Room Time Research Articles

116 Clinical Impact of Transitioning from a Burn Provider-based to Hospitalist-based Sedation Service

IntroductionBurn patients often experience a tremendous amount of pain and anxiety during dressing changes and other procedures, frequently requiring a moderate sedation (MS) or deep sedation (DS) for successful completion. We previously reported our primarily Nurse Practitioner-based model for procedural sedation but recently transitioned to a primarily hospitalist-based sedation service. We evaluated the clinical and financial impact of this transition.MethodsRetrospective chart review of patients undergoing MS or DS from June 2019 to June 2020 (burn provider-based [BPB]) and August 2020 to August 2021 (hospitalist-based [HB]). Data included demographics, number and types of sedation, provider type, American Society of Anesthesiology Physical Status Classification (ASA score), complications and relative value units (RVU)/anesthesia units generated. Our hospitalist completed a combined Internal Medicine-Pediatrics residency and is credentialed by the institution for procedural sedation.ResultsDuring the BPB sedation timeframe, 263 patients were admitted to the burn center, of which 55 patients (21%) underwent 203 sedations (average: 3.6 sedations/patient). Twenty-one (10%) were DS. The most common medications used for DS were a combination of Midazolam, Ketamine, Fentanyl, Glycopyrrolate and Ondansetron (81%); and for MS, a combination of Fentanyl and Midazolam (77.5%). Ten percent of patients had an ASA of 3 or greater.During the HB sedation timeframe, 203 patients were admitted, of which 73 patients (36%) underwent 353 sedations for an average of 4.8 sedations/patient (74% increase). Ninety-one (26%) were DS (333% increase). Medication combinations were similar as above for DS (90%) and MS (93%). Nineteen percent of patients had an ASA of 3 or greater.Our hospitalist performed 16% of the sedations in the BPB timeframe and 72% in the HB timeframe. In the BPB group there were 4 desaturation events (0.02%) among all sedations, compared to 8 desaturation and 1 hemodynamic change events (0.025%) in the HB group. Total work relative value units (wRVUs) and anesthesia units of service (for the DS) generated were 599.6 and 133 respectively in the BPB group compared to 1104.2 (84% increase) and 784 (489% increase) respectively in the HB group. During the BPB timeframe 40 patients were taken to the OR for dressing changes for a total of 69.3 hours, compared to zero in the HB timeframe.ConclusionsTransitioning from a BPB to HB sedation service resulted in increased sedation numbers and percentage of patients undergoing a sedation, especially DS, as well as increased RVU generation. Sedations were performed in patients with higher ASA scores without a significant increase in adverse events. There was operating room cost and time savings. HB sedation services can be an efficacious and safe model in a burn center.

A Psychological Evaluation Model of a Good Conversation in Knowledge Creative Activities by Multiple People

Japanese companies have been focusing on enhancing the knowledge creative activities of older office workers in recent years. In addition, the way of working in the office has been shifting from traditional divisional routine work to collaborative or creative work, and office spaces are becoming quieter, with an increasing number of extremely quiet spaces (noise level < 40 dB). A sound environment that is too quiet gives workers the impression that it is difficult to converse with others, because they are worried about what people around them may think. The appearance of the knowledge creative society in recent years has led to a desire for changes in the workplace environment to improve the productivity of intellectual activities. To realize a sound environment that encourages knowledge creative activities, study outcomes need to be accumulated. Therefore, to clarify what kind of sound environment would be appropriate for knowledge creative activities by multiple people, we conducted psychoacoustic experiments to examine the effects of sound pressure level (signal-to-noise ratio), type of sound, and reverberation time in conference rooms on the impression of a “good conversation”. In addition, we considered a causal model for the psychological evaluation of a “good conversation” by conducting a multiple regression analysis of psychological evaluations of the experimental participants. The results indicated that a sound environment considered too quiet for multiple people to have discussions about knowledge creative activities lowers the impression of a “good conversation”, whereas high levels of relaxation lead to the impression of a “good conversation”.

Bladder filling in patients undergoing prostate radiotherapy on a MR-linac: The dosimetric impact.

The implementation of adaptive radiotherapy for prostate cancer compensates for inter-fraction motion, at the penalty of increased time in room. The subsequent increase in bladder filling may impact dosimetry, which we have investigated on ten patients treated on the MR-linac. Patients drank water before treatment, to achieve a bladder volume of 200-300cm3. Bladder and bowel were re-outlined offline on 140 images and plans recalculated. All mandatory bladder dose constraints and 99.1% of bowel constraints were achieved at time of treatment, despite varying bladder volumes and varying adherence to original bladder filling guidance.

Guidelines for consultations regarding incontinence care products

An investigation of the German consumer organisation "Stiftung Warentest" in 2017 confirmed significant deficiencies in the information, advice and supply of incontinence care products received by urinary incontinence patients. The German Society of Urology (DGU) thereupon drafted and later published guidelines concerning the consultation of patients in the context of incontinence care. Important aspects of the consultation process include the determination of the type of incontinence as well as its severity, clinical examination, and advice regarding possible curative treatments. However, the advice appointment takes centre stage and should ideally be conducted by aqualified person in aseparate room granting sufficient privacy and time. Furthermore, repeated supply of aselection of samples for differing degrees and types of incontinence, accommodating the patient's individual preferences and anatomical features, is crucial in order to ensure optimal incontinence care. In the case of commercial health care service providers, transparency relating to the financial implications of e.g. expensive products is key, which is what has been intended by German health insurance providers. The new guidelines concerning urinary incontinence care consultation constitute astep towards the improvement and structuring of processes in the consultation regarding, and the supply of, incontinence care products.

Application of Dexmedetomidine combined with Propofol Intravenous Anesthesia in Laparoscopic Day Surgery in Pediatric Urology.

ABSTRACTObjectives:To evaluate the sedative and analgesic effects of dexmedetomidine combined with propofol intravenous anesthesia in laparoscopic day surgery in pediatric urology.Methods:Eighty male children with cryptorchidism and hydrocele who underwent laparoscopic daytime surgery in our hospital from January 2019 to January 2021 were selected and randomly divided into two groups: the experimental group and the control group. Children in the experimental group ranged in age from 5.7 to 11.3, with an average of 8.52±2.17 years old, while those in the control group ranged in age from 5.3 to 12.0, with an average of 8.60±2.07 years old. There were 12 cases of cryptorchidism and 28 cases of hydrocele in the experimental group, and 14 cases of cryptorchidism and 26 cases of hydrocele in the control group. Children in the control group received conventional propofol intravenous combined anesthesia, while those in the experimental group were given dexmedetomidine (2-5 ug/kg) intranasally on the basis of conventional propofol intravenous anesthesia. The anesthetic effect, analgesic effect, serum levels of inflammatory cytokines before and after surgery and adverse drug reactions in the two groups were compared and analyzed.Results:The awakening time, extubation time and retention time in the resuscitation room of the experimental group were shorter than those of the control group, with a statistically significant difference (P<0.05); The VAS pain scores of the experimental group were significantly lower than those of the control group at 15minutes, 12hour and 24hour after awakening, with a statistically significant difference (P<0.05). In addition, the levels of TNF-a, CRP, IL-6 and other inflammatory factors in the control group were significantly higher compared with those in the experimental group 24h after surgery, with a statistical significance (TNF-a, P=0.02; CRP, P=0.00; IL-6, P=0.03); The incidence of adverse drug reactions in the experimental group was 17.5%, while that in the control group was 12.5%, which was not statistically significant (P=0.53).Conclusion:Dexmedetomidine combined with intravenous propofol anesthesia may be helpful to shorten the extubation time, the recovery time and the stay time in the anesthesia resuscative room, improve the analgesic effect, and may reduce the inflammatory response and the expression of serum inflammatory cytokines, with no significant increase in side effects.

Print newspaper as an interactional affordance in an interaction with a person with dementia

Background/method: Using conversation analytical methodology, this article presents a detailed analysis of how a person with dementia uses the affordances of a print newspaper to initiate, manage, and close topics in an interaction with a visiting researcher during leisure time in the common room of a dementia unit. Results: The analyses show how a print newspaper is introduced and handled effortlessly by a person with dementia and used for communication purposes. The person with dementia recurrently contributes to the interaction by making observations about and assessments of the visual appearance of the newspaper, reading aloud from the newspaper, and commenting. Discussion/conclusion: The study discusses how social interaction that is anchored in familiar objects such as a newspaper may help persons with dementia and their interactional partners find common conversational ground that does not rely on access to specific memories of the past, which may increase active participation by the person with dementia.

Return of the Banana Knife: An Alternative Instrument for Laparoscopic Pyloromyotomy.

Background: When the disposable arthroscopic banana knife (Linvatec, Largo, FL) became unavailable, many pediatric surgeons adapted the use of spatula tip cautery for laparoscopic pyloromyotomy; however, reusable arthroscopic knives remain readily available and are well suited to the procedure. Methods: We compared laparoscopic pyloromyotomy with a reusable arthroscopic banana knife (Sklar, West Chester, PA; catalog no. 45-6050) to those using spatula tip cautery at a single institution between September 1, 2012, and December 31, 2019. Mann-Whitney U test was used to compare operative time, room time, and time to discharge between groups. Results: Overall, 109 patients underwent pyloromyotomy for hypertrophic pyloric stenosis during the study time period. Of these, 12 were open and one was undertaken with the Storz pyloromyotomy knife, so these were excluded. A total of 74 (77.1%) laparoscopic cases with spatula tip cautery and 22 (22.9%) with the banana knife were included. Mean age at the time of surgery was ∼37 days. The majority of patients in each group were white, male, and full term. The most common comorbid conditions were reactive airway disease and neonatal abstinence syndrome. There were no significant differences in operative time (P = .61), room time (P = .41), or time from surgery to discharge (P = .26) between procedures using the banana knife and those using the cautery spatula tip. There were no perforations or recurrences. Conclusion: Our findings suggest that the reusable banana knife is a safe and effective alternative to spatula tip cautery for laparoscopic pyloromyotomy, with no difference in operative time, time from surgery to discharge, or complications.

Lumbar spine fusion outcomes using a cellular bone allograft with lineage-committed bone-forming cells in 96 patients

BackgroundInstrumented posterior lumbar fusion (IPLF) with and without transforaminal interbody fusion (TLIF) is a common treatment for low back pain when conservative interventions have failed. Certain patient comorbidities and lifestyle risk factors, such as obesity and smoking, are known to negatively affect these procedures. An advanced cellular bone allograft (CBA) with viable osteogenic cells (V-CBA) has demonstrated high fusion rates, but the rates for patients with severe and/or multiple comorbidities remain understudied. The purpose of this study was to assess fusion outcomes in patients undergoing IPLF/TLIF using V-CBA with baseline comorbidities and lifestyle risk factors known to negatively affect bone fusion.MethodsThis was a retrospective study of de-identified data from consecutive patients at an academic medical center who underwent IPLF procedures with or without TLIF, and with V-CBA. Baseline patient and procedure characteristics were assessed. Radiological outcomes included fusion rates per the Lenke scale. Patient-reported clinical outcomes were evaluated via the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for back and leg pain. Operating room (OR) times and intraoperative blood loss rates were also assessed.ResultsData from 96 patients were assessed with a total of 222 levels treated overall (mean: 2.3 levels) and a median follow-up time of 16 months (range: 6 to 45 months). Successful fusion (Lenke A or B) was reported for 88 of 96 patients (91.7%) overall, including in all IPLF-only patients. Of 22 patients with diabetes in the IPLF+TLIF group, fusion was reported in 20 patients (90.9%). In IPLF+TLIF patients currently using tobacco (n = 19), fusion was reported in 16 patients (84.3%), while in those with a history of tobacco use (n = 53), fusion was observed in 48 patients (90.6%). Successful fusion was reported in all 6 patients overall with previous pseudarthrosis at the same level. Mean postoperative ODI and VAS scores were significantly reduced versus preoperative ratings.ConclusionThe results of this study suggest that V-CBA consistently yields successful fusion and significant decreases in patient-reported ODI and VAS, despite patient comorbidities and lifestyle risk factors that are known to negatively affect such bony healing.

Outcomes of Surgical Treatment for 138 Patients With Severe Sagittal Deformity at a Minimum 2-Year Follow-up: A Case Series.

Operative treatment of adult spinal deformity (ASD) can be very challenging with high complication rates. It is well established that patients benefit from such treatment; however, the surgical outcomes for patients with severe sagittal deformity have not been reported. To report the outcomes of patients undergoing surgical correction for severe sagittal deformity. Retrospective review of a prospective, multicenter ASD database. Inclusion criteria: operative patients age≥18, sagittal vertical axis (SVA)≥15 cm, mismatch between pelvic incidence and lumbar lordosis (PI-LL)≥30°, and/or lumbar kyphosis≥5° with minimum 2 yr follow-up. Health-related quality of life (HRQOL) scores including minimal clinically important difference (MCID)/substantial clinical benefit (SCB), sagittal and coronal radiographic values, demographic, frailty, surgical, and complication data were collected. Comparisons between 2 yr postoperative and baseline HRQOL/radiographic data were made. P<.05 was significant. A total of 138 patients were included from 502 operative patients (54.3% Female, Average (Avg) age 63.3±11.5 yr). Avg operating room (OR) time 386.2±136.5 min, estimated blood loss (EBL) 1829.8±1474.6 cc. A total of 71(51.4%) had prior fusion. A total of 89.9% were posterior fusion only. Mean posterior levels fused 11.5±4.1. A total of 44.9% had a 3-column osteotomy. All 2 yr postoperative radiographic parameters were significantly improved compared to baseline (P<.001 for all). All 2yr HRQOL measures were significantly improved compared to baseline (P<.004 for all). A total of 46.6% to 73.8% of patients met either MCID/SCB for all HRQOL. A total of 74.6% of patients had at least 1 complication, 11.6% had 4 or more complications, 33.3% had minimum 1 major complication, and 42(30.4%) had a postop revision. Patients with severe sagittal malalignment benefit from surgical correction at 2 yr postoperative both radiographically and clinically despite having a high complication rate.

Pedestrian flow in two dimensions: Optimal psychological stress leads to less evacuation time and decongestion.

Collective motion is an innate ability of all living systems, which depends on physiological and psychosocial factors in the case of humans. Such a collective organization is becoming of great interest in collective motion in human crowds. Using a cellular automaton (CA) simulation model, we demonstrate that emergency egress from a two-dimensional corridor with optimal stress leads to less evacuation time and efficient mass evacuations. We study how three types of stress (i.e., mild stress, optimal stress, and anxiety) described in the literature have a significant impact on the collective dynamics. We found that low-stress levels could decrease the evacuation time in an entire occupied room since agents choose alternative routes rather than the shortest path to the exit and display cooperative behavior. Therefore, the combination of mild and optimal stress can lead to efficient evacuations. Also CA simulations may be used to find safer and more efficient ways to conduct mass evacuation procedures.

A Case-Control Study of Hip Fracture Surgery Timing and Mortality at an Academic Hospital: Day Surgery May Be Safer than Night Surgery.

Time from hospital admission to operative intervention has been consistently demonstrated to have a significant impact on mortality. Nonetheless, the relationship between operative start time (day versus night) and associated mortality has not been thoroughly investigated. Methods: All patients who underwent hip fracture surgery at a single academic institution were retrospectively analyzed. Operative start times were dichotomized: (1) day operation—7 a.m. to 4 p.m.; (2) night operation—4 p.m. to 7 a.m. Outcomes between the two groups were evaluated. Results: Overall, 170 patients were included in this study. The average admission to operating room (OR) time was 26.0 ± 18.0 h, and 71.2% of cases were performed as a day operation. The overall 90-day mortality rate was 7.1% and was significantly higher for night operations (18.4% vs. 2.5%; p = 0.001). Following multivariable logistic regression analysis, only night operations were independently associated with 90-day mortality (aOR 8.91, 95% confidence interval 2.19–33.22; p = 0.002). Moreover, these patients were significantly more likely to return to the hospital within 50 days (34.7% vs. 19.0%; p = 0.029) and experience mortality prior to discharge (8.2% vs. 0.8%; p = 0.025). Notably, admission to OR time was not associated with in-hospital mortality (29.22 vs. 25.90 h; p = 0.685). Hip fracture surgery during daytime operative hours may minimize mortalities.

Pre-operative fasting times for clear liquids at a tertiary children's hospital; what can be improved?

BackgroundThe goal of preoperative fasting is to prevent pulmonary aspiration during general anesthesia. Fasting times are often prolonged leading to patient discomfort and risk for adverse events. This retrospective quality improvement survey evaluated effective nil-per-os (NPO) times and causes for prolonged NPO times with the aim to suggest improvement strategies by a newly founded fasting task force.MethodsData from all electronic anesthesia records from 2019 at our institution were reviewed for fasting times. Our NPO instructions follow American Society of Anesthesiology guidelines and are calculated based on the patient’s arrival time (90 min before operating room [OR] time). Primary outcome was the effective NPO time for clear liquids, secondary outcomes were incidence of delays and the parental compliance with the NPO instructions. Data are presented as median (interquartile range).ResultsIn total 9,625 cases were included in the analysis. NPO time was documented in 72.1% with a median effective NPO time of 7:13 h (7:36). OR in room times were documented in 72.8%, 2,075 (29.5%; median time 0:10 h [0:21]) were earlier and 4,939 (70.5%; median time 0:29 h [0:54]) were later than scheduled. Parental NPO compliance showed a median deviation for clear liquid intake of 0:55 h (8:30).ConclusionsThis study revealed that effective NPO times were longer than current ASA guidelines. Contributing causes include case delays and parental non-compliance to NPO instructions. Thus, task force recommendations include change NPO instruction calculations to scheduled OR time versus arrival time, and encourage parents to give their child clear liquids at the instructed time.

Evaluation of the quality composition of micromycetes in the air of the premises of stationary medical institutions

Introduction. Today, micromycetes are the most common pathogens found in residential and industrial premises and in the hospital environment. At the same time, mold fungi are the cause not only of allergic diseases but also of mycoses of various localization. Mold fungi are hazardous for patients in hospitals on long-term treatment and exposed to immunosuppression factors. Medical personnel who spent a long time in rooms with high contamination by micromycetes in the air can develop mycogenic sensitization. The aim of this work was to show the quantitative and qualitative composition of fungi surrounding the patient and the doctor in multidisciplinary hospitals. Materials and methods. With the help of a microbiological aspirator, air samples were taken in the premises of class B of surgical and therapeutic departments, followed by sowing on Saburo agar. The identified fungi were identified using classical methods and MALDI-ToF mass spectrometry using Microflex LT (Bruker). Results. In the course of the study, the assessment of fungal contamination of class B premises in treatment and prophylactic institutions was carried out to assess the qualitative and quantitative composition. Also, comparing the composition and number of micromycetes between the premises of departments of different profiles was carried out. A high level of contamination of micromycetes in medical premises of class B - 100% of cases was revealed in studies of objects of the hospital environment. The structure of the identified fungi was very diverse. In all air samples were isolated fungi genera Aspergillus, Penicillium, Mucor, Alternaria, and Ulcoladium. Spores of these fungi belonging to opportunistic or saprophytes are found in the air everywhere. Still, a significant increase in microbial load due to micromycetes can cause such typical allergic diseases as bronchial asthma, allergic skin dermatoses, and allergies of other locations. Conclusion. The study results revealed increased fungal contamination in healthcare facilities that require a more careful approach to compliance with the microclimate parameters.

Experience with 10\xa0years of a robotic surgery program at an Academic Medical Center

BackgroundFew studies have examined robotic surgery from a programmatic standpoint, yet this is how hospitals evaluate return on investment clinically and fiscally. This study examines the 10-year experience of a robotic program at a single academic institution.Study designAll robotic operations performed at our institution from August 2005 to December 2016 were reviewed. Data were collected from the robotic system and hospital databases.ResultsA total of 3485 robotic operations were performed. Yearly case volume nearly quadrupled. There have been 37 robotic-trained surgeons in 5 specialties performing 53 different operations. Rate of conversion to open was 4.2%. American Society of Anesthesiologists (ASA) class increased over time, with ASA class 3 increasing from 20% of patients to 45% of patients.Average case time in 2005 was 453 min, but decreased by 46% to 246 min by 2007, then remained relatively stable (range 226–247). Operating efficiency improved, with room time and case time decreasing by 9% in the past 4 years.Average cost for robotic supplies was $1519 per case. Additional costs per case related to equipment and contracts totaled an average of $11,822.Average length of stay (LOS) for robotic cases was 3.3 days, compared to 3.0 days for laparoscopic and 7.0 for open. Cost per day for admission after robotic surgery was 1.7 times greater than the cost of open or laparoscopic surgery. Total admission costs of robotic operations were 1.5 times those of laparoscopic surgery, but less than open operations. Readmissions following robotic cases were lower than open (15% v 26%, p < 0.0001).ConclusionsOver 10 years, the use of robotic technology has grown significantly at our institution, with good fiscal and clinical outcomes. Operating room costs are high; however, efficiency has improved, LOS is shorter, admission costs are lower than open operations, and readmission rates are lower.

Reducing Pediatric Patient Anxiety: Implementing a Nonpharmacologic Intervention to Aid Patients Undergoing Radiation Therapy.

Pharmacologic interventions are often used to assist with immobilization and decrease anxiety in pediatric patients undergoing radiation therapy. For these patients, distraction can be an alternative to using pharmacologic measures to address anxiety. As a distraction technique, this pilot project placed pediatric patients aged 3 to 6 years in a remote-controlled ride-on car (RC-ROC) to enter and exit the radiation therapy treatment room. Evaluation of the effectiveness of this distraction technique included patient propofol dosing, time sedated, and time in the treatment room, as well as staff satisfaction with the technique.

The Design and Development of the Destiny-Class CyberCANOE Hybrid Reality Environment

The Destiny-class CyberCANOE (Destiny) is a Hybrid Reality environment that provides 20/20 visual acuity in a 13-foot-wide, 320-degree cylindrical structure comprised of tiled passive stereo-capable organic light emitting diode (OLED) displays. Hybrid Reality systems combine surround-screen virtual reality environments with ultra-high-resolution digital project-rooms. They are intended as collaborative environments that enable multiple users to work minimally encumbered for long periods of time in rooms surrounded by data in the form of visualizations that benefit from being displayed at resolutions matching visual acuity and/or in stereoscopic 3D. Destiny is unique in that it is the first Hybrid Reality system to use OLED displays and it uses a real-time GPU-based approach for minimizing stereoscopic crosstalk. This paper chronicles the non-trivial engineering research and attention-to-detail that is required to develop a production quality hybrid-reality environment by providing details about Destiny’s design and construction process. This detailed account of how a Hybrid Reality system is designed and constructed from the ground up will help VR researchers and developers understand the engineering complexity of developing such systems. This paper also discusses a GPU-based crosstalk mitigation technique and evaluation, and the use of Microsoft’s augmented reality headset, the HoloLens, as a design and training aid during construction.

Postoperative single-sequence (PoSSe) MRI: imaging work-up for CT-guided or endoscopic drainage indication of collections after hepatopancreaticobiliary surgery

PurposeFluid collections due to anastomotic leakage are a common complication after hepatopancreaticobiliary (HPB) surgery and are usually treated with drainage. We conducted a study to evaluate imaging work-up with a postoperative single-sequence (PoSSe) MRI for the detection of collections and indication of drainage.Material and methodsForty-six patients who developed signs of leakage (fever, pain, laboratory findings) after HPB surgery were prospectively enrolled. Each patient was examined by abdominal sonography and our PoSSe MRI protocol (axial T2-weighted HASTE only). PoSSe MRI examination time (from entering to leaving the MR scanner room) was measured. Sonography and MRI were evaluated regarding the detection and localization of fluid collections. Each examination was classified for diagnostic sufficiency and an imaging-based recommendation if CT-guided or endoscopic drainage is reasonable or not was proposed. Imaging work-up was evaluated in terms of feasibility and the possibility of drainage indication.ResultsSonography, as first-line modality, detected 21 focal fluid collections and allowed to decide about the need for drainage in 41% of patients. The average time in the scanning room for PoSSe MRI was 9:23 min [7:50–13:32 min]. PoSSe MRI detected 46 focal collections and allowed therapeutic decisions in all patients. Drainage was suggested based on PoSSe MRI in 25 patients (54%) and subsequently indicated and performed in 21 patients (100% sensitivity and 84% specificity). No patient needed further imaging to optimize the treatment.ConclusionsThe PoSSe MRI approach is feasible in the early and intermediate postoperative setting after HPB surgery and shows a higher detection rate than sonography. Imaging work-up regarding drainage of collections was successful in all patients and our proposed PoSSe MRI algorithm provides an alternative to the standard work-up.

High Accuracy of Digital Tomosynthesis-Guided Bronchoscopic Biopsy Confirmed by Intraprocedural Computed Tomography

Background: Digital fluoroscopic tomosynthesis-guided electromagnetic navigational bronchoscopy (F-ENB) is a novel adjunct to ENB associated with higher diagnostic yield. The likelihood of F-ENB allowing accurate placement of a biopsy needle within a target remains unclear. Objective: This study intends to determine the accuracy of F-ENB as confirmed by cone-beam computed tomography (CBCT) scan. Methods: Patients undergoing CBCT-assisted ENB for lung nodule biopsy were prospectively enrolled. ENB was performed followed by digital tomosynthesis correction. Once optimal F-ENB alignment was achieved, and a needle was advanced into the expected location of the nodule followed by CBCT. The primary outcome was the percentage of “needle-in-lesion” hits, defined as needle tip within the nodule in 3 planes. Secondary outcomes were diagnostic yield, procedure and room time, complications, radiation, and distance between the needle tip and nodule. Results: Twenty-six patients with a total of 29 nodules were enrolled. Mean nodule size was 13 mm (±4 mm) in maximal axial dimension, 83% (n = 24) were located in the peripheral third of the chest, and 17% (n = 5) had a bronchus sign. F-ENB guidance resulted in needle-in-lesion in 21 of 29 nodules (72%). Mean needle tip-to-nodule distance for nonhits was 1.75 mm (±1.35 mm). There were no complications. Conclusion: F-ENB resulted in a needle-in-lesion biopsy in greater than 70% of nodules despite features traditionally associated with poor diagnostic yield (size, absence of bronchus sign). Mean distance between needle tip and target for nonhits was less than 2 mm. These data suggest F-ENB alignment is accurate for small peripheral nodules.

The implementation of TORS for head and neck surgery in Thailand

Transoral robotic surgery (TORS) is a novel surgical treatment of head and neck cancers, mainly for limited tumor in oropharynx and supraglottis. Despite the major advantage of favorable postoperative functional outcomes, many obstacles exist during the implementation of TORS, especially in a country where financial resources are modest. We demonstrated our experience of initiating this sophisticated technology at the largest tertiary hospital in Thailand. A retrospective review study was conducted in patients with benign or malignant lesions during 2014-2020 at Siriraj Hospital. Different periods of operation time between initial and subsequent cases were compared to evaluate learning-curve improvement. A total of 36 patients underwent TORS, with median follow-up time of 18months. The average time of room set-up, anesthesia, and positioning was 37 ± 14, 13 ± 7, and 15 ± 7min, respectively. Whilst, the average robotic procedure time and total time in room were 44 ± 19 and 118 ± 31min, consecutively. There was no significant difference in any time interval, except the set-up time between initial and subsequent cases. The worthwhile utilization of TORS could be administered cost-effectively despite the complicated and daunting implementation of TORS. Whilst, meticulous planning and sufficient training prior to the initiation of TORS can favorably shorten the learning curve of operative staffs in the TORS team.

Vacuum-Assisted Hot-Forming Using Tailored Laminate Temperature

A non-isothermal vacuum assisted hot-forming process using tailored laminate temperature is introduced. By using process simulation and manufacturing experiments, improved laminate quality is achieved compared to the standard hot-forming process. Furthermore, it is also shown that the manufacturing time in the clean room can be reduced to one tenth of the standard process time. In this study 8.4 mm thick quasi-isotropic laminates from unidirectional prepreg were laid up flat with an automatic tape laying machine and hot-formed to a U-shaped laminate. The laminates were then cured in a concave mould with standard bag on the inside. A complete tailored temperature hot-forming cycle of 7.5 min produced a very good final laminate quality with a total thickness variation as low as 4.0% and without wrinkles or indications of porosity. With a 4 min hot-forming cycle the thickness variation was also acceptable at 8%.