Mutations in the glucocerebrosidase gene (GBA) are associated with Gaucher's disease, the most common lysosomal storage disorder. Parkinsonism is an established feature of Gaucher's disease and an ...increased frequency of mutations in GBA has been reported in several different ethnic series with sporadic Parkinson's disease. In this study, we evaluated the frequency of GBA mutations in British patients affected by Parkinson's disease. We utilized the DNA of 790 patients and 257 controls, matched for age and ethnicity, to screen for mutations within the GBA gene. Clinical data on all identified GBA mutation carriers was reviewed and analysed. Additionally, in all cases where brain material was available, a neuropathological evaluation was performed and compared to sporadic Parkinson's disease without GBA mutations. The frequency of GBA mutations among the British patients (33/790 = 4.18%) was significantly higher (P = 0.01; odds ratio = 3.7; 95% confidence interval = 1.12–12.14) when compared to the control group (3/257 = 1.17%). Fourteen different GBA mutations were identified, including three previously undescribed mutations, K7E, D443N and G193E. Pathological examination revealed widespread and abundant α-synuclein pathology in all 17 GBA mutation carriers, which were graded as Braak stage of 5–6, and had McKeith's limbic or diffuse neocortical Lewy body-type pathology. Diffuse neocortical Lewy body-type pathology tended to occur more frequently in the group with GBA mutations compared to matched Parkinson's disease controls. Clinical features comprised an early onset of the disease, the presence of hallucinations in 45% (14/31) and symptoms of cognitive decline or dementia in 48% (15/31) of patients. This study demonstrates that GBA mutations are found in British subjects at a higher frequency than any other known Parkinson's disease gene. This is the largest study to date on a non-Jewish patient sample with a detailed genotype/phenotype/pathological analyses which strengthens the hypothesis that GBA mutations represent a significant risk factor for the development of Parkinson's disease and suggest that to date, this is the most common genetic factor identified for the disease.
Purpose
This single-center study aimed to develop a convolutional neural network to segment multiple consecutive axial magnetic resonance imaging (MRI) slices of the lumbar spinal muscles of patients ...with lower back pain and automatically classify fatty muscle degeneration.
Methods
We developed a fully connected deep convolutional neural network (CNN) with a pre-trained U-Net model trained on a dataset of 3,650 axial T2-weighted MRI images from 100 patients with lower back pain. We included all qualities of MRI; the exclusion criteria were fractures, tumors, infection, or spine implants. The training was performed using k-fold cross-validation (k = 10), and performance was evaluated using the dice similarity coefficient (DSC) and cross-sectional area error (CSA error). For clinical correlation, we used a simplified Goutallier classification (SGC) system with three classes.
Results
The mean DSC was high for overall muscle (0.91) and muscle tissue segmentation (0.83) but showed deficiencies in fatty tissue segmentation (0.51). The CSA error was small for the overall muscle area of 8.42%, and fatty tissue segmentation showed a high mean CSA error of 40.74%. The SGC classification was correctly predicted in 75% of the patients.
Conclusion
Our fully connected CNN segmented overall muscle and muscle tissue with high precision and recall, as well as good DSC values. The mean predicted SGC values of all available patient axial slices showed promising results. With an overall Error of 25%, further development is needed for clinical implementation. Larger datasets and training of other model architectures are required to segment fatty tissue more accurately.
Abstract
Background
Due to the growing economic pressure, there is an increasing interest in the optimization of operational processes within surgical operating rooms (ORs). Surgical departments are ...frequently dealing with limited resources, complex processes with unexpected events as well as constantly changing conditions. In order to use available resources efficiently, existing workflows and processes have to be analyzed and optimized continuously. Structural and procedural changes without prior data-driven analyses may impair the performance of the OR team and the overall efficiency of the department. The aim of this study is to develop an adaptable software toolset for surgical workflow analysis and perioperative process optimization in arthroscopic surgery.
Methods
In this study, the perioperative processes of arthroscopic interventions have been recorded and analyzed subsequently. A total of 53 arthroscopic operations were recorded at a maximum care university hospital (UH) and 66 arthroscopic operations were acquired at a special outpatient clinic (OC). The recording includes regular perioperative processes (i.a. patient positioning, skin incision, application of wound dressing) and disruptive influences on these processes (e.g. telephone calls, missing or defective instruments, etc.). For this purpose, a software tool was developed (‘s.w.an Suite Arthroscopic toolset’). Based on the data obtained, the processes of the maximum care provider and the special outpatient clinic have been analyzed in terms of performance measures (e.g. Closure-To-Incision-Time), efficiency (e.g. activity duration, OR resource utilization) as well as intra-process disturbances and then compared to one another.
Results
Despite many similar processes, the results revealed considerable differences in performance indices. The OC required significantly less time than UH for surgical preoperative (UH: 30:47 min, OC: 26:01 min) and postoperative phase (UH: 15:04 min, OC: 9:56 min) as well as changeover time (UH: 32:33 min, OC: 6:02 min). In addition, these phases result in the Closure-to-Incision-Time, which lasted longer at the UH (UH: 80:01 min, OC: 41:12 min).
Conclusion
The perioperative process organization, team collaboration, and the avoidance of disruptive factors had a considerable influence on the progress of the surgeries. Furthermore, differences in terms of staffing and spatial capacities could be identified. Based on the acquired process data (such as the duration for different surgical steps or the number of interfering events) and the comparison of different arthroscopic departments, approaches for perioperative process optimization to decrease the time of work steps and reduce disruptive influences were identified.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objectives
In-depth knowledge about surgical processes is a crucial prerequisite for future systems in operating rooms and the advancement of standards and patient safety in surgery. A holistic ...approach is required, but research in the field of surgical instrument tables, standardized instrument setups and involved personnel, such as nurses, is sparse in general. The goal of this study is to evaluate whether there is an existing standard within clinics for an instrument table setup. We also evaluate to which extent it is known to the personnel and whether it is accepted.
Materials and Methods
The study makes use of the
Nosco Trainer
, a scrub nurse training and simulation system developed to analyze various aspects of the workplace of scrub nurses. The system contains a virtual instrument table, which is used to perform and record instrument table setups. We introduce a metric which delivers a measurable score for the similarity of surgical instrument table setups. The study is complemented with a questionnaire covering related aspects.
Results
Fifteen scrub nurses of the Otolaryngology departments at three clinics in Germany and Switzerland performed a table setup for a Functional Endoscopic Sinus Surgery intervention and completed the questionnaire. The analysis of the developed metric with a leave one out cross-validation correctly allocated 14 of the 15 participants to their clinic.
Discussion
In contrast to the identified similarities of table setups within clinics with the collected data, only a third of the participants confirmed in the questionnaire that there is an existing table setup standard for Functional Endoscopic Sinus Surgery interventions in their facility, but almost three quarters would support a written standard and acknowledge its possible benefits for trainees and new entrants in the operating room.
Conclusions
The structured analysis of the surgical instrument table using a data-driven metric for comparison is a novel approach to gain deeper knowledge about intra-operative processes. The insights can contribute to patient safety by improving the workflow between surgeon and scrub nurse and also open the way for goal-oriented standardization.
The design and internal layout of modern operating rooms (OR) are influencing the surgical team's collaboration and communication, ergonomics, as well as intraoperative hygiene substantially. Yet, ...there is no objective method for the assessment and design of operating room setups for different surgical disciplines and intervention types available. The aim of this work is to establish an improved OR setup for common procedures in arthroplasty.
With the help of computer simulation, a method for the design and assessment of enhanced OR setups was developed. New OR setups were designed, analyzed in a computer simulation environment and evaluated in the actual intraoperative setting. Thereby, a 3D graphical simulation representation enabled the strong involvement of clinical stakeholders in all phases of the design and decision-making process of the new setup alternatives.
The implementation of improved OR setups reduces the instrument handover time between the surgeon and the scrub nurse, the travel paths of the OR team as well as shortens the procedure duration. Additionally, the ergonomics of the OR staff were improved.
The developed simulation method was evaluated in the actual intraoperative setting and proved its benefit for the design and optimization of OR setups for different surgical intervention types. As a clinical result, enhanced setups for total knee arthroplasty and total hip arthroplasty surgeries were established in daily clinical routine and the OR efficiency was improved.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Purpose: With the ongoing work on the Health Level Seven (HL7) standards and the IEEE 11073 Serviceoriented Device Connectivity (SDC) family, the demand for open integration of medical devices in the ...operating room (OR) has become clear. Nevertheless, there are very few interoperable medical devices available to date. This work describes a practical example of connecting an intraoperative neuromonitoring (IONM) device with a radiofrequency (RF) surgical device based on SDC and with the hospital information system (HIS) based on HL7. Methods: Before starting the surgery, patient-related data must be entered into the neuromonitoring system. To minimize manual input, we integrated an automized patient data query based on HL7, which completes all other necessary data provided by the HIS after entering the patient identification number. During the surgery, while mapping neural structures in the situs using IONM, the parallel operation of RF devices for coagulation generates artifacts in the neuromonitoring signals, which makes a reliable interpretation of the IONM signals impossible. Therefore, we developed an IEEE 11073 SDC interface for the neuromonitoring device and implemented an SDC-based OR control panel. While placing the hand probe for mapping neural structures in the situs, the OR control panel suppresses the coagulation of the electrosurgical instrument and only reenables it, after the mapping has been terminated. After the surgery, the generated IONM report can be uploaded into the HIS using HL7. Therewith it is assigned automatically to the previously selected patient. Result: With the SDC- and HL7-enabled neuromonitoring system, we showed a practical use case of interoperable medical devices to optimize surgical workflow.
We introduce a system that allows the immediate identification and inspection of fat and muscle structures around the lumbar spine as a means of orthopaedic diagnostics before surgical treatment. The ...system comprises a backend component that accepts MRI data from a web-based interactive frontend as REST requests. The MRI data is passed through a U-net model, fine-tuned on lumbar MRI images, to generate segmentation masks of fat and muscle areas. The result is sent back to the frontend that functions as an inspection tool. For the model training, 4000 MRI images from 108 patients were used in a k-fold cross-validation study with k = 10. The model training was performed over 25-30 epochs. We applied shift, scale, and rotation operations as well as elastic deformation and distortion functions for image augmentation and a combined objective function using Dice and Focal loss. The trained models reached a mean dice score of 0.83 and 0.52 and a mean area error tissue of 0.1 and 0.3 for muscle and fat tissue, respectively. The interactive webbased frontend as an inspection tool was evaluated by clinicians to be suitable for the exploration of patient data as well as the assessment of segmentation results. We developed a system that uses semantic segmentation to identify fat and muscle tissue areas in MRI images of the lumbar spine. Further improvements should focus on the segmentation accuracy of fat tissue, as it is a determining factor in surgical decisionmaking. To our knowledge, this is the first system that automatically provides semantic information of the respective lumbar tissues.
Data from preclinical emergency care is often not available in an integrated, electronic way. Data flow between ambulances and trauma centers lacks a communication approach that allows for efficient ...aggregation, transmission and reuse. We present the results of the requirement analysis for 5G-supported emergency care scenarios. With the illustarted requirements and derived structural consequences, we conclude with a proposal that will allow us to provide mechanisms and technologies to enable integrated emergency communication for preclinical care using modern communication technologies.
An essential aspect for workflow management support in operating room environments is the description and visualization of the underlying processes and activities in a machine readable format as ...Surgical Process Models (SPM). However, the process models often vary in terms of granularity, naming and representation of process elements and their modeling structure. The aim of this paper is to present a new methodology for standardized semantic workflow modeling and a framework for semantic work-flow execution and management in the surgical domain.
Hip and knee arthroplasties are very frequently performed surgeries with high quality standards and continuous optimization potential. Intraoperative processes can be standardized and simplified by ...optimization of table setups in the operating room to improve the quality and to increase efficiency.
The existing surgical setups for primary hip and knee arthroplasties in a university maximum care hospital with endoprosthesis center were simulated and analysed with a computer program and optimized setup suggestions were worked out, based on handover times, walking distance and ergonomic aspects determined in the program. In a prospective monocentric analysis, primary hip arthroplasties and knee arthroplasties were examined in currently used and in the new optimized setups (standard procedure according to in-house SOP, senior and main surgeons, no assistants). The surgeries were externally and independently supervised and analysed, whereby the time between incision and suture beginning, handovers per minute and handover times were documented, amongst other things. In addition, an evaluation sheet, which showed the satisfaction with the new setup, was filled by the surgical team.
In the period from April 2016 to December 2018, 19 hip arthroplasties in currently used and 15 in the new optimized setup as well as 9 knee arthroplasties in currently used and 13 in the new setup were performed. Attention was paid to constant conditions in the compared groups and disruptive factors (assisted surgeries, complex surgeries, different cementings, etc.) were excluded. In the group of hip arthroplasties, the handover times were significantly different (old 1.82 +/- 1.43 s.; new 1.08 +/- 0.78 s.; p <0.001), as well as the handovers per minute (old 1.62 +/- 0.45 handovers/min.; new 2.10 +/- 0.32 handovers/min.; p = 0,001). The time between incision and suture beginning indicated no significant difference (old 53.89 +/- 18.92 min.; new 49.73 +/- 12.18 min; p = 0.466): During the knee arthroplasties, handovers per minute were significantly different (old 1.83 +/- 0.38 handovers/min.; new 2.40 +/- 0.35 handovers/min.; p = 0.002). The time between incision and suture beginning (old 71.11 +/- 20.72 min.; new 70.69 +/- 17.12 min.; p = 0.959) and the handover times (old 1.06 +/- 0.64 s.; new 0.91 +/- 0.59 s.; p = 0.152) indicated no significant difference. The evaluation of the questionnaires showed a significant difference (p < 0.001) in the group of hip arthroplasties in the category "visibility". For the knee arthroplasties, all items except "visibility" (p = 0.261) differed significantly. Overall, a high level of staff satisfaction with the new setup was achieved.
In both groups, more handovers per minute could be achieved in the optimized setup and in the group of the hip arthroplasties, the handover times were significantly faster. The evaluation sheet showed a high satisfaction of the surgical staff with the new setup. No reduction of the time between incision and suture beginning could be determined. This can be attributed to a certain training effect, the adjustment to the setup modification and the low number of cases. The new setup offers a practical alternative for hip arthroplasties as well as for knee arthroplasties as it optimizes the events in the operating room in many ways. For example, there were more handovers per minute possible and passing of the surgical instruments free from interferences. Moreover, it increases the efficiency and achieves a high satisfaction of the staff.
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