ongoing prospective cohort study including 989 women undergoing 2565 IUI procedures for unexplained or mild/moderate male infertility. These data were analysed in order to study the importance of different covariates influencing IUI success. Generalised estimating equations (GEEs) were used for statistical analysis. Results of two periods (2011-2015, period 1 and 2016-2018, period 2) were examined and compared. From January 2016 (period 2) onwards, a standardised SRI procedure instead of bolus injection of sperm was applied. The primary outcome parameter was the difference in clinical pregnancy rate (CPR) per cycle between period 1 (bolus IUI) and period 2 (modified SRI). Secondary outcome results included all other parameters significantly influencing CPR after IUI. Following the application of modified SRI the CPR increased significantly, from 9.03% (period 1) to 13.52% (period 2) (p = 0.0016). Other covariates significantly influencing CPR were partner's age, smoking/non-smoking partner, BMI patient, ovarian stimulation protocol and Inseminating Motile Count (after semen processing). Conclusions: The intentional application of modified slow-release of processed semen appears to significantly increase CPRs after IUI with homologous semen. Future studies should investigate whether SRI, patient-centred measures, or a combination of both, are responsible for this improvement.

Abstract 6943: Ablation Index-guided Pulmonary Vein Isolation Improve Performance and Safety of Treatment of Atrial Fibrillation

Introduction: Pulmonary vein isolation (PVI) is a pivotal therapy for treatment of atrial fibrillation (AF), especially paroxysmal AF. Previous studies suggest that ablation index (AI) which integrated contact force (CF), time and power in a weighted formula improved success rate and safety of PVI. Hypothesis: Recently, our group has raised a novel protocol of AI-guided AF ablation according to different wall thickness of left atrium and compared the performance and safety of VisiTag ablation with or without this AI strategy. Methods: In this retrospectively study, AI parameters were set as 300-380U, 400-450U, 380-400U, 380-400U and 450-500U for posterior, anterior, inferior, roof and ridge respectively ( Figure 1 ). Radiofrequency energy was delivered at a maximum power output of 25-35 W depending on the ablation site (25-30W for the posterior aspects of the right and left PVs and 30-35 W for the anterior, inferior, Roof and ridge aspects). Results: No significant difference of patient characteristics was observed in VisiTag+AI group versus VisiTag group. One year after the procedure, the overall success rate was higher in VisiTag+AI group as compared to VisiTag group without differentiation of paroxysmal AF and persistent AF (95.1% vs. 83.3%, P=0.02). In subgroup analysis, the 1-year success rate in paroxysmal AF patients were 95.5% versus 82.5% in VisiTag+AI group versus VisiTag group (P=0.03), whereas the 1-year success rate in persistent AF patients were 93.3% versus 84.6% in VisiTag+AI group versus VisiTag group (P=0.40).Only one case of minor pericardial effusion without additional management was observed in VisiTag+AI group, whereas two cases of minor pericardial effusion and one case of pericardial tamponade were observed in VisiTag group during perioperative care. Conclusions: Improved performance and safety was observed in VisiTag ablation with this novel AI strategy in paroxysmal AF patients.

His-Purkinje conduction system pacing: A systematic review and network meta-analysis in bradycardia and conduction disorders.

His-Purkinje conduction system pacing (HPCSP) has emerged as an effective alternative to overcome the limitations of right ventricular pacing (RVP) via physiological left ventricular activation, but there remains a paucity of comparative information for His bundle pacing (HBP) and left bundle branch pacing (LBBP). A Bayesian random-effects network analysis was conducted to compare the relative effects of HBP, LBBP, and RVP in patients with bradycardia and conduction disorders. PubMed, Embase, Cochrane Library, and Web of Science were systematically searched from database inception until September 21, 2021. Twenty-eight studies involving 4160 patients were included in this meta-analysis. LBBP significantly improved success rate, pacing threshold, pacing impedance, and R-wave amplitude compared with HBP. LBBP also demonstrated a nonsignificant trend towards superior outcomes of lead complications, heart failure hospitalization, atrial fibrillation, and all-cause death. However, HBP was associated with significantly shorter paced QRS duration relative to LBBP. Despite higher success rates, shorter procedure/fluoroscopy duration, and fewer lead complications, patients receiving RVP were more likely to experience reduced left ventricular ejection fraction, longer paced QRS duration, and higher rates of heart failure hospitalization than those receiving HPCSP. No statistical differences were observed in the remaining outcome measures. This network meta-analysis demonstrates the efficacy and safety of HPCSP for the treatment of bradycardia and conduction disorders, with differences in pacing parameters, electrophysiology characteristics, and clinical outcomes between HBP and LBBP. Larger-scale, long-term comparative studies are warranted for further verification.

Intraoperative ultrasound imaging and sono-scintigraphic concordance improves success rates of minimally invasive parathyroidectomy

This study aimed to evaluate the effect of sono-scintigraphic correlation on the success of minimal invasive parathyroidectomy (MIP) via surgeon performed continuous intraoperative sonographic guidance in patients operated for primary hyperparathyroidism (PHPT) without intact parathormone (PTH) measurement. A retrospective analysis of a prospective database was conducted to review patients who underwent MIP (July 2017-October 2019). The screened parameters were preoperative PTH level, preoperative ultrasonography (US), preoperative scintigraphy, intraoperative US, intraoperative frozen section analysis, postoperative PTH level, and permanent pathology rep ort. Intraoperative intact PTH measurement was not employed due to institutional policy. Preoperative US alone localized the specific side (right/left, inferior/superior) of abnormality in 54 out of 74 (72.97%) cases. Scintigraphy alone localized the specific side in 58 (78.37%) cases. The sensitivity of preoperative US and scintigraphy alone was 76.05% and 86.56%, respectively. Sono-scintigraphic discordance was present in 6 cases (8.1%) and intraoperative real-time US predicted accurate localization of adenoma in 4 (66.6%) and scintigraphy in 2 (44.4%) patients. The frozen section analysis confirmed parathyroid cells in all cases evaluated. Sono-scintigraphic concordance with intraoperative real-time imaging increases surgical success rates in cases where MIP is planned under the circumstances of limited resources regarding unavailability of intact PTH measurement.

Guillotine Amputation Prior to Major Amputation Decreases Infectious Complications and Long-term Amputation Failure in Lower Extremity Chronic Wound Patients

PURPOSE: Chronic wounds of the lower extremity (LE) are often complicated by infection. Definitive treatment of wounds resistant to conservative management often entails major amputation and/or reconstruction. For severely infected chronic wounds, a guillotine amputation performed before definitive amputation can help control infection and maximize success of subsequent major amputation. A recent study demonstrated that this two-stage approach may decrease short-term complications; however long-term outcomes are yet to be evaluated.1 This study aims to assess the effect of guillotine amputation on rates of long-term success of major amputation. METHODS: A retrospective review of all major LE amputations performed between January 2017 and July 2020 at our tertiary wound center was conducted. Major amputation was performed in the setting of chronic and/or infected LE wounds that were not amenable to limb salvage. Patients who were lost to follow up or who expired during the study period, as well as patients undergoing amputation for trauma, chronic pain, a non-infected limb deformity, or cancer, were excluded. Patient characteristics, preoperative labs, and amputation data were collected. Postoperative complications assessed included rates of hematoma, dehiscence, infection, and infection requiring takeback to the operating room. Other outcomes of interest included stump revision, time to complete healing, and amputation failure, which was defined as failure to heal or need for more proximal amputation. Patients were separated into guillotine and no guillotine amputation groups. Statistical analysis was performed to compare patient characteristics and amputation outcomes between groups. Student t-test and Mann-Whitney U-test were used to analyze continuous variable while Chi-square test and Fisher exact test were used to analyze binary variables, as appropriate. RESULTS: An estimated 193 patients meeting inclusion criteria were identified: 54 did not undergo guillotine amputation; 139 underwent guillotine amputation before definitive major amputation. Demographics, comorbidities, relevant preoperative laboratories, and amputation location were not statistically different between the two groups. Rates of hematoma and dehiscence were similar between groups; however, the guillotine group had significantly decreased rates of infection (7.19% versus 22.22%, P = 0.003), infection requiring takeback to operating room (4.32% versus 20.37%, P < 0.001), stump revision (2.88% versus 10.91%, P = 0.032), and amputation failure (4.32% versus 12.73%, P = 0.035) compared with the no guillotine group. Time to healing for successful amputations (2.76 versus 2.32 months, P = 0.925) and follow-up (15.07 versus 14.33 months, P = 0.445) were similar between groups. CONCLUSIONS: The results of this study suggest that guillotine amputation prior to definitive major amputation play a significant role in limiting the spread of infection, resulting in decreased infectious complications and improved success rates following major amputation, compared with single-stage major amputations. A two-stage approach is also advantageous in decreasing the need to return to the operating room for infection or stump revision. Guillotine amputations should be considered in the setting of infected chronic lower extremity wounds to improve long-term patient outcomes. REFERENCE: 1. Cheun TJ, Jayakumar L, Sideman MJ, et al. Short-term contemporary outcomes for staged versus primary lower limb amputation in diabetic foot disease. J Vascular Surgery. 2020;72:658–666.e2. doi:10.1016/j.jvs.2019.10.083

Super-Resolution Cine Image Enhancement for Fetal Cardiac Magnetic Resonance Imaging.

Fetal cardiac magnetic resonance imaging (MRI) improves the diagnosis of congenital heart defects, but is sensitive to fetal motion due to long image acquisition time. This may be overcome with faster image acquisition with low resolution, followed by image enhancement to provide clinically useful images. To combine phase-encoding undersampling with super-resolution neural networks to achieve high-resolution fetal cine cardiac MR images with short acquisition time. Prospective. Twenty-eight fetuses (gestational week 36 [interquartile range 33-38 weeks]). 1.5 T, balanced steady-state free precession (bSSFP) cine sequence. Images were acquired using fully sampled Doppler ultrasound-gated clinical bSSFP cine as reference, with equivalent cine sequences with decreased phase-encoding resolution (25%, 33%, and 50% of clinical standard). Two super-resolution methods based on convolutional neural networks were proposed and evaluated (phasrGAN and phasrresnet). Data were partitioned into training (36 cine slices), validation (3 cine slices), and test sets (67 cine slices) without overlap. Conventional reconstruction methods using bicubic interpolation and k-space zeropadding were used for comparison. Three blinded observers scored image quality between 1 and 10. Image scores are reported as median [interquartile range] and were compared using Mann-Whitney's nonparametric test with P < 0.05 showing statistically significant differences. Both proposed methods showed no significant difference in image quality compared to clinical images (8 [7-8.5]) down to 33% (phasrGAN 8 [6.5-8]; phasrresnet 8 [7-8], all P ≥ 0.19) phase-encoding resolution, i.e., up to three times faster image acquisition, whereas bicubic interpolation and k-space zeropadding showed significantly lower quality for 33% phase-encoding resolution (both 7 [6-8]). Super-resolution enhancement can be used for fetal cine cardiac MRI to reduce image acquisition time while maintaining image quality. This may lead to an improved success rate for fetal cine MR imaging, as the impact of fetal motion is lessened by shortened acquisitions. 1 TECHNICAL EFFICACY: Stage 2.

Decreasing Incisional Hernia by Teaching 4:1 Suture to Wound Length Ratio Early in Surgical Education

Incisional hernia formation has become a major burden for our healthcare system. One factor that has been shown to reduce incisional hernia rates that can be impacted on by the surgeon is the ability to achieve a 4:1 suture to wound length ratio. The purpose of this study is to evaluate whether a focused educational program for surgical residents can help improve laparotomy closures and be successful in achieving 4:1 suture to wound length ratios. Following Institutional Review Board approval, consecutive abdominal wall closures were reviewed from December 2013 to July 2016. S:W length ratios were calculated in all cases and after 100 cases a formal audit of success and risk factors for not achieving a 4:1 ratio was performed followed by a formal resident education on laparotomy closure. The ability to achieve a 4:1 ratio for the first 100 cases following resident education was then compared to the 100 patients preceding the education with a p-value of <0.05 considered significant. Two hundred patients underwent midline laparotomy with S:W length ratio calculated. In the first 100 patients, 76% of patients received a 4:1 S:W closure. Following resident education, this improved to 90% in the second 100 patients (p = 0.0083). Among patients where 2 residents performed the abdominal closure, 50% got an adequate 4:1 closure. This improved to 92% for the second 100 patients (p = 0.016). A 4:1 S:W length ratio is a simple technique that has been proven to decrease incisional hernia. It requires no additional cost and can easily be implemented into practice. The act of formal resident education and measuring suture tails to calculate a S:W ratio on each case holds surgeons accountable and improves success rate of achieving a 4:1 ratio.