Patient Safety in the Operating Room During Urologic Surgery: The OR Black Box Experience.

PURPOSE: To mitigate intraoperative adverse events, it is important to understand the context in which these errors occur. The purpose of this study is to characterize the IAEs and potential distractions that occur in minimally invasive urologic procedures. METHODS: We conducted a prospective cohort study in patients undergoing laparoscopic urologic surgery at an academic health center. The OR Black Box, a unique technology system which captures video and audio recordings of the operating room as well as the operative field, was used to collect data regarding procedure type, critical step, IAEs, and distractions. RESULTS: Of a total of 80 cases analyzed, the majority of these cases were partial nephrectomy (n = 36; 45%), radical nephrectomy (n = 20; 25%), and adrenalectomy (n = 4; 5%). Across all cases, there were a total of 138 clinically significant IAEs, 10 of which (14%) were of the highest severity (five on the SEVerity of intraoperative Events and Rectification Tool (SEVERE) matrix). Of these, 70 (51%) occurred during an a priori defined critical step of the operation. Distractions were common across all cases. The median rate of external communication per case was 16 events (IQR 11-22); and per critical step was 4 (IQR 2.75-8), while median room traffic per case was 65 entries/exits (IQR 42-76); and per critical step was 17 (IQR 10-65). CONCLUSION: Our data demonstrate that IAEs occur frequently during all phases of the operation at hand. Future study will be required to examine the role of distractions and IAE as well as IAE and their relationship to post-operative clinical outcomes.

Impact of Short-Range Forces on Defect Production from High-Energy Collisions.

Primary radiation damage formation in solid materials typically involves collisions between atoms that have up to a few hundred keV of kinetic energy. During these collisions, the distance between two colliding atoms can approach 0.05 nm. At such small atomic separations, force fields fitted to equilibrium properties tend to significantly underestimate the potential energy of the colliding dimer. To enable molecular dynamics simulations of high-energy collisions, it is common practice to use a screened Coulomb force field to describe the interactions and to smoothly join this to the equilibrium force field at a suitable interatomic spacing. However, there is no accepted standard method for choosing the parameters used in the joining process, and our results prove that defect production is sensitive to how the force fields are linked. A new procedure is presented that involves the use of ab initio calculations to determine the magnitude and spatial dependence of the pair interactions at intermediate distances, along with systematic criteria for choosing the joining parameters. Results are presented for the case of nickel, which demonstrate the use and validity of the procedure.

Electron-phonon coupling in Ni-based binary alloys with application to displacement cascade modeling.

Energy transfer between lattice atoms and electrons is an important channel of energy dissipation during displacement cascade evolution in irradiated materials. On the assumption of small atomic displacements, the intensity of this transfer is controlled by the strength of electron-phonon (el-ph) coupling. The el-ph coupling in concentrated Ni-based alloys was calculated using electronic structure results obtained within the coherent potential approximation. It was found that Ni0.5Fe0.5, Ni0.5Co0.5 and Ni0.5Pd0.5 are ordered ferromagnetically, whereas Ni0.5Cr0.5 is nonmagnetic. Since the magnetism in these alloys has a Stoner-type origin, the magnetic ordering is accompanied by a decrease of electronic density of states at the Fermi level, which in turn reduces the el-ph coupling. Thus, the el-ph coupling values for all alloys are approximately 50% smaller in the magnetic state than for the same alloy in a nonmagnetic state. As the temperature increases, the calculated coupling initially increases. After passing the Curie temperature, the coupling decreases. The rate of decrease is controlled by the shape of the density of states above the Fermi level. Introducing a two-temperature model based on these parameters in 10 keV molecular dynamics cascade simulation increases defect production by 10-20% in the alloys under consideration.

The Angelchik antireflux prosthesis: long-term clinical and technical follow-up.

OBJECTIVE: To evaluate the long-term clinical outcome and compare the rupture rate of the two generations of the silicone Angelchik antireflux prosthesis. DESIGN: A cohort study. Follow-up ranged from 61 to 119 months. SETTING: A university teaching hospital. PATIENTS: Sixty-three patients: 33 patients received the first generation Angelchik device (group 1) and 30 patients received a second generation design (group 2). The two groups were comparable for sex ratio, mean age and duration of symptoms. INTERVENTIONS: Implantation of the Angelchik prosthesis. MAIN OUTCOME MEASURES: Comparison of the rupture rate and migration of the prosthesis as assessed by patient questionnaire, telephone interview and radiography of the abdomen. RESULTS: The prosthesis remained in a good position in 53% of group 1 patients and 93% of group 2 patients. The prosthesis was removed in 40% of group 1 patients, most often for rupture, and in only 7% of patients in group 2, to relieve dysphagia (p < 0.01). Grading on a Visick scale demonstrated a good result in 37% of group 1 patients and 69% of group 2 patients. Long-term dysphagia was the most prevalent adverse effect, seen in 45% of patients whose prosthesis was in a good position, and symptomatic reflux recurred in 8%. CONCLUSIONS: The second generation of the Angelchik prosthesis, resulted in a reduced rupture rate of the prosthesis. Nevertheless the high complication and the failure rates militate against continued implantation of the prosthesis.

Complete response to combination therapy with an LHRH agonist and flutamide in metastatic male breast cancer: a case report.

Twelve months after modified radical mastectomy with axillary dissection (4 out of 13 nodes found positive) in a 66-year old man, bone scintigraphy showed multiple bone metastases. Treatment was started with the combined administration of an LHRH agonist and the pure antiandrogen Flutamide. Six and a half months later, bone scintigraphy was normal while serum testosterone was reduced to 10% of control and the serum concentration of the adrenal steroids was decreased by 23 to 45%. Following relapse of the disease at 12 months, more complete blockade of adrenal steroid secretion was achieved with aminoglutethimide and hydrocortisone. Stability of the disease was then observed up to the last evaluation performed in January 1990 (5 years of stable disease). Since the adrenal steroids are converted into active androgens and estrogens in peripheral tissues, including the breast, the combined therapy has the advantage of reducing the source of potentially active estrogens and androgens while blocking the action of androgens in target tissues. No side-effects other than those due to hypoandrogenicity, namely hot flushes and loss of libido and potency were observed. This well-tolerated treatment achieves complete medical castration, partial medical adrenalectomy, and neutralization of peripheral androgen action.

[Congenital diaphragmatic hernia. Therapeutic re-evaluation]. / La hernie diaphragmatique congénitale. Réévaluation thérapeutique.

Twenty-eight patients with "High-Risk" diaphragmatic hernia were treated without postoperative ipsilateral chest drains. Overall survival was 71%. This study suggests that, in cases of complete absence of the diaphragm, the use of a mesh pervious to air is as noxious postoperatively as an underwater chest drain. This idea is supported by experiments in cats with a left pneumonectomy, in which part of the diaphragm was replaced either by a macroporous mesh or by a microporous prosthesis impervious to air at normal pressures. Moreover, barotrauma may occur preoperatively and when assisted ventilation is required, inspiratory pressure must be strictly limited.

Short-term antibiotherapy for peritonitis: prospective, randomized trial comparing cefotaxime-metronidazole and clindamycin-tobramycin.

The combination of cefotaxime and metronidazole has been suggested for the treatment of peritonitis. We compared their effectiveness with that of tobramycin and clindamycin. Since antibiotics have most of their beneficial effect within a few days a four day course was used and a randomized trial was undertaken. The effectiveness of the 4-day course was 86% and no difference was seen between the two groups of the study.

Another look at the Sparks-Mandril arterial graft precursor for vascular repair. - Pathology by scanning electron microscopy.

The Sparks-Mandril blood vessel precursor system, an autogenous tissue growth-promoting device, in spite of its ingenuity and its surgical elegance, has received only limited usage. At technique for peripheral blood vessels by several authors. In the latter period, this laboratory also undertook similar work. The results of seven implantations in dogs and two in patients are reported here in the context of a program on the evaluation of blood vessel substitutes, their mode of operation and their long term performance. The clinical status and the pathology of the grafts at time of failure were investigated using techniques of scanning electron microscopy. This work confirms the findings of other centres regarding the generally unsatisfactory performance of the Sparks-Mandril system. Possible causes for failure in mandril-formed blood vessels are discussed.