Measures of performance and proficiency in robotic assisted surgery: a systematic review.

Robotic assisted surgery (RAS) has seen a global rise in adoption. Despite this, there is not a standardised training curricula nor a standardised measure of performance. We performed a systematic review across the surgical specialties in RAS and evaluated tools used to assess surgeons' technical performance. Using the PRISMA 2020 guidelines, Pubmed, Embase and the Cochrane Library were searched systematically for full texts published on or after January 2020-January 2022. Observational studies and RCTs were included; review articles and systematic reviews were excluded. The papers' quality and bias score were assessed using the Newcastle Ottawa Score for the observational studies and Cochrane Risk Tool for the RCTs. The initial search yielded 1189 papers of which 72 fit the eligibility criteria. 27 unique performance metrics were identified. Global assessments were the most common tool of assessment (n = 13); the most used was GEARS (Global Evaluative Assessment of Robotic Skills). 11 metrics (42%) were objective tools of performance. Automated performance metrics (APMs) were the most widely used objective metrics whilst the remaining (n = 15, 58%) were subjective. The results demonstrate variation in tools used to assess technical performance in RAS. A large proportion of the metrics are subjective measures which increases the risk of bias amongst users. A standardised objective metric which measures all domains of technical performance from global to cognitive is required. The metric should be applicable to all RAS procedures and easily implementable. Automated performance metrics (APMs) have demonstrated promise in their wide use of accurate measures.

Effects of feeding various dosages of Saccharomyces cerevisiae fermentation product in transition dairy cows.

Feeding 56 versus 0 g/d of Saccharomyces cerevisiae fermentation product (SCFP; Diamond V Original XP; Diamond V, Cedar Rapids, IA) can increase feed intake and milk production in transition dairy cows. To evaluate the effects of various dosages of SCFP, Holstein cows were given individually a supplement containing 0 (n=14), 56 (n=15), or 112 g (n=13) of SCFP daily during morning lockup as a topdressing to their total mixed ration. The supplement consisted of 0, 56, or 112 g of SCFP mixed with 84 g of molasses and 168, 112, or 56 g of corn meal, respectively. Supplement feeding began 28 d before predicted calving date (no less than 14 d) and ended 28 d postpartum, and supplement intake was evaluated daily. Blood samples were collected at d -21, -14, -7, -3, -1, 0, 1, 3, 7, 14, 21, and 28 to measure serum concentrations of macrominerals, metabolites, acute-phase proteins, immunoglobulin, and hormones. Milk weights were measured and milk samples were collected 2 times/wk on nonconsecutive days and analyzed for milk fat, protein, lactose, and somatic cell count (SCC). During the first day after calving, feeding SCFP versus no SCFP decreased serum cortisol concentrations and at least tended to increase supplement intake and serum concentrations of calcium, glucose, urea N, and serum amyloid A. During the first 4 wk postpartum, feeding SCFP versus no SCFP decreased milk SCC and increased milk production and serum phosphorus concentrations. Feeding 112 versus 56 g of SCFP/d did not show additional effects. Feeding SCFP may have a dosage-independent beneficial effect in supporting the physiologic adaptations after parturition, resulting in higher milk production and lower milk SCC.

Late-onset prosthetic valve endocarditis caused by Mycoplasma hominis, diagnosed using broad-range bacterial PCR.

We report what is believed to be the first case of late-onset prosthetic valve endocarditis caused by Mycoplasma hominis in a case of blood culture-negative endocarditis. The objective of this report is to emphasize the use of a broad-range PCR technique for bacterial 16S rRNA genes in identifying the causative pathogen, thus enabling targeted antimicrobial treatment.

[Anti-p200 pemphigoid: a spectacular response to dapsone]. / Pemphigoïde anti-p200 : réponse spectaculaire à la dapsone.

BACKGROUND: Types of subepidermal autoimmune bullous dermatosis (AIBD) are classified by anatomoclinical picture and target antigen. A new entity has recently been identified: anti-p200 pemphigoid. PATIENTS AND METHODS: An 82-year-old man consulted for a profuse pruritic bullous eruption refractory to the standard treatments for bullous pemphigoid (BP). Direct immunofluorescence examination of a skin biopsy revealed linear deposits of IgG and of C3 at the dermal-epidermal junction, but Elisa screening for circulating anti-BP180 and anti-BP230 antibodies was negative. Indirect immunofluorescence (IIF) testing of cleaved skin revealed a deposit of IgG4 antibodies on the dermal side. Immunoblotting was negative for a dermal extract but showed an antibody directed against a 200-kD epidermal antigen. A diagnosis of anti-p200 pemphigoid was eventually made and the patient was successfully treated with dapsone. DISCUSSION: The diagnosis of anti-p200 pemphigoid was made in this case in spite of discrepancy between the IIF and immunoblotting results, and despite the fact that the target antigen in this disease is considered as being restricted to dermal sites. Anti-p200 pemphigoid usually begins in the second part of life and differs from standard bullous pemphigoid in terms of more frequent mucous membrane and cephalic involvement, as well as a greater degree of miliary scarring. This disease appears more prominent in males and is associated with psoriasis in around one third of cases. Autoantibodies recognize laminin gamma-1, an extra-desmosomal protein that contributes to dermal-epidermal adhesion. CONCLUSION: This recently described disease as probably under-diagnosed in France. It should be considered in atypical presentations of bullous disease. Diagnosis is confirmed by immunoblotting detection of autoantibodies directed against a 200-kD antigen normally present in the extract. Dapsone appears to be the most effective treatment.

Upregulated TRPC1 channel in vascular injury in vivo and its role in human neointimal hyperplasia.

Occlusive vascular disease is a widespread abnormality leading to lethal or debilitating outcomes such as myocardial infarction and stroke. It is part of atherosclerosis and is evoked by clinical procedures including angioplasty and grafting of saphenous vein in bypass surgery. A causative factor is the switch in smooth muscle cells to an invasive and proliferative mode, leading to neointimal hyperplasia. Here we reveal the importance to this process of TRPC1, a homolog of Drosophila transient receptor potential. Using 2 different in vivo models of vascular injury in rodents we show hyperplasic smooth muscle cells have upregulated TRPC1 associated with enhanced calcium entry and cell cycle activity. Neointimal smooth muscle cells after balloon angioplasty of pig coronary artery also express TRPC1. Furthermore, human vein samples obtained during coronary artery bypass graft surgery commonly exhibit an intimal structure containing smooth muscle cells that expressed more TRPC1 than the medial layer cells. Veins were organ cultured to allow growth of neointimal smooth muscle cells over a 2-week period. To explore the functional relevance of TRPC1, we used a specific E3-targeted antibody to TRPC1 and chemical blocker 2-aminoethoxydiphenyl borate. Both agents significantly reduced neointimal growth in human vein, as well as calcium entry and proliferation of smooth muscle cells in culture. The data suggest upregulated TRPC1 is a general feature of smooth muscle cells in occlusive vascular disease and that TRPC1 inhibitors have potential as protective agents against human vascular failure.

Mitral repair best practice: proposed standards.

OBJECTIVES: To define best practice standards for mitral valve repair surgery. DESIGN: Development of standards for process and outcome by consensus. SETTING: Multidisciplinary panel of surgeons, anaesthetists, and cardiologists with interests and expertise in caring for patients with severe mitral regurgitation. MAIN OUTCOME MEASURES: Standards for best practice were defined including the full spectrum of multidisciplinary aspects of care. RESULTS: 19 criteria for best practice were defined including recommendations on surgical training, intraoperative transoesophageal echocardiography, surgery for atrial fibrillation, audit, and cardiology and imaging issues. CONCLUSIONS: Standards for best practice in mitral valve repair were defined by multidisciplinary consensus. This study gives centres undertaking mitral valve repair an opportunity to benchmark their care against agreed standards that are challenging but achievable. Working towards these standards should act as a stimulus towards improvements in care.

Effect of radial artery harvesting on tissue perfusion and function of the hand.

This study was designed to measure the degree to which hand and forearm blood flow is reduced following harvesting of the radial artery in myocardial revascularization surgery and determine whether there is an effect on hand function. Twenty patients who had the radial artery used for myocardial revascularization underwent bilateral blood flow assessment of hands and forearms using Technetium-99m human serum albumin and clinical evaluation of hand function. Mean tissue perfusion in ml/100 ml/min +/- SD was as follows: donor hand 21.9 +/- 5.6, non-donor hand 25.5 +/- 6.1 (P = 0.00043), donor arm (hand and forearm) 17.5 +/- 3.7 and non-donor arm (hand and forearm) 21 +/- 5.1 (P = 0.000681). No clinical evidence of hand claudication was detected. This study suggests that removal of the radial artery reduces the tissue perfusion of the hand and forearm but does not affect hand function in the short term. The use of radial artery grafts in patients at risk of developing peripheral vascular disease should be carefully considered

Rho-kinase inhibitors prevent agonist-induced vasospasm in human internal mammary artery.

1. Vasospasm of arterial conduits used for coronary artery surgery is an important cause of graft failure and is likely to result partly from raised levels of vasoconstrictor substances such as thromboxane A(2) and endothelin-1. Our aim was to find pharmacological agents that could prevent agonist-induced vasospasm. 2. Isometric tension was recorded from discarded segments of human left internal mammary artery (LIMA). Submaximal contraction evoked by the thromboxane A(2) mimetic U46619 (10 nM) was not inhibited by a blocker of store- and receptor-operated Ca(2+) channels (30 microM SKF96365) in the presence of diltiazem. Furthermore, contractions to < or =1 nM U46619 were preserved when extracellular Ca(2+) was reduced from 2.5 mM to 60 nM. Thus, sustained U46619-evoked contraction occurred without Ca(2+) influx. 3., We hypothesized that contraction might occur via Rho-kinase-mediated Ca(2+)-sensitization of myofilaments. Inhibitors of Rho-kinase (Y27632 and HA1077) were profound relaxants. If contraction was pre-evoked by 10 nM U46619, Y27632 and HA1077 caused full relaxation with EC(50)s of 1.67+/-0.22 microM and 3.58+/-0.35 microM respectively. Y27632 was also effective if applied before U46619, but was less potent. 4. Y27632 abolished contraction evoked by endothelin-1 and significantly reduced resting tone in the absence of a vasoconstrictor. 5. Rho-kinase-mediated Ca(2+)-sensitization appears to be a major mechanism of vasoconstriction in human LIMA. Rho-kinase inhibitors may have an important role in preventing vasospasm in arterial grafts used for coronary artery surgery.

Redo cardiac surgery in a Jehovah's Witness, the importance of a multidisciplinary approach to blood conservation.

Although Jehovah's Witnesses present a particular problem when undergoing surgery because of their refusal to accept stored blood, it is now quite common to undertake uncomplicated cardiac surgery in these patients. Complex or redo cardiac surgery however, is often associated with major blood loss, and is conventionally contraindicated in Jehovah's Witnesses. We describe the perioperative management of a Jehovah's Witness who underwent a resternotomy for mitral valve replacement and coronary artery bypass grafting having previously had an aortic valve replacement and mitral valve repair. The importance of a multidisciplinary approach to blood conservation is discussed.

Management of isolated sternal fractures: determining the risk of blunt cardiac injury.

A review of the management of isolated sternal fractures in a regional cardiothoracic unit reveals that, in a 2 year period, 37 consecutive patients were admitted for observation and further investigation, including echocardiography and cardiac enzyme measurements to exclude blunt cardiac injury. Minor blunt cardiac injury was detected in only one patient, and was associated with an acutely abnormal electrocardiogram (ECG). ECG showed acute changes in 8 further patients, whilst 3 patients had an abnormal chest X-ray (CXR) due to widening of the mediastinum (1 patient had abnormal CXR and ECG), but none had evidence of cardiac injury. CXR and ECG were both normal in 23 patients, and were predictive of the absence of significant complications. A survey of 22 other cardiothoracic units around the UK confirms that the management of patients with isolated sternal fractures varies considerably from hospital to hospital. As suggested by previous reports, we believe that patients, who are otherwise fit and have normal ECG and CXR on presentation, can be safely discharged home on oral analgesics. The routine use of echocardiography and creatinine kinase (CK) assays in the assessment of isolated sternal fractures is not indicated. The introduction of these guidelines has resulted in a dramatic reduction in the number of patients admitted with isolated sternal fractures to our unit.

Attenuation of pulmonary vascular hypertension and cardiac hypertrophy with sitaxsentan sodium, an orally active ET(A) receptor antagonist.

Effects of sitaxsentan (TBC11251), an orally active, highly selective antagonist of endothelin A receptors, were examined on the development and maintenance of pulmonary hypertension, pulmonary vascular remodeling, and cardiac hypertrophy in the rat. The pulmonary vasoconstrictor response to acute hypoxia (10% O(2)for 90 min) was prevented with sitaxsentan (5 mg/kg infused iv 10 min prior to the onset of hypoxia) while BQ-788 (a specific endothelin B receptor antagonist) was without effect. The same dose of sitaxsentan delivered iv 50 min after the onset of hypoxia reversed the established pulmonary vasoconstriction. In a 2-week model of hypoxia using 10% O(2), treatment with sitaxsentan (15 mg/kg per day in drinking water) attenuated pulmonary hypertension and the associated right ventricular hypertrophy, and prevented the remodeling of small pulmonary arteries (50-100 microM) without affecting systemic arterial blood pressure or heart rate. Institution of sitaxsentan treatment (15 and 30 mg/kg per day in drinking water) for 4 weeks after 2 weeks of untreated hypoxia produced a significant, dose dependent reversal of the established pulmonary hypertension, right heart hypertrophy, and pulmonary vascular remodeling despite continued hypoxic exposure. Sitaxsentan blocked increased plasma endothelin levels in the prevention protocol but did not affect the established elevated levels in the intervention study. Sitaxsentan dose dependently (10 and 50 mg/kg per day in the drinking water) attenuated right ventricular systolic pressure, right heart hypertrophy, and pulmonary vascular remodeling observed 3 weeks after a single subcutaneous injection of monocrotaline. These findings support the hypothesis that endothelin-1 plays a significant role in the development of pulmonary hypertension, pulmonary vascular remodeling, and the associated cardiac hypertrophy, and further suggest that specific endothelin-A receptor blockade may be useful in the treatment of pulmonary hypertension of diverse etiologies.

Vasorelaxant properties of nicorandil on human radial artery.

OBJECTIVE: The radial artery is becoming popular as a conduit for coronary artery surgery but there is concern about its tendency to vasospasm. Diltiazem is used clinically in an effort to prevent vasospasm but there are suggestions that it is relatively ineffective. The first aim of the study was to test the effectiveness of Ca(2+) antagonists against vasospasm evoked by vasoconstrictor agonists. Because a large component of vasospasm was resistant to Ca(2+) antagonists, the second aim was to test if a different class of vasodilator, nicorandil, might relax the residual tone. METHODS: Isometric tension was recorded in human radial artery segments harvested from patients undergoing myocardial revascularization surgery. RESULTS: Diltiazem at 10 microM, which strongly inhibits L-type voltage-gated Ca(2+) channels, induced partial relaxation (mean+/-SEM, 44.6+/-3.5%, n=31) of phenylephrine-evoked contraction, but only 14.0+/-4.1% (n=10) and 12. 2+/-4.2% (n=10) relaxation of U46619- (a thromboxane A(2) analogue) or endothelin-1-evoked contraction. Strikingly, nicorandil relaxed agonist-evoked contractions that were resistant to diltiazem or nicardipine. In the absence of a Ca(2+) antagonist, nicorandil (30 microM) evoked 74.1+/-5.6% (n=24), 36.8+/-9.3% (n=10) and 64.5+/-7. 9% (n=14) relaxation of phenylephrine-, U46619- and endothelin-1-evoked contractions. CONCLUSIONS: Nicorandil has a marked relaxant effect on contractions evoked by three different vasoconstrictor agonists, and relaxes vasospasm that is resistant to conventional Ca(2+) antagonists. These in vitro data suggest that nicorandil might be a useful drug for the inhibition of radial artery vasospasm in myocardial revascularization surgery.

Cystic tumour of the atrioventricular nodal region: report of a case successfully treated with surgery.

A case is reported of a 59 year old woman who presented with palpitations. Electrocardiographic studies revealed atrial fibrillation and atrioventricular block. Echocardiography and magnetic resonance imaging showed a right atrial cystic mass attached to the interatrial septum. The patient underwent surgical excision of the mass. Histopathological findings were of a cystic tumour of the atrioventricular nodal region. This is the second report of this condition diagnosed antemortem and treated successfully with surgical excision.

Haemolysis during cardiopulmonary bypass: an in vivo comparison of standard roller pumps, nonocclusive roller pumps and centrifugal pumps.

Cardiopulmonary bypass (CPB) involves the use of either an occlusive roller pump or centrifugal pump. Damage to blood elements, including haemolysis, may arise from occlusion when using a roller pump; the appropriate degree of occlusion has not yet been determined scientifically. Centrifugal and nonocclusive roller pumps are reputed to reduce haemolysis. The objective of this study was to compare haemolysis caused by a standard roller pump with a dynamically set nonocclusive roller pump and with a centrifugal pump. We prospectively randomized 60 patients undergoing routine coronary artery surgery into three groups: standard roller pump (STD, n = 20), dynamically set roller pump (DYN, n = 20), or centrifugal pump (CEN, n = 20). The level of plasma free haemoglobin (FHb) was measured preoperatively, and the rate of formation of FHb (in mg/dl/min) was determined at the end of the ischaemic phase and at the end of CPB. Cardiotomy suction blood was isolated for the ischaemic phase and returned before the end of CPB. It was found that there were no differences between the groups in demographic or operative variables. The rate of formation of FHb at the end of the ischaemic phase was similar for all groups (STD 0.108 +/- 0.10, DYN 0.117 +/- 0.08, CEN 0.129 +/- 0.07). At the end of CPB, after return of the cardiotomy suction blood, there was a significant (< 0.001) increase in the rate of formation of FHb in all groups. The increase was similar for each of the groups (STD 0.424 +/- 0.17, DYN 0.481 +/- 0.20, CEN 0.471 +/- 0.18). We conclude that the rates of haemolysis are similar for each of the pump types, and no benefit is conferred by the use of either a dynamically set roller pump or a centrifugal pump compared with the standard roller pump. The return of the cardiotomy suction blood to the circulation is the principal source of plasma free haemoglobin.

Enhancing liver blood flow after cardiopulmonary bypass: the effects of dopamine and dopexamine.

Liver blood flow is reduced after cardiopulmonary bypass (CPB) and both dopamine and dopexamine are used to overcome this. This study compares the effects of these agents on liver blood flow. Thirty patients undergoing elective coronary artery bypass graft surgery were randomized into three groups (n = 10 per group). Six hours after surgery baseline liver blood flow was determined by the percentage disappearance rate of indocyanine green measured by dichromatic auricular densitometery. Patients then received infusions of either: (1) placebo (dextrose 5%); (2) dopamine (4 micrograms/kg/min); (3) dopexamine (1 microgram/kg/min increasing to 2 micrograms/kg/min). One hour after infusion, liver blood flow measurements were repeated. In the dopexamine group the infusion was increased and the measurements repeated another hour later. We found that patient-specific variables and operative details were similar for all groups. Postoperative cardiac index and heart rate were increased significantly by dopamine (cardiac index 2.82 +/- 0.46 l/m/m2 vs 3.28 +/- 0.67 l/m/m2: p < 0.001 and heart rate 87.5 +/- 13.2 vs 96 +/- 16: p < 0.05) and dopexamine at 2 micrograms/kg/min (cardiac index 2.71 +/- 0.53 l/m/m2 vs 3.45 +/- 0.67 l/m/m2: p < 0.05 and heart rate 89.0 +/- 18.9 vs 107.4 +/- 13.6: p < 0.001) compared to placebo (cardiac index 2.97 +/- 0.8 l/m/m2 vs 3.18 +/- 0.9 l/m/m2: p > 0.05 and heart rate 77.2 +/- 7.4 vs 77.3 +/- 8: p > 0.05) despite similar atrial and systemic arterial pressures. The disappearance rate of indocyanine green was not altered during infusion of placebo group (9.0 +/- 3.2%/min vs 7.9 +/- 3.0%/min: p > 0.05) or dopexamine at 1 microgram/kg/min (9.7 +/- 3.1%/min vs 11.2 +/- 4.1%/min: p > 0.05). The disappearance rate was increased with dopamine (6.7 +/- 3.7%/min vs 11.8 +/- 3.0%/min: p < 0.05) and dopexamine 2 micrograms/kg/min (9.7 +/- 3.1%/min vs 13.5 +/- 3.2%/min: p < 0.05). This indicates a 76% increase in liver blood flow with dopamine and a 38% increase with dopexamine. We conclude that dopamine 4 micrograms/kg/min and dopexamine 2 micrograms/kg/min increase liver blood flow, although this may, in part, be related to an increase in cardiac output. Dopexamine shows no advantage over dopamine in enhancing liver blood flow after CPB.

Unruptured aneurysm of the left sinus of Valsalva extending into the left ventricular outflow tract: presentation and imaging.

The symptomatic presentation of an unruptured sinus of Valsalva aneurysm is rare. A 48 year old man with a history of treated hypothyroidism, and a five year history of ileocolonic Crohn's disease of chronic low grade activity presented with a profound left hemiplegia. He was in sinus rhythm and normotensive. Cardiac auscultation was repeatedly normal. Computed tomography of the head performed early in the course of the illness was reported as normal. Duplex Doppler examination of the carotid arteries performed six months later revealed no significant atheroma. There was complete resolution of the neurological deficit over a period of months. A year later he presented with chest pain suggestive of myocardial ischaemia. Computed tomography, magnetic resonance imaging, transthoracic and transoesophageal echocardiography, and cardiac catheterisation pointed to a sinus of Valsalva aneurysm protruding into the left ventricular outflow tract. In view of the previous neurological event and ongoing chest pain suggestive of myocardial ischaemia, the lesion was resected. The patient made a good recovery and postoperative transoesophageal echocardiography showed normal aortic valve function with no residual regurgitation. This is the first reported case of pure left ventricular outflow tract extension of an unruptured left sinus aneurysm. The presentation with ischaemic cardiac pain does not seem to be explained by conventional mechanisms.

Angiogenesis induced by tumor necrosis factor-agr; is mediated by alpha4 integrins.

Tumor necrosis factor-alpha (TNF-alpha) and fibroblast growth factor-2 (FGF-2 or bFGF) are potent stimulators of angiogenesis. TNF- alpha, but not FGF-2, can induce the expression of vascular cell adhesion molecule-1 (VCAM-1) on the surface of endothelial cells. The soluble form of VCAM-1 has recently been demonstrated to function as an angiogenic mediator. Here we demonstrate that monoclonal antibodies directed against VCAM-1 or its alpha4 integrin counter- receptor inhibited TNF-alpha-induced endothelial cell migration in vitro. Angiogenesis induced in vivo in rat corneas by TNF-alpha was inhibited by a neutralizing antibody directed against the rat alpha4 integrin subunit. A peptide antagonist of the a4 integrins blocked TNF-alpha-induced endothelial cell migration in vitro and angiogenesis in rat corneas in vivo. No inhibition by the antibodies or peptide antagonist was observed either in vitro or in vivo when FGF-2 was used as the stimulus. The peptide antagonist did not inhibit TNF-a binding to its receptor nor did it block the function of alphavbeta3, an integrin previously implicated in TNF-a and FGF- 2 mediated angiogenesis. These results demonstrate that angiogenic processes induced by TNF-alpha are mediated in part by agr;4 integrins possibly by a mechanism involving the induction of soluble VCAM-1.