Using OR Black Box Technology to Determine Quality Improvement Outcomes for In-situ Timeout and Debrief Simulation.

OBJECTIVE: The purpose of this study was to determine quality improvement outcomes following the pilot implementation of an in-situ simulation designed to enhance surgical safety checklist performance. BACKGROUND: OR Black Box (ORBB) technology allows near real-time assessment for surgical safety checklist performance. Before our study, timeout quality was 73.3%, compliance was 99.9%, and engagement was 89.7% (n=1993 cases); Debrief Quality was 76.0%, compliance was 66.9%, and engagement was 66.7% (n=1842 cases). METHODS: This IRB-approved study used prospective convergent multi-methods. During 2 months, a 15-minute in-situ simulation, incorporating rapid cycle deliberate practice, was implemented for OR teams. ORBB analytics generated Timeout and Debrief scores for actual operations performed by surgeons who participated in simulation (Sim-group) versus those who did not (No-sim group) over 6 months, including 2 months pre-intervention, during-intervention, and post-intervention. Inductive content analysis was performed based on simulation discussions to determine team member perspectives. RESULTS: Thirty simulations with 163 interprofessional participants were conducted. ORBB data from 1570 cases were analyzed. Scores were significantly better for the Sim-group compared with the No-sim group for debrief quality (84% vs. 79% P<0.001, during-intervention), compliance (73% vs. 66%, P<0.001, post-intervention), and engagement (80% vs. 73%, P=0.012, during-intervention). There were no between-group differences for Timeout scores. Thematic analysis identified 2 primary categories: "culture of safety" and "policy." CONCLUSIONS: This simulation-based QI intervention created a psychologically safe training environment for OR teams. The novel use of ORBB technology facilitated outcome analysis and showed significantly better Debrief scores for simulation-trained surgeons compared with nontrained surgeons.

Temperature and luminosity outputs of endoscopes used in transcanal endoscopic ear surgery: an experimental study.

OBJECTIVE: To establish the relationship between endoscope temperatures and luminosity with a variety of light source types, endoscope ages, endoscope sizes, angles and operative distance in transcanal endoscopic ear surgery. METHODS: Transcanal endoscopic ear surgery was simulated in an operating theatre using 7 mm plastic suction tubing coated in insulating tape. An ATP ET-959 thermometer was used to record temperatures, and a Trotec BF06 lux meter was used to measure luminosity. Luminosity and temperature recordings were taken at 0 mm and 5 mm from the endoscope tip. RESULTS: Thermal energy transfer from operating endoscopes is greatest when: the light intensity is high, there is a light-emitting diode light source and the endoscope is touching the surface. Additionally, larger-diameter endoscopes, angled endoscopes and new endoscopes generated greater heat. CONCLUSION: It is recommended that operative light intensity is maintained at the lowest level possible, and that the surgeon avoids contact between patient tissues and the endoscope tip.

On the identification of individual level pleiotropic, pure direct, and principal stratum direct effects without cross world assumptions.

The analysis of natural direct and principal stratum direct effects has a controversial history in statistics and causal inference as these effects are commonly identified with either untestable cross world independence or graphical assumptions. This article demonstrates that the presence of individual level natural direct and principal stratum direct effects can be identified without cross world independence assumptions. We also define a new type of causal effect, called pleiotropy, that is of interest in genomics, and provide empirical conditions to detect such an effect as well. Our results are applicable for all types of distributions concerning the mediator and outcome.

Noninvasive Continuous Hemoglobin Monitoring: Role in Cardiovascular Surgery.

Blood transfusions in the operating room are associated with increased morbidity and mortality as well as increased cost. The technology exists for continuous noninvasive hemoglobin monitoring (SpHb), which could allow for the rapid diagnosis and treatment of acute blood loss anemia secondary to surgical bleeding. However, the accuracy of this technology has been called into question. SpHb in the operating room could reduce cost by decreasing lab draws, unnecessary transfusions, and the morbidity associated with blood transfusions. This review examines the accuracy of noninvasive hemoglobin monitoring as well as the role it may play in the operating room.

Costochondral grafting for paediatric temporomandibular joint reconstruction: 10-year outcomes in 55 cases.

Costochondral grafting (CCG) can be used for the reconstruction of ankylotic, hypoplastic, and resected temporomandibular joint (TMJ) defects. CCGs have previously been considered the gold standard in children due to their growth potential and autogenous origin, but the disadvantages are unpredictable growth and joint ankylosis. This was a retrospective study of all children who received CCGs for TMJ reconstruction from 1985 to 2004, to allow a 10-year follow-up. Fifty-five patients were included in this study, with 74 grafts being placed; their mean age was 7.9±4.2years. Infection-related ankylosis (18.2%) and craniofacial microsomia (16.4%) were the most common diagnoses. Overall, 58.2% of patients suffered one or more complications over the follow-up period, with ankylosis (32.7%) and overgrowth (16.4%) being most common. There was a significant correlation between those with infection-related ankylosis and subsequent complications (χ2=8.8, df=1, P<0.005), while ankylotic patients in general exhibited greater overall complication rates (χ2=9.0, df=1, P<0.005). Patients with congenital TMJ defects were more likely to be complication-free than those with acquired defects (χ2=4.0, df=1, P<0.05). Caution is advised when placing CCGs in paediatric patients with ankylosed TMJs, especially those with infection-related ankylosis.

Elucidating the molecular basis of PPCD: Effects of decreased ZEB1 expression on corneal endothelial cell function.

PURPOSE: To investigate the functional role that the zinc e-box binding homeobox 1 (ZEB1) gene, which underlies the genetic basis of posterior polymorphous corneal dystrophy 3 (PPCD3), plays in corneal endothelial cell proliferation, apoptosis, migration, and barrier function. METHODS: A human corneal endothelial cell line (HCEnC-21T) was transfected with siRNA targeting ZEB1 mRNA. Cell proliferation, apoptosis, migration, and barrier assays were performed: Cell proliferation was assessed with cell counting using a hemocytometer; cell apoptosis, induced by either ultraviolet C (UVC) radiation or doxorubicin treatment, was quantified by measuring cleaved caspase 3 (cCASP3) protein levels; and cell migration and barrier function were monitored with electric cell-substrate impedance sensing (ECIS). RESULTS: ZEB1 knockdown in HCEnC-21T cells transfected with siRNA targeting ZEB1 did not result in a significant difference in cell proliferation when compared with control. Although knockdown of ZEB1 in HCEnC-21T cells sensitized the cells to UV-induced apoptosis, ZEB1 knockdown did not alter the cells' susceptibility to doxorubicin-induced apoptosis, as measured with cCASP3 protein levels, compared with controls. Similarly, no difference was observed in cell migration following ZEB1 knockdown. However, cell barrier function increased significantly following ZEB1 knockdown. CONCLUSIONS: The corneal endothelium in PPCD3 is characterized by morphologic, anatomic, and molecular features that are more consistent with an epithelial-like rather than an endothelial-like phenotype. Although these characteristics have been well documented, we demonstrate for the first time that susceptibility to UV-induced apoptosis and cell barrier function are significantly altered in the setting of reduced ZEB1. The significance of an altered cellular response to apoptotic stimuli and increased cell barrier function in the pathobiology of PPCD remains to be fully elucidated.

Vortex Pattern of Corneal Deposits in Granular Corneal Dystrophy Associated With the p.(Arg555Trp) Mutation in TGFBI.

PURPOSE: To describe 2 unrelated families with multiple members demonstrating a less commonly recognized vortex pattern of corneal deposits confirmed to be granular corneal dystrophy type 1 (GCD1) after identification of the p.(Arg555Trp) mutation in the transforming growth factor ß-induced gene (TGFBI). METHODS: A slit-lamp examination was performed on individuals from 2 families, one of Mexican descent and a second of Italian descent. After DNA extraction from affected individuals and their unaffected relatives, TGFBI screening was performed. RESULTS: Eight of 20 individuals in the Mexican family and 20 of 55 in the Italian family demonstrated corneal stromal opacities. Seven of the 8 affected individuals in the Mexican family and 4 of the 20 affected individuals in the Italian family demonstrated a phenotype characterized by a "sea fan" or vortex pattern of superficial stromal corneal deposits originating from the inferior aspect of the cornea. Screening of TGFBI in both families revealed a heterozygous missense mutation [p.(Arg555Trp)] in exon 12, confirming the diagnosis of GCD1. CONCLUSIONS: Our findings demonstrate that GCD1 may present with a vortex pattern of anterior stromal deposits. Although this pattern of dystrophic deposits is not recognized by clinicians as a typical phenotype of GCD1, it is consistent with the production of the majority of the TGFBI protein by the corneal epithelium.

Relationship Between Binocular Summation and Stereoacuity After Strabismus Surgery.

PURPOSE: To describe the relationship between binocular summation and stereoacuity after strabismus surgery. DESIGN: Prospective case series. METHODS: setting: Stein Eye Institute, University of California Los Angeles. PATIENT POPULATION: Pediatric strabismic patients who underwent strabismus surgery between 2010 and 2015. OBSERVATION PROCEDURES: Early Treatment Diabetic Retinopathy Study visual acuity, Sloan low-contrast acuity (LCA, 2.5% and 1.25%), and Randot stereoacuity 2 months following surgical correction of strabismus. MAIN OUTCOME MEASURES: The relationship between binocular summation (BiS), calculated as the difference between the binocular visual acuity score and that of the better eye, and stereoacuity. RESULTS: A total of 130 postoperative strabismic patients were studied. The relationship between binocular summation and stereoacuity was studied by Spearman correlation. There were significant correlations between BiS for 2.5% LCA with near and distance stereoacuity (P = .006 and P = .009). BiS for 1.25% LCA was also significantly correlated with near stereoacuity (P = .04). Near stereoacuity and BiS for 2.5% and 1.25% LCA were significantly dependent (Pearson χ(2), P = .006 and P = .026). Patients with stereoacuity demonstrated significantly more BiS in 2.5% LCA of 2.7 (P = .022) and 3.1 (P = .014) letters than did those without near or distance stereoacuity, respectively. CONCLUSIONS: These findings demonstrate that stereopsis and binocular summation are significantly correlated in patients who have undergone surgical correction of strabismus.

The effectiveness of cast wedging for the treatment of pediatric fractures.

We present the results of cast wedging for correction of alignment during the closed treatment of tibial and radial shaft fractures in children. We retrospectively reviewed the radiographic and clinical outcome of 249 cast wedges performed after reangulation of a previously manipulated tibial or radial shaft fracture. A mean improvement of close to 5 in coronal alignment was observed. A satisfactory outcome was obtained in 96% of patients with tibial fractures and 94% of patients with radial fractures. Cast wedging is a safe and effective tool for the treatment of angulated, pediatric tibial and radial shaft fractures.

3'-monoiodothyronine sulfate and Triac sulfate are thyroid hormone metabolites in developing sheep.

We used novel 3'-monoiodothyronine sulfate (3'-T1S) and 3,3',5-triiodothyroacetic acid sulfate (TriacS) RIAs to characterize sulfation pathways in fetal thyroid hormone metabolism. 3'-T1S and TriacS levels were measured in serum samples obtained from fetal (n = 21, 94-145 d gestational age), newborn (NB, n = 5), and adult sheep (AD, n = 5) as well as from fetuses after total thyroidectomy (Tx), or sham-operated twin fetuses controls, conducted at gestational age 110-113 d (n = 5). Peak levels (expressed as ng/dL) of both 3'-T1S and TriacS occurred at 130 d gestation. These levels in fetuses were higher than those in NB and AD. In Tx fetuses, there was a significant decrease in the mean serum level of 3'-T1S, but not TriacS. The decrease in 3'-T1S in Tx is similar to that observed for thyroxine sulfate (T4S) and 3,3',5'-triiodothyronine sulfate (rT3S), whereas TriacS levels were not altered in the hypothyroid state, similarly to 3,3',5-triiodothyronine sulfate (T3S). These data demonstrate that 3'-T1S and TriacS are normal thyroid hormone metabolites in ovine serum and that TriacS is likely derived from T3S or from the same precursor(s) as T3S.

Oman Eye Study 2005: prevalence and determinants of glaucoma.

This community-based study was carried out to estimate the prevalence and identify the determinants of glaucoma in the Omani population in 2005-06. Residents of 75 randomly selected houses in 25 clusters participated in the survey. We interviewed and examined 3324 individuals aged > or = 30 years in their homes and in eye clinics to note personal details, glaucoma status and presence of selected risk factors: 180 were diagnosed as having glaucoma. Projected prevalence of glaucoma among the Omani population > or = 30 years was 4.75%. Open angle and angle closure types of glaucoma contributed 40.6% and 37.8% respectively. History of hypertension was negatively, and older age and family history of glaucoma were positively, associated with glaucoma.

Oman Eye Study 2005: prevalence and determinants of glaucoma

This community-based study was carried out to estimate the prevalence and identify the determinants of glaucoma in the Omani population in 2005-06. Residents of 75 randomly selected houses in 25 clusters participated in the survey. We interviewed and examined 3324 individuals aged >/= 30 years in their homes and in eye clinics to note personal details, glaucoma status and presence of selected risk factors: 180 were diagnosed as having glaucoma. Projected prevalence of glaucoma among the Omani population >/= 30 years was 4.75%. Open angle and angle closure types of glaucoma contributed 40.6% and 37.8% respectively. History of hypertension was negatively, and older age and family history of glaucoma were positively, associated with glaucoma

Sentinel lymph node biopsy in the Sultanate of Oman.

OBJECTIVE: To establish the feasibility of newly started sentinel lymph node (SLN) biopsy in our center at the Royal Hospital in the Sultanate of Oman. METHODS: Twenty five patients with Breast cancer and melanoma were staged with sentinel lymph node (SLN) biopsy, followed by Axillary lymph Node Dissection (ALND). Axillary SLN were detected by injection of blue dye alone or with radioisotope. Intraoperatively, a gamma probe detector identified the isotope-labeled SLN. Two patients underwent preoperative lymphoscintigraphy. The SLNs were examined histologically by hematoxylin-eosin staining and, if negative by this method an immunohistochemical staining (IHC) was done. RESULTS: The only failure to detect inguinal SLN was one case after neoadjuvant chemotherapy. Total detection rate of SLN was of 96%. Metastatic spread occurred in 11 patients of these 9 had other lymph node (LN) involved. Nine patients had no SLN involvement and no other LNs involved. CONCLUSIONS: Ethically, according to the international recommendations and looking to the statistics of the Sultanate all clinical NO should have the choise of SLN biopsy prior to ALND.

Expression of Human papillomavirus type 16 major capsid protein in transgenic Nicotiana tabacum cv. Xanthi.

The production of vaccine antigens in plants is a safe and potentially very cost-effective alternative to traditional expression systems. We investigated the possibility of transgenic plant expression of the Human papillomavirus (HPV) type 16 L1 major capsid protein, with and without nuclear localisation signals, in Nicotiana tabacum cv. Xanthi plants. The genes were stably integrated into the N. tabacum genome, and both the expressed proteins were capable of assembling into capsomers and virus-like particles. The proteins in concentrated leaf extracts (L1(Tr)) were tested for antigenicity using a panel of characterised monoclonal antibodies (Mabs). Neutralising and conformation-specific Mabs (H16:V5 and H16:E70) were shown to bind to both types of the plant-produced particles. We estimated the L1(Tr) product yield to be 2-4 microg per kg of fresh leaf material. Rabbits immunised with small doses of plant-produced particles elicited a weak anti-HPV-16 L1 immune response. Our results support the feasibility of using transgenic plants for the production of HPV vaccines.

Immunogenicity of measles and rubella vaccines in Oman: a prospective clinical trial.

A prospective immunogenicity trial of measles and rubella vaccines was conducted in Oman. Children received measles vaccine at age 9 months and measles-rubella vaccine at age 15 months. Serum specimens were tested for measles-specific IgG and rubella-specific IgG. Of 1025 eligible infants, 881 (86.0%) returned for all five visits and had adequate serum samples for testing. Seroconversion to measles after vaccination at 9 months was 98.1%. At 15 months, 47 (5.3%) of the 881 children were seronegative for measles; of these, 44 (93.6%) seroconverted. At 16 months, 99% of the children seronegative at age 9 months seroconverted after receiving two doses of measles vaccine. At age 15 months, 684 (77.6%) children were seronegative for rubella. Of these, 676 (98.8%) seroconverted by age 16 months. One dose of measles vaccine at age 9 months was highly immunogenic. One dose of measles-rubella vaccine at age 15 months closed the remaining measles immunogenicity gap and resulted in a high rate of rubella seroconversion.

Subcellular organization of N2-fixing nodules of cowpea (Vigna unguiculata) supplied with silicon.

Provision of silicon (0, 0.048, 0.096, 0.24, 0.48, and 0.96 g/l) in the form of silicic acid (H4SiO4) to nodulated cowpea plants (Vignia unguiculata [L.] Walp.) grown in liquid culture resulted in considerable changes in the internal organization of nodule structure. Compared to the control plants which received no added silicate, bacteroid numbers increased significantly (P < or = 0.05) at silicate concentrations of both 0.096 and 0.48 g/l. The number of symbiosomes also increased by 3.2-fold at the silicate concentration of 0.96 g/l compared to the control. In contrast, the size of bacteroids and symbiosomes decreased significantly (P < 0.05) inside nodules of silicate-treated plants. The peribacteroid space was also decreased considerably (P < 0.05) with the application of 0.096 and 0.96 g of silicate per liter to plants. However, the size of intercellular spaces adjacent to infected and uninfected interstitial cells within the nodule medulla increased significantly (P < or = 0.05) at 0.096 g of silicate per liter followed by a sharply marked (P < or = 0.05) decrease with each subsequent increase in silicate application. The result was a large decrease (P < 0.05) in the area of bacteria-infected tissue occupied by intercellular space at the highest silicate concentration, which was caused by a significant (P < or = 0.05) increase in cell wall thickness. Our findings show that the positive effects of silicon on N2 fixation might actually be due to an increased number of bacteroids and symbiosomes.