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.

Chemotactic factor inducing Interleukin-8 (IL8) gene is transcriptionally elevated in experimental enterotoxaemia in goats caused by Clostridium perfringens type D

The current study was designed to analyse the effects of experimental induction of enterotoxaemia through intra-duodenal inoculation of C. perfringens type D culture isolated from spontaneous outbreaks in goats. Twenty goats (6–9 month age) were divided into four groups and C. perfringens type D culture was inoculated intra-duodenally as per following: Group-I (whole cultures-WC), group-II (culture supernatant-CS), group-III (washed cells-WS), and group-IV (uninfected control-C). The treated animals were sacrificed after 72 h post infection (hpi), and necropsy showed gross changes including haemorrhages and congestion in the ileal and colon mucosa, pulmonary congestion and edema in lung. Kidney, brain and spleen exhibited severe to moderate congestion. Microscopic changes like haemorrhages, degenerative and necrotic changes in the mucosal epithelium of intestine and haemorrhages in kidney parenchyma were observed in the H&E stained sections. Lung alveolar sacs were filled with proteinaceous fluid. Immunohistochemistry revealed positive immunolabelling for etx (epsilon toxin) in the mucosa of intestine in WC and CS group. Control animals did not exhibit any significant gross or microscopic changes. PCR amplification of DNA extracted from intestinal tissues of WC and CS groups showed positive for etx gene demonstrating the production of epsilon toxin. Transcriptional responses in experimental groups were assessed by quantitative reverse transcription real time PCR (qRT-PCR). Genes including IL-1β and IL2 showed up-regulation in all the experimental groups (WC, CS&WS). Specifically the toxin-based experimental groups (WC&CS) showed up-regulation of the gene responsible for chemotaxis viz. IL-8, while the washed cells group (WS) showed higher transcriptional response to Cathepsin-L (Cat-L) gene denoting the acute inflammatory response due to neutrophil elastase activity. These results take a cue on the evolving nature of the enterotoxaemia in goats due to various strains circulating in the field. The host response and its modulation due to the novel enterotoxaemia strains throws light on the current challenges in efficient control of the disease in goats.

A Cell Culture-Adapted Vaccine Virus against the Current African Swine Fever Virus Pandemic Strain

African swine fever virus (ASFV) causes a virulent, deadly infection in wild and domestic swine and is currently causing a pandemic covering a contiguous geographical area from Central and Eastern Europe to Asia. No commercial vaccines are available to prevent African swine fever (ASF), resulting in devastating economic losses to the swine industry. The most advanced vaccine candidates are live attenuated strains developed using a genetically modified virulent parental virus. Recently, we developed a vaccine candidate, ASFV-G-ΔI177L, by deleting the I177L gene from the genome of the highly virulent ASFV pandemic strain Georgia (ASFV-G). ASFV-G-ΔI177L is safe and highly efficacious in challenge studies using parental ASFV-G. Large-scale production of ASFV-G-ΔI177L has been limited because it can replicate efficiently only in primary swine macrophages. Here, we present the development of an ASFV-G-ΔI177L derivative strain, ASFV-G-ΔI177L/ΔLVR, that replicates efficiently in a stable porcine cell line. In challenge studies, ASFV-G-ΔI177L/ΔLVR maintained the same level of attenuation, immunogenic characteristics, and protective efficacy as ASFV-G-ΔI177L. ASFV-G-ΔI177L/ΔLVR is the first rationally designed ASF vaccine candidate that can be used for large-scale commercial vaccine manufacture. IMPORTANCE African swine fever is currently causing a pandemic resulting in devastating losses to the swine industry. Experimental ASF vaccines rely on the production of vaccine in primary swine macrophages, which are difficult to use for the production of a vaccine on a commercial level. Here, we report a vaccine for ASFV with a deletion in the left variable region (LVR). This deletion allows for growth in stable cell cultures while maintaining the potency and efficacy of the parental vaccine strain. This discovery will allow for the production of an ASF vaccine on a commercial scale.

AB0205 A NOVEL METHOD FOR PREDICTING 1-YEAR RETENTION OF ABATACEPT USING MACHINE LEARNING TECHNIQUES: DIRECTIONALITY AND IMPORTANCE OF PREDICTORS

Background:

In the ACTION (NCT02109666) study, multivariable Cox proportional hazards regression models showed that the predictors of 1-year retention to abatacept treatment were: patient global pain assessment, country, reason for stopping last biologic, number of prior biologic treatments, abatacept monotherapy, RF/anti-cyclic citrullinated peptide (CCP) status, previous neoplasms, psychiatric disorders and cardiac disorders.1 Machine learning techniques, using the gradient-boosting model, subsequently identified additional predictors of abatacept retention in patients with moderate-to-severe RA enrolled in ACTION; however, the analysis did not show the directionality of the predictors.2

Objectives:

To improve the clinical interpretability of the machine learning model in terms of directionality and the importance of each variable in predicting retention.

Methods:

Previous analyses using the gradient-boosting model to identify predictors of abatacept retention at 1 year in the ACTION study have been described.2 This analysis used SHapley Additive exPlanations (SHAP), a mathematical framework, to show how a particular predictor value influences prediction in the context of all other predictors. Higher SHAP values indicate a higher likelihood of retention. The contribution of every variable in the model’s prediction (with the exception of country variables) was computed for each data point to capture individual variable impact. This enabled interpretation for level of importance and directionality at a patient level.

Results:

Using data from 2350 patients enrolled in ACTION (May 2008 to December 2013), the mean retention rate at 1 year was 59.3% (n=1393). Overall variable importance is shown in Figure 1. After removal of country variables, the top five baseline predictors of retention were: no previous corticosteroid use, ACR functional class II, ≥2 prior biologic treatments prior to abatacept initiation, abatacept monotherapy and HAQ-DI. In terms of directionality, no previous corticosteroid use, ≥2 prior biologic treatments prior to abatacept initiation, abatacept monotherapy and a higher HAQ-DI score at baseline were associated with a lower likelihood of retention; ACR functional class II was associated with a higher likelihood of retention.

Conclusion:

The gradient-boosting model previously identified predictors of abatacept retention from ACTION;2 the addition of SHAP in this analysis has provided information on the importance and directionality of those predictors. The most important predictor of abatacept retention was no previous corticosteroid use, which was associated with lower retention. The models and predictors identified could be further refined by using additional datasets from clinical trials. Machine learning offers an innovative and complementary approach to biostatistics and could be used to identify treatment response predictors at an individual patient level, leading to a more personalised treatment approach.

References:

[1]Alten R, et al. RMD Open 2017;3:e000538.

[2]Alten R, et al. Presented at the virtual ACR Convergence 2020; 5–9 November 2020. Poster number 1745.

Acknowledgements:

This study was supported by Bristol Myers Squibb. Professional medical writing and editorial assistance was provided by Claire Line, PhD, at Caudex and was funded by Bristol Myers Squibb.

Disclosure of Interests:

Rieke Alten Speakers bureau: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Consultant of: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Grant/research support from: AbbVie, Bristol Myers Squibb, Gilead, Janssen, Lilly, Pfizer, Claire Behar Shareholder of: I have not invested directly in pharmaceutical companies producing drugs/devices for use in rheumatology however I may have shares via the funds linked to my life insurance., Consultant of: Bristol Myers Squibb, Christine Boileau Consultant of: AstraZeneca, Bristol Myers Squibb, Nanobiotix, Pierre Merckaert Consultant of: Bristol Myers Squibb, Ebenezer Afari Consultant of: Bristol Myers Squibb, Virginie Vannier-Moreau Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Sean Connolly Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb, Aurelie Najm Speakers bureau: Bristol Myers Squibb, Consultant of: Bristol Myers Squibb, Pierre-Antoine Juge Consultant of: Bristol Myers Squibb, Angshu Rai Shareholder of: Amgen Inc, Consultant of: Amgen Inc, Employee of: Amgen Inc, Bristol Myers Squibb, Yedid Elbez Consultant of: Bristol Myers Squibb, Karissa Lozenski Shareholder of: Bristol Myers Squibb, Employee of: Bristol Myers Squibb

686 Emergencies in Plastic Surgery – The Impact of a One-Day Conference on Medical Students’ Confidence

Introduction

Plastic surgery emergencies, such as facial trauma, burns, and gunshot wounds, are commonly presenting injuries to the emergency department. However, these topics are rarely part of medical school curriculums and few educational conferences exist on these topics. Hence, we created a novel international medical student conference entitled “Emergencies in Plastic Surgery”. We then evaluated its effectiveness in improving confidence in management of plastic surgery-related emergencies.

Method

We administered pre- and post-event online questionnaires to delegates evaluating self-reported confidence for Facial Trauma, Gunshot Wounds, Burns, Tendon Repair, Splinting, and Lacerations on a 5-point Likert-scale. Responses were matched before statistical analysis.

Results

Of the 85 attendees, three quarters responded (76%, n = 65). The conference significantly increased confidence ratings in all topics (p < 0.001). Prior to the conference, Lacerations had the highest confidence scores (2.36 ± 1.19) whereas Facial Trauma scored the lowest (1.79 ± 0.858). Facial Trauma had the greatest improvement in confidence (mean difference = 2.09 ± 0.974), whereas Lacerations yielded the lowest improvement (mean difference 1.21 ± 1.28). Facial Trauma also yielded the greatest mean satisfaction rating (4.68 ± 0.594).

Conclusions

The conference improved student confidence in all plastic surgery emergencies topics. More complex topics, e.g. facial trauma, yielded the greatest satisfaction and improvement in confidence.

A novel post stamp technique for conservative management of OKC: Rai Technique

A novel technique of Conservative management of OKCs via post stamp method of removing the buccal cortical plate of posterior mandible to expose the cystic lesion and carried out enucleation, curettage and chemical cauterization has been described in the present paper. Also the diseased bone has been used as a bone graft to maintain the contour deformity of the mandible. The present technique has been used in 9 patients with good quality of life and postoperative esthetic results with five years follow up.

Occlusal Characteristics of Primary Dentition among School Going Children

BACKGROUND

Certain characteristics of the primary dentition have been described that may be required in the smooth transition from primary to permanent dentition and therefore development of ideal occlusion in permanent dentition. The objectives of this study were to assess different occlusal characteristics of primary dentition among school going children of Dharan, Nepal and to compare these occlusal characteristics based on gender and race.

METHODS

A community based cross-sectional study was conducted among 625 school children of Mongolian and Caucasian race, aged 3 to 7 years, and having complete set of primary dentition. A close-ended questionnaire was developed to gather demographic information followed by the examination of occlusal and soft tissue parameters.

RESULTS

The result showed 77.2% of the children had developmental spaces and 83.1% had primate spaces. Flush terminal plane molar and class I canine relationships were present in 68.8% and 81.6%, respectively with normal overjet (53.5%), normal overbite (41.1%), straight facial profile (86.7%) and competent lips (98.6%). Crowding was present in 35.4%, midline discrepancy in 11.3%, crossbite in 7.2%, scissor bite in 0.6% and open bite in 2.1% of the children examined.

CONCLUSIONS

Most of the occlusal characteristics were desirable but with the existence of some malocclusion traits, necessitating timely recognition and correction through early screening. Gender and racial influences were also observed and it emphasizes the need for treatment plan based on them.

Earlier the Better: Interceptive Orthodontics to Correct Various Forms of Malocclusion in a Nine-year-old Boy

Guidance of eruption and development of the primary, mixed, and permanent dentitions is an integral component of comprehensive oral healthcare for all pediatric dental patients; which should contribute to the development of a permanent dentition that is stable, and functionally and esthetically acceptable. In this case note, we present a case in which various forms of interceptive treatment modalities like; extraction of impacted and erupted supernumerary teeth, correction of anterior crossbite and irregularities using Z-springs and Hawley’s labial bow, and provision of lingual holding arch space maintainer were done to correct malocclusion in a nine-year-old patient. Arch alignment was achieved within seven month of starting of treatment, which was acceptable to the patient.

Assessment of preclinical effect of (+)-catechin hydrate on sexual function: An in silico and in vivo study

Considering dopamine-enhancing effect of (+)-catechin, the present study was designed to evaluate dopamine-2 (D2) receptor agonistic and phosphodiesterase-5 (PDE5) enzyme inhibitory effects in in silico and effect on male sexual function of Sprague Dawley rats in vivo. (+)-Catechin and standard (sildenafil and bromocriptine) were docked using Autodock Vina 1.1.2 and visualised by UCSF Chimera 1.14. Significant interactions in terms of binding energies were observed for catechin with both proteins. In in vivo study, the rats were dosed orally for 54 days with (+)-catechin hydrate (50 mg/kg), sildenafil citrate (standard, 4 mg/kg) and carboxymethylcellulose (vehicle, 0.25% w/v). The aphrodisiac effects were evaluated on the day 14, 28, 42 and 54 using the behavioural parameters of mounting and intromission. After the study, animals were sacrificed and testes and spermatozoa were assessed for safety profile. Results showed a significant increase in mount and intromission frequencies and a significant reduction in mount and intromission latencies in the catechin group on all tested days when compared to vehicle control. (+)-Catechin was found to be safe on histology of testes, sperm count, sperm motility and sperm morphology parameters. In conclusion, catechin demonstrated an enhancement in sexual behaviour without eliciting toxicity on the male reproductive system in rats.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Permcath - A Vascular Access for Hemodialysis, Our Experience in Last Two Years

Background The double lumen tunneled catheter (Permcath) is mostly used as an alternative access, not as a temporary access in End Stage Renal Disease patients requiring hemodialysis. If there is no possibility of other access modalities, failed or unable to create native arteriovenous fistula (AVF), Permcath can be a very good alternative. Objective To find the indications, complications and results of Permcath insertion. Method We reviewed the results of 92 Permcath inserted under ultrasound guidance in two different hospitals, 45 in Sahid Dharma Bhakta National Transplant Center (SDNTC), Bhaktapur and 47 in Nidan Hospital Pvt. Ltd., Lalitpur from April 2016 to April 2018 retrospectively. Result We had inserted 55 Permcath (59.78%) in right internal jugular vein (IJV), 25 (27.17%) in left internal jugular vein and 12(13.04%) in femoral vein. In terms of major complications, two (2.17%) patients had profound hypotension, bradycardia and cardiac arrest due to left internal jugular vein tear. Three patients (3.26%) died within a week due to septicemia and 23 patients (25%) died with multiple causes within one year. Of the cases, till now in 39 cases (42.39%) Permcath has been removed. Major reasons of removal of Permcath are post renal transplant in 18 cases (19.57%), Arterio Venous Fistula maturation in 13 cases (14.13%), Infection in six patients (6.52%) and non functioning Permcath in two patients (2.17%). Conclusion Permcath remains a reliable method for short term vascular access, hence can be used as a bridge to renal transplant or arteriovenous fistula maturation.

Catechin ameliorates depressive symptoms in Sprague Dawley rats subjected to chronic unpredictable mild stress by decreasing oxidative stress

Catechin is an active ingredient of green tea. It is reported to inhibit corticosteroid-induced anxiety and depression-like symptoms. Considering the complex nature of depression, effects of catechin need to be studied in a clinically relevant depression model. The present study was designed to explore the antidepressant effect of catechin in Sprague Dawley rats subjected to chronic unpredictable mild stress (CUMS). Animals were subjected to CUMS and treated with (+)-catechin (50 mg/kg) or escitalopram (10 mg/kg) orally; a CUMS control and a vehicle control that was not exposed to CUMS were also established. Various stressors were applied daily in an unpredictable manner for 8 weeks achieve CUMS. Sucrose preference test were performed after 4 and 8 weeks and forced swim tests (FSTs) were conducted at weeks 4, 6 and 8. At the end of week 8, animals were sacrificed and the brain homogenate was studied for antioxidant parameters. Compared with the vehicle control, animals of the CUMS control group showed a significant decrease in sucrose intake. Catechin and escitalopram treatment significantly improved the sucrose intake compared with the CUMS control. A similar trend was observed in the FSTs, where catechin and escitalopram treatment significantly reduced the immobility time, and antioxidant parameters, including catalase, glutathione and superoxide dismutase levels were recovered in treated animals compared with the CUMS control. Thus, it was concluded that catechin reverses CUMS-induced depression in rats by ameliorating oxidative stress, which may help to develop a novel treatment for major depressive disorder.

Adenomatoid Odontogenic Tumor of the Mandible: An Unusual Clinical Presentation

Adenomatoid odontogenic tumor (AOT) is a rare benign neoplasm of odontogenic epithelial origin. A 12-year-old male reported to the department of pedodontics and preventive dentistry with swelling on lower part of face since seven months. On examination, firm to hard, nontender swelling, sized approximately 3 × 3 cm, extending from mandibular left canine to right lateral incisor with expansion of labial and lingual cortices was present. Radiograph revealed a well demarcated unilocular radiolucency exhibiting sclerotic border with flecks of calcification and displaced roots of mandibular anteriors and expansion of both cortices. Incisional biopsy confirmed the diagnosis of AOT. Enucleation of the lesion along with #31, 32 and curetiage was done under general anesthesia. Ribbond fiber prosthesis was given to maintain the arch integrity and esthetics. AOT in mandible (35%) of young male (36%) of extrafollicular variant (24%) is rare. We may encounter only 2-3 out of 100 AOT cases as typical as the case presented here.  BJHS 2018;3(2)6: 504-507.