Troubleshooting Robotics During Total Hip and Knee Arthroplasty

The introduction of new surgical technology highlights appreciable concerns; robotic arthroplasty is no exception. Acquiring comprehensive understanding of the robotic technology to avoid complications during surgery and devising troubleshooting strategies to overcome potential difficulties is of paramount importance. Troubleshooting algorithms depend on the stage of the procedure and problem encountered, such as loosening of the pins or array, registration or verification problems, or malfunctioning of the device, which is rare. This article aims to outline reproducible workflows and solutions for troubleshooting during robotic-arm assisted total hip arthroplasty and total knee arthroplasty.

Immunohistochemistry for Cancer Stem Cell Detection: Principles and Methods

Cancer stem cells (CSCs) are rare immortal cells within tumors with capabilities of self-renewal, differentiation, and tumorigenicity. CSCs play a pivotal role in the tumor development, progression, relapse, and resistance of anticancer therapy. The technique of choice to detect CSCs in formalin-fixed and paraffin-embedded (FFPE) samples is immunohistochemistry (IHC) since it is inexpensive and widespread in most laboratories. The main aims of this chapter are the description of the protocols and the automated immunohistochemical systems used for the identification of CSCs. Furthermore, a focus on the most common troubleshooting in CSC IHC is provided. Finally, an overview of the main markers of cancer stem cells in several cancer types will be provided.

Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: Practical Application

Why is intravascular ultrasounography (IVUS) highly encouraged for the practical guidance of percutaneous coronary intervention (PCI)? First reason is to understand the mechanism of revascularization. Even if stenoses look similar in angiography, the pathophysiology could be different in each lesion. Second reason is to anticipate possible complications in advance. With prediction and appropriate preparation, most complications can be avoided or managed calmly when they occur. Third reason is to optimize PCI results with interactive IVUS use during the procedure. All these are essential to maximize the results of revascularization while minimizing acute complications, ultimately leading to improved long-term clinical outcomes.

Review of the Use of Liquid Chromatography-Tandem Mass Spectrometry in Clinical Laboratories: Part II-Operations

Liquid chromatography-tandem mass spectrometry (LC-MS/MS) is increasingly utilized in clinical laboratories because it has advantages in terms of specificity and sensitivity over other analytical technologies. These advantages come with additional responsibilities and challenges given that many assays and platforms are not provided to laboratories as a single kit or device. The skills, staff, and assays used in LC-MS/MS are internally developed by the laboratory, with relatively few exceptions. Hence, a laboratory that deploys LC-MS/MS assays must be conscientious of the practices and procedures adopted to overcome the challenges associated with the technology. This review discusses the post-development landscape of LC-MS/MS assays, including validation, quality assurance, operations, and troubleshooting. The content knowledge of LC-MS/MS users is quite broad and deep and spans multiple scientific fields, including biology, clinical chemistry, chromatography, engineering, and MS. However, there are no formal academic programs or specific literature to train laboratory staff on the fundamentals of LC-MS/MS beyond the reports on method development. Therefore, depending on their experience level, some readers may be familiar with aspects of the laboratory practices described herein, while others may be not. This review endeavors to assemble aspects of LC-MS/MS operations in the clinical laboratory to provide a framework for the thoughtful development and execution of LC-MS/MS applications.

Immunochemistry Analysis Using Chromogenic Substrates on Tissue Sections

Immunohistochemistry (IHC) is a highly sensitive protein detection technique developed using the principle of antigen-antibody binding reaction. With immunohistochemistry, it is possible to visualize the abundance, distribution, and localization of proteins in situ. This chapter discusses the standard protocols involved in IHC detection using chromogenic substrates, including pre-treatment of tissues, types of chromogenic substrates, and troubleshooting at various stages of the protocol.

Cardiac device troubleshooting in the intensive care unit: an educational review

Numerous patients with a cardiac implantable electronic device are admitted to the cardiac intensive care unit (ICU). When taking care of these patients, it is essential to have basic knowledge of potential device problems and how they could be tackled. This review summarizes common issues with pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization devices and provides a framework for troubleshooting in the ICU. In addition, specific aspects of intensive care that might interfere with cardiac devices are discussed.

Method to transfer Chinese hamster ovary (CHO) batch shake flask experiments to large-scale, computer-controlled fed-batch bioreactors

Chinese hamster ovary (CHO) cell cultures in industry are most commonly conducted as fed-batch cultures in computer-controlled bioreactors, though most preliminary studies are conducted in fed-batch shake flasks. To improve comparability between bioreactor studies and shake flask studies, shake flask studies should be conducted as fed-batch. However, the smaller volumes and reduced control in shake flasks can impact pH and aeration, which leads to performance differences. Planning and awareness of these vessel and control differences can assist with experimental design as well as troubleshooting. This method will highlight several of the configuration and control issues that should be considered during the transitions from batch to fed-batch and shake flasks to bioreactors, as well as approaches to mitigate the differences. Furthermore, if significant differences occur between bioreactor and shake flask studies, approaches will be presented to isolate the main contributors for these differences.

Integrating quality control and external quality assurance

Effective management of clinical laboratories relies upon an understanding of Quality Control and External Quality Assurance principles. These processes, when applied effectively, reduce patient risk and drive quality improvement. In this Review, we will describe the purpose of QC and EQA and their role in identifying analytical and process error. The two concepts are linked, and we will illustrate that linkage. Some EQA providers offer far more than analytical surveillance. They facilitate training and education and extend quality improvement and identify areas where there is potential for patient harm into the pre-and post-analytical phases of the total testing process.

Robotic Roux-en-Y Gastric Bypass Procedure Guide

Purpose

This is a step-by-step procedural guide to help new and unexperienced surgeons with the implementation of a robotic program for the surgical treatment of morbid obesity.

Methods

Based on our vast robotic experience, we present our standardized technique and also, with a PubMed research, discuss the different surgical aspects.

Results

We present our trainings pathway towards the first robotic Roux-en-Y gastric bypass, a step-by-step procedural guide with helpful hints when it comes to troubleshooting and also discuss some surgical aspects.

Conclusion

The robotic Roux-en-Y gastric bypass is safe and feasible, and might offer some advantages in comparison to the laparoscopic approach.

[Pifalls in the interpretation of pacemaker ECGs]

The analysis of the pacemaker ECG is usually regarded as difficult and may generate rather mediocre interpretations. It is a common opinion that a pacemaker ECG can only be analyzed if the type of pacemaker (single-, dual-, triple-chamber, manufacturer, model) and its programming are known. The following pitfalls illustrate how to achieve a clinically meaningful ECG interpretation in daily practice, even if these details are not known. A systematic approach to ECG interpretation is particularly crucial in this context: Basic rhythm (P waves, intrinsic or paced rhythm), paced QRS complex (axis, width, bundle branch block morphology), signs of pacemaker malfunction (under‑/oversensing, loss of capture), arrhythmia to which the pacemaker reacts, or activity of any pacemaker algorithm. Many small details should not be overlooked and many questions can be answered if a few principles are applied. Understanding of the pacemaker ECG can improve the life of a device patient at the touch of a button.

Pitfalls of the S-ICD therapy: experiences from a large tertiary centre

Aim

The subcutaneous ICD (S-ICD) has evolved to a potential first option for many patients who have to be protected from sudden cardiac death. Many trials have underlined a similar performance regarding its effectiveness in relation to transvenous ICDs and have shown the expected benefits concerning infective endocarditis and lead failure. However, there have also been problems due to the peculiarities of the device, such as oversensing and myopotentials. In this study, we present patients from a large tertiary centre suffering from complications with an S-ICD and propose possible solutions.

Methods and results

All S-ICD patients who experienced complications related to the device (n = 40) of our large-scale single-centre S-ICD registry (n = 351 patients) were included in this study. Baseline characteristics, complications occurring and solutions to these problems were documented over a mean follow-up of 50 months. In most cases (n = 23), patients suffered from oversensing (18 cases with T wave or P wave oversensing, 5 due to myopotentials). Re-programming successfully prevented further oversensing episode in 13/23 patients. In 9 patients, generator or lead-related complications, mostly due to infectious reasons (5/9), occurred. Further problems consisted of ineffective shocks in one patient and need for antibradycardia stimulation in 2 patients and indication for CRT in 2 other patients. In total, the S-ICD had to be extracted in 10 patients. 7 of them received a tv-ICD subsequently, 3 patients refused re-implantation of any ICD. One other patient kept the ICD but had antitachycardic therapy deactivated due to inappropriate shocks for myopotential oversensing.

Conclusion

The S-ICD is a valuable option for many patients for the prevention of sudden cardiac death. Nonetheless, certain problems are immanent to the S-ICD (limited re-programming options, size of the generator) and should be addressed in future generations of the S-ICD.

Graphic abstract

Methodology for Whole Mount and Fluorescent RNA In Situ Hybridization in Echinoderms: Single, Double, and Beyond

Identifying the location of a specific RNA in a cell, tissue, or embryo is essential to understand its function. Here we use echinoderm embryos to demonstrate the power of fluorescence in situ RNA hybridizations to localize sites of specific RNA accumulation in whole mount embryo applications. We add to this technology the use of various probe-labeling technologies to colabel multiple RNAs in one application and we describe protocols for incorporating immunofluorescence approaches to maximize the information obtained in situ. We offer alternatives for these protocols and troubleshooting advice to identify steps in which the procedure may have failed. Overall, echinoderms are wonderfully suited for these technologies, and these protocols are applicable to a wide range of cells, tissues, and embryos.

Troubleshooting in thoracoscopic anatomical lung resection for lung cancer

Video-assisted thoracoscopic surgery (VATS) anatomical lung resection (ALR) has been gaining popularity in the treatment of lung cancer in line with remarkable advances in both equipment and technique. The development and refinement of its technique have allowed thoracic surgeons to perform a wide variety of challenging and complex procedures in a minimally invasive fashion. Careful and meticulous preparation may shift in the future with the increasing sophistication and capabilities of VATS ALR. Moreover, constant awareness and a structured plan of the procedure are imperative to reducing or preventing complications. Intraoperative major complications during VATS ALR are infrequent, but can have catastrophic consequences. The decision to continue with VATS should take into consideration the surgeon's skill level and ease with the approach and the relative potential benefit against the risk to the patient. We conducted this study to investigate the possible problems during VATS ALR and identify how to solve them based on the previous literature and our institutional data sampling.

Papanicolaou Staining and Processing Troubleshooting Exercise Using Digital Pathology: Peer Comparison in an External Quality Assurance Setting

BACKGROUND

The Royal College of Pathologists of Australasia Quality Assurance Programs (RCPAQAP) offers a comprehensive range of External Quality Assurance programs for all disciplines of pathology and is committed to delivering programs to advance outcomes in patient care and promote excellence in laboratory diagnostic and technical proficiency. Proficiency testing in cytopreparatory techniques became available for formal enrolment in 2018. The 2019 technical program focused on the demonstration of a laboratory to troubleshoot problems encountered during staining and processing. The exercise provided a peer comparison of a laboratory's ability to (1) identify the problem viewed from a digital image and (2) describe the troubleshooting steps to rectify the problem using assessment guidelines.

METHODS

Ten troubleshooting exercises including whole-slide z-stacked virtual images, a reference slide, and an online Result Entry questionnaire were provided. Common staining and processing problems were demonstrated in these exercises. Multiple-choice responses were made available to participants for each case with 1 response requiring submission. Participants were then allowed free text to describe how they would rectify the problem.

RESULTS

Of the 72 participants who participated, 62 participants (86%) achieved a satisfactory assessment, 6 participants (8%) received a borderline assessment, and 4 participants (6%) received an unsatisfactory assessment. The average mark obtained was 32.7 out of a total of 45 marks, which equates to a satisfactory assessment. The highest mark obtained for this survey was 42.5.

CONCLUSIONS

Quality cytopathology preparatory techniques are integral to mitigating the risk of diagnostic error. The digital pathology platform allowed homogeneity of samples for all participants and appeared to be a satisfactory mode for demonstrating the technical problems to participants. Laboratories participating in this survey showed good performance in identifying processing and staining problems on virtual images and working through the troubleshooting steps. The exercise also identified a method for troubleshooting formalin vapour-affected slides using citrate buffer which may be useful for laboratories following in-house validation.

Production of Intrinsically Disordered Proteins for Biophysical Studies: Tips and Tricks

Intrinsically disordered proteins (IDPs) have no single, fixed tertiary structure, yet they take on many vital functions in biology. In recent years, considerable effort has been put into the structural characterization of their conformational ensembles, to understand the link between the transient, short- and long-range organizations of IDPs and their functions. Such biophysical studies require substantial amounts of pure protein, representing a major bottleneck in the studies of IDPs. However, the unique physicochemical properties resulting from their compositional bias may be exploited for simple yet effective purification strategies. In this chapter, we provide tips and tricks for IDP production and describe the most important analyses to carry out before bringing an IDP of interest to the laboratory. We outline four purification protocols utilizing the unique properties of IDPs as well as some commonly encountered challenges and pitfalls.

Permanent His Bundle Pacing: A programming and troubleshooting guide

Permanent His Bundle Pacing (HBP) has recently gained popularity. However, implanting physicians and those who perform the device checks must invest in additional education in order to accurately program these devices, identify changes in morphology and perform troubleshooting to help achieve the best outcomes for the patients. This paper reviews key aspects of HBP and provides the educational tools for successful HBP follow-up and troubleshooting.

Programming and follow-up of patients with His bundle pacing

His bundle pacing (HBP) is being increasingly adopted worldwide, with the aim of providing more physiological stimulation of the heart as opposed to right ventricular pacing or as an alternative to cardiac resynchronization therapy (CRT). Current devices are not specifically designed for HBP, which gives rise to programming challenges. This article aims to provide practical recommendations for HBP programming and follow-up.

Why do we need training? - A "Training school on molecular methods used for foodborne parasite diagnostics in different matrices" is a example of knowledge transfer to foster research quality in EU

Foodborne parasites with zoonotic potential are of particular concern for human health, being responsible for serious and potentially life threatening diseases. In the last decades, the development of molecular biology techniques have been successfully implemented for clinical diagnosis of FBPs in animal or human samples providing cheaper, less labor intensive, reliable and more sensitive tests. It is apparent from recent publications that unsubstantiated molecular methods for parasite detection that have undergone scant evaluation for sensitivity and specificity are becoming increasingly common. The aim of the organized Training Schools was to transfer knowledge on application, optimization and troubleshooting for methods used to extract, amplify, and sequence nucleic acids from contaminated matrices and isolated FBPs. The organized Training Schools fulfilled the trainees' expectations, whom acquired useful knowledge for their research activities.

[Management of a bi-caval dual lumen cannula clot obstruction after TEE guided diagnosis: a case-report]

BACKGROUND

Veno-venous extracorporeal membrane oxygenation is an established therapy for patients with refractory acute respiratory distress syndrome (ARDS). One complication related to the use of veno-venous extracorporeal membrane oxygenation is thrombosis despite proper anticoagulation. We report the diagnosis and management of a clot-obstruction in a single site cannula placed through the internal jugular vein, guided by transesophageal echocardiography.

CASE REPORT

A 39 year-old male developed acute respiratory distress syndrome and hemodynamic instability after an episode of pulmonary aspiration in the ICU. Eight hours after placement of a single site veno-venous extracorporeal membrane oxygenation, suddenly the perfusionist noticed a reduction in flow. TEE showed a thrombus-like mass obstructing the inflow port in SVC and inflow at IVC was intact. After unsuccessful attempts to reposition the cannula, the team decided to insert additional femoral inflow cannula through the IVC. The single site catheter was then pulled out until its tip was positioned in the right atrium and all three ports of the catheter were switched to the infusion ports. After this, flows and oxygenation improved significantly. Unfortunately, despite all of the efforts, the patient died 2 days later.

DISCUSSION

The diagnosis of veno-venous extracorporeal membrane oxygenation cannula obstruction is based on reduced inflow rates, hemodynamic instability and poor oxygenation of blood. TEE allows evaluation of the flows inside the cannula and in this case, an obstruction was found. The management presented points to the fact that in a situation of catheter obstruction caused by a clot, there is a feasible alternative to assure minimal interruption of the hemodynamic support offered by the veno-venous extracorporeal membrane oxygenation.

Troubleshooting in the histology laboratory

Humans and machines both have an inherent error rate. As long as this is true, sub-optimal events will occur in the histology laboratory. The best approach to troubleshooting and remedying these events is to (1) understand the various theories of action behind histology procedures and stains then (2) apply a problem-solving mentality to develop a corrective action. These theories and problem solving strategies are presented in this review article.

Immunohistochemistry for Cancer Stem Cells Detection: Principles and Methods

Cancer stem cells (CSCs) are rare immortal cells within a tumor that can self-renew and drive tumorigenesis. CSCs play a pivotal role in the tumor development, progression and relapse, as well as in the resistance of anticancer therapy. Different tools could help in the analysis of CSCs, especially Immunohistochemistry (IHC) represents a useful technique able to identify several specific CSC markers. The main aims of this chapter are the description of the explain immunohistochemical methods used in the characterization of CSCs. Furthermore, focus on the most common troubleshooting in CSCs IHC is provided, especially the pitfalls of the CSCs markers IHC on tissue microarrays.

Management of Intraoperative Difficulties During Uniportal Video-Assisted Thoracoscopic Surgery

The learning curve of the uniportal video-assisted thoracoscopic surgery (VATS) approach is linked to a larger rate of intraoperative complications, which can lead to an emergency conversion to thoracotomy. Despite technical advancements and the large number of surgical videos posted on specialized websites, live surgery events and experimental courses have significantly contributed to accelerate the learning and evolution of minimally invasive thoracic surgery. Bleeding and other complications are the most dreaded event for many VATS surgeons. This article analyzes possible major intraoperative complications during uniportal VATS and explains how to manage them effectively and safely.

Human-centered design (HCD) of a fault-finding application for mobile devices and its impact on the reduction of time in fault diagnosis in the manufacturing industry

The present article describes the design process of a fault-finding application for mobile devices, which was built to support workers' performance by guiding them through a systematic strategy to stay focused during a fault-finding process. In collaboration with a project partner in the manufacturing industry, a fault diagnosis application was conceptualized based on a human-centered design approach (ISO 9241-210:2010). A field study with 42 maintenance workers was conducted for the purpose of evaluating the performance enhancement of fault finding in three different scenarios as well as for assessing the workers' acceptance of the technology. Workers using the mobile device application were twice as fast at fault finding as the control group without the application and perceived the application as very useful. The results indicate a vast potential of the mobile application for fault diagnosis in contemporary manufacturing systems.

Zymography Principles

Zymography, the detection, identification, and even quantification of enzyme activity fractionated by gel electrophoresis, has received increasing attention in the last years, as revealed by the number of articles published. A number of enzymes are routinely detected by zymography, especially with clinical interest. This introductory chapter reviews the major principles behind zymography. New advances of this method are basically focused towards two-dimensional zymography and transfer zymography as will be explained in the rest of the chapters. Some general considerations when performing the experiments are outlined as well as the major troubleshooting and safety issues necessary for correct development of the electrophoresis.

Principles and Methods of Immunohistochemistry

Immunohistochemical techniques detect antigens in tissue sections by means of immunological and chemical reactions. This technique is highly sensitive and specific and can detect a wide variety of antigens in multiple animal species. This chapter reviews common immunohistochemical methods used in the characterization of normal and pathologic tissue and the reagents used. Pretreatments such as blocking steps for endogenous activities and antigen retrieval are included. Standard procedures on formalin-fixed, paraffin-embedded tissues as well as method standardization for new antibodies and troubleshooting are emphasized.

The efficacy of thoracoscopic fissureless lobectomy in patients with dense fissures

BACKGROUND

Prolonged air leakage after a lobectomy remains a frequent complication in patients with dense fissures. To avoid postoperative air leakage, we used the "thoracoscopic fissureless technique" for patients with dense fissures. A thoracoscopic approach is useful for the fissureless technique because it gives a good operative view from various angles without dividing the fissure. In this study, we compared the peri- or intraoperative results of thoracoscopic fissureless lobectomies to traditional lobectomies with fissure dissection for pulmonary artery (PA) exposure in order to identify the efficacy of thoracoscopic fissureless lobectomy.

METHODS

Between April 2012 and November 2015, 175 patients underwent a thoracoscopic lobectomy with three or four ports, of whom 14 underwent a fissureless lobectomy because of dense fissures. We compared the characteristics and perioperative outcomes of the patients who underwent the fissureless technique (fissureless technique group, n=14) and the traditional fissure dissection technique for PA exposure (traditional technique group, n=161). In our department, fissureless lobectomy is indicated for patients with a fused fissure (fissural grade III or IV as proposed by Craig in 1997) or inflammation makes it difficult to expose the PA, while the traditional technique is used for other patients.

RESULTS

Although the fissureless technique group had longer operation time than the traditional technique group (P=0.0045), there was no significant inter-group difference about blood loss (P=0.85), occurrence rate of intraoperative massive bleeding (P=0.6) or conversion rate to thoracotomy (P=0.31). According to postoperative results, there was no significant inter-group difference in duration of chest tube drainage (P=0.56), length of postoperative hospital stay (P=0.14), or morbidity rate (P=0.16). No mortality occurred in either group.

CONCLUSIONS

A thoracoscopic fissureless lobectomy is feasible and safe, and useful to avoid postoperative air-leakage in patients with dense fissures.

Pitfalls in PCR troubleshooting: Expect the unexpected?

PCR is a well-understood and established laboratory technique often used in molecular diagnostics. Huge experience has been accumulated over the last years regarding the design of PCR assays and their set-up, including in-depth troubleshooting to obtain the optimal PCR assay for each purpose. Here we report a PCR troubleshooting that came up with a surprising result never observed before. With this report we hope to sensitize the reader to this peculiar problem and to save troubleshooting efforts in similar situations, especially in time-critical and ambitious diagnostic settings.

Troubleshooting of the determination of bisphenol A at ultra-trace levels by liquid chromatography and tandem mass spectrometry

Determination of trace amounts of bisphenol A (BPA) may cause problems mainly related to the presence of BPA in solvents (even in LC-MS grade), laboratory vessels, and plastic equipment used for sample preparation. Variable and sometimes significant amounts of BPA present in the background cause problems in obtaining good repeatability of measurements at the ultra-trace levels. Such observations (i.e., poor repeatability of results) were made during development of the LC-MS/MS method for determination of BPA in human serum samples. The method included gradient separation of the sample’s constituents. The BPA peak was present in the chromatograms not only when procedural blanks were injected but also when void injections were made. One of the possible ways to eliminate background contamination is to change the source of solvents, use a different water purification system, and introduce rigorous equipment cleaning procedures. However, despite the use of these recommended guidelines, the peak of BPA was still present in the system blank. It was observed that the intensity of the BPA peak was proportional to the time of column conditioning. It was concluded that BPA, present in the components of the mobile phase, is being enriched in the front of the separation column during its conditioning (i.e., when mobile phase elution strength was low). This paper describes effects of gradient and isocratic elution conditions on LC-MS/MS system blank. The problem of spurious BPA peak, originating from the mobile phase, was solved by replacing gradient with isocratic elution mode. The use of isocratic elution conditions with the mobile phase of relatively high elution strength (50 % of acetonitrile) allowed elimination of the peak of BPA coming from the mobile phase and significantly improved the precision of determination of BPA at low concentration levels.

Troubleshooting ProSeal LMA

Supraglottic devices have changed the face of the airway management. These devices have contributed in a big way in airway management especially, in the difficult airway scenario significantly decreasing the pharyngolaryngeal morbidity. There is a plethora of these devices, which has been well matched by their wider acceptance in clinical practice. ProSeal laryngeal mask airway (PLMA) is one such frequently used device employed for spontaneous as well as controlled ventilation. However, the use of PLMA at times maybe associated with certain problems. Some of the problems related with its use are unique while others are akin to the classic laryngeal mask airway (cLMA). However, expertise is needed for its safe and judicious use, correct placement, recognition and management of its various malpositions and complications. The present article describes the tests employed for proper confirmation of placement to assess the ventilatory and the drain tube functions of the mask, diagnosis of various malpositions and the management of these aspects. All these areas have been highlighted under the heading of troubleshooting PLMA. Many problems can be solved by proper patient and procedure selection, maintaining adequate depth of anaesthesia, diagnosis and management of malpositions. Proper fixation of the device and monitoring cuff pressure intraoperatively may bring down the incidence of airway morbidity.