Intra-operative touch preparation cytology; does it have a role in re-excision lumpectomy?

OBJECTIVE

Breast carcinoma is the most frequently diagnosed malignancy in women of North America. The combination of breast conservation surgery and radiotherapy has become a standard of treatment for the majority of breast cancers. It is critical to obtain clear margins to minimize local recurrence. However, avoiding multiple re-excisions for margin clearance helps optimize cosmetic results in patients undergoing breast conservation surgery. Intra-operative touch preparation cytology (IOTPC) may decrease the need for multiple re-excisions and thereby improve cosmesis. The literature suggests that IOTPC can be useful in evaluation of margins. Klimberg et al. evaluated the touch preparation technique prospectively in 428 patients undergoing breast biopsy for undiagnosed breast masses. Margin evaluation was correct in 100% of the lesions and was used to re-excise the margins when touch prep results were positive. They reported a diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 100% for the touch prep technique. To the best of our knowledge, there has been no published data on the role of IOTPC for evaluation of margins in re-excision cases. This report describes our experience with IOTPC for margin assessment for re-excision partial mastectomy at Beth Israel Medical Center (BIMC). The purpose of this study is to determine whether IOTPC is reliable for evaluating margins in patients undergoing re-excision for involved or close margins.

METHODS

A prospective study of 30 patients, who have undergone re-excision partial mastectomy for involved or close margins after breast conservation surgery with the use of IOTPC for margin assessment at BIMC was performed. The re-excision lumpectomy specimens were oriented by the surgeon intra-operatively and were submitted fresh to pathology for cytologic assessment. The touch prep method consisted of touching the corresponding margin onto the glass slide. The principle of this technique is that if cancer cells are present they will stick to the slide, while fat cells will not. A slide was prepared for each re-excision specimen. Air-dried samples were stained immediately using the Diff-Quik method and examined under the microscope by a cytopathologist.

RESULTS

Thirty patients underwent re-excision lumpectomy for involved or close margins with touch preparation cytology for assessment of 68 margins. Twenty-six patients had invasive ductal carcinoma and/or ductal carcinoma in situ, three patients had invasive lobular carcinoma and the remaining one patient had a combination of invasive lobular and ductal carcinoma. There was a correlation between touch prep cytology and final pathology in 56/68 margins, which accounts for 82.4% of the cases.

CONCLUSION

Intra-operative touch preparation cytology for assessment of margins in patients undergoing re-excision lumpectomy for involved or close margins has a sensitivity of 75%, specificity of 82.8%, positive predictive value of 21.4%, and negative predictive value of 98.2%. This high negative predictive value and a single false negative margin are quite significant. Therefore, based on our experience, IOTPC can be a useful tool for intra-operative assessment of margins for patients undergoing re-excision partial mastectomy.

[Awareness with recall during general anesthesia: analysis of 2015 cases]

OBJECTIVE

To investigate the incidence of awareness with recall during general anesthesia in elective operation with modern anesthetic methods and to analyze the risk factors thereof.

METHODS

2025 patients, 1001 males and 1024 females, aged 53 +/- 16, underwent general anesthesia during different kinds of elective operation. Interview was conducted 1 - 3 days postoperatively to survey the incidence of awareness during operation. Two weeks later follow-up was conducted again to know if sequelae existed.

RESULTS

Twenty-eight patients (1.4%) were identified as with awareness. Multiple regression analysis showed that awareness during operation was associated with being female (OR = 2.836, 95% CI = 1.81 - 6.810), use of laryngeal mask airway (LMA, OR = 19.609, 95% CI = 3.918 - 98.740), not use volatile anesthetics at a time or continuously during maintenance of anesthesia (OR = 3.084, 95% CI = 1.246 - 7.629), and intra-operative blood pressure fluctuation (OR = 10.430, 95% CI = 3.918 - 27.763), Premedicated patients had lower incidence of awareness during operation (OR = 0.326, 95% CI = 0.110 - 0.965). Twenty-three of the 28 patients with awareness during operation (82%) had auditory perception, 2 (7%) had both auditory and visual perception, 7 felt pain at different degrees, and 10 (36%) felt anxiety during operation. After effects appeared in 6 of the 28 patients (21%).

CONCLUSION

Awareness occurs in some patients undergoing elective operation. Being female, use of LMA, not using volatile anesthetics at a time or continuously during maintenance of anesthesia, and intra-operative blood pressure fluctuation are risk factors. Premedication may help prevent awareness during operation.

Intraoperative radiation therapy using mobile electron linear accelerators: report of AAPM Radiation Therapy Committee Task Group No. 72

Intraoperative radiation therapy (IORT) has been customarily performed either in a shielded operating suite located in the operating room (OR) or in a shielded treatment room located within the Department of Radiation Oncology. In both cases, this cancer treatment modality uses stationary linear accelerators. With the development of new technology, mobile linear accelerators have recently become available for IORT. Mobility offers flexibility in treatment location and is leading to a renewed interest in IORT. These mobile accelerator units, which can be transported any day of use to almost any location within a hospital setting, are assembled in a nondedicated environment and used to deliver IORT. Numerous aspects of the design of these new units differ from that of conventional linear accelerators. The scope of this Task Group (TG-72) will focus on items that particularly apply to mobile IORT electron systems. More specifically, the charges to this Task Group are to (i) identify the key differences between stationary and mobile electron linear accelerators used for IORT, (ii) describe and recommend the implementation of an IORT program within the OR environment, (iii) present and discuss radiation protection issues and consequences of working within a nondedicated radiotherapy environment, (iv) describe and recommend the acceptance and machine commissioning of items that are specific to mobile electron linear accelerators, and (v) design and recommend an efficient quality assurance program for mobile systems.

Intraoperative sigmoidoscopy in gynecologic surgery

Intraoperative sigmoidoscopy is underused by the majority of practicing gynecologists and is not widely taught in obstetrics and gynecology training programs. In this report, a step-by-step approach is provided in order to perform sigmoidoscopy. Indications for use, along with various intraoperative applications, are discussed. Results from our center's experience with its use during laparoscopic treatment of adhesions, endometriosis, and associated disease of the bowel also are provided. Intraoperative sigmoidoscopy is a safe and efficacious procedure that can aid in the evaluation and treatment of pelvic pathology and facilitate identification and management of bowel injuries. It should be considered a valuable adjunct when such cases are encountered by gynecologic and pelvic surgeons.

Intraoperative High-Field Magnetic Resonance Imaging in Transsphenoidal Surgery of Hormonally Inactivepituitary Macroadenomas

OBJECTIVE

The aim of the study was to evaluate the effect of intraoperative, high-field (1.5 T) magnetic resonance imaging (MRI) on the results of transsphenoidal surgery of hormonally inactive pituitary macroadenomas.

METHODS

One hundred six patients (tumor size, 29.9 +/- 10.1 mm; minimum, 11.3 mm; maximum, 57.2 mm) with hormonally inactive pituitary macroadenoma were investigated by intraoperative high-field MRI during transsphenoidal surgery. If intraoperative imaging depicted an accessible tumor remnant, resection was continued.

RESULTS

Among the 85 patients in whom complete tumor removal was intended preoperatively, intraoperative imaging revealed definite tumor remnants or suspicious findings in 36 (42%) patients. Imaging led to an extended resection in 29 (34%) patients of this group. Among them, resection could be completed in 21. This increased the rate of complete tumor removal from 58% (49 out of 85) to 82% (70 out of 85). In the group of patients with intended partial removal (n = 21), resection was extended in 38% (eight out of 21) because of intraoperative imaging. Comparison with scanning 3 months after surgery did not reveal any false-negative findings of intraoperative MRI; in six cases, intraoperative MRI was suspicious for some minor remnant that could not be reproduced in the postoperative control.

CONCLUSION

The extent of resection in transsphenoidal surgery can be reliably assessed using intraoperative high-field MRI. In addition to the suprasellar compartment, intra- and parasellar structures are also visualized in great detail. Intraoperative imaging acts as an immediate intraoperative quality control, allowing one to not only increase the extent of resection, but to also increase the percentage of complete removals.

Surgical treatment of scoliosis with pelvic obliquity in cerebral palsy: the influence of intraoperative traction

STUDY DESIGN

Continuous retrospective series.

OBJECTIVES

To compare two techniques sequentially used for surgical correction of neuromuscular scoliosis with pelvic obliquity in children with cerebral palsy.

SUMMARY OF BACKGROUND DATA

In nonwalking patients with cerebral palsy, scoliosis is frequently associated with pelvic obliquity. We compared intraoperative traction with no traction with instrumentation to the pelvis to correct pelvic obliquity.

METHODS

The initial 59 patients had surgery in the knee-chest position with pelvic obliquity correction by posterior vertebral instrumentation distraction, rotation, and compression. The sequential 51 patients were placed prone and had asymmetric traction applied between a halo and the high pelvic side lower extremity with pelvic correction maneuvers done before posterior surgery and instrumentation.

RESULTS

Anesthetic duration was longer in Group 1 because of complexity of the intraoperative correction maneuvers, which also produced less correction of scoliosis and pelvic obliquity compared with the asymmetric traction technique. At 8.6 years of follow-up, frontal and sagittal plane correction improved in all surviving patients.

CONCLUSION

We think that intraoperative reduction by asymmetric traction is a reliable and safe technique to correct neuromuscular scoliosis and pelvic obliquity in nonwalking spastic quadriplegic patients.

[Elective colon surgery according to a 'fast-track' programme]

In fast-track surgical programmes, a variety ofperioperative elements are combined in an intensive multidisciplinary approach for the purpose of preserving the preoperative body composition and organ functions and actively stimulating functional recovery. Such programmes have already been introduced in several surgical procedures. The essence of fast-track colon surgery consists of extensive preoperative counselling, adequate preoperative nutrition with the avoidance of prolonged fasting, a minimum of invasive procedures and anaesthesia, no routine use of drains and nasogastric tubes, adequate perioperative analgesia encompassing high thoracic epidural anaesthesia, rapid mobilisation, rapid resumption of postoperative feeding, and medicinal support with prokinetics and laxatives. A systematic review shows that this programme accelerates recovery and hence shortens the primary and total hospital stay.

Intraoperative electron beam radiotherapy (ELIOT) to the breast: A need for a quality assurance programme

Intraoperative radiotherapy (IORT) is a technique in which a high, single-fraction radiation dose is delivered directly to the tumour bed during a surgical intervention, after the removal of a neoplastic mass. IORT has been recently used in early stage cancer as an exclusive radiation modality, rather than as a boost, especially for breast tumours, in particular at the European Institute of Oncology in Milan, where the technique has been called electron intraoperative therapy (ELIOT). Our studies on more than 1000 patients have demonstrated the feasibility of the technique and it is expected that its application will become more widespread in the immediate future. It is important to emphasise that ELIOT relies not only on new technological developments, but also on a multidisciplinary team with clear roles and responsibilities, the establishment of a programme of quality assurance with appropriate guidelines and a comprehensive staff development programme.

Awareness during anaesthesia: what can be done to prevent it?

Awareness during general anaesthesia is a potentially traumatising risk of any general anaesthetic, which can have lasting effects on the patients who experience it. This article assesses the issues and causes of anaesthetic awareness, together with the current status of research being conducted into its prevention, and the effect of market forces and litigation.

Accuracy of intraoperative frozen-section analysis of breast cancer lumpectomy-bed margins

BACKGROUND

My colleagues and I have been using intraoperative frozen-section analysis (FSA) to evaluate lumpectomy margins in an attempt to reduce the number of additional operations that patients with ductal carcinoma in situ or stage I and II breast cancer would have to endure. We review our experience in breast-conservation therapy (BCT) at the University of Florida (Gainesville) to determine the effectiveness of this approach.

STUDY DESIGN

Operative reports, operative logs, and pathology reports were retrospectively reviewed for patients who had BCT from January 2001 to January 2004. Ninety-seven patients (116 operations) were reviewed.

RESULTS

Nineteen patients required an additional operation (19.6%). Forty-three patients had positive margins on paraffin-embedded histologic analysis (44.3%). Accuracy of FSA was 84% when evaluated on a per-case basis, and 96% on a per-slide basis. False negatives were identified in 22 patients, affecting the operative pathway of 19 patients (19.6%) and were identified more frequently in cases of ductal carcinoma in situ (p < 0.001). There were no false positives. Additional operative time required for FSA was approximately 13 minutes per case. Eighty-four (86.6%) patients had successful BCT and 13 patients (13.4%) required mastectomy.

CONCLUSIONS

Intraoperative analysis of margins using FSA is effective at minimizing the number of additional operations, with 19 patients benefiting from immediate intervention in this study. The authors believe that the number of second operations prevented and the high BCT rates justify performing FSA. Ductal carcinoma in situ is more difficult to identify in FSA. Preoperative discussions with the patient should reflect these findings.

Medication Safety-Reliability of Preference Cards

A CLINICAL ANALYSIS of surgeons' preference cards was initiated in one hospital as part of a comprehensive analysis to reduce medication-error risks by standardizing and simplifying the intraoperative medication-use process specific to the sterile field. THE PREFERENCE CARD ANALYSIS involved two subanalyses: a review of the information as it appeared on the cards and a failure mode and effects analysis of the process involved in using and maintaining the cards. THE ANALYSIS FOUND that the preference card system in use at this hospital is outdated. Variations and inconsistencies within the preference card system indicate that the use of preference cards as guides for medication selection for surgical procedures presents an opportunity for medication errors to occur.

Open Guide Suture Technique for Safe Microvascular Anastomosis

Despite the evident advances in microsurgery, anastomosis of small vessels or anastomosis of vessels having size discrepancy, remains one of the most precise and technically demanding issues in replantation surgery and free tissue transfer procedure. The patency of the vascular anastomosis is critical and essential for a successful outcome. In this study, a microvascular anastomosing technique called open guide suture technique is introduced. The technique starts with a conventional whole-layer stitch and continues under the control of a guided suture that is inserted but not completed to a knot 180 degrees distant from the initial suture. Recently, we used this technique in 30 free flap transfers and 4 replantation procedures. A total of 103 anastomoses were performed. Only 1 flap, which had both arterial and venous problems, and 1 finger replantation case that had arterial problems required revision. Both the revised cases were salvaged, giving a revision rate of 2.91% for the total number of anastomoses (3 of 103), and a 100% success rate for final flap and replanted part survival. In conclusion, this technique provides a safe anastomosis performed under completely clear visualization at each step with well-arranged knot intervals.

Influence of head position on the effectiveness of twist drill craniostomy for chronic subdural hematoma

BACKGROUND

Twist drill craniostomy with closed system drainage (TDC-CSD) is a well-accepted treatment of chronic subdural hematomas (CSDH). Although this intervention has a long track record of effectiveness, little is known of its relationship with the head position of the patient (flat vs elevated). This study evaluated if the position of the patient's head influences outcome.

METHODS

The database of a University Hospital Center was queried for patients who had CSDH treated by TDC-CSD between January 1997 and March 2001. Identified patients were grouped into 2 categories: head of bed (HOB) at 30% and HOB flat while undergoing treatment. Outcomes were then evaluated with regard to amount of drainage, complications, recurrence, and length of hospital stay (LOS).

RESULTS

Forty-four patients were identified who received TDC-CSD treatment of CSDH. Of these, 24 patients had flat HOB and 20 had HOB elevated to 30 degrees . Although patients with elevated HOB had higher amounts of drainage (239 vs 166 mL), this figure did not reach statistical significance (P = .23). The number of recurrences and complications likewise did not reach statistical significance. Despite these findings, a statistically significant difference in LOS was found between the groups (flat = 5.5 days, elevated = 8.1 days, P = .03). This was believed secondary to bias resulting from placing the HOB of healthier patients (based on Glasgow Coma Scale) flat.

CONCLUSIONS

Elevation of the patient's head during TDC-CSD treatment of CSDH does not seem to impact the amount of drainage, recurrence frequency, or complication rate. Although a statistically significant difference in LOS was observed based on this variable, it appeared to be the result of bias in patient selection for HOB elevation.

Limited resection trial for pulmonary ground-glass opacity nodules: fifty-case experience

OBJECTIVE

This study was undertaken to determine the recurrence rate after limited resection of small lung carcinoma and to evaluate intraoperative frozen-section examination accuracy for Noguchi classification.

METHODS

Enrollment requirements were as follows: pulmonary nodule 2 cm or smaller, diagnosed or suspected clinical T1 N0 M0 carcinoma in the lung periphery, and ground-glass opacity findings and lack of evident pleural indentations or vascular convergence on high-resolution computed tomographic scan. A wedge or segmental resection specimen, removed with custom stapler cartridges, was immediately reinflated and examined by frozen-section with hematoxylin-eosin and Victoria blue-van Gieson stains. If the tumor was confirmed as Noguchi type A or B with resection margins greater than 1 cm, the patient was closed and followed up on an outpatient basis. End points were 5-year disease-free survival and intraoperative classification accuracy.

RESULTS

From August 1998 through October 2002, a total of 50 patients were enrolled (20 men and 30 women, ages 30-77 years). Tumor sizes ranged from 2 to 21 mm (11 mm average). There were 2 Noguchi type A tumors, 23 Noguchi type B tumors, 15 Noguchi type C tumors, 5 atypical adenomatous hyperplasias, 4 fibroses, and 1 granuloma. Frozen-section accuracy was approximately 98% (39/40). One intraoperative type B diagnosis was revised to type C after postoperative pathologic study. No morbidity, mortality, or recurrence has been seen with a median follow-up of 50 months.

CONCLUSION

Noguchi type A and B tumors may well be in situ carcinomas, and frozen-section examination was highly accurate. Neither local recurrence nor distant metastases have been found to date. Limited resection initial results appear promising.

[Suitability of intraoperative autotransfusion]

This work presents the procedure applied by our hospital to assess the quality and security of intra operative autotransfusion. The suitability of the three following variables has to be constantly assessed: performance of the machines to concentrate and wash collected blood, bacterial contamination of processed blood and rate of adverse events. We note that the procedure is applied with participation of medical and nursing staff. Since its setting-up, we note an amelioration of suitable variables.

Effects of intraoperative fluid infusions, sample storage time, and sample handling on unbound propofol assay in human blood plasma

Free drug assay in physiological fluids is getting more and more attention nowadays. The principal reason is the fact that the unbound drug form is responsible for the therapeutic or toxic effects of its application. Unbound drug concentration significantly depends on the extent of its binding by plasma. This article describes the influence of different factors on unbound propofol concentration. These factors are presence of infusion fluids in blood, type of anticoagulant, sample storage time and plasma freezing. The following conclusions result from the experiments carried out: 1. The lowest free drug fractions are observed in samples containing carbohydrate infusion fluids. The free drug percentage is virtually independent of its total concentration in the range of clinically relevant concentrations. 2. There is no evident anticoagulant influence (heparin, citrate, EDTA and oxalate) on free propofol level in plasma samples. 3. Longer storage of plasma at 4 degrees C causes a slight rise of free propofol concentration in heparinised plasma and no evident changes in plasma containing citrate. 4. Plasma freezing induces the increase of free drug concentration both for citrate and heparin. These findings are valuable both for clinicists and pharmacologists, and important for chemical analysts.

[What is "Fast-track"-surgery?]

"Fast-track"-surgery -- also called "fast-track"-rehabilitation -- is an interdisciplinary, multimodal concept to accelerate postoperative reconvalescence and reduce general morbidity. "Fast-track"-rehabilitation focuses on preoperative patient education, atraumatic and minimal-invasive access to the operative field, optimized anesthesia under normovolemia and prevention of intraoperative hypoxia and hypothermia, effective analgetic therapy without high systemic doses of opioids, enforced postoperative patient mobilisation, early postoperative oral feeding, and avoidance of tubes and drains. "Fast-track"-rehabilitation plans have been published for numerous operative procedures in general-, visceral-, vascular- and thoracic surgery, as well for orthopaedic, urological and gynaecological operations. Until today, "fast-track"-rehabilitation was evaluated most thoroughly in elective colonic surgery. Here, the multimodal regime decreased general morbidity from 20 - 30 % to below 10 %, while postoperative hospital stay was reduced from 10 - 15 to 2 - 5 days. "Fast-track"-rehabilitation for major surgery should be evaluated in randomised, controlled trials.

The Impact of the Joint Commission for Accreditation of Healthcare Organizations Pain Initiative on Perioperative Opiate Consumption and Recovery Room Length of Stay

The enhanced organizational emphasis on the management of pain in hospitalized patients mandated by the Joint Commission for Accreditation of Health Care Organizations (JCAHO) pain initiative precipitated a number of changes by the perioperative services at our facility. In October 2002, a numeric pain scale became mandatory in our postanesthesia care unit (PACU). Response to analgesia in the PACU was recorded using this scale. In addition, an acceptable pain score was required for discharge from the PACU. We evaluated the effects of these changes in the pain management of 1082 patients undergoing general, orthopedic, neurosurgical, urologic, and gynecologic surgeries. We detected an overall increase in the average consumption of opiates (morphine equivalents) in 2002 compared with 2000 (46.6 +/- 20.4 mg versus 40.4 +/- 13.2 mg, P <0.001). This increase was most significant in the PACU (10.5 +/- 10.4 mg versus 6.5 +/- 7.3 mg, P <0.001 between the 2 periods, respectively). This increase in opiate use was not associated with an increased length of stay, an increase in the requirement for naloxone, or an increase in treatment for postoperative nausea and vomiting. We conclude that the increase in opiate use, which could be explained by compliance with the JCAHO pain initiative, was not associated with additional opiate-induced morbidity in the immediate postoperative period.

Accuracy of intraoperative gross examination of surgical margin status in women undergoing partial mastectomy for breast malignancy

Margin status is an important prognostic factor for local recurrence after partial mastectomy for breast malignancy. Options for intraoperative evaluation of margin status include gross examination of the specimen, frozen section, and "touch preparation" cytology. This study evaluates the accuracy of gross examination without other intraoperative pathological analysis as a method of determining margin status. Records of 254 consecutive patients undergoing partial mastectomy for 255 breast malignancies (199 invasive, 56 DCIS) over 6 years were analyzed retrospectively. All women underwent en bloc excision of the primary lesion with gross examination of margin status by the surgeon and pathologist. All suspicious areas were reexcised, and the specimen was inked, serially sectioned at 2-3 mm intervals and examined with hematoxylin and eosin (H&E) stains. Specimens with tumor <2 mm from a margin were considered margin-positive and those with all tumor > or =2 mm from the margin were designated margin-negative. One hundred fourteen (45%) of the 255 segmental resections were considered to have grossly tumor-free margins, and intraoperative reexcision was not performed. Ninety-six (84%) of these specimens had histologically negative margins. Gross examination prompted intraoperative reexcision in 141 (55%) cases. Ninety-five (67%) of these 141 resections had tumor-free margins on histopathology. Overall, the final margin was involved in 64 of the 255 partial mastectomies. Seventeen (27%) women with initially margin-positive resections underwent mastectomy, while 46 (72%) underwent reexcision, which was margin-negative in 41 (89%). After a median follow-up of 42 months, there have been eight (3.5%) local recurrences. The initial margin-positive rate was similar in ductal carcinoma in situ (DCIS) (30%) and invasive carcinoma (24%). Margin status was correlated with nodal status; there was no correlation with age, tumor size, grade hormone receptor status, or type of diagnostic biopsy. Gross examination of the resection specimen does not reflect margin status in at least 25 per cent of women undergoing partial mastectomy for breast malignancy. Other techniques for evaluation of margin status should be considered to reduce the need for reexcision of involved margins. We are currently designing a prospective clinical trial to examine the efficacy of new techniques for intraoperative evaluation of margin status.

Distilled water peritoneal lavage after colorectal cancer surgery

PURPOSE

Tumor cells exfoliated into the peritoneal cavity during colorectal cancer surgery are viable and tumorigenic and may contribute to peritoneal recurrence. Although commonly used, the tumoricidal effectiveness of antiseptics in peritoneal lavage is doubted because of their chemical alteration by peritoneal secretions. In contrast, osmotic lysis by incubation in distilled water may offer an effective tumoricidal activity. Data defining the susceptibility of colorectal carcinoma cells to osmotic lysis are lacking and hence there is no consensus on optimal lavage methodology.

METHODS

We examined the cytocidal activity of water on colorectal cancer cell lines in culture and determined the effect of peritoneal secretions in vivo on the tumoricidal effectiveness of water.

RESULTS

Incubation of cells in distilled water resulted in cell lysis, with 100 percent lysis achieved after 14 minutes of incubation. In vivo, contamination of lavage water by peritoneal secretions produced a resultant solution with an osmolality of 50 mM. Sequential lavages reduced this contamination, enabling a final resultant solution with an osmolality of 10 mM, which produced 100 percent cell lysis after 32 minutes of incubation.

CONCLUSIONS

Current peritoneal lavage methodology is inadequate because complete cell lysis requires water incubation for longer time periods than is currently practiced. Solutions to this problem are discussed.