Determination of plasma uracil as a screening for dihydropyrimidine dehydrogenase deficiency: clinical application in oncological treatments

AIMS

Treatment with dihydropyrimidines poses a significant risk of serious adverse reactions for patients with dihydropyrimidine dehydrogenase (DPD) deficiency. This study seeks to analyse the correlation between DPD deficiency and plasmatic uracil values in patients who are candidates for a fluoropyrimidine scheme. It also studies the incidence of adverse events (AEs) in patients with DPD deficiency established with plasmatic uracil determination.

METHODS

This was a retrospective observational study conducted in a tertiary level establishment from September 2020 to April 2021. Patients included were diagnosed with gastrointestinal tumours, were of good status, and were initiated into a fluoropyrimidine-based regimen. The incidence and grade of AEs, according Common Terminology Criteria for Adverse Events (CTCAE), were collected and compared in patients with and without DPD deficiency.

RESULTS

119 patients diagnosed with gastrointestinal cancer met the inclusion criteria. In 92 (77%) patients there was no DPD deficiency according to plasmatic uracil thresholds. In the group of patients without deficit, dose reductions oscillated between 10-25% (mean 17.4%). In the no DPD deficiency group, 43 (46%) patients experienced AEs. Patients who had a DPD deficiency according to plasmatic uracil measurements were started on a 5-fluorouracil (5-FU) regimen with a dose reduction of 15-50% (mean 35%). In this group, 12 patients (44%) experienced some AEs.

CONCLUSION

New research is needed to clarify the correlation between plasma uracil values and DPD deficiency to achieve an optimal balance between clinical benefit and toxicity.

Digitizing fluid balance monitoring may offer a solution for optimizing patient care

BACKGROUND

Precise fluid balance monitoring is essential for patient treatment, as incorrect fluid balance can lead to disorders.

OBJECTIVE

This study aimed to assess the accuracy of the digital technology LICENSE (LIquid balanCE moNitoring SystEm) for fluid balance charting and compare it to the standard method (SM) to determine its usability in clinical practice.

METHODS

This prospective study included 20 patients. The results from LICENSE were compared to those from SM and a reference measurement (manual weight of fluids, RM). Three LICENSE devices were used for urine output, intravenous fluids, and oral fluid intake. The accuracy of methods was evaluated using Bland Altman plots.

RESULTS

The mean difference between LICENSE and RM was less than 2 millilitres (p= 0.031 and p= 0.047), whereas the mean difference between SM and RM was 6.6 ml and 10.8 ml (p< 0.0001). The range between the upper and lower limits of agreement was between 16.4 and 27.8 ml for LICENSE measurements and 25.2 and 52 ml for SM.

CONCLUSION

LICENSE is comparable to or more accurate than the standard method for fluid balance monitoring. The use of LICENSE may improve the accuracy of fluid balance measurements. Further research is needed to evaluate its feasibility in daily clinical practice.

Performance of a Chemical Heat Blanket in Dry, Damp, and Wet Conditions Inside a Mountain Rescue Hypothermia Wrap

INTRODUCTION

Casualties with accidental hypothermia are evacuated using multilayer wraps, typically including a chemical heat blanket (CHB), a vapor barrier, and an insulating outer bag. We investigated CHB performance against dry, damp, and wet fabric, in a multilayer wrap, in response to a case report indicating diminished performance when wet.

METHODS

We wrapped a torso manikin in a base layer, CHB, vapor barrier, casualty bag, and vacuum mattress, recording CHB panel temperatures at intervals of up to 7 h. Experimental conditions were dry, damp, and wet clothing, with 2 blankets tested in each condition. We subsequently used a forward-looking infrared camera to assess whether the panels heated evenly and heat flux sensors to quantify heat transfer across 2 dry, 1 damp, and 1 wet fleece under CHB panels.

RESULTS

Chemical heat blankets maintained heat output for >7 h inside the wraps. Median (IQR) panel steady state temperatures were 52°C (39-56°C) against dry fleece, 41°C (36-45°C) against damp fleece, and 30°C (29-33°C) against wet fleece. Peak panel temperature was 67°C. The heat flux results indicated that CHBs generated similar quantities of heat in dry and damp conditions, as the lower temperatures were compensated by more efficient transfer of heat across the moist clothing layer. Chemical heat blanket heat output was diminished in wet conditions.

CONCLUSIONS

Rescuers should cut off saturated clothing in a protected environment before wrapping casualties, but damp clothing need not be removed. Because of the high peak temperatures recorded on the surfaces of CHBs, they should not be placed directly against skin, and compression straps should not be placed directly over CHBs.

A comparative study on the influence of equipment design on the efficiency of dynamic maceration of Azadirachta excelsa leaves

Dynamic maceration facilitates diffusion in solid-liquid extraction through controlling temperature and providing agitation. However, equipment design for dynamic maceration in previous investigations resulted in inadequate homogeneity of temperature and solid dispersion. A laboratory scale extractor was designed to aid the heat and mass transfer process while preventing solvent vaporization when performing dynamic maceration in a controlled environment. This study aimed to evaluate the efficiency of dynamic maceration using the laboratory scale extractor compared to a shaker incubator to extract triterpenoid saponins from Azadirachta excelsa leaves. The dynamic maceration of A. excelsa leaves was optimized using a Face-centered central composite design (FCCCD) with response surface methodology (RSM). Independent variables analyzed include ethanol-to-chloroform ratio, extraction temperature, extraction time, and sample-to-solvent ratio, while responses include yield of extract and triterpenoid saponins content (TSC). Optimum conditions were ethanol-to-chloroform ratio of 90:10, extraction temperature of 45 °C, extraction time of 60 minutes, and sample-to-solvent ratio of 1:50 g/ml. There was a significant percentage of increase in yield of extract and TSC by 41.1% and 13.3%, respectively, for the laboratory scale extractor compared to the shaker incubator. This study showed the importance of equipment design in enhancing triterpenoid saponins extraction through elevating the efficiency of the dynamic maceration process.

Feasibility of customized 3D-printed assistive technology within an existing multidisciplinary amyotrophic lateral sclerosis clinic

PURPOSE

Three-dimensional (3 D) printing of assistive technology (AT) is an emerging intervention in rehabilitation sciences. Existing research primarily considers narrow applications of this technology with most studies focussing on a single type of assistive device. Individuals with amyotrophic lateral scleroses (ALS) have high abandonment rates of prefabricated AT. Therefore, the goal of this project was to determine the implementation and acceptability feasibility of meeting AT needs through the creation of customized, 3D-printed devices within an existing multidisciplinary ALS clinic.

METHODS

Implementation feasibility was measured using descriptive statistics about the research team's ability to fulfil device requests. Acceptability was evaluated using semi-structured patient satisfaction interviews after AT device provision. The study utilized thematic analysis to identify patterns in the qualitative data collected from participant interviews.

RESULTS

Nine participants identified at least one need for 3D-printed assistive devices customized to their unique performance abilities and needs. Seven participants received 3D-printed devices, four of whom completed the follow-up interview. The research team was able to fulfil 20 of 34 device requests, supporting implementation feasibility. Thematic analysis revealed three themes from the interviews: Satisfaction with Devices and Services, Value of Training as a Service, and Increased Participation and Choice.

CONCLUSIONS

These findings demonstrate implementation feasibility and participant satisfaction with the process of receiving devices, supporting acceptability feasibility. Future research into the efficacy of customized 3D-printed AT is recommended.Implications for rehabilitationIndividuals with ALS have unmet needs in assistive technology.Custom AT development using 3D printing can be implemented within an existing, multidisciplinary ALS clinic.Future 3D printing research should rigorously investigate methods to meet the unique needs and challenges of individuals in this setting.

Comparison of three automated compounding devices for parenteral nutrition according to four key technical tests

OBJECTIVES

Automation of parenteral nutrition (PN) preparation is nowadays a recommended practice in order to reduce human errors and thus improve the safety and accuracy of the finished product. Other benefits of automation may include full documentation of preparation and a reduction in personnel requirements or staff injuries. The market of automation compounding presents different automated compounding devices (ACDs). The aim of this study is to compare the technical characteristics of ACDs by carrying out four specific challenges.

METHODS

Three ACDs: Two piston pumps with ACD 1: MediMix Multi 4120R (Impromediform) and ACD 2: Mibmix Compounder C12 (Hemedis), and one peristaltic pump ACD 3: ExactaMix Compounder EM2400 (Baxter) were assessed in a pharmaceutical manufacturing unit within a controlled atmosphere area, under horizontal laminar flow hood (LFH) according to four tests: volumetric accuracy, flush volume, smoke test, and a production test with three configurations of PN bags. For this test, a PN bag was considered accepted when all quality controls (weight, molar concentration of sodium, potassium and calcium) were fulfilled.

RESULTS

The maximum relative biases found for the different ACDs were heterogeneous. ACD 1 had the best volumetric accuracy with respect to supplier specifications and for extreme volumes (0.2 mL). Evaluation of the flushing volume allowed the validation of 50 mL volumes for ACD 1 and ACD 3. The smoke test was only conclusive for ACD 1 under a horizontal LFH. The percentage of PN bags accepted were 98.8% for ACD 1, 70% for ACD 2%, and 95.5% for ACD 3.

CONCLUSION

This study compared three ACDs according to four relevant and specific tests. Based on the data acquired, we conclude that ACD 1 is the most accurate, has the lowest flushing volume, is suitable for use in a LFH, and achieves the best results in the production test.

Automation of parenteral nutrition: impact on process and cost analysis

OBJECTIVES

On the basis of its safety and accuracy, automation is recommended for parenteral nutrition (PN). The aim of this study was to highlight the changes in practices related to the automation of PN and to perform a cost study comparing manual vs automated production costs.

METHODS

We conducted a micro-costing study using 1 year of manual production data for adult, neonatal and paediatric PN bagsat a hospital. We used the data to estimate the costs of automating the production process for adult, neonatal and paediatric bags.

RESULTS

Major modification to the PN production process resulted in: rationalisation of raw materials, computerisation and optimisation of human needs. Switching from a manual to an automated process reduced the cost of neonatal/paediatric custom bags (€130.73 vs €124.58) and semi-custom bags (€172.08 vs €166.86); but increased the cost of adult bags (€93.06 vs €127.92).

CONCLUSIONS

The changes resulting from the automation and revision of the production process globally increased annual expenditures by approximately 9.7%. However, automation minimised the risk of misproduction, bag contamination, and led to a more secure production process that reduced risks incurred by the teams. In view of the gain in patient and staff safety (linked to the use of an automated compounding device) the moderate economic impact (<10%) should not deter the automation of PN production circuits.

Usability of the GAIMplank Video Game Controller for People With Mobility Impairments: Observational Study

BACKGROUND

Replacing sedentary behaviors during leisure time with active video gaming has been shown to be an enjoyable option for increasing physical activity. However, most off-the-shelf active video gaming controllers are not accessible or usable for individuals with mobility impairments. To address this requirement, a universal video game controller (called the GAIMplank) was designed and developed.

OBJECTIVE

This study aimed to assess the usability of the GAIMplank video game controller for playing PC video games among individuals with mobility impairments. Measures of enjoyment, perceived exertion, and qualitative data on the user experience were also examined.

METHODS

Adults (aged 18-75 years) with a mobility impairment were recruited to participate in a single testing session in the laboratory. Before testing began, basic demographic information, along with minutes of weekday and weekend physical activity, minutes of weekday and weekend video game play, and video game play experience were collected. The GAIMplank was mapped to operate as a typical joystick controller. Depending on their comfort and functional ability, participants chose to play seated in a chair, standing, or in their own manual wheelchair. Leaning movements of the trunk created corresponding action in the game (ie, lean right to move right). The participants played a total of 5 preselected video games for approximately 5 minutes each. Data were collected to assess the usability of the GAIMplank, along with self-efficacy regarding execution of game play actions, rating of perceived exertion and enjoyment for each game, and overall qualitative feedback.

RESULTS

A total of 21 adults (n=15, 71% men; n=6, 29% women) completed the usability testing, with a mean age of 48.8 (SD 13.8; range 21-73) years. Overall, 38% (8/21) of adults played while standing, 33% (7/21) of adults played while seated in a chair, and 29% (6/21) played in their own manual wheelchair. Scores from the System Usability Scale indicated above average (74.8, SD 14.5) usability, with scores best for those who played seated in a chair, followed by those standing, and then individuals who played seated in their own wheelchairs. Inconsistencies in the responsiveness of the controller and general feedback for minor improvements were documented. Rating of perceived exertion scores ranged from light to moderate intensity, with the highest scores for those who played seated in a chair. Participants rated their experience with playing each game from above average to very enjoyable.

CONCLUSIONS

The GAIMplank video game controller was found to be usable and accessible, providing an enjoyable option for light-to-moderate intensity exercise among adults with mobility impairments. Minor issues with inconsistencies in controller responsiveness were also recorded. Following further development and refinement, the next phase will include a pilot exercise intervention using the GAIMplank system.

Developing Assistive Bedside Furniture for Early Postoperative Mobilization in a Healthcare Setting With an Attentive Empathetic Design Approach

OBJECTIVES

This work endeavored to design and develop a tool to assist surgical patients with postoperative mobilization in a hospital.

BACKGROUND

Early postoperative mobilization after surgery can effectively help prevent complications, but it is difficult to achieve in practice.

METHOD

An attentive empathetic design approach was used to gain insights into the users' functional needs, characteristics, contexts, as well as their emotional needs, behaviors, and psychology. The insights led to a design that leveraged psychological heuristics and habit-building principles to effect necessary mindset and behavioral changes of the stakeholders. Over four iterations, design ideas were prototyped, tested, and improved with participation of 30 patients and 30 nurses.

RESULTS

Valuable insights were discovered. Most importantly, besides the medically critical need to avoid postoperative complications, the patients also had emotional needs for independence, confidence, and self-worthiness, while the nurses needed the patients' trust. Consequently, assistive bedside furniture prototypes were designed to enable the patients to move around safely by themselves. Feedback on the prototypes showed that the patients sat up more often, enjoyed doing more activities, became more confident and less fearful of moving around, and felt less burdening on the care providers. Moreover, the nurses appreciated that the prototypes reduced their patient-mobilization workload, facilitated patient empowerment, and improved their relationship with the patients.

CONCLUSIONS

An attentive empathetic design approach can comprehend complex challenges of and subsequently design an effective solution for healthcare contexts, in which the stakeholders' medical necessities intertwine with emotional, psychological, behavioral, and sociocultural needs.

Use of Accessible Weight Scales and Examination Tables/Chairs for Patients with Significant Mobility Limitations by Physicians Nationwide

BACKGROUND

Mobility limitations are the most common disability type among the 61 million Americans with disability. Studies of patients with mobility limitations suggest that inaccessible medical diagnostic equipment poses significant barriers to care.

METHODS

The study team surveyed randomly selected US physicians nationwide representing seven specialties about their reported use of accessible weight scales and exam tables/chairs when caring for patients with mobility limitations. A descriptive analysis of responses was performed, and multivariable logistic regression was used to examine associations between accessible equipment and participants' characteristics.

RESULTS

The 714 participants (survey response rate = 61.0%) were primarily male, White, and urban, and had practiced for 20 or more years. Among those reporting routinely recording patients' weights (n = 399), only 22.6% (standard error [SE] = 2.2) reported always or usually using accessible weight scales for patients with significant mobility limitations. To determine weights of patients with mobility limitations, 8.1% always, 24.3% usually, and 40.0% sometimes asked patients. Physicians practicing ≥ 20 years were much less likely than other physicians to use accessible weight scales: odds ratio (OR) = 0.51 (95% confidence interval [CI] = 0.26-0.99). Among participants seeing patients with significant mobility limitations (n = 584), only 40.3% (SE = 2.2) always or usually used accessible exam tables or chairs. Specialists were much more likely than primary care physicians to use accessible exam tables/chairs: OR = 1.96 (95% CI = 1.29-2.99).

CONCLUSION

More than 30 years after enactment of the Americans with Disabilities Act, most physicians surveyed do not use accessible equipment for routine care of patients with chronic significant mobility limitations.

The assessment of usability of pain medical device by physiatrists and physiotherapists: A Delphi survey

When developing a new medical device, it is essential to assess the usability of such a device through various stakeholders.This study assessed the usability of pain medical devices through a Delphi survey administered to physiatrists and physiotherapists.A Delphi survey was conducted on the problems and improvements in hardware and software for a panel consisting of 10 physiatrists and 10 physiotherapists. A total of 3 rounds of surveys were conducted, and the third round of survey was confirmed through a Likert scale (1 = strongly agree to 5 = strongly disagree).The 2 groups generally had a common perception of the problems and improvements in pain medical devices. However, the physiatrist group mostly identified problems such as linking patient information, whereas the physiotherapist group deemed hardware problems such as device weight or connection cables as being more important (mean [standard deviation]; physiatrist, hardware 2.90 [0.93], software 2.28 [0.91] / physiotherapist, hardware 3.04 [0.84], software 3.03 [1.13]).To date, analysis has not been conducted by dividing the focus of various stakeholders using pain medical devices. The difference in view of the usability of these 2 stakeholder groups should be considered when improving the hardware or software of pain medical devices in the future. Further research is warranted to investigate other stakeholders such as patients and device developers to improve the devices.

En Bloc AngioVac Removal of Thoracic Aortic Mass

The AngioVac system, designed for suction during extracorporeal bypass, is used to aspirate masses, thrombi, and other undesirable material from the cardiovascular system. To date, it has been used extensively in the venous system and right side of the heart; however, its use in the arterial system has been limited because of smaller vessel sizes and the requirement for a 26F sheath. We report the case of a 45-year-old woman with a history of angiosarcoma who presented with acute embolic events that affected her spleen and lower extremities. We removed a large mobile mass en bloc from her distal thoracic aorta by using the AngioVac system as an alternative to surgical resection. The patient recovered with no recurrence. We discuss the benefits and challenges of using the AngioVac within small vessels of the arterial system.

Burden and Unmet Needs with Portable Oxygen in Patients on Long-Term Oxygen Therapy

Rationale: Over 1.5 million Americans receive long-term oxygen therapy (LTOT) for the treatment of chronic hypoxemia to optimize functional status and quality of life. However, current portable oxygen equipment, including portable gas tanks (GTs), portable liquid tanks (LTs), and portable oxygen concentrators (POCs), each have limitations that can hinder patient mobility and daily activities. Objectives: To examine patient experiences with portable oxygen to guide equipment innovation and thereby improve patient care on oxygen therapy. Methods: The burden and unmet needs with portable oxygen equipment were assessed in 836 LTOT patients with chronic lung disease (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) through an online survey. The survey included a combination of multiple-choice, Likert-scale, short-answer, and open-ended questions. Distribution was achieved through patient support organizations, including the U.S. COPD Coalition, the Pulmonary Fibrosis Foundation, and the Pulmonary Hypertension Association. Results: Improvements in portability were ranked as the highest priority by patients across all equipment types, followed by increases in the duration of oxygen supply for GTs, accessibility for LTs, and flow capabilities for POCs. All device types were found to be burdensome, with the greatest burden among GT users, 51% of whom characterized GT use as "strenuous" or "extremely strenuous" (high burden). POCs ranked as the most common (61%) and least burdensome devices; however, 29% of POC users still reported a high associated burden. Forty-seven percent of POC respondents described using a POC despite it not meeting their oxygen needs to benefit from advantages over alternative equipment. Among non-POC users, limited oxygen flow rate capabilities and cost were the top reasons preventing POC use. Conclusions: Although improvements have been made to portable oxygen equipment, this study highlights the burden that remains and reveals a clear need for advances in technology to improve the functional status and quality of life of portable LTOT users.

Voice alerting as a medical alarm modality for next-generation patient monitoring: a randomised international multicentre trial

BACKGROUND

Acoustic alarms in medical devices are vital for patient safety. State-of-the-art patient monitoring alarms are indistinguishable and contribute to alarm fatigue. There are two promising new sound modalities for vital sign alarms. Auditory icons convey alarms as brief metaphorical sounds, and voice alerts transmit information using a clear-spoken language. We compared how reliably healthcare professionals identified alarms using these two modalities.

METHODS

This investigator-initiated computer-based multicentre simulation study included 28 anaesthesia providers who were asked to identify vital sign alarms in randomised order, once with voice alerts and once with auditory icons. We further assessed time to decision, diagnostic confidence, and perceived helpfulness. We analysed the results using mixed models, adjusted for possible confounders.

RESULTS

We assessed 14 alarms for each modality, resulting in 392 comparisons across all participants. Compared with auditory icons, healthcare providers had 58 times higher odds of correctly identifying alarms using voice alerts (odds ratio 58.0; 95% confidence interval [CI]: 25.1-133.6; P<0.001), made their decisions about 14 s faster (coefficient -13.9; 95% CI: -15.8 to -12.1 s; P<0.001), perceived higher diagnostic confidence (100% [392 of 392] vs 43% [169 of 392; P<0.001]), and rated voice alerts as more helpful (odds ratio 138.2; 95% CI: 64.9-294.1; P<0.001). The participants were able to identify significantly higher proportions of alarms with voice alerts (98.5%; P<0.001) and auditory icons (54.1%; P<0.001) compared with state-of-the-art alarms (17.9%).

CONCLUSIONS

Voice alerts were superior to auditory icons, and both were superior to current state-of-the-art auditory alarms. These findings demonstrate the potential that voice alerts hold for patient monitoring.

Car Ratings Take a Back Seat to Vehicle Type: Outcomes of SUV Versus Passenger Car Crashes

Background

Car safety ratings are routinely utilized in making automobile purchase decisions. These 1- to 5-star ratings are based on crash test data comparing vehicles of similar type, size and weight.

Objectives

We hypothesized that car safety ratings are less important than vehicle factors such as vehicle type and weight in predicting outcomes of head-on crashes.

Methods

A retrospective study was conducted on severe head-on motor vehicle crashes entered into the FARS (Fatality Analysis Reporting System) database between 1995 and 2010. This database includes all US motor vehicle crashes that resulted in a death within 30 days of the accident. Outcomes of SUV versus passenger car and passenger car versus passenger car head-on crashes were compared by safety rating. Exclusion criteria was added to eliminate collisions with insufficient information or unbelted passengers. The paired crash results were entered into a logistic regression model with driver death as the outcome of interest.

Results

The database contained 83,251 vehicles of any type that were involved in head-on crashes. In head-on crashes where the passenger car front driver crash rating was superior to the SUV's, the odds of death were 4.52 times higher for the driver of the passenger car (95% CI: 3.06-6.66). Ignoring crash ratings, the odds of death were 7.64 times higher for the passenger car driver (95% CI: 5.59-10.44). In passenger car versus passenger car head-on crashes, a lower car safety rating was associated with a 1.28 times higher odds of death (95% CI: 1.05-1.57). In passenger car vs. passenger car head-on crashes, each one point lower car safety rating resulted in a 1.22 times higher odds of death (95% CI: 1.03-1.44).

Conclusion

Vehicle type (passenger car versus SUV) is a much more important predictor of death than crash safety ratings in SUV versus passenger car head-on crashes.

Effects of industrial back-support exoskeletons on body loading and user experience: an updated systematic review

This study is an updated systematic review of papers published in the last 5 years on industrial back-support exoskeletons. The research questions were aimed at addressing the recent findings regarding objective (e.g. body loading, user performance) and subjective evaluations (e.g. user satisfaction), potential side effects, and methodological aspects of usability testing. Thirteen studies of active and twenty of passive exoskeletons were identified. The exoskeletons were tested during lifting and bending tasks, predominantly in laboratory settings and among healthy young men. In general, decreases in participants' back-muscle activity, peak L5/S1 moments and spinal compression forces were reported. User endurance during lifting and static bending improved, but performance declined during tasks that required increased agility. The overall user satisfaction was moderate. Some side effects were observed, including increased abdominal/lower-limb muscle activity and changes in joint angles. A need was identified for further field studies, involving industrial workers, and reflecting actual work situations. Practitioner summary: Due to increased research activity in the field, a systematic review was performed of recent studies on industrial back-support exoskeletons, addressing objective and subjective evaluations, side effects, and methodological aspects of usability testing. The results indicate the efficiency of exoskeletons in back-load reduction and a need for further studies in real work situations. Abbrevaitions: BB: biceps brachii; BF: biceps femoris; CoM: centre of mass; DA: deltoideus anterior; EMG: electromyography; ES: erector spinae; ES-C: erector spinae-cervical; ESI: erector spinae iliocostalis; ESI-L: erector spinae iliocostalis-lumborum; ESL: erector spinae longissimus; ES-L: erector spinae-lumbar; ESL-L: erector spinae longissimus-lumborum; ESL-T: erector spinae longissimus-thoracis; ES-T: erector spinae-thoracic; GM: glutaeus maximus; LBP: low back pain; LD: latissimus dorsi; LPD: local perceived discomfort scale; LPP: local perceived pressure scale; MS: multifidus spinae; MSD: musculoskeletal disorder; M-SFS: modified spinal function sort; NMV: no mean value provided; OA: obliquus abdominis (internus and externus); OEA: obliquus externus abdominis; OIA : obliquus internus abdominis; RA: rectus abdominis; RF: rectus femoris; RoM: range of motion; SUS: system usability scale; T: trapezius (pars Ascendens and Descendens); TA: trapezius pars ascendens; TC: mid-cervical trapezius; TD: trapezius pars descendens; VAS: visual analog scale; VL: vastus lateralis; VM: vastus medialis.

Off-Pump Continuous-Flow Left Ventricular Assist Device Implantation

Continuous-flow left ventricular assist device implantation is the typical treatment for end-stage heart failure. Improvements in device engineering and technology, surgical experience and technique, and perioperative management have advanced the field, and short-term results approach those of heart transplantation. Further improvements may be achieved by minimizing adverse physiologic effects associated with cardiopulmonary bypass. Therefore, we have developed an off-pump implantation approach for continuous-flow left ventricular assist devices. We detail our surgical technique for off-pump implantation of the HeartWare device.

Flows and function of the Infant Flow neonatal continuous positive airway pressure device investigated with computational fluid dynamics

AIM

The first dedicated neonatal continuous positive airway pressure (CPAP) device using variable flow was the Infant Flow. The system was pressure stable with a low resistance to breathing. The aim of this study was to describe the flow and function of the Infant Flow geometry using simulated breathing and computational fluid dynamics.

METHOD

The original Infant Flow geometry was used with simulated term infant breathing at three levels of CPAP. The large eddy simulation methodology was applied in combination with the WALE sub-grid scale model.

RESULTS

The simulation fully resolved the flow phenomena in the Infant Flow geometry. The main flow feature during inspiration was support by gas entrainment and mixing. During expiration, the jet deflected towards the outlet with unstable impingement of the jet at the opposing edge.

CONCLUSION

The proposed mechanism has previously been based on theoretical reasoning, and our results present the first detailed description of the Infant Flow. The pressure stability was based on a jet supporting inspiration by gas entrainment and then being deflected during exhalation. This confirmed previously assumed principles of function and flows within the geometry and provided a base for further developments.

Laryngeal Force Sensor for Suspension Microlaryngoscopy: A Prospective Controlled Trial

OBJECTIVES

The laryngeal force sensor (LFS) provides real-time force data for suspension microlaryngoscopy. This study investigates whether active use of the LFS can prevent the development of complications.

STUDY DESIGN

Prospective controlled trial.

SETTING

Academic tertiary center.

METHODS

The LFS and custom software were developed to track intraoperative force metrics. A consecutive series of 100 patients had force data collected with operating surgeons blinded to intraoperative readings. The subsequent 100 patients had surgeons actively use the LFS monitoring system. Patients were prospectively enrolled, completing pre- and postoperative surveys to assess the development of tongue pain, paresthesia, paresis, dysgeusia, or dysphagia.

RESULTS

On univariate analysis, the active monitoring group had lower total impulse (P < .001) and fewer extralaryngeal complications (P < .01). On multiple logistic regression, maximum force (odds ratio [OR], 1.08; 95% CI, 1.01-1.16; P = .02) was a significant predictive variable for the development of postoperative complications. Similarly, active LFS monitoring showed a 29.1% (95% CI, 15.7%-42.4%; P < .001) decrease in the likelihood of developing postoperative complications. These effects persisted at the first postoperative visit for maximum force (P = .04) and active LFS monitoring (P = .01). Maximum force (OR, 1.11; 95% CI, 1.04-1.18; P < .01) and active LFS monitoring (16.6%; 95% CI, 2.7%-30.5%; P = .02) were also predictive for the development of an abnormal 10-item Eating Assessment Tool score. These effects also persisted at the first postoperative visit for maximum force (P = .01) and active LFS monitoring (P = .01).

CONCLUSION

Maximum force is predictive of the development postoperative complications. Active monitoring with the LFS is able to mitigate these forces and prevent postoperative complications.

LEVEL OF EVIDENCE

2.

Neonatal Resuscitation With T-Piece Systems: Risk of Inadvertent PEEP Related to Mechanical Properties

Background: Resuscitation of infants using T-piece resuscitators (TPR) allow positive pressure ventilation with positive end-expiratory pressure (PEEP). The adjustable PEEP valve adds resistance to expiration and could contribute to inadvertent PEEP. The study indirectly investigated risk of inadvertent peep by determining expiratory time constants. The aim was to measure system expiratory time constants for a TPR device in a passive mechanical model with infant lung properties. Methods: We used adiabatic bottles to generate four levels of compliance (0.5-3.4 mL/cm H₂O). Expiratory time constants were recorded for combinations of fresh gas flow (8, 10, 15 L/min), PEEP (5, 8, 10 cm H₂O), airway resistance (50, 200 cm H₂O/L/sec and none), endotracheal tube (none, size 2.5, 3.0, 3.5) with a peak inflation pressure of 15 cm H₂O above PEEP. Results: Low compliances resulted in time constants below 0.17 s contrasting to higher compliances where the expiratory time constants were 0.25-0.81 s. Time constants increased with increased resistance, lower fresh gas flows, higher set PEEP levels and with an added airway resistance or endotracheal tube. Conclusions: The risk of inadvertent PEEP increases with a shorter time for expiration in combination with a higher compliance or resistance. The TPR resistance can be reduced by increasing the fresh gas flow or reducing PEEP. The expiratory time constants indicate that this may be clinically important. The risk of inadvertent PEEP would be highest in intubated term infants with highly compliant lungs. These results are useful for interpreting clinical events and recordings.

Novel voice prosthesis after total laryngectomy with laryngoplasty reconstruction

BACKGROUND

Although many patients achieve serviceable speech after total laryngectomy (TL), others are limited by un-naturally low pitch. We describe a cadaveric study to provide proof of concept for a novel voice prosthesis after TL with free tissue laryngoplasty.

METHODS

Devices were implanted into fresh frozen cadavers after TL and free tissue laryngoplasty. Phonation pressures were measured using a custom Blom-Singer Manometer (InHealth Technologies, Carpinteria, CA) and acoustic files were analyzed using Praat, a speech analysis software.

RESULTS

Two fresh frozen cadavers were implanted with the voice prosthesis. Both prostheses demonstrated appropriate stenting of the laryngoplasty. Successful sound production was achieved after airflow generation at the proximal trachea. An average phonation pressure of 3.5 cmH₂ O (SD 1.7 cmH₂ O) was necessary to generate a sound intensity of 80.6 dB (SD 0.2 dB) at an average fundamental frequency of 299.5 Hz (SD 112.6 Hz).

CONCLUSIONS

The novel voice prosthesis described herein offers a feasible voice generation mechanism.

Refinement of international recommendations for cubicles, based on the identification of associations between cubicle characteristics and dairy cow welfare measures

Maladjusted cubicles for dairy cattle may cause increased skin alterations, lameness, and dirtiness. The International Commission of Agricultural and Biosystems Engineering has produced several recommendations for cubicle design, but a previous study showed that not all of them seem efficient. Here, we aim to refine and complete these recommendations. We collected data on 76 dairy farms (2,404 cows). We modeled the association between combinations of cubicle properties (e.g., type of bedding litter) and dimensions (e.g., cubicle width) relative to cow size, and prevalence of cow skin alterations, lameness, and dirtiness. We used weighted multivariable logistic regression models to predict the presence of skin alteration on the carpus; the neck, shoulder, and back; the flank, side, and udder; and the tarsus or hindquarters. We also evaluated the presence of lameness as well as the dirtiness of the lower hind legs including hocks; the hindquarters, upper hind legs, and flank; the cow rear including tail; and the udder. The risk factors highlighted led us to recommend (1) position cubicles in a way that leaves more than 1 m of clearance from any obstacle in front of the cubicle; (2) if there is an obstacle on the lateral plane (i.e., where the cubicle partition is) in front ahead of the cow, put the obstacle in front of the fore knees; (3) if there is an obstacle in front of the cow on the median plane (e.g., neck or front rail), the position the obstacle between 1.25 and 1.5 of the cow length from the curb and between 1.0 and 1.25 of its height; (4) use curb height between 0.11 and 0.15 of cow height with no sharp edges on the curb; (5) use round or at least has no sharp edges brisket board; (6) use a stone-free soil instead of concrete or use a mattress thicker than 1 cm, with microrelief, and a soft fixing area at the curb, (7) litter with straw (rather than nothing or sawdust) and keep it dry. This risk factor analysis should be followed by experiments in controlled environments to further validate these conclusions and used to update the International Commission of Agricultural and Biosystems Engineering recommendations.

Design-in-use applied to Brazilian agriculture: The case of citrus and sugarcane harvesting

BACKGROUND

Harvesting is one of the most critical phases in any crop once it determines the quality of raw material obtained and future production for the next seasons. Sugarcane crops are more uniform allowing the complete mechanization of harvesting. Citrus crops, on the other hand, present variability and require special handling to preserve quality so the harvesting process remains manual preponderantly.

OBJECTIVE

The aim of this research was to explore how the distinct characteristics of sugarcane and citrus crops influence the design of respective instruments, promoting a discussion about design-in-use in Brazilian fields and its role to improve productivity and safety.

METHODS

Multiple case studies were conducted at 9 sites: 3 sites of sugarcane crops and 6 sites of citrus crops. Task analysis, observations, interviews, questionnaires and video footage were undertaken at each site.

RESULTS

The modifications made by the harvesting teams in all studied sites aimed the appropriateness of objects to local conditions and real needs, transforming them in instruments, improving reliability, safety, health and productivity.

CONCLUSIONS

In agriculture, a sector where working conditions still need to be significantly improved especially in developing countries, design-in-use appears as a solution for the problems faced by workers in the field, as an essential mean to maintain health and productivity at work.

The usability of ventilator maintenance user interface: A comparative evaluation of user task performance, workload, and user experience

Poor usability designed of ventilator user interface can easily lead to human error. In this study, we evaluated the usability design of ventilator maintenance user interface and identified problems related to the usability of user interface that could easily cause human error. Sixteen respiratory therapists participated in this usability study. The usability of the ventilator maintenance user interface was evaluated by participants' task performance (task completion time, task error rate), physiological workload (eye-fixation duration) and perceived workload (NASA-TLX), and user experience (questionnaire). For task performance, task completion time and task error rate showed significant differences. For task completion time, significant difference was found when conducting ventilator self-test (p < 0.001), replace the breathing circuit (p = 0.047), and check battery status (p = 0.005). For task error rate, the three ventilators showed significant difference (p = 0.012), and the Serov I showed a significantly higher task error rate than the Boaray 5000D (p = 0.031). For workload, the Serov I was associated with higher physiological and perceived workloads than other ventilators (p < 0.05). For user experience, the Boaray 5000D received better scores among the ventilators in terms of ease to maintain, friendly to maintain, and willingness to use (p < 0.05, respectively). Our study adds available literature for usability evaluation of ventilator maintenance user interface. The results indicate that the maintenance user interface of the Boaray 5000D performed better than the other two tested ventilators. Moreover, the study results also proved that eye-fixation duration can be a reliable tool for evaluating the usability of ventilator user interface.

Patient-maintained propofol sedation for adult patients undergoing surgical or medical procedures: a scoping review of current evidence and technology

Patient-maintained propofol sedation (PMPS) is the delivery of procedural propofol sedation by target-controlled infusion with the patient exerting an element of control over their target-site propofol concentration. This scoping review aims to establish the extent and nature of current knowledge regarding PMPS from both a clinical and technological perspective, thereby identifying knowledge gaps to guide future research. We searched MEDLINE, EMBASE, and OpenGrey databases, identifying 17 clinical studies for analysis. PMPS is described in the context of healthy volunteers and in orthopaedic, general surgical, dental, and endoscopic clinical settings. All studies used modifications to existing commercially-available infusion devices to achieve prototype systems capable of PMPS. The current literature precludes rigorous generalisable conclusions regarding the safety or comparative clinical effectiveness of PMPS, however cautious acknowledgement of efficacy in specific clinical settings is appropriate. Based on the existing literature, together with new standardised outcome reporting recommendations for sedation research and frameworks designed to assess novel health technologies research, we have made recommendations for future pharmacological, clinical, behavioural, and health economic research on PMPS. We conclude that high-quality experimental clinical trials with relevant comparator groups assessing the impact of PMPS on standardised patient-orientated outcome measures are urgently required.

Breast and torso characteristics of female contact football players: implications for the design of sports bras and breast protection

This study aimed to provide normative data characterising the breast size, breast position and torso size of female contact football players. 117 AFL, Rugby League, Rugby Union and Rugby 7s players attended a single testing session where a three-dimensional scan was taken of their naked breasts and torso. Dimensions relevant to the design of sports bras and breast protective equipment were then calculated from the scans. Several breast and torso characteristics of female contact football athletes differed to measurements reported for females in the general population and amongst the contact football codes. Designers and manufacturers of sports bras or breast protective equipment should consider the specific breast and torso dimensions of female contact football players to maximise the fit, comfort and efficacy of these garments. Practitioner summary: Using three-dimensional scanning, this study characterised the breast and torso size and shape of 117 female contact football players. These normative data should be used to improve the fit and comfort of sports bras and breast protective equipment for female contact football players.

Robotic-Assisted Percutaneous Coronary Intervention Through Transradial Approach: Experience in 4 Patients with Complex Lesions

Robotic-assisted percutaneous coronary intervention can reduce the exposure of interventional cardiologists to radiation and minimize the risk of occupational orthopedic injuries from wearing heavy protective aprons. The PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) study showed the efficacy and safety of robotic-assisted procedures for relatively low-risk lesions in single coronary arteries. Several reports have described robotic-assisted treatment of complex high-risk lesions, mostly through the transfemoral approach. We report 4 cases of patients in whom we used the transradial approach to treat complex lesions in the left anterior descending coronary artery with bifurcation balloon angioplasty reconstruction (2 cases), in the ostium of the first diagonal branch, and in the right coronary artery.

Orbital Atherectomy and Heavily Calcified Saphenous Vein Graft Intervention

Percutaneous coronary intervention in the diseased saphenous vein graft differs significantly from that in the diseased native coronary artery. After being exposed to arterial pressures over time, vein grafts have substantially different plaque characteristics, with more inflammatory cells, more diffuse disease, and less calcification. Severe calcification of saphenous vein grafts, although uncommon, poses a high risk of stent underexpansion. Orbital atherectomy for treatment of de novo calcified coronary lesions has been associated with better outcomes at 5-year follow-up. However, there are no published data on the use of orbital atherectomy to treat severely calcified saphenous vein graft lesions. We present the case of a 77-year-old woman with non-ST-segment-elevation myocardial infarction who underwent successful orbital atherectomy to prepare a severely calcified saphenous vein graft lesion for stent implantation.

Oropharyngeal Oxygen Concentration Is Dependent on the Oxygen Mask System and Sampling Location

BACKGROUND

Numerous oxygen delivery systems are used to treat hypoxemia. It is unknown if F_IO2 at the lips predicts oropharyngeal F_IO2 for various oxygen mask systems. We tested whether F_IO2 measurements differed between the lips and oropharynx, and whether this difference depends on the mask system.

METHODS

Ten healthy volunteers had one sampling catheter positioned at the lips and another catheter in the oropharynx. F_IO2 was sampled at each location while the subjects breathed normal tidal volumes with oxygen at 15 L/min via 4 delivery devices: a simple mask, a non-rebreather mask, a face mask with a diffuser that concentrates and directs O₂ toward the mouth and nose (mask with diffuser), and a closed mask with a Jackson-Rees circuit. Data were analyzed by using a linear mixed model to account for subject crossover in the repeated measures design.

RESULTS

F_IO2 levels differed significantly for the 4 delivery mask systems (P < .001) and by sampling catheter location (P < .001). Differences in mean F_IO2 between the lips and the oropharynx were observed for the mask with diffuser (difference 0.30, 95% CI 0.25-0.36; P < .001), and non-rebreather mask (difference 0.09, 95% CI 0.04-0.15; P = .001). The mean F_IO2 at the oropharynx was highest for the closed mask (0.97, 95% CI 0.92-1.00), followed by the non-rebreather mask (0.76, 95% CI 0.72-0.81), simple mask (0.62, 95% CI 0.58-0.67), and the mask with diffuser (0.51, 95% CI 0.46-0.56). At the lips, the mean F_IO2 was highest for the closed mask (0.97, 95% CI 0.92-1.00), followed by the non-rebreather mask (0.86, 95% CI 0.81- 0.90), OxyMask (0.81, 95% CI 0.76-0.86), and simple mask (0.67, 95% CI 0.62-0.71).

CONCLUSIONS

With high oxygen flows and normal tidal volume breathing, F_IO2 measurements obtained at the oropharynx or at the lips depended on the device used, with the mask with diffuser showing the most significant discrepancies. F_IO2 measures at the oropharynx and the lips were only consistent for the closed mask system. (ClinicalTrials.gov registration NCT02523586.).

Development of Treatments for Localized Prostate Cancer in Patients Eligible for Active Surveillance: U.S. Food and Drug Administration Oncology Center of Excellence Public Workshop

PURPOSE

The following is a summary of discussion at a United States FDA (Food and Drug Administration) public workshop reviewing potential trial designs and end points to develop therapies to treat localized prostate cancer.

MATERIALS AND METHODS

The workshop focused on the challenge that drug and device development to treat localized prostate cancer has been limited by the large trial sizes and lengthy timelines required to demonstrate an improvement in overall or metastasis-free survival and by the lack of agreed on alternative end points. Additionally, evolving treatment paradigms in the management of localized prostate cancer include the widespread use of active surveillance of patients with low and some intermediate risk prostate cancer, and the availability of advances in imaging and genomics.

RESULTS

The workshop addressed issues related to trial design in this setting. Attendees discussed several potential novel end points such as a delay of morbidity due to radiation or prostatectomy and pathological end points such as Gleason Grade Group upgrade.

CONCLUSIONS

The workshop provided an open forum for multiple stakeholder engagement to advance the development of effective treatment options for men with localized prostate cancer.

Minimally Invasive Endovascular Repair of Ascending Thoracic Aortic Aneurysm with Use of Local Anesthesia and Conscious Sedation

Ascending thoracic aortic aneurysm (ATAA) is typically treated surgically. No commercially available device has been specifically designed for endovascular ATAA repair, and currently, multiple anatomic and technical challenges affect its feasibility. Previously, such repairs have been performed with the patients under general anesthesia. We describe a novel, minimally invasive approach to endovascular repair of ATAA, involving local anesthesia, conscious sedation, and 24-hour hospitalization. Two consecutive male patients (ages, 79 and 54 yr) who had comorbidities underwent percutaneous transfemoral endovascular ATAA repair with use of commercially available endografts. Patient 1 had a saccular aneurysm, and Patient 2 had a pseudoaneurysm consequent to recent surgical ATAA repair. The patients were discharged from the hospital 24 hours after technically successful, uncomplicated procedures. At 2 months, computed tomograms showed no endoleak or stent-graft migration. Our experience shows that minimally invasive endovascular ATAA repair is feasible for selected high-risk patients. We describe the procedure, access and closure devices, and challenges associated with this approach.

Effect of Percutaneous Suction Thromboembolectomy on Improved Right Ventricular Function

Venous thromboembolism is a leading cause of cardiovascular death. Historically, surgical intervention has been associated with high morbidity rates. Pharmacologic therapy alone can be inadequate for patients with substantial hemodynamic compromise, so minimally invasive procedures are being developed to reduce clot burden. We describe our initial experience with using the AngioVac system to remove thromboemboli percutaneously. We reviewed all suction thromboembolectomy procedures performed at our institution from March 2013 through August 2015. The main indications for the procedure were failed catheter-directed therapy, contraindication to thrombolysis, bleeding-related complications, and clot-in-transit phenomena. We collected details on patient characteristics, procedural indications, thrombus location, hemodynamic values, cardiac function, pharmacologic support, and survival to discharge from the hospital. The Wilcoxon signed-rank test was used for statistical analysis. Thirteen patients (mean age, 56 ± 15 yr; 10 men) underwent suction thromboembolectomy; 10 (77%) survived to hospital discharge. The median follow-up time was 74 days (interquartile range [IQR], 23-221 d). Preprocedurally, 8 patients (62%) had severe right ventricular dysfunction; afterwards, 11 (85%) had normal function or mild-to-moderate dysfunction, and only 2 (17%) had severe dysfunction (P=0.031). Percutaneous suction thromboembolectomy, a promising therapeutic option for patients, appears to be safe, and we found it to be associated with improved right ventricular function.

Methodology and feasibility of a 3D printed assistive technology intervention

Three-dimensional (3D) printing now allows rehabilitation professionals to design and manufacture assistive technologies in a few hours. However, there is limited guidance for researchers and clinicians for implementing 3D printing assistive technology interventions and measuring their outcomes. The goal of this study was to develop a standardized 3D printing assistive technology intervention and a research methodology, using pillboxes as an example. Fourteen pillbox users engaged in a study comparing their use of an off-the-shelf pillbox to a customized 3D printed pillbox. Study outcomes were evaluated on feasibility (recruitment capability, study procedures and outcome measures, acceptability of the study procedures, the research team's ability to manage and implement the study, and the participant's preliminary response to intervention). Participant outcomes were measured on satisfaction with the device and medication adherence. Fourteen participants completed the study and received customized 3D printed pillboxes. The study design performed well on all aspects of feasibility except the research team's ability to manage and implement the study, as they experienced several technical issues. Notably, the participants reported improved device satisfaction and medication adherence with the 3D printed device with large effect sizes. The 3D printed assistive technology intervention is a replicable process that supports professionals in printing their own assistive technologies. Recommendations are made to further enhance feasibility of 3D printing assistive technology studies. Future research is warranted.IMPLICATIONS FOR REHABILITATION3D printing is an increasingly feasible approach allowing for the design and manufacture of customized assistive technologyEvaluation for assistive technology that will be 3D printed should include information about the person's activities, routines, skills, abilities, and preferences. Evaluation of outcomes should include satisfaction with the device and a functional measure.3D printed assistive technology interventions should include the collaboration between the assistive technology professional and client. It should also include device training.Future 3D printing research studies should report pragmatic data including printing device, time to print, and number of errors.

A Usability Study of 3 Radiotherapy Systems: A Comparative Evaluation Based on Expert Evaluation and User Experience

BACKGROUND The complex user interface design of radiotherapy treatment delivery systems can lead to use error and patient harm. In this study, we present the results of a comparison of 3 radiotherapy treatment delivery systems now used in China. MATERIAL AND METHODS We conducted a comprehensive usability study of 3 radiotherapy treatment delivery systems. Expert evaluation was performed through heuristic evaluation with 3 human-factors experts and 1 experienced radiation therapist for each system. User experience was assessed through perceived system usability and workload, using the National Aeronautics and Space Administration Task Load Index and the Post-Study System Usability Questionnaire. RESULTS For the expert evaluation, 47 usability problems were identified for Varian Trilogy, 75 for Elekta Precise, and 37 for Shinva XHA600E. Most problems were classified as major and minor usability problems, and were found in the process of patient setup and setup verification. For the user experience, radiation therapists presented a lower workload for Varian Trilogy compared to Elekta Precise (P<0.01) and Shinva XHA600E (P<0.01), and a lower workload for Elekta Precise compared to Shinva XHA600E (P=0.020). Radiation therapists perceived a higher system usability for Varian Trilogy compared to Shinva XHA600E (P<0.01), and a higher system usability for Elekta Precise compared to Shinva XHA600E (P<0.01). CONCLUSIONS This research provides valuable data on how 3 radiotherapy treatment delivery systems compare. The results of this study may be useful for hospital equipment procurement decisions, and designing next-generation products to improve patient safety.

A Tablet-Based Interactive Movement Tool for Pediatric Rehabilitation: Development and Preliminary Usability Evaluation

BACKGROUND

Motivating interactive tools may increase adherence to repetitive practice for children with disabilities, but many virtual reality and active video gaming systems are too challenging for children with significant needs.

OBJECTIVE

The objective of this study was to develop and conduct a usability evaluation of the Fun, Interactive Therapy Board (FITBoard), a movement toy bridging digital and physical interactions for children with disabilities.

METHODS

The FITBoard is a tablet app involving games controlled by hand, head, or foot touch of configurable, wired surfaces. Usability evaluation involved a cognitive walkthrough and think-aloud processes. Participants verbalized aloud while completing a series of 26 task actions involved in selecting a game and configuring the FITBoard to achieve the therapeutic goal. Therapists then responded to questions about usability perceptions. Unsuccessful actions were categorized as goal or action failures. Qualitative content analysis supported understanding of usability problems.

RESULTS

Participants included 5 pediatric physical therapists and 2 occupational therapists from 2 clinical sites. Goal failure was experienced by all participants in 2 tasks, and action failure was experienced by all participants in 2 tasks. For 14 additional tasks, 1 or more patients experienced goal or action failure, with an overall failure rate of 69% (18 of 26 tasks). Content analysis revealed 4 main categories: hardware usability, software usability, facilitators of therapy goals, and improvement suggestions.

CONCLUSIONS

FITBoard hardware and software changes are needed to address goal and action failures to rectify identified usability issues. Results highlight potential FITBoard applications to address therapeutic goals and outline important practical considerations for product use by therapists. Subsequent research will evaluate therapist, parent, and child perspectives on FITBoard clinical utility when integrated within regular therapy interventions.

An Experience of Improvised Laryngoscopy

Airway management in the wilderness runs the gamut from basic airway support to endotracheal intubation. Fortunately, direct laryngoscopy is a seldom called upon skill in expedition medicine. However, the medical skills required during a mission or expedition are never truly known in advance. Improvisation during evolving medical events is a mainstay of expedition medicine education and practice. It is unlikely, given constraints of weight and size of expedition medical kits, that a conventional laryngoscope would find its way into a standard "go bag." Faced with the real but rare event of needing to intubate a patient in an austere environment, how can improvisation be used? Multiple ideas for improvised laryngoscopes can be found in the wilderness medicine literature, but which, if any, of these devices have true clinical utility? To this end, participants of a recent Wilderness Medical Society preconference in medical elements of light search and rescue were given the opportunity to devise and construct their own improvised laryngoscopes and attempt intubation of a training mannequin. Participants with varying degrees of intubating experience improvised effective laryngoscopes from provided materials and successfully intubated an airway mannequin.

Impella RP Support and Catheter-Directed Thrombolysis to Treat Right Ventricular Failure Caused by Pulmonary Embolism in 2 Patients

Right ventricular failure secondary to pulmonary embolism is associated with morbidity and death. The Impella RP System has often been used for percutaneous mechanical circulatory support in patients with right ventricular failure from other causes, including myocardial infarction, cardiac surgery, and left ventricular assist device implantation. We report 2 cases of massive pulmonary embolism in which combined Impella RP use and ultrasound-assisted catheter-directed thrombolysis effectively treated shock caused by right ventricular failure and contributed to successful outcomes. To our knowledge, only one other patient with this indication had been treated with the Impella RP device.

Long-Term Continuous-Flow Biventricular Support in a 63-Year-Old Woman

We describe the successful use of long-term biventricular continuous-flow mechanical circulatory support as a bridge to transplantation in a small-framed 63-year-old woman with long-standing nonischemic cardiomyopathy. After placement of a left-sided HeartWare HVAD, persistent right-sided heart failure necessitated implantation of a second HeartWare device for long-term right ventricular support. After 262 days, the patient underwent successful orthotopic heart transplantation and was discharged from the hospital. This report indicates the feasibility of biventricular device support in older patients of relatively small stature, and our results may encourage others to consider this therapy in similar patient populations.

New Pulmonary Valvuloplasty Technique by Use of an Hourglass-Shaped Balloon in 3 Adults with Severe Pulmonary Valve Stenosis

Percutaneous balloon pulmonary valvuloplasty is the preferred therapy for pulmonary valve stenosis. However, the designs of the cylindrical balloons historically used for valvuloplasty have limitations, especially in patients who have large pulmonary annular diameters. The hourglass-shaped V8 Aortic Valvuloplasty Balloon may prove to be an effective alternative. The balloon has 2 large bulbous segments that are separated by a narrowed waist. The geometric shape is maintained throughout inflation, improving fixation and enabling broader leaflet opening. We present our first experience with the V8 balloon in 3 adults who had severe, symptomatic pulmonary valve stenosis. In addition to describing their cases, we detail our sizing technique for pulmonary valvuloplasty with the V8 balloon. Our successful results suggest that the V8 balloon is efficient and safe for balloon pulmonary valvuloplasty in adults with severe pulmonary valve stenosis.

Distances from vocal cords to mid-trachea for optimizing endotracheal tubes depth markers according to gestational age

BACKGROUND

Adequate endotracheal tube positioning in preterm infants is complicated by the short length of the airway. Distal markers were designed to help with the insertion of endotracheal tubes at an appropriate depth below the vocal cords. However, those markers are not standardized between manufacturers, each tube size displays only one (sometimes 2) markers to provide information for infants of various gestational ages, and indicated distances are often too long for extremely preterm infants.

AIMS

The study aims to describe vocal cords to mid-tracheal distance for different gestational ages and determine if depth markers should be adjusted accordingly.

METHODS

Half the tracheal length added to the height of the posterior lamina of the cricoids approximates the distance between vocal cords and mid-trachea. Those dimensions were retrospectively retrieved from a database of laryngo-tracheal measurements obtained during autopsies of fetuses and newborn infants free of upper airway malformations. The equation of correlation between gestational age and distance from vocal cords to mid-trachea was used to calculate those distances for different gestational ages.

RESULTS

Data were derived from 114 patients. Vocal cords to mid-trachea distance is linearly correlated with gestational age (r = .90; distance = 2.831 + 0.6208 × gestational age). We suggest depth markers at 17.7, 19.0, 20.8, 22.7, 24.6, and 26.4 mm for gestational ages of 24, 26, 29, 32, 35, and 38 weeks, respectively, indicated by contrasting colors.

CONCLUSION

The linear relationship between laryngo-tracheal size and gestational age offers the opportunity to revise endotracheal tube depth markers for the smallest patients. Trials comparing those suggested markers with those currently in use are needed before implementation.

Adapting the Wii Fit Balance Board to Enable Active Video Game Play by Wheelchair Users: User-Centered Design and Usability Evaluation

Background

Active video game (AVG) playing, also known as “exergaming,” is increasingly employed to promote physical activity across all age groups. The Wii Fit Balance Board is a popular gaming controller for AVGs and is used in a variety of settings. However, the commercial off-the-shelf (OTS) design poses several limitations. It is inaccessible to wheelchair users, does not support the use of stabilization assistive devices, and requires the ability to shift the center of balance (COB) in all directions to fully engage in game play.

Objective

The aim of this study was to design an adapted version of the Wii Fit Balance Board to overcome the identified limitations and to evaluate the usability of the newly designed adapted Wii Fit Balance Board in persons with mobility impairments.

Methods

In a previous study, 16 participants tried the OTS version of the Wii Fit Balance Board. On the basis of observed limitations, a team of engineers developed and adapted the design of the Wii Fit Balance Board, which was then subjected to multiple iterations of user feedback and design tweaks. On design completion, we recruited a new pool of participants with mobility impairments for a larger study. During their first visit, we assessed lower-extremity function using selected mobility tasks from the International Classification of Functioning, Disability and Health. During a subsequent session, participants played 2 sets of games on both the OTS and adapted versions of the Wii Fit Balance Board. Order of controller version played first was randomized. After participants played each version, we administered the System Usability Scale (SUS) to examine the participants’ perceived usability.

Results

The adapted version of the Wii Fit Balance Board resulting from the user-centered design approach met the needs of a variety of users. The adapted controller (1) allowed manual wheelchair users to engage in game play, which was previously not possible; (2) included Americans with Disabilities Act-compliant handrails as part of the controller, enabling stable and safe game play; and (3) included a sensitivity control feature, allowing users to fine-tune the controller to match the users’ range of COB motion. More than half the sample could not use the OTS version of the Wii Fit Balance Board, while all participants were able to use the adapted version. All participants rated the adapted Wii Fit Balance Board at a minimum as “good,” while those who could not use the OTS Wii Fit Balance Board rated the adapted Wii Fit Balance Board as “excellent.” We found a significant negative correlation between lower-extremity function and differences between OTS and adapted SUS scores, indicating that as lower-extremity function decreased, participants perceived the adapted Wii Fit Balance Board as more usable.

Conclusions

This study demonstrated a successful adaptation of a widely used AVG controller. The adapted controller’s potential to increase physical activity levels among people with mobility impairments will be evaluated in a subsequent trial.

Trial Registration

ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199 (Archived by WebCite at http://www.webcitation.org/6xWTyiJWf)

Loss of Surfacten® during bolus administration with a feeding catheter

BACKGROUND

Surfactant replacement therapy is widely used for treating neonatal respiratory distress syndrome, but insufficient evidence is available on the use of Surfacten® (S-TA). This study investigated the inadvertent loss of S-TA during instillation via feeding catheters with different bore sizes.

METHODS

In this bench-based study, we measured the weight of syringes and tubes before and after surfactant treatment using a high-accuracy balance, and determined the amount of S-TA lost in tubes. We injected 120 mg of S-TA suspended in 4 or 3 mL into tubes followed with or without air boluses. Experiments were performed in triplicate. Percent weight loss of S-TA in each tube was calculated with or without air boluses.

RESULTS

Percent weight loss of S-TA was significantly higher in larger-bore tubes (P < 0.01, overall ANOVA), and was significantly lower after air bolus flushing in 3 Fr, 4 Fr, and 5 Fr tubes (P < 0.005, respectively). The 3 mL S-TA suspensions had a significantly higher percent loss than the 4 mL S-TA suspensions when using 4 Fr and 5 Fr tubes, and the 5 Fr closed system (P < 0.05, respectively).

CONCLUSIONS

Routine air bolus flushing effectively reduces S-TA loss in tubes. The 3 mL S-TA suspensions appear to be more susceptible to inadvertent S-TA loss during instillation. Therefore, caution is warranted for this procedure.

Performance of the New Turbine Mid-Level Critical Care Ventilators

BACKGROUND

During recent years, ventilators using turbines as flow-generating systems have become increasingly more relevant. This bench study was designed to compare triggering and pressurization of 7 turbine mid-level ICU ventilators.

METHODS

We used a dual-chamber lung model to test 7 mid-level ICU ventilators in pressure support mode with levels of 10, 15, and 20 cm H₂O with 2 PEEP levels of 5 cm H₂O and the minimum level allowed by the ventilator. A ventilator was connected to the master chamber to simulate 2 different effort levels. Pressure drop, trigger delay time, time to minimum pressure, and pressure time products (PTP) during trigger and the first 300 and 500 ms were analyzed.

RESULTS

In the trigger evaluation, the Savina had the highest delay time, whereas the C2, the V60, and the Trilogy had the lowest pressure drops and PTP values in both effort levels. In pressurization capacity assessment using ideal PTP300 and PTP500 percentages, the C2 and the V680 had the best results, and the Carina and the Savina had lower values, with no differences between both effort levels. Differences between PEEP levels did not seem to be relevant.

CONCLUSIONS

Pressure support mode for tested ventilators worked properly, but pressurization capacity and trigger function performance were clearly superior in the newest machines. The use of PEEP did not modify the results.

Full-shift and task-specific upper extremity muscle activity among US large-herd dairy parlour workers

US large-herd dairy parlour workers experience a high prevalence of musculoskeletal symptoms in the upper extremity. The purpose of this study was to estimate and compare full-shift and task-specific muscle activity of the upper extremity among parlour workers. Surface electromyography data were recorded continuously throughout a full work shift for each participant (n = 60). For a subset of participants (n = 33), muscular effort was estimated for milking task cycles. Lower muscle activity levels and higher per cent muscular rest was observed among rotary parlour participants as compared to herringbone and parallel parlour participants for anterior deltoid, forearm flexor and forearm extensor muscles. These findings suggest rotary parlours may offer workstation designs or work organisational dynamics which may be more beneficial to the health and performance of the worker, as compared to parallel or herringbone parlours. Practitioner Summary: Study findings suggest milking parlour configurations present different biomechanical demands on workers which may influence worker health and performance. Our findings will enable more informed decisions regarding both engineering (e.g. parlour configuration or milking equipment) and administrative (e.g. work organisation) control strategies for large-herd milking parlours.

A Prospective Case-Control Study Comparing LithoVue, a Single-Use, Flexible Disposable Ureteroscope, with Flexible, Reusable Fiber-Optic Ureteroscopes

OBJECTIVE

LithoVue™ is a novel, single-use, digital flexible ureteroscope that was released to the US market in January 2016. There are scant data regarding its performance in humans. Procedural outcomes comparing LithoVue with reusable ureteroscopes are presented in patients undergoing ureteroscopy for upper urinary tract pathology.

PATIENTS AND METHODS

Clinical outcomes between two groups of patients undergoing flexible ureteroscopy for upper urinary tract pathology were analyzed. The first group underwent surgery utilizing LithoVue, and the second group used reusable fiber-optic flexible ureteroscopes. Differences in procedural outcomes, operative times, and time spent in hospital were analyzed using two-tailed t-tests and chi-squared and Fisher's exact tests.

RESULTS

One hundred fifteen cases utilizing LithoVue and 65 cases utilizing reusable ureteroscopes were included in this study. Demographics, surgical indications, stone size, location, total stone burden, composition, procedural outcomes, and complications were comparable between groups. For all cases, LithoVue procedures lasted 54.1 ± 25.7 minutes compared with 64.5 ± 37.0 minutes for reusable scope procedures (p < 0.05) and for stone removal cases, 57.3 ± 25.1 vs 70.3 ± 36.9 minutes, respectively (p < 0.05). Scope failure occurred in 4.4% of LithoVue cases and 7.7% of reusable cases (p = 0.27).

CONCLUSIONS

LithoVue represents a feasible alternative to reusable ureteroscopes with a low rate of scope failure comparable with reusable ureteroscopes. Its use shortens procedure duration, a finding that warrants further investigation.

Titanium Plug Closure after HeartWare Ventricular Assist Device Explantation in a 15-Year-Old Girl: First U.S. Experience

We describe the case of a teenage girl with anthracycline-induced cardiomyopathy who received a HeartWare ventricular assist device and underwent successful device explantation after cardiac recovery. During device support, the patient's cardiac function returned to normal. Twelve months after implantation, we explanted the device via repeat median sternotomy. To close the hole in the left ventricular apex and preserve the sewing ring in case future device support is needed, we used a German-manufactured titanium plug, developed specifically for this purpose. To our knowledge, this is the first use of this plug in the United States. The patient recovered uneventfully and was discharged from the hospital on postoperative day 11. Left ventricular biopsy specimens at explantation revealed the resolution of previous degenerative sarcomeric changes. Our patient did well clinically; however, recurrent late anthracycline cardiotoxicity might subsequently cause her cardiac function to deteriorate. In this event, our use of the titanium plug to preserve the left ventricular sewing ring would enable easier device replacement than would other explantation options.

Drop-off detection with the long cane: effect of cane shaft weight and rigidity on performance

Most travellers who are blind rely on a long cane to detect drop-offs on their walking paths. We examined how different cane shaft materials affect drop-off detection performance through providing different vibrotactile and proprioceptive feedbacks to the cane user. Results of the study showed a significant interaction between cane shaft weight and how the cane is used. A heavier cane was advantageous for detecting drop-offs when the individual used the 'constant contact technique' - cane tip stays in contact with the walking surface at all times - but not when he used the 'two-point touch technique' - cane tip is rhythmically tapped on the surface. In addition, a more flexible cane was advantageous for detecting drop-offs when the two-point touch technique was used but not when the constant contact technique was used. It is recommended that, when blind individuals select a cane shaft material, they consider which long cane technique they use more often. Practitioner Summary: Long cane shaft material affects how well a blind individual can detect drop-offs. A heavier shaft was advantageous when using the constant contact technique (cane tip stays in continuous contact with the surface), while a more flexible shaft was better when using the two-point touch technique (cane tip rhythmically taps the surface).

Development and Application of a Clinical Microsystem Simulation Methodology for Human Factors-Based Research of Alarm Fatigue

OBJECTIVES

(1) To develop a clinical microsystem simulation methodology for alarm fatigue research with a human factors engineering (HFE) assessment framework and (2) to explore its application to the comparative examination of different approaches to patient monitoring and provider notification.

BACKGROUND

Problems with the design, implementation, and real-world use of patient monitoring systems result in alarm fatigue. A multidisciplinary team is developing an open-source tool kit to promote bedside informatics research and mitigate alarm fatigue.

METHOD

Simulation, HFE, and computer science experts created a novel simulation methodology to study alarm fatigue. Featuring multiple interconnected simulated patient scenarios with scripted timeline, "distractor" patient care tasks, and triggered true and false alarms, the methodology incorporated objective metrics to assess provider and system performance. Developed materials were implemented during institutional review board-approved study sessions that assessed and compared an experimental multiparametric alerting system with a standard monitor telemetry system for subject response, use characteristics, and end-user feedback.

RESULTS

A four-patient simulation setup featuring objective metrics for participant task-related performance and response to alarms was developed along with accompanying structured HFE assessment (questionnaire and interview) for monitor systems use testing. Two pilot and four study sessions with individual nurse subjects elicited true alarm and false alarm responses (including diversion from assigned tasks) as well as nonresponses to true alarms. In-simulation observation and subject questionnaires were used to test the experimental system's approach to suppressing false alarms and alerting providers.

CONCLUSIONS

A novel investigative methodology applied simulation and HFE techniques to replicate and study alarm fatigue in controlled settings for systems assessment and experimental research purposes.