Ready Times Research Articles

Enhancing operating room efficiency and patient outcomes: The impact of preoperative neuraxial ultrasound in cesarean deliveries

BackgroundThe operating room (OR) is a pivotal financial hub in modern healthcare, accounting for up to 40 % of hospital costs and generating 60–70 % of revenue. Optimizing OR efficiency is crucial for financial sustainability, patient safety, OR throughput, and satisfaction among patients, surgeons, and staff. ObjectiveThis Quality Improvement (QI) project aims to evaluate whether pre-procedure neuraxial ultrasound can enhance obstetric OR efficiency by reducing the time and attempts needed for epidural placement. The secondary objective is to assess improvements in patient comfort, safety, and satisfaction. MethodsConducted at a tertiary hospital in Miami from January to March 2022, the study included 98 parturients undergoing elective cesarean delivery. Patients were randomized into two groups: one receiving preoperative ultrasound (n = 49) and the other not (n = 49). Key metrics recorded included patient demographics, procedural times, number of attempts, pain scores, and patient satisfaction. ResultsThe ultrasound group demonstrated significant improvements in OR efficiency: shorter epidural placement times (median 9 vs. 13 min, p < 0.001), fewer attempts (median 1 vs. 2, p < 0.001), reduced anesthesia ready times (median 22 vs. 31 min, p < 0.001), and decreased total OR times (median 122 vs. 140 min, p = 0.004). Patients in the ultrasound group reported less back pain (median score 0 vs. 1, p < 0.001) and higher satisfaction (median score 10 vs. 9, p < 0.001). ConclusionPreoperative neuraxial ultrasound significantly improves OR case duration and enhances patient outcomes in obstetric anesthesia. While the study's single-site data and lack of blinding are limitations, the findings support larger, multi-institutional studies to confirm these benefits and explore further efficiency improvements.

Randomized control study to evaluate the effect of adding Dexmedetomdine to levobupivacaine in femoral sciatic block in total knee replacement

Background In recent years there has been an increasing interest in the practice of regional anesthesia especially peripheral nerve blocks for surgical anesthesia and postoperative analgesia. Imaging guidance for nerve localization helps the promise of improving block success with fewer complications. Among the imaging modalities available nowadays, ultrasonography seems to be the most suitable for regional anesthesia. One the most significant advantage of ultrasound (US) technology is the availability to provide anatomic examination of the area of interest. Aim The aim of this study is to evaluate the additive effect of dexmedetomidine to levobupivacaine in femoral sciatic block in total knee replacement regarding the onset and duration of both sensory and motor blockade, postoperative analgesia requirements. Patients and methods After ethical approval, 60 patients aged 45–65 years old, with an American Society of Anesthesiologists (ASA) physical class I and II who underwent total knee replacement using combined femoral-sciatic nerve block, were included in this prospective, randomized, controlled, double-blinded study. Patients were randomly assigned to receive levobupivacaine alone (group B) or dexmedetomidine 100 µg added to levobupivacaine (group BD) [n=30 patients for each group] for combined femoral-sciatic nerve block. Results This study showed that the addition of dexmedetomidine 100 µg to levobupivacaine during ultrasound-guided combined femoral-sciatic nerve block for total knee replacement was associated with, −20% shorter onset times for sensory and motor block, −25% faster time for surgical readiness, and longer duration of sensory and motor block (+45% and +40%, respectively) and +50% longer duration of analgesia. Conclusion Addition of dexmedetomidine to levobupivacaine during combined femoral-sciatic nerve block for total knee replacement was associated with faster onset of sensory and motor block, decrease intraoperative and postoperative requirements of analgesia and longer duration of motor block than levobupvicaine alone.

Real-time schedule adjustments for conflict-free vehicle routing

Conflict-Free Vehicle Routing Problems (CFVRPs) arise in manufacturing, transportation and logistics applications where Automated Guided Vehicles (AGVs) are utilized to move pallets and containers. A peculiar feature of these problems is that collision avoidance among vehicles must be considered explicitly. To make things more complex, the uncertainty affecting both travel times and machine ready times often results in vehicle delays or anticipations that require real-time modifications to the fleet nominal plan. In this paper, the determination of such modifications (schedule adjustment problem in CFVRPs) is modeled as a sequential decision problem for which we develop a tailored fast exact algorithm suitable for any objective function that is non-decreasing in the arrival times. Computational results show that optimal solutions can be found within at most 3.3 milliseconds for instances with up to 300 vehicles with improvements of various performance measures up to 74% compared to state-of-the-art solution algorithms.

A new dispatching mechanism for parallel-machine scheduling with different efficiencies and sequence-dependent setup times

The Apparent Tardiness Cost (ATC) dispatching rule was initially developed to minimize tardiness in single-machine scheduling problems. ATC extensions have been frequently applied in other production settings, relying heavily on blocking idle machine capacity with a single-machine outlook; this approach may not result in the best outcomes, considering that machines have different efficiencies. This study develops a new dispatching rule for parallel-machine scheduling, considering different machine efficiencies, ready times, and sequence-dependent setup times to minimize the total weighted tardiness. The proposed method reduces the time interference factor of the denominator item in the dispatching rule and uses more effective methods for selecting the best processing machine for the jobs. The grid approach is used to evaluate the method against the state-of-the-art. The experimental results confirm that the developed method is superior regardless of the type of parallel machines, the problem scale, and other operational parameters. It is also shown that other ATC dispatching rules can be improved by applying the proposed approach. The proposed method could be incorporated into soft computing techniques for more effective and efficient scheduling.

Single Machine Scheduling Proportionally Deteriorating Jobs with Ready Times Subject to the Total Weighted Completion Time Minimization

In this paper, we investigate a single machine scheduling problem with a proportional job deterioration. Under release times (dates) of jobs, the objective is to minimize the total weighted completion time. For the general condition, some dominance properties, a lower bound and an upper bound are given, then a branch-and-bound algorithm is proposed. In addition, some meta-heuristic algorithms (including the tabu search (TS), simulated annealing (SA) and heuristic (NEH) algorithms) are proposed. Finally, experimental results are provided to compare the branch-and-bound algorithm and another three algorithms, which indicate that the branch-and-bound algorithm can solve instances of 40 jobs within a reasonable time and that the NEH and SA are more accurate than the TS.

A simultaneous time and fuel minimization robust possibilistic multiobjective programming approach for truck-sharing scheduling in container terminals under uncertainty

The issue of integrated scheduling and sequencing operation of unloading and loading equipment in container ports has been one of the most important issues concerning time efficiency. In addition, with the emergence of green harbor concepts, the inclusion of criteria for minimizing energy consumption, fuel and emission reduction are among the other issues that have been noticed by planners in the field of energy efficiency. Furthermore, due to the complexity and scope of activities of a container terminal, uncertainty in operational parameters such as transportation time, time of readiness and entry of work into the system and the velocity of the transportation fleet are inevitable in this operational environment. Therefore, this research with the aim of sharing trucks among loading and unloading equipment, proposes a robust multi-objective integer programming model for the synchronized scheduling of truck operations with other handling equipment to decrease the fuel consumption of trucks and the flow time of containers, considering the uncertainty in operational parameters as fuzzy numbers. To find the Pareto solutions for this model, the ε-Constraint technique is employed. Finally, the performance of the model in deterministic and uncertain modes is evaluated, compared and analyzed employing the inputs gathered from Shahid Rajaei port. The findings demonstrate that using this model will result in a substantial decrease in both fuel consumption and flow time of containers in comparison to the current procedure. Additionally, results will demonstrate the extent to which the terminal's fuel and time consumption will increase under conditions of uncertainty in operational parameters when the optimal plans derived from the robust model are implemented.

The impact of COVID-19 on smoking cessation services with insights for post-pandemic delivery.

Smoking is a leading cause of preventable morbidity and mortality globally. During the COVID-19 pandemic, Smoking Cessation (SC) services faced many challenges, including lockdown and social distancing restrictions. Consequently, SC services had to adapt to the challenges in different ways or halt delivery. This research evaluated the impact of COVID-19 on the delivery and outcomes of SC services. This was achieved by comparing service delivery and outcomes pre-COVID-19 and during the pandemic and drawing insights for the delivery of SC services post-pandemic. Secondary analysis was performed on the data of 11,533 participants who attended the One Life Suffolk (OLS) SC services pre- and during the COVID-19 pandemic. A total of 4923 and 6610 participants attended SC services pre-COVID-19 and during COVID-19 respectively. Fifty-four percent of participants achieved quit status at week-4 while attending the SC services during the COVID-19 pandemic, compared with 46% pre-COVID-19, (X2(1) = 38.2, p-value<0.001). Participants who attended the SC services during the COVID-19 period were 1.7 times more likely to achieve quit status at week-4 than pre-COVID-19. However, the proportion of participants lost-to-follow-up (LTF) was significantly higher during the COVID-19 period (11%) compared to pre-COVID-19 (7%), (X2(1) = 51.4, p-value <0.001). There was an increased participation and quit rate during the pandemic for modified, remotely delivered SC services indicating successful delivery of remote services during the pandemic. Although switching from face-to-face to online helped some smokers to access the service at a time of motivational readiness, despite the COVID-19 restrictions, some smokers could not access or use some aspects of the remote delivery due to a lack of internet access, poor digital literacy, no peer support and no commitment to a group during face-to-face sessions, contributing to an increased rate of LTF. Posing a major challenge to SC services delivery, COVID-19 compelled OLS SC services to adapt and be more innovative in their delivery. SC services need to continue to evolve and adapt by applying the lessons learnt during the pandemic in terms of flexibility and person-centered delivery given what did and did not work well for different demographics within the population.

Continuous adductor canal block versus continuous femoral nerve block for postoperative pain in patients undergoing knee arthroplasty: An updated meta-analysis of randomized controlled trials.

Continuous adductor canal block (CACB) is almost a pure sensory nerve block and can provide effective analgesia without blocking the motor branch of the femoral nerve. Thus, the objective of this study was to systematically evaluate the efficacy of CACB versus continuous femoral nerve block (CFNB) on analgesia and functional activities in patients undergoing knee arthroplasty. PubMed, Embase and the Cochrane Central Register of Controlled Trials (from inception to 3 October 2023) were searched for randomized controlled trials (RCTs) that compared CACB with CFNB in patients undergoing knee arthroplasty. Registration in the PROSPERO International prospective register of the meta-analysis was completed, prior to initiation of the study (registration number: CRD42022363756). Two independent reviewers selected the studies, extracted data and evaluated risk of bias by quality assessment. Revman 5.4 software was used for meta-analysis and the summary effect measure were calculated by mean differences and 95% confidence intervals. Eleven studies with a total of 748 patients were finally included. Pooled analysis suggested that both CACB and CFNB showed the same degree of pain relief at rest and at motion at 12 h, 24 h and 48 h in patients undergoing knee arthroplasty. Compared with CFNB, CACB preserved the quadriceps muscle strength better (P<0.05) and significantly shortened the discharge readiness time (P<0.05). In addition, there was no significant difference in opioid consumption, knee extension and flexion, timed up and go (TUG) test, or risk of falls between the two groups. Thus, Compared with CFNB, CACB has similar effects on pain relief both at rest and at motion and opioid consumption for patients undergoing knee arthroplasty, while CACB is better than CFNB in preserving quadriceps muscle strength and shortening the discharge readiness time.

Исследование кварцевых резонаторов в миниатюрных металлокерамических корпусах с целью дальнейшего применения в термокомпенсированных генераторах

With the advent of new technologies, the requirements for the sources of reference vibrations are becoming more stringent. They must be compact, quickly reach frequency, operate in a wide temperature range and have a small relative frequency drift in the operating temperature range. Changes in ambient temperature are the most destabilizing factor for the oscillator output frequency. Ensuring frequency stability over a wide temperature range is a pressing task. Thermal compensation allows increasing frequency stability over a wide range of operating temperatures. This is achieved by compensating for the effect of the destabilizing factor on the generator so that the frequency drift tends to zero as the temperature changes. Temperature-compensated quartz oscillators are highly stable and have a short readiness time. However, to create generators with a frequency stability of ± 0,1 ppm, imported components are required, which makes their production difficult in modern conditions. A technological chain is created at the JSC «LIT-PHONON», which allows producing a quartz resonator using only Russian components. The goal is to use these resonators in temperature-compensated oscillators with frequency stability of ± 0,1 ppm. However, the analysis showed that the resonators have problems with frequency drift over time during operation at a maximum operating temperature of + 85 ºС. Additional adjustment of generators during operation is required. It is also revealed that some Russian components are not ideally suited to the developed technological process, which may negatively affect the yield of suitable products. The measuring setup also has an error of ± 0,5 ppm, which does not allow an accurate assessment of the frequency stability of the resonators.

A multi-agent resource bidding algorithm for order acceptance and assembly job shop scheduling

This study uses an agent-based approach with a combinatorial auction mechanism to solve the joint order acceptance and assembly job shop scheduling problem. A set of jobs is offered. Each job has a revenue, ready time, due date, deadline, and consists of a set of operations with precedence relationships. Jobs that deviate from their due dates incur earliness/tardiness penalties. An operation may require several units of capacity per time unit and a resource could have multiple units of capacity. The manufacturer can reject any job to satisfy the capacity constraints and maximise the overall profit. We develop a mathematical model for the problem, then use an agent-based approach to solve it. First, the relaxed problem is decomposed into a set of job-level subproblems. Each job is optimised individually without considering the capacity constraints. Profitable jobs at the individual level submit their optimal schedules as combinatorial bids to an auctioneer to acquire combinations of resource capacity-time units. Then, the auctioneer records the profit upper bound, resolves capacity conflicts to reach a feasible solution, records the profit lower bound, and updates the dual variables. Experimental results show that the proposed methodology can solve large-sized problems in reasonable CPU times.

Lung ultrasound supports clinical evaluation of feeding competence development in preterm neonates.

The achievement of alimentary competencies is a milestone in the development of preterm neonates. Ten percent of neonates <37 weeks of gestational age and 25% of those VLBW experience swallowing disorders, with an increased risk of problems in the early phase of life (failure to thrive, growth retardation, inhalation, and consequent risk of pulmonary infection) and later in life due to delayed development of oromotor skills.The main diagnostic tools for swallowing disorders are endoscopic (fiber-optic endoscopic examination of swallowing, FEES) or radiographic (videofluoroscopic swallowing study, VFSS) exams. Given the invasiveness of these methods and the bias due to rheologic differences between bolus and contrast medium, FEES and VFSS are poorly reproducible. Moreover, neither of the technique is capable of detecting post-meal inhalations, especially microinhalations or those consequent to a whole meal rather than to a single swallowing.Lung ultrasound (LUS) is a widespread, repeatable, safe, fast point-of-care tool and we reported previous encouraging results in detecting silent and overt inhalation related to the meal in children with dysphagia/gastroesophageal reflux disease (GERD) risk factors. We report a pilot study, that investigated LUS approach (performing imaging before and after meals) to assess feeding competence development in a cohort of n. 19 newborns <32 weeks of age. Meal monitoring by LUS did not show any significant difference in scoring before/after eating. The achievement of full enteral feeding correlates with GA at birth (p < 0.001) but not with LUS scoring. The introduction of the first meal by bottle correlates both with gestational age (p < 0.001) and ultrasound scores (p = 0.004). LUS score at 7 days of life resulted predictive for length of invasive/non-invasive respiratory support (p = 0.002) and length of oxygen supply (p = 0.001), while LUS score at 48 h of life did not (p n.s.). Our study suggests that the development of oral feeding skills is not strictly dependent on gestational age. Moreover, our research suggests the predominant role of LUS in predicting the time of readiness to oral feeding, as the LUS score can be a marker of respiratory and lung wellness, and consequently a predictor of neonate stability during deglutitory apnea.

Emergency Department Arrival Modes: Time for Mandatory Pediatric Readiness.

Because small children can be transported by private vehicles, many children seek emergency care outside of Emergency Medical Services (EMS). Such transports may access the closest emergency departments (EDs) without knowledge of their pediatric competence. This study quantifies this practice and the concept of mandatory pediatric readiness. The electronic health records of 3 general EDs and 2 pediatric EDs were queried for all pediatric and young adult visits for the year 2022. Data collected included patient age, ED type, arrival mode (EMS/police or private mode), and disposition (admission/transfer or discharge). Study patients were categorized as "small children" if aged younger than 10 years, "large children" if 10 to 18 years, and "young adult" if 19 to 40 years. Associations between mode of arrival, ED type, and disposition were analyzed through χ 2 and analysis of variance. The study population included 37,866 small children, 19,108 large children, and 68,293 young adults. When compared with EMS/police transports, a private arrival mode was selected by 96.1% of small children, 90.0% of large children, and 85.4% of young adults ( P < 0.0001). For the admission/transfer patients, private transportation was selected by 87.4% of small children, 73.8% of large children, and 78.8% of young adults ( P < 0.0001). For admitted/transferred children, the private mode was used by 80.4% of those in the general ED and 81.9% in the pediatric ED ( P > 0.41). Pediatric patients seeking ED care overwhelmingly arrive through a private mode regardless of the severity of their problem or type of ED in which treated. Emergency Medical Services programs and state hospital regulatory agencies need to recognize this practice and assure the pediatric competence of every ED within their system.

Recovering feasibility in real-time conflict-free vehicle routing

Conflict-Free Vehicle Routing Problems (CF-VRPs) arise in manufacturing, transportation and logistics facilities where Automated Guided Vehicles (AGVs) are utilized to move loads. Unlike Vehicle Routing Problems arising in distribution management, CF-VRPs explicitly consider the limited capacity of the arcs of the guide path network to avoid collisions among vehicles. AGV applications have two peculiar features. First, the uncertainty affecting both travel times and machine ready times may result in vehicle delays or anticipations with respect to the fleet nominal plan. Second, the relatively high vehicle speed (in the order of one or two meters per second) requires vehicle plans to be revised in a very short amount of time (usually few milliseconds) in order to avoid collisions. In this paper we present fast exact algorithms to recover plan feasibility in real-time. In particular, we identify two corrective actions that can be implemented in real-time and formulate the problem as a linear program with the aim to optimize four common performance measures (total vehicle delay, total weighted delay, maximum route duration and total lateness). Moreover, we develop tailored algorithms which, tested on randomly generated instances of various sizes, prove to be three orders of magnitude faster than using off-the-shelf solvers.

Predictors of anesthesia ready time: Analysis and benchmark data

ObjectivePatients undergoing congenital cardiac surgery require induction of anesthesia. Our objective was to identify the median anesthesia ready time and the predictors of this time. MethodsBy using the Society of Thoracic Surgeons Congenital Heart Surgery Database, we identified patients who underwent cardiopulmonary bypass procedures from 2017 to 2021. Univariate and multivariable regression modeling to predict the anesthesia ready time was performed using mixed-effects linear regression. ResultsAfter exclusion of outliers, 44,418 cases were analyzed. The median anesthesia ready time was 51 minutes (interquartile range, 38-66). On multivariable analysis, independent predictors of a longer anesthesia ready time included decreasing weight (0.3 min/10 kg, 95% CI, 0.1-0.6; P = .011), prematurity (1.5 minutes, 95% CI, 0.8-2.2; P < .001), and presence of chromosomal abnormality (3.4 minutes, 95% CI, 1.5-5.2; P < .001). An increase in the duration in anesthesia ready time was seen with increasing Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery mortality category with an additional 7.8 minutes (95% CI, 5.2-10.4; P < .001) for a Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery 5 procedure compared with Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery 1. Emergency versus elective case designation was associated with an anesthesia ready time reduction of 3.6 minutes (95% CI, 1.1-6.1; P = .005), and an afternoon case start was associated with an anesthesia ready time reduction of 4.2 minutes (95% CI, 2.8-5.6; P < .001). The presence of an anesthesia trainee increased the anesthesia ready time by 3.8 minutes (95% CI, 2.6-5.0; P < .001). The presence of an airway in situ decreased the anesthesia ready time by 3.6 minutes (95% CI, 1.6-5.5; P < .001), whereas an in situ arterial line decreased the anesthesia ready time by 7.4 minutes (95% CI, 4.6-10.2; P < .001). Placement of a central venous line increased the anesthesia ready time by 8.5 minutes (95% CI, 5.9-11.1; P < .001). ConclusionsThe median anesthesia ready time was 51 minutes. For patients with characteristics associated with prolonged anesthesia ready time, consideration should be given to allocation of additional anesthesia staffing to improve efficiency.

Ayak cerrahisinde kullanılan periferal sinir blok uygulamasında iki metodun karşılaştırılması: USG yardımlı ve anatomic landmark yardımlı.

Aim: Ankle peripheral nerve block is applied by two methods. These are peripheral block that is performed using USG-assisted and anatomical landmarks that do not require the use of Ultrasonography (USG). In our study, we aimed to compare these two methods applied in foot surgeries retrospectively. Methods :Peripheral block patients performed with the USG-guided (group 1) were 20, anatomical landmarks- guided (group 2) were 20. In both groups, 40 cc of anesthetic mixture was used (bupivacaine + lidocaine). The recorded information of the patients were as follows: Block application time (BAT), surgery readiness time (SRT), duration of surgery (DoS), duration of block anesthesia (DBA) and intraoperative-postoperative Visual Analogue Scale (VAS). The results of the VAS applied to the patients postoperatively were obtained. Patients were contacted by phone and asked if they were satisfied with the anesthesia. Results : The BAT and DBA values of the patients in Group 1 were high. SRT and VAS 6 values of the patients in group 2 were high. No significant difference was found between the groups in other parameters. No additional dose of anesthetic was needed in group 1 during the intraoperative period. In group 2, local additional dose was administered to 3 patients. Conclusion: Peripheral block preparation USG-guided takes a long time. However, it is more comfortable during surgery. The USG-guided peripheral nerve block is more advantageous when considering the possibility of prolonging the duration of surgery for any reason and early postoperative pain control after surgery.

An Iterated Population-Based Metaheuristic for Order Acceptance and Scheduling in Unrelated Parallel Machines with Several Practical Constraints

This study considers order acceptance and scheduling problems in unrelated parallel machines with several practical constraints, including order release times, sequence-dependent setup times, machines’ unequal ready times, and preventive maintenance. In a make-to-order production environment, issues with order acceptance and scheduling are mainly caused by the limited production capacity of a factory, which makes it impossible to accept all orders. Consequently, some orders must be rejected in order to maximize profits and the accepted orders must be completed by the due date or no later than the deadline. An iterated population-based metaheuristic is proposed to solve the problems. The algorithm begins with an efficient initial solution generator to generate an initial solution, and then uses the destruction and construction procedure to generate a population with multiple solutions. Then, a solution is selected from the population, and a variable neighborhood descent search algorithm with several new reduced-size neighborhood structures is applied to improve the selected solution. Following the completion of the local search, a method for updating the members of the population was devised to enhance its diversity. Finally, the metaheuristic allows the populations to evolve for several generations until the termination condition is satisfied. To evaluate the performance of the proposed metaheuristic, a heuristic rule and an iterated local search algorithm are examined and compared. The computational experimental results indicate that the presented metaheuristic outperforms the other heuristics.

A Hybrid Large Neighborhood Search Method for Minimizing Makespan on Unrelated Parallel Batch Processing Machines with Incompatible Job Families

This paper studies a scheduling problem with non-identical job sizes, arbitrary job ready times, and incompatible family constraints for unrelated parallel batch processing machines, where the batches are limited to the jobs from the same family. The scheduling objective is to minimize the maximum completion time (makespan). The problem is important and has wide applications in the semiconductor manufacturing industries. This study proposes a mixed integer programming (MIP) model, which can be efficiently and optimally solved by commercial solvers for small-scale instances. Since the problem is known to be NP-hard, a hybrid large neighborhood search (HLNS) combined with tabu strategy and local search is proposed to solve large-scale problems, and a lower bound is proposed to evaluate the effectiveness of the proposed algorithm. The proposed algorithm is evaluated on numerous compatible benchmark instances and newly generated incompatible instances. The results of computational experiments indicate that the HLNS outperforms the commercial solver and the lower bound for incompatible problems, while for compatible problems, the HLNS outperforms the existing algorithm. Meanwhile, the comparison results indicate the effectiveness of the tabu and local search strategies.

Minimising makespan of a batch processing machine with unequal job ready times using simulated annealing

Minimising makespan of a batch processing machine with unequal job ready times using simulated annealing

Energy Efficiency Based Load Balancing Optimization Routing Protocol In 5G Wireless Communication Networks

A significant study area in cloud computing that still requires attention is how to distribute the workload among virtual machines and resources. Main goal of this research is to develop an efficient cloud load balancing approach, improve response time, decrease readiness time, maximise source utilisation, and decrease activity rejection time. This research propose novel technique in load balancing based network optimization using routing protocol for 5G wireless communication networks. the network load balancing has been carried out using cloud based software defined multi-objective optimization routing protocol. then the network security has been enhanced by data classification utilizing deep belief Boltzmann NN. Experimental analysis has been carried out based on load balancing and security data classification in terms of throughput, packet delivery ratio, energy efficiency, latency, accuracy, precision, recall.

Sugammadex versus neostigmine for neuromuscular blockade reversal in outpatient surgeries: A randomized controlled trial to evaluate efficacy and associated healthcare cost in an academic center.

Neuromuscular blockade is an essential component of the general anesthesia as it allows for a better airway management and optimal surgical conditions. Despite significant reductions in extubation and OR readiness-for-discharge times have been associated with the use of sugammadex, the cost-effectiveness of this drug remains controversial. We aimed to compare the time to reach a train-of-four (TOF) response of ≥0.9 and operating room readiness for discharge in patients who received sugammadex for moderate neuromuscular blockade reversal when compared to neostigmine during outpatient surgeries under general anesthesia. Potential reduction in time for OR discharge readiness as a result of sugammadex use may compensate for the existing cost-gap between sugammadex and neostigmine. We conducted a single-center, randomized, double arm, open-label, prospective clinical trial involving adult patients undergoing outpatient surgeries under general anesthesia. Eligible subjects were randomized (1:1 ratio) into two groups to receive either sugammadex (Groups S), or neostigmine/glycopyrrolate (Group N) at the time of neuromuscular blockade reversal. The primary outcome was the time to reverse moderate rocuronium-induced neuromuscular blockade (TOF ratio ≥0.9) in both groups. In addition, post-anesthesia care unit (PACU)/hospital length of stay (LOS) and perioperative costs were compared among groups as secondary outcomes. Thirty-seven subjects were included in our statistical analysis (Group S= 18 subjects and Group N= 19 subjects). The median time to reach a TOF ratio ≥0.9 was significantly reduced in Group S when compared to Group N (180 versus 540 seconds; p = 0.0052). PACU and hospital LOS were comparable among groups. Postoperative nausea and vomiting was the main adverse effect reported in Group S (22.2% versus 5.3% in Group N; p = 0.18), while urinary retention (10.5%) and shortness of breath (5.3%) were only experienced by some patients in Group N. Moreover, no statistical differences were found between groups regarding OR/anesthesia, PACU, and total admission costs. Sugammadex use was associated with a significantly faster moderate neuromuscular blockade reversal. We found no evidence of increased perioperative costs associated with the use of sugammadex in patients undergoing outpatient surgeries in our academic institution. [https://clinicaltrials.gov/] identifier number [NCT03579589].