Patient Positioning Research Articles

Validation of a deep-learning segmentation model for adult and pediatric head and neck radiotherapy in different patient positions

Background and purposeAutocontouring for radiotherapy has the potential to significantly save time and reduce interobserver variability. We aimed to assess the performance of a commercial autocontouring model for head and neck (H&N) patients in eight orientations relevant to particle therapy with fixed beam lines, focusing on validation and implementation for routine clinical use. Materials and methodsAutocontouring was performed on sixteen organs at risk (OARs) for 98 adult and pediatric patients with 137 H&N CT scans in eight orientations. A geometric comparison of the autocontours and manual segmentations was performed using the Hausdorff Distance 95th percentile, Dice Similarity Coefficient (DSC) and surface DSC and compared to interobserver variability where available. Additional qualitative scoring and dose-volume-histogram (DVH) parameters analyses were performed for twenty patients in two positions, consisting of scoring on a 0–3 scale based on clinical usability and comparing the mean (Dmean) and near-maximum (D2%) dose, respectively. ResultsFor the geometric analysis, the model performance in head-first-supine straight and hyperextended orientations was in the same range as the interobserver variability. HD95, DSC and surface DSC was heterogeneous in other orientations. No significant geometric differences were found between pediatric and adult autocontours. The qualitative scoring yielded a median score of ≥ 2 for 13/16 OARs while 7/32 DVH parameters were significantly different. ConclusionsFor head-first-supine straight and hyperextended scans, we found that 13/16 OAR autocontours were suited for use in daily clinical practice and subsequently implemented. Further development is needed for other patient orientations before implementation.

Deep learning-based tools to distinguish plan-specific from generic deviations in EPID-based in vivo dosimetry.

Dose distributions calculated with electronic portal imaging device (EPID)-based in vivo dosimetry (EIVD) differ from planned dose distributions due to generic and plan-specific deviations. Generic deviations are characteristic to a class of plans. Examples include limitations in EIVD dose reconstruction, inaccuracies in treatment planning system (TPS) calculations and systematic machine deviations. Plan-specific deviations have an unpredictable character. Examples include discrepancies between the patient model used for dose calculation and the patient position or anatomy during delivery, random machine deviations, and data transfer, human or software errors. During the inspection work performed with traditional γ-evaluation statistical methods: (i) generic deviations raise alerts that need to be inspected but that rarely lead to action as their root cause is usually understood and (ii) the detection of relevant plan-specific deviations may be hindered by the presence of generic deviations. To investigate whether deep learning-based tools can help in identifying γ-alerts raised by generic deviations and in improving the detectability of plan-specific deviations. A 3D U-Net was trained as an autoencoder to reconstruct underlying patterns of generic deviations in γ-distributions. The network was trained for four treatment disease sites differently affected by generic deviations: volumetric modulated arc therapy (VMAT) lung (no known deviations), VMAT prostate (TPS inaccuracies), VMAT head-and-neck (EIVD limitations) and intensity modulated radiation therapy (IMRT) breast (large EIVD limitations). The network was trained with virtual non-transit γ-distributions: 60 train/10 validation for the VMAT sites and 30 train/10 validation for IMRT breast. It was hypothesized that in vivo γ-distributions obtained in the presence of plan-specific deviations would differ from those seen during training. For each disease site, the sensitivity of γ-analysis and the network to detect (synthetically introduced) patient-related deviations was compared by receiver operator characteristic analysis. The investigated deviations were patient positioning errors, weight gain or loss, and tumor volume changes. The clinical relevance was illustrated qualitatively with 793 in vivo clinical cases (141 lung, 136 head-and-neck, 209 prostate and 307 breast). Error detectability of patient-related deviations was better with the network than with γ-analysis. The average area under the curve values over all sites were 0.86±0.12(1SD) and 0.69±0.25(1SD), respectively. Regarding in vivo clinical results, the percentage of cases differently classified by γ-analysis and the network was 1%, 19%, 18% and 64% for lung, head-and-neck, prostate, and breast, respectively. In head-and-neck and breast cases, 45 γ-only alerts were examined, of which 43 were attributed to EPID dose reconstruction limitations. For prostate, all 15 investigated γ-only alerts were due to known TPS inaccuracies. All 59 investigated network alerts were explained by either patient-related deviations or EPID acquisition incidents. Some patient-related deviations detected by the network were not detected by γ-analysis. Deep learning-based tools trained to reconstruct underlying patterns of generic deviations in γ-distributions can be used to (i) automatically identify false positives within the set of γ-alerts and (ii) improve the detection of plan-specific deviations, hence minimizing the likelihood of false negatives. The presented method provides clear additional value to the γ-alert management process for large scale EIVD systems.

Impact of standardising indocyanine green fluorescence angiography technique for visual and quantitative interpretation on interuser variability in colorectal surgery.

Intra-operative colonic perfusion assessment via indocyanine green fluorescence angiography (ICGFA) aims to address malperfusion-related anastomotic complications; however, its interpretation suffers interuser variability (IUV), especially early in ICGFA experience. This work assesses the impact of a protocol developed for both operator-based judgement and computational development on interpretation consistency, focusing on senior surgeons yet to start using ICGFA. Experienced and junior gastrointestinal surgeons were invited to complete an ICGFA-experience questionnaire. They subsequently interpreted nine operative ICGFA videos regarding perfusion sufficiency of a surgically prepared distal colon during laparoscopic anterior resection by indicating their preferred site of proximal transection using an online annotation platform (mindstamp.com). Six ICGFA videos had been prepared with a clinical standardisation protocol controlling camera and patient positioning of which three each had monochrome near infrared (NIR) and overlay display. Three others were non-standardised controls with synchronous NIR and overlay picture-in-picture display. Differences in transection level between different cohorts were assessed for intraclass correlation coefficient (ICC) via ImageJ and IBM SPSS. 58 clinicians (12 ICGFA experts, 46 ICGFA inexperienced of whom 23 were either finished or within one year of finishing training and 23 were junior trainees) participated as per power calculations. 63% felt that ICGFA should be routinely deployed with 57% believing interpretative competence requires 11-50 cases. Transection level concordance was generally good (ICC = 0.869) across all videos and levels of expertise (0.833-0.915). However, poor agreement was evident with the standardised protocol videos for overlay presentation (0.208-0.345). Similarly, poor agreement was seen for the monochrome display (0.392-0.517), except for those who were trained but ICG inexperienced (0.877) although even here agreement was less than with unstandardised videos (0.943). Colorectal ICGFA acquisition and display standardisation impacts IUV with this specific protocol tending to diminish surgeon interpretation consistency. ICGFA video recording for computational development may require dedicated protocols.

Real-Time Camera Image-Guided Nasoenteric Tube Placement in Prone COVID-19 ICU Patients: A Single-Center Study.

Background & Aims: This study aims to assess the application value of the real-time camera image-guided nasoenteric tube placement in critically ill COVID-19 patients undergoing endotracheal intubation and prone position ventilation therapy. Methods: We enrolled 116 COVID-19 patients receiving endotracheal intubation and prone position ventilation therapy in the intensive care unit (ICU). Patients were randomly divided into the real-time camera image-guided nasoenteric tube placement (n = 58) and bedside blind insertion (n = 58) groups. The success rate, placement time, complications, cost, heart rate, respiratory rate, Glasgow Coma Scale (GCS), and Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores were compared between the 2 groups. Results: For ICU patients with COVID-19 undergoing prone position ventilation therapy, the success rate and cost were significantly higher in the real-time camera image-guided group compared to the bedside blind group (P < .05). The placement time and complication incidence were significantly lower in the real-time camera image-guided group (P < .05). The differences in heart rate, respiratory rate, GCS scores, and APACHE-II scores were insignificant (P > .05). Conclusions: The real-time camera image-guided nasoenteric tube placement system had advantages for ICU COVID-19 patients undergoing prone position ventilation therapy, including a high success rate, short placement time, and no impact on patient position during tube placement. Real-time camera image-guided nasoenteric tube placement can be performed in any position, and demonstrates high efficiency, safety, and accuracy.

“3D surface scanner in Maxillofacial Surgery: State of the art.”

Physicians are used to having complementary studies that help us in all phases of our work. In the maxillofacial surgery field the most commonly used tests are radiological tests (CT and NMR) and digital clinical photographs.In recent years, the concept of 3D surgery has been developed and consists of the use of 3D technology applied to surgery. 3D surgery allows us to move from on-site planning of the surgery to pre-surgical planning, with a simulation and preview of the result at the bone and soft tissue level.Radiological studies are of very limited use in soft tissue planning and digital photography is two-dimensional and dependent on patient positioning. The use of the surface scanner solves these limitations as it computes the spatial coordinates of the patient's anatomical surface in order to create a 3D digital model.

Measurement of tibial slope using biplanar stereoradiography (EOS®).

Posterior tibial slope (PTS) is an important anatomic parameter of the knee related to anteroposterior instability. Biplanar stereoradiography allows for simultaneous low-dose acquisition of anteroposterior and lateral views with 3D capability, enabling separate lateral and medial plateau analyses. We aimed to evaluate the possibility and compare the reproducibility of measuring medial and lateral PTS on EOS® images with two different patient positionings and compare it with CT of the knees as the gold standard. This is a retrospective study including volunteers who underwent lower limb stereoradiography and knee CT from 01/08/2016 to 07/31/2019. Sixty legs from 30 patients were studied. PTS were measured using stereoradiography and CT by two radiologists. Intraclass correlation was used to calculate intrarater and interrater reproducibilities. Pearson's correlation coefficients were used to calculate the correlation between stereoradiography and CT. We also compared the reproducibility of the stereoradiography of volunteers with 2 different positionings. The mean stereoradiography PTS values for right and left knees were as follows: lateral, 12.2° (SD: 4.1) and 10.1° (SD: 3.5); medial,12.2° (SD: 4.4) and 11.6° (SD: 3.9). CT PTS mean values for right and left knee are as follows: lateral, 10.3° (SD:2.5) and 10.6° (SD: 2.8); medial: 8.7° (SD: 3.7) and 10.4° (SD: 3.5). Agreement between CT and EOS for angles between lateral and medial PTS was good (right, 0.874; left, 0.871). Regarding patient positioning on stereoradiography, interrater and intrarater reproducibilities were greater for patients with nonparallel feet (0.738-0.883 and 0.870-0.975). Stereoradiography allows for appropriate delineation of tibial plateaus, especially in patients with nonparallel feet, for the purpose of measuring PTS. The main advantage is lower radiation doses compared to radiography and CT.

CT validation of intraoperative imageless navigation (Naviswiss) for component positioning accuracy in primary total hip arthroplasty in supine patient position: a prospective observational cohort study in a single-surgeon practice

BackgroundThe aim of this study was to report on the validity of the Naviswiss handheld image-free navigation device for accurate intraoperative measurement of THA component positioning, in comparison with the three-dimensional (3D) reconstruction of computed tomography (CT) images as the gold standard.MethodsA series of patients presenting to a single-surgeon clinic with end-stage hip osteoarthritis received primary hip arthroplasty with the anterolateral muscle-sparing surgical approach in the supine position. Imageless navigation was applied during the procedure with bone-mounted trackers applied to the greater trochanter and ASIS. Patients underwent routine CT scans before and after surgery and these were analyzed by using three-dimensional reconstruction to generate cup orientation, offset and leg length changes, which were compared to the intraoperative measurements provided by the navigation system. Estimates of agreement between the intraoperative and image-derived measurements were assessed with and without correction for bias and declared cases with potential measurement issues.ResultsThe mean difference between intraoperative and postoperative CT measurements was within 2° for angular measurements and 2 mm for leg length. Absolute differences for the two indices were between 5° and 4 mm. Mean bias was 1.9°–3.6° underestimation for cup orientation and up to 2 mm overestimation for leg length change, but absolute thresholds of 10° and 10 mm were not exceeded by 95% limits of agreement (LOA), especially after correction for bias. Four cases (12%) were declared intraoperatively for issues with fixation on the greater trochanter. Inclusion of these cases generated acceptable accuracy overall and their omission failed to improve between-case variability in accuracy or LOA for both offset and leg length.ConclusionsThe accuracy of the Naviswiss system applied during primary THA in a supine position and anterolateral surgical approach falls within clinically acceptable recommendations for acetabular cup placement, femoral offset, and length. With refinements to surgical technique to adapt to the navigation hardware, the system could be further improved with regression-based bias correction.Trial registrationRegistered with the Australian New Zealand Clinical Trials Registry (ACTRN12618000317291)

Evaluasi Tata Laksana Pemeriksaan CT Scan Kepala: Efek Miscentering Pada Dosis Lensa Mata dan Kualitas Citra

Improper patient position in the isocenter position can interfere with optimization efforts. This study aimed to evaluate the management of head CT scans by knowing the effect of miscentering on the eye lens dose and noise. We used a water phantom and patient image and conducted a retrospective study of 1025 patients. Doses were calculated using IndoseCT software, while noise and miscentering were calculated using IndoQCT software. The difference in the right and left eye lens doses was tested using the student's t-test. The water phantom's position is above and below the isocenter of ±10, ±20, and ±30 mm. While the patient is correct at the center of the gantry (isocenter), the laser marker is between the patient's eyes and the symphysis pubic, and the height of the table is adjusted to the patient's center of mass. The vertical miscentering rate (posterior-anterior) is around 67.8%, with a miscentering range from -30 to -21 mm. There was no significant difference between the right and left eye lens doses (P-value &gt; 0.05). The eye lens dose increases as the phantom or patient position decreases from the isocenter and decreases as the phantom or patient position increases from the isocenter. Likewise, with noise, it increases as the phantom or patient position increases from the isocenter and decreases as the phantom or patient position decreases from the isocenter. Miscentering above the isocenter position can potentially reduce the eye lens dose. Keywords: Miscentering, Eye lens dose, noise

Risk Factors in Administering Spinal Anesthesia: A Comprehensive Review.

Numerous advantages, including a quick start and consistent anesthesia, are provided by spinal anesthesia, a method often utilized in contemporary medicine for various surgical operations. However, it has some hazards, just like any medical procedure.With an emphasis on identifying and assessing the risk factors associated with administering spinal anesthesia, the review analyzes published literature and clinical investigations carried out in the field of anesthesia. Various key factors, including technique-related procedural and patient-related aspects, can influence the effectiveness of spinal anesthesia. Among these factors are age, sex, body mass index, concurrent conditions (such as cardiovascular disease, diabetes, and respiratory problems), pre-existing neurological issues, allergies, and a history of adverse responses to anesthesia drugs. Additionally, the chance of problems might be increased by physical abnormalities or malformations in the spinal canal and vertebral column. The safety and effectiveness of spinal anesthesia depend significantly on procedural factors, such as the type and dosage of anesthesia agents administered and the patient's position and alignment maintained during the entire surgical procedure and the injection rate. Increased risks can also be caused by inadequate monitoring and a slow response to unfavorable circumstances. Risk factors related to the technique include the expertise and competency of the anesthesiologist or medical professional carrying out the procedure. Inadequate post-procedure monitoring, inadvertent dural puncture, and improper needle placement might lead to complications during or after the spinal anesthesia administration. This review emphasizes the need for a complete preoperative assessment, suitable patient selection, and rigorous procedural planning to reduce the likelihood of problems during the administration of spinal anesthesia. It also emphasizes the significance of ongoing monitoring and timely management of adverse events to guarantee patient safety and the best results. Healthcare professionals may put preventative measures in place and follow best practices to limit possible consequences efficiently by recognizing the risk factors associated with spinal anesthesia. This review helps encourage safer anesthesia practices and improvepatient care as medical knowledge and technology advance. However, further study and evidence-based recommendations are required to enhance patient outcomes and risk assessment.

Evaluasi Diagnostic Reference Levels (DRL) Pada Pemeriksaan Thorax PA di Pulau Jawa Berdasarkan Database DRL BAPETEN

The International Commission of Radiation Protection (ICRP) defines the diagnostic Reference Level (DRL) as a tool for optimizing patient radiation dose during radiological examinations. However, its implementation has obstacles, such as the unavailability and completeness of inspection data. Because DRL plays a role in controlling the patient's dose so that it is optimal, regular DRL evaluation is needed, especially on the island of Java. This research is a retrospective study of the results of PA chest radiography examinations in the database BAPETEN DRL between 2018-2022. PA chest radiography examination data used are examination procedure, patient position, age, body weight, exposure factors (kVp and mAs), and ESAK dose (mGy). After that, statistical analysis was carried out using IBM SPSS version 26 and Microsoft Excel with descriptive statistical analysis of the mean, median, standard deviation, 1st quartile, 2nd quartile, 3rd quartile, and minimum to maximum ratio values for the ESAK dose. Next, the 3rd quartile values of the Java island province were analyzed and compared with several Asian countries and Australia. The results of the research on the 3rd quartile radiation dose values on the island of Java with the highest to the lowest were West Java (0,31 mGy, n=1273), Yogyakarta (0,5 mGy, n=33), East Java (0,24 mGy, n=1206), Central of Java (0,22 mGy, n=725), Banten (0,20 mGy, n=2349), Jakarta (0,17 mGy, n=1870). The DRL on the island of Java is still controlled and lower than the National DRL and DRL in Asian countries and Australia. Keywords: Java Island, Diagnostic Reference Level, Thorax PA, 3rd quartile.

Perbandingan Dosis Radiasi Pemeriksaan Radiografi Thoraks PA Menggunakan Faktor Eksposi: Standar dan High kVp Berdasarkan Database DRL Si-INTAN BAPETEN

The usage of high kV has yet to be debated, so it is not fully used in PA chest radiographic examinations. However, The World Health Organization (WHO) and the Commission of European Communities (CEC) recommend using high kV, which can reduce the radiation dose to a minimum while maintaining the quality of the radiographic image. This study aimed to analyze the radiation dose for posterior-anterior (PA) chest radiography examinations using exposure factors: standard and high kV. This research method uses a retrospective study of the results of PA chest radiography examinations database diagnostic reference level (DRL) BAPETEN between 2018-2022. The PA chest examination data are the procedure, patient position, age, body weight, exposure factors (kVp and mAs), and ESAK dose (mGy). Then, use a standard exposure factor between 60-75 kVp and tube current-time of 6-12 mAs, while the exposure factor is high kV between 90-109 kVp and tube current-time of 0.7-4 mAs. After that, statistical analysis was carried out using IBM SPSS version 26 and Microsoft Excel. Determination of the average value and percentage difference in radiation dose of standard exposure factors and high kV. Then, proceed with statistical tests mann-whitney to determine the difference in the average radiation dose value between standard and exposure factors high kVp. The study showed that the average radiation dose for the standard kV exposure factor for the PA chest radiography examination was 0.179 mGy, while the high kV was 0.146 mGy. The dose difference between standard kV and high kV is 18.43%, with exposure factor radiation dose high kV lower than the standard exposure factor. For statistical test results, mann-whitney results p-value &lt; 0,000. High kV could be a procedure to optimize exposure factors for PA chest radiography examination. Keywords: Exposure factors, High kV, Optimization, DRL, Chest PA

The Single-Person Lateral Decubitus Ankle Sling Fracture Reduction Technique

Ankle fractures are common pathologies encountered in the emergency department. Reduction of ankle fractures can be a challenging task to perform alone and can place medical personnel in mechanically disadvantageous positions. In addition, body weight and awkward lifting are leading preventable causes of musculoskeletal injuries among medical staff. The single-person lateral decubitus ankle sling fracture reduction method described is a simple and reproducible technique that utilizes the classic principles described by Dr Quigley in 1959. This technique optimizes patient positioning, utilizes gravity, and incorporates a stable ankle sling. This also incorporates a relaxed patient position to promote a successful ankle fracture reduction. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radiographic Positioning Standards for Joint Radiography Quality Assessment at Al Makkased Hospital-Jerusalem

The fact that anatomical structures overlap makes imaging the body challenging. Radiograph diagnostic accuracy generally refers to the degree to which an examination can be used to forecast the existence (or absence) of an illness or condition. By supplying diagnostic images, the technologist plays a crucial part in increasing diagnostic accuracy. To isolate and provide a clearer view of a body area being scanned, a technologist must be knowledgeable about the many postures and techniques needed. Different projections not only make anatomical parts easier to perceive, but they also aid in the anatomization of abnormalities and the localization of foreign bodies. This study focused on the precise positioning of patients’ X-rays in the Al-Makkased Hospital emergency room when they reached there as a consequence of various accidents, falls, or other causes. Emergency photos from January to June (2020) were examined as part of our examination of digital radiography (DR) imaging, and problems with the photos were discovered. Our research revealed that the percentage of examination errors is just 14.6%, which is not a very significant number. The four joints that were evaluated in this investigation were the elbow, wrist, knee, and ankle. The three fundamental flaws that were examined while assessing projections were parallelism, location, and anatomy additional exposure errors were also found. Specifically, this project discussed standards for joint radiography quality, technique, framework, structure, and findings.

Bilateral axillo-breast approach (BABA) robotic neck dissection for papillary thyroid carcinomas

Papillary thyroid carcinoma (PTC), the most commonly diagnosed thyroid malignancy, frequently presents with lymph node metastases. Effective management of metastatic lymph nodes is crucial due to the disease's high recurrence rates. Herein, we present our approach to robotic thyroidectomy and central/lateral neck node dissection, which has shown comparable oncologic outcomes, reduced complications, and improved cosmetic results compared to open surgeries. We detail the surgical procedure, from patient positioning and flap dissection, through central and lateral neck dissection, to closure. The BABA robotic modified radical neck dissection (MRND) is primarily recommended for patients with well-differentiated thyroid carcinoma, predominantly PTC, presenting with suspected or pathologically confirmed lateral neck metastasis. We also discuss the application of the da Vinci robot settings in performing precise procedures and preserving critical anatomical structures. This comprehensive review provides insights into the effectiveness of BABA robotic thyroid surgery and central/lateral neck node dissection in managing PTC.

Abdominal compartment syndrome in critically ill patients.

Intra-abdominal hypertension can have severe consequences, including abdominal compartment syndrome, which can contribute to multi-organ failure. An increase in intra-abdominal hypertension is influenced by factors such as diminished abdominal wall compliance, increased intraluminal content, and certain systemic conditions. Regular measurement of intra-abdominal pressure is essential, and particular attention must be paid to patient positioning. Nonsurgical treatments, such as decompression of intraluminal content using a nasogastric tube, percutaneous drainage, and fluid balance optimization, play crucial roles. Additionally, point-of-care ultrasonography aids in the diagnosis and treatment of intra-abdominal hypertension. Emphasizing the importance of regular measurements, timely decompressive laparotomy is a definitive, but complex, treatment option. Balancing the urgency of surgical intervention against potential postoperative complications is challenging.

Utilizing a Quality Improvement Approach to Improve Positioning of Acute Burn Patients.

Patient positioning, using "anti-deformity positioning," is a standard practice in burn rehabilitation to assist with edema management, scar contracture prevention, and wound healing. Consistently providing proper positioning requires the combined effort of the multidisciplinary burn team. Our primary goal was to increase the frequency that patients were correctly positioned to over 90%. At a medium-sized, academic burn unit, random audits were conducted by burn lead therapists on the compliance of proper patient positioning over 6 months. Using this data as a trigger, a quality improvement project was designed using the Plan-Do-Study-Act (PDSA) cycle. Surveys were distributed to therapy and nursing staff to identify barriers to proper positioning. Effects on positioning compliance postintervention were monitored. In the 6 months prior to intervention, the average correct positioning was 76%. Surveys identified the following barriers to care: nursing needed more education and the approach was too heavily reliant on nursing efforts alone. To address this, therapists provided education to all nurses, communicated daily about positioning expectations, shifted the project to a multidisciplinary approach, and made changes in therapy workflow. The median compliance improved from 79% to 91% (P < .05). Coordinating efforts of the entire burn team improve consistency for positioning in burn patients. Utilizing the PDSA cycle allowed us to identify areas for improvement and develop appropriate interventions to increase education for nursing staff and workflow improvements for therapists. Following the completion of our interventions, we were able to obtain an immediate improvement in our patient positioning compliance.

Assessment of Correlation between Dimensions of Ball Phantom and Distortion Rate of Panoramic Radiography in Dental Cone Beam Computed Tomography

The objective of this study was to assess correlation between dimensions of ball phantom and distortion rate of panoramic radiography in dental cone beam computed tomography (CBCT) system using appropriate standard methods. The results revealed that only two measurement (2.99%) out of 67 measurements exceeded the recommended threshold value for distortion rate. There was no correlation between the ball diameter and the distortion produced. However, a low positive correlation was observed between the distortion rate and the ratio of the horizontal to the vertical diameter of the ball images. Also, the matlab code, presented results which are closer to the acceptable limit than the Romexis software. Patient positioning should be carefully and correctly considered to prevent and to bring the image distortion rate to its barest minimum for proper diagnosis in dental CBCT. For proper diagnosis and treatment planning, this distortion must be accounted for during clinical applications.

Increase in robot assisted operating room efficiency: A quality improvement study

Pyeloplasties are time-sensitive, and the most common robot assisted intervention performed in pediatric urology. Early intervention is intended to avoid permanent loss of renal function with negative long-term effects if surgery is delayed when indicated. A need to increase capacity has become a premium value in patient care. Our aim was to reduce operative time, providing value by reducing total robotic console time in robot assisted pyeloplasty (RP) cases. We hypothesized that process improvement and supply management during RP leads to a significant reduction in operative time. Intraoperative surgical workflow was reviewed and routine tasks performed during the various sections were selected with the goal of reducing Operating room inactivity. We focused on robotic arm activity, and total operative time to assess our outcomes. Our intervention was to standardize an OR staff task list, a priori supply inventory procurement for each anticipated major step in the case, confirmed prior to each major step. Baseline RP duration data for a single Pediatric Urologist were identified and recorded before any interventions. A clinical standard work (CSW) was developed based on optimization of equipment/supplies for the RP procedure, compartmentalized into the 8 key steps for RP. These major steps included: patient positioning, docking, retroperitoneal and ureteral dissection, hitch stitch, pyelotomy, stent placement, and anastomosis. Balancing measures included percentage trainee console use, preparatory time, and OR block start/end time. Baseline data for RP cases performed between 11/2020 and 2/2022 were automatically extracted from charts and analyzed using AdaptX (Seattle, WA). Post-intervention was between 3/2022 to 3/2023. Mann-WhitneyU was used for continuous variables for non-parametric distribution. 37 patients underwent RP during the study period. 15 cases were performed prior to intervention and 22 post intervention Total console time prior to intervention was 152 vs 109min after intervention (p=0.0002). Dual instrument inactivity was reduced from 13.1% to 7.1% (p<0.0001). Dual consoles were used in 40% vs ∼69% pre-vs post-intervention, respectively (p=0.5000). No difference in patient age distribution between groups was seen (p=0.1498). Trainee operative time did not differ statistically pre- and post-intervention (63.0 vs 48.6%, p=0.0871). Decreasing surgical lapses and standardizing intraoperative tasks can result in more efficient case completion, potentially increasing OR capacity.

Unveiling the Uncommon: Acute Urinary Retention in Second Trimester Pregnancy due to Retroverted Uterus - A Self Case Report

Acute urinary retention (AUR) during pregnancy is a rare yet significant complication, particularly when it occurs in the second trimester due to retroverted uterus. This case report sheds light on this unusual phenomenon, clinical implications, diagnostic approaches, and management strategies. A 27-year-old primigravida at 12 weeks' gestation experienced intermittent urinary retention. Foley catheterization relieved an acute episode, evacuating 1.2 liters of urine. Recurrent AUR required intermittent catheterization and probiotics. Gynecological examination and ultrasonography confirmed a retroverted uterus as the cause. Over four weeks, the patient improved, with the uterus repositioning anteriorly by the 16th week, leading to spontaneous resolution. This case highlights the rarity of second-trimester AUR due to retroverted uterus during pregnancy. The interplay of anatomical variations and physiological changes can result in unusual clinical presentations. Swift intervention, including Foley catheterization and patient positioning, achieved successful resolution. Elevated clinical awareness and personalized management are vital for unique pregnancy challenges.

EGS P38 Audit of operative notes/ Clinical documentation of emergency laparotomy &amp; laparoscopic bowel resection procedures

Abstract Background Laparotomies and laparoscopic bowel resections are common emergency procedures carried out in General Surgery emergency theatres. Get It Right First Time (GIRFT), Royal College of Surgeons (RCS) and The Association of Surgeons of Great Britain and Ireland (ASGBI) have made best practice recommendations for documenting operative notes, to ensure effective communication with colleagues and for medicolegal purposes. Ensuing medicolegal issues and patient complaints have cost departments in recent times, due to poor documentation. This audit within a busy General surgery unit, assesses the quality of operative documentations against the standards set by GIRFT, RCS and ASGBI. Methods A retrospective audit of operative notes and relevant clinical documentation of 100 emergency laparotomies and laparoscopic bowel resections between August 2022 and March 2023 at a local General surgery unit. Patient Identification Numbers were extracted from the National Emergency Laparotomy Audit (NELA) database. Operative records and clinical documentations were obtained from electronic clinical records. The recommendations from the “GIRFT RCS and ASGBI Best Practice for Laparotomy and Laparoscopic Bowel Resection Surgery Documentation” guidance was used as the Standard. Up to 60 variables were assessed across different stages of the patient journey, from preoperative to intraoperative and postoperative stages. Results In the period reviewed, there was varying performance. Good performance in documentations of Indications, Operator names, patient position, incision, and findings, seen in 99, 100, 100, 100 and 100 percent of cases respectively. Anaesthetist name was documented in 48% of cases, whilst WHO checklist was documented in only 20% of cases. 64 of these cases had bowel resections. In this cohort, methods and location of resection was described in 95% of cases. Only 43% had the state of bowel prefusion at transection site documented. VTE prophylaxis, Antibiotics, sutures/clip plan, were documented in 87, 65 and 13 % of cases respectively. Conclusions The audit highlights deficits in important areas of documentation, despite the set guideline. Important medicolegal issues can arise when documentations are not clear, and steps considered routine as not written in the operative notes or patient’s records. The findings will be disseminated, and recommendations will be suggested across all grades of surgeons, with the aim to re-audit and improve quality of documentation and ultimately improve delivery of surgical care. A plan to have electronic documentation template or checklist for these procedures has been carried out for trial with the aim of developing standardised documentation process.