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Purpose: To realize a systematic review with prospective meta-analysis aiming to compare the accuracy of static fully guided implant placement depending on the drill key modality (conventional drill key surgery systems vs newer keyless systems) and evaluate the impact of deviation factors. Materials and Methods: An electronic systematic search was conducted to identify prospective clinical trials matching inclusion criteria. The variables of interest were coronal global, apical, vertical, and angular deviations. The types of edentulism and surgical guide support were investigated as deviation factors. Meta-regression (mixed-effect model) was performed. Heterogeneity was assessed using Cochrane's I² test and interpretation thresholds. Results: A total of 1,233 implants in 475 patients were analyzed (18 studies included). Coronal global deviation was significantly lower in the keyless group than in the key group (-0.36 mm; 95% CI -0.62, -0.09; P = .008). Angulation control of the keyless system was superior to that of the key system (-0.36 degrees; 95% CI -0.75, 0.02; P = .063). Nonsignificant differences were found between both groups in apical (P = .684) and vertical deviations (P = .958). Significant influence of the type of edentulism (single, partial, total) and surgical guide support (tooth, mucosa, bone) on the overall amount of coronal global, apical, and angular deviations was found (P < .001). The lowest deviations were found in partial edentulism and tooth-supported surgical guide groups. (P < .001). Conclusions: Keyless static fully guided surgical systems allowed significantly better control of coronal and angular deviations than conventional systems. The types of edentulism and surgical guide support seemed to influence the positioning accuracy. [ABSTRACT FROM AUTHOR]

Background: Acute Respiratory Distress Syndrome (ARDS) has a high morbidity and mortality. One therapy that can decrease mortality is ventilation in the prone position (PP). Patients undergoing PP are amongst the sickest, and there is a need for early identification of patients at particularly high risk of death. These patients may benefit from an in-depth review of treatment or consideration of rescue therapies. We report the development of a machine learning model trained to predict early mortality in patients undergoing prone positioning as part of the management of their ARDS. Methods: Prospectively collected clinical data were analysed retrospectively from a single tertiary ICU. The records of patients who underwent an initial session of prone positioning whilst receiving invasive mechanical ventilation were identified (n = 131). The decision to perform prone positioning was based on the criteria in the PROSEVA study. A C5.0 classifier algorithm with adaptive boosting was trained on data gathered before, during, and after initial proning. Data was split between training (85% of data) and testing (15% of data). Hyperparameter tuning was achieved through a grid-search using a maximal entropy configuration. Predictions for 7-day mortality after initial proning session were made on the training and testing data. Results: The model demonstrated good performance in predicting 7-day mortality (AUROC: 0.89 training, 0.78 testing). Seven variables were used for prediction. Sensitivity was 0.80 and specificity was 0.67 on the testing data set. Patients predicted to survive had 13.3% mortality, while those predicted to die had 66.67% mortality. Among patients in whom the model predicted patient would survive to day 7 based on their response, mortality at day 7 was 13.3%. Conversely, if the model predicted the patient would not survive to day 7, mortality was 66.67%. Conclusions: This proof-of-concept study shows that with a limited data set, a C5.0 classifier can predict 7-day mortality from a number of variables, including the response to initial proning, and identify a cohort at significantly higher risk of death. This can help identify patients failing conventional therapies who may benefit from a thorough review of their management, including consideration of rescue treatments, such as extracorporeal membrane oxygenation. This study shows the potential of a machine learning model to identify ARDS patients at high risk of early mortality following PP. This information can guide clinicians in tailoring treatment strategies and considering rescue therapies. Further validation in larger cohorts is needed. [ABSTRACT FROM AUTHOR]

Background: Rib fractures are common in trauma patients, often leading to complications such as pneumonia and prolonged hospitalization. Surgical Stabilization of Rib Fractures (SSRF) has become increasingly prevalent in treating severe cases. However, traditional approaches, like posterolateral thoracotomy, are invasive and cause significant muscle damage. Recently, muscle-sparing minimally invasive techniques have been introduced, yet they still require advanced reduction and fixation techniques to avoid complications. This study presents an "ultra" minimally invasive SSRF (uMI-SSRF) technique designed to minimize surgical wounds and soft tissue damage while maintaining the benefits of rib fixation. Methods: This study involved 76 patients with multiple rib fractures treated using the uMI-SSRF technique between August 2021 and December 2023. Preoperative chest tomography with 3D reconstruction was used for surgical planning. The technique employed small incisions (3–5 cm), muscle-sparing approaches, and advanced fixation techniques. Data on patient demographics, intraoperative details, and postoperative outcomes were collected. Results: The mean patient age was 58 years, with 66% being male. On average, patients had 6.4 fractured ribs, and 3.5 ribs with 3.88 plates were fixed per surgery, achieving a fixation/fracture ratio of 59%. The average wound length was 4.2 cm, with a mean operation time of 122 min. Most patients required only one incision (74%). The median hospital length of stay was 7 days, with a pneumonia rate of 5%. No wound infections or implant-related complications were observed. Conclusions: The uMI-SSRF technique effectively reduces wound size and soft tissue damage in rib fracture stabilization while maintaining high fixation quality. This method shows promise for improving patient outcomes, reducing recovery time, and minimizing complications. Further studies with larger sample sizes and comparisons with other methods are warranted to verify the advantages of uMI-SSRF. [ABSTRACT FROM AUTHOR]

Aim Method Conclusion Laparoscopic complete mesocolic excision (CME) with D3 lymphadenectomy for right colon cancer is gaining acceptance. However, this procedure has not yet been standardized like total mesorectal excision. Ergonomics is very important in this surgery (e.g. patient positioning, port placement) and identification of vascular anatomy is a critical step. The aim of this work is to present ten procedural steps that are simple and reproducible.The French position is adopted. The surgeon stands between the patient's legs. Four ports are placed: a camera port 2.5 cm to the left of the umbilicus; two working ports—a 12 mm right‐hand port 5–7 cm below the umbilicus in the midline and a 5 mm left‐hand port 2.5 cm medial and at the level of anterior superior iliac spine—and an assistant port at the level of the umbilicus at the pararectal line. This is most comfortable position in the ‘caudal to cranial approach’ for CME dissection. The right‐hand instrument always dissects parallel to the superior mesenteric artery (SMA) axis so there is less chance of injury to major vascular structures. When clipping the ileocolic, right colic and gastrocolic trunk (GCT) branches, the instrument is always perpendicular to these structures, giving ease of clipping and division. An intentional attempt is made to dissect all tributaries of the GCT. This avoids inadvertent injury and bleeding. Identifying the SMA/superior mesenteric vein (SMV) axis and ileocolic pedicle is the most crucial step. We use surface landmarks for this—the ligamentum teres and SMA/SMV are both midline structures. Giving traction on the transverse mesocolon just below the ligamentum makes the pulsatile SMA visible irrespective of the patient's body mass index. Giving traction at the ileocaecal junction mesentery makes the ileocolic pedicle prominent. These two landmarks for identification of the vascular anatomy make this technique unique and reproducible. CME dissection is done caudal to cranial and lateral to medial. Supracolic and lateral mobilization of the colon is simple. While starting dissection in the right paracolic gutter the already dissected CME plane make this step easier. Anastomosis can be made intracorporeal or extracorporeal.Ergonomics and landmarks for identification of the vascular anatomy make this technique simple and reproducible. [ABSTRACT FROM AUTHOR]

Stress hyperglycaemia is common in critical illness. We have previously observed that increasing severity of respiratory failure in patients with severe COVID-19 is associated with increased insulin demand. Given previously reported direct effects of hypoxia on insulin action, we reasoned that rapid improvements in oxygenation following prone positioning may improve insulin sensitivity and increase risk of hypoglycaemia. A retrospective multi-centre service evaluation comparing blood glucose and insulin administration in patients with COVID-19 pneumonitis receiving prone mechanical ventilation, comparing the 16 h pre-prone and 16 h post-prone time periods. 155 patients were included in this analysis. Oxygenation improved significantly following prone positioning (change in SpO2/FIO2 per hour prone: 3.01 ± 0.14, P < 0.0001). Glycaemic control was similar during the supine and prone study periods, and there were no hypoglycaemic events in the prone study period. Prone positioning was associated with an unexpected modest but significant increase in insulin requirements (mean difference in total insulin dose (IU): 8.32 ± 2.14, P < 0.001) that was robust to several sensitivity analyses, and could not be explained by changes in carbohydrate intake. We did not observe an increased rate of hypoglycaemia during prone ventilation and the adequacy of glycaemic control was comparable during the supine and prone study periods. Unexpectedly, prone ventilation was associated with an increase in insulin requirements despite significant improvement in hypoxaemia. Our findings support the safety of prone ventilation with respect to glycaemic control and identify a novel relationship between ventilation position and insulin requirements in critical illness. [ABSTRACT FROM AUTHOR]

The rotator cuff, comprising the subscapularis, supraspina-tus, infraspinatus, and teres minor muscles, plays a crucial role in stabilizing the glenohumeral joint by securing the head of the humerus within the glenoid cavity of the scapula. The tendinous insertions of these muscles generate tension within the capsule, enhancing joint stability during muscular activity. The rotator cuff is susceptible to damage from disease, injury, or trauma, which can result in tears or ruptures of one or more tendons. The evaluation of the infraspinatus muscle and tendon is vital for diagnosing and managing various shoulder pathologies. Accurate imaging to determine the specific muscle involvement and injury severity significantly impacts treatment decisions. Diagnostic musculoskeletal ultrasound (MSK-US) has emerged as a valuable tool for assessing the infraspinatus muscle and tendon, offering real-time, dynamic assessment capabilities essential for precise diagnosis and effective rehabilitation planning. This article reviews the utility and advantages of MSK-US in evaluating the infraspinatus muscle and tendon, emphasizing technique specifics, diagnostic accuracy, and comparative efficacy against other imaging modalities. It details a systematic approach to the ultrasound examination technique for the infraspinatus, including patient positioning and identification of common pathologies such as tears, tendinopathy, and calcifications. With recent advancements in transducer strength, image resolution, and operator training, ultrasound serves as an excellent alternative imaging modality for diagnosing rotator cuff tears. This article aims to equip rehabilitation professionals with a comprehensive understanding of MSK-US as a diagnostic tool for the infraspinatus, promoting more precise diagnosis, treatment planning and improved patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Gastro-tracheal fistula is a rare but serious complication after esophageal surgery, often requiring long-term treatment and invasive procedures. Gastro-tracheal fistula usually occurs through the posterior mediastinal route and rarely through the retrosternal route. No previous reports have described gastro-tracheal fistula after retrosternal route reconstruction was cured by conservative treatment. Case presentation: A 70-year-old man with lower thoracic esophageal cancer underwent thoracoscopic esophagectomy in the prone position and gastric tube reconstruction through the retrosternal route with neck anastomosis after neoadjuvant chemotherapy. Despite anastomotic leakage on postoperative day 10, his general condition was stable, and he was managed conservatively with antibiotics and gastric tube decompression. On day 29, he presented with high fever and a gastro-tracheal fistula was observed by esophagography. Conservative management was continued because the patient remained stable. On day 48, esophagography showed that the fistula was undetectable. The patient was able to take fluids orally. He progressed well on an oral diet and was transferred to a different hospital. Conclusions: A gastro-tracheal fistula, although rare, can occur after retrosternal route reconstruction. When a patient is stable, gastro-tracheal fistula after retrosternal route reconstruction may be cured by conservative treatment. [ABSTRACT FROM AUTHOR]

Purpose: Although many factors were suggested to affect acetabular cup positioning during primary total hip arthroplasty, the effect of surgeon handedness was rarely evaluated. We aimed primarily to assess the difference in cup positioning (inclination and anteversion) between the right and left sides during primary THA. Secondly, to check the difference in the percentages of cups positioned in the safe zone for inclination and anteversion and if there will be a difference in cup positioning according to the type of cup fixation (cemented vs. cementless). Methods: Cup inclination and anteversion of 420 THAs were radiographically evaluated retrospectively. THAs were performed by a senior right-handed surgeon, who operated through a direct lateral approach in a lateral decubitus position using manual instruments and freehand technique for cup placement. Patients were assigned to two groups: Group A (right, or dominant side), and Group B (left, or non-dominant side), with equal cases of THAs (n = 210) in each group. Results: No difference was found in patients' basic characteristics, preoperative diagnosis, and cup fixation (54.3% cemented and 45.7% cementless) between the two groups. There was a significant difference in cup inclination between Groups A and Group B (40.1° ± 6.3° vs. 38.2° ± 6.1°) (P = 0.002). No significant difference was revealed in anteversion between the two groups (11.7° ± 4.4° vs. 11.8° ± 4.7°) (P = 0.95). The percentage of cups located within the safe zone in terms of both inclination and anteversion was 85.2% vs. 83.8% and 69% vs. 73.3% for Group A and Group B, according to Lewinnek and Callahan's safe zones, respectively. There existed a significant difference in the cemented cup inclination between Group A and Group B (40.8° ± 6.4° vs. 38.3° ± 6.3°) (P = 0.004). Conclusion: Cup inclination is affected by the surgeon's handedness when operating through a direct lateral approach and using a freehand technique, while anteversion is less affected. Furthermore, the difference is greater with cemented cups. [ABSTRACT FROM AUTHOR]

Lateral extra-articular tenodesis (LET) has shown an upswing in popularity since the role of antero-lateral rotatory instability (ALRI) in ACL tears has become better understood. Its primary aim is to restore antero-lateral rotatory stability and hence reduce stresses placed on the ACL graft in high-risk individuals which should reduce graft failure rates. Many techniques have been described for LET using a variety of fixation methods (screws, anchors, etc.). Most of these techniques rely on a large incision laterally. We describe a novel technique ('mini-LET') which uses a 3–4 cm incision, to improve cosmesis. [ABSTRACT FROM AUTHOR]

Background/Objectives: In spinal surgery, it is especially crucial to insert implants in the correct location. Intraoperative fluoroscopy is often necessary to safely perform spinal surgery because of serious complications that can occur if the screw deviates. However, the use of intraoperative fluoroscopy comes at the cost of radiation exposure to the surgeons and operating room staff. Therefore, it is desirable for spinal surgeons to understand the characteristics of radiation in order to minimize patient and medical staff exposure. This study aimed to create an aerial radiation dose distribution map for lateral fluoroscopy, a commonly used technique for posterior spinal fusion. Methods: A human body-equivalent phantom was placed in a prone position on the Jackson Table. The measurement method used was a lateral fluoroscopic evaluation, assuming posterior spinal fusion. Measurements were taken at three levels: 80 (gonadal), 100 (thoracoabdominal), and 150 cm (lens and thyroid). Results: The highest radiation doses were received by primary surgeons. The scrub nurse was the next most exposed. Conclusions: We developed an aerial dose distribution map for lateral fluoroscopy in posterior spinal fusion. Radiation exposure was the highest among primary surgeons. [ABSTRACT FROM AUTHOR]

Purpose: Age- and disease-related changes in oropharyngeal anatomy and physiology may be identified through quantitative videofluoroscopic measures of pharyngeal area and dynamics. Pixel-based measures of nonconstricted pharyngeal area (PhAR) are typically taken during oral bolus hold tasks or on post-swallow rest frames. A recent study in 87 healthy adults reported mean post-swallow PhAR of 62%(C2-4)², (range: 25%-135%), and significantly larger PhAR in males. The fact that measures were taken after initial bolus swallows without controlling for the presence of subsequent clearing swallows was identified as a potential source of variation. A subset of study participants had completed a protocol including additional static nonswallowing tasks, enabling us to explore variability across those tasks, taking sex differences into account. Method: Videofluoroscopy still shots were analyzed for 20 healthy adults (10 males, 10 females, Mage = 26 years) in head-neutral position, chin-down and chin-up positions, a sustained /a/ vowel vocalization, and oral bolus hold tasks (1-cc, 5-cc). Trained raters used ImageJ software to measure PhAR in %(C2-4)² units. Measures were compared to previously reported mean postswallow PhAR for the same participants: (a) explorations of sex differences; (b) pairwise linear mixed-model analyses of variance (ANOVAs) of PhAR for each nonswallowing task versus postswallow measures, controlling for sex; and (c) a combined mixed-model ANOVA to confirm comparability of the subset of tasks showing no significant differences from postswallow measures in Step 2. Results: Overall, PhAR measures were significantly larger in male participants; however, most pairwise task comparisons did not differ by sex. No significant differences from postswallow measures were seen for 5-cc bolus hold, chin-down and chin-up postures, and the second (but not the first) of two repeated head neutral still shots. PhAR during a 5-cc bolus hold was most similar to postswallow measures: mean ± standard deviation of 51 ± 13%(C2-4)² in females and 64 ± 16%(C2-4)² in males. Conclusions: PhAR is larger in men than in women. Oral bolus hold tasks with a 5-cc liquid bolus yield similar measures to those obtained from postswallow rest frames. [ABSTRACT FROM AUTHOR]

Background: Nasal irrigation is among the most widely used treatment modalities for sinonasal diseases. The extent of irrigation is well studied in operated sinuses but not for non-operated sinuses. Moreover, the preferred head positioning during irrigation is not known. Herein, we studied the extent of nasal irrigation in cadaveric heads with non-operated sinuses. Methods: Nine cadaveric heads were used. Normal saline solution mixed with radiological contrast material was used to irrigate the nasal cavities with the heads in 2 different positions: standing-leaning-forward (SLF) and Head-down forward (HDF). After each irrigation, computed tomography images of the head were acquired. The extent of irrigation was assessed for each subunit of the sinonasal cavity. Results: Irrigation was performed twice on a total of 18 sides, each time in 1 position. Nine subunits were evaluated: inferior, middle, and superior meati; the olfactory cleft; and the frontal, maxillary, anterior, and posterior ethmoid and sphenoid sinuses. The extent of irrigation was significantly better in the HDF position for the olfactory cleft (100% vs 33%), P -value=.001, frontal sinus (33% vs 11%), P -value=.002, maxillary sinus (78% vs 17%), P -value=.001, and anterior ethmoid sinus (89% vs 17%), P -value=.001. There was no significant difference in the extent of irrigation between the 2 positions for the other evaluated subunits. The overall extent of irrigation was 70.37% of the subunits in HDF position and 45.06% of the subunits for SLF position, P -value=.001 Conclusions: Nasal irrigation reached the cavities of non-operated paranasal sinuses. However, while the extent of irrigation was limited in the SLF, it was well achieved in the HDF position. Studies on the clinical efficacy of irrigation in this position are recommended. [ABSTRACT FROM AUTHOR]

Why you should read this article: • To be aware that orofacial clefts are the most common facial congenital abnormalities in humans • To read a case study presenting an overview of the care provided for an infant born with a cleft palate • To recognise the vital role of children’s nurses in supporting family-centred care. Orofacial clefts are the most common facial congenital abnormalities in humans. Their management is complex due to a range of immediate and ongoing challenges. These include breathing, feeding, speech, hearing and dental issues. This article uses a case study approach to outline these challenges for a patient who was born with a cleft palate. The case is followed by a discussion of contemporary evidence-based care. The article focuses on family-centred care and multidisciplinary teamwork, and the author also details the central role of the children’s nurse. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive surgical necrosectomy plays an important role in the management of infected pancreatic necrosis, with a goal of removing debris and debriding necrotic tissue. Pulse lavage is designed to simultaneously hydrostatically debride and remove the infected necrotic tissue with suction. It is also able to remove significant amounts of debris without traumatic manipulation of the necrotic tissue which may be adherent to surrounding tissue and can result in injury. Methods and results: The surgical technique of utilising a waterjet pulse lavage device during the minimally invasive necrosectomy is detailed. Sixteen patients being managed via a step-up approach underwent endoscopic necrosectomy via a radiologically placed drain tract. All sixteen patients were successfully managed endoscopically without conversion to open necrosectomy, and survived their admission. There were no complications associated with the use of the waterjet pulse lavage. Conclusion: Waterjet pulse lavage is a useful adjunct in minimally invasive necrosectomy, which reduces the length of the necrosectomy procedure, and facilitates removal of necrotic tissue while minimising the risk of traumatising healthy tissue. [ABSTRACT FROM AUTHOR]

Background: The Johnson–DeMeester composite score (DMS) is the historical gold standard for diagnosing gastroesophageal reflux disease (GERD). The Lyon Consensus outlines criteria for diagnosing GERD by pH monitoring, defining normal acid exposure time (AET) as < 4% and pathological as > 6%, presenting diagnostic uncertainty from 4 to 6%. We aimed to (i) calculate the proportion of borderline studies defined by total AET alone that are reclassified as normal or pathological by the DMS, (ii) determine the importance of supine AET for reclassification, and (iii) propose a new classification system using a composite score that considers positional changes. Methods: This single-center, retrospective, observational study analyzed data from patients with an overall total AET from 2 to 6% on 48-h pH monitoring (Bravo pH capsule). Preselected predictors (supine and upright AET) were included in a model to create a composite score (i.e., pHoenix score) using the regression coefficients. The model was internally validated, and discriminative ability was tested against the DMS and compared to the total AET. Results: We identified 114 patients (80 [70.2%] women; median age, 55 years). Using the total AET, 26 (22.8%) were classified as normal and 88 (77.2%) as borderline; however, using the DMS, 45 (39.5%) were classified as normal and 69 (60.5%) as pathological. The new pHoenix score demonstrated strong discriminative ability (AUC: 0.957 [95% CI 0.917, 0.998]) with high sensitivity and specificity (lower threshold, 94.4% and 79.2%; upper threshold, 87 and 95.8%). Compared to the total AET alone, the pHoenix score significantly decreased the proportion of inconclusive cases (77.2% vs. 13.2%, p < 0.001). Conclusion: Total AET has low sensitivity to identify pathological reflux as it disregards supine versus upright reflux. The pHoenix score improves the distinction between normal and pathological cases and reduces ambiguity, offering an alternative approach to diagnosing GERD that addresses the limitations of using total AET alone or the DMS. [ABSTRACT FROM AUTHOR]

Background: Although cone beam computed tomography (CBCT) has lower resolution compared to planning CTs (pCT), its lower dose, higher high‐contrast resolution, and shorter scanning time support its widespread use in clinical applications, especially in ensuring accurate patient positioning during the image‐guided radiation therapy (IGRT) process. Purpose: While CBCT is critical to IGRT, CBCT image quality can be compromised by severe stripe and scattering artifacts. Tumor movement secondary to respiratory motion also decreases CBCT resolution. In order to improve the image quality of CBCT, we propose a Lung Diffusion Model (L‐DM) framework. Methods: Our proposed algorithm is based on a conditional diffusion model trained on pCT and deformed CBCT (dCBCT) image pairs to synthesize lung CT images from dCBCT images and benefit CBCT‐based radiotherapy. dCBCT images were used as the constraint for the L‐DM. The image quality and Hounsfield unit (HU) values of the synthetic CTs (sCT) images generated by the proposed L‐DM were compared to three selected mainstream generation models. Results: We verified our model in both an institutional lung cancer dataset and a selected public dataset. Our L‐DM showed significant improvement in the four metrics of mean absolute error (MAE), peak signal‐to‐noise ratio (PSNR), normalized cross‐correlation (NCC), and structural similarity index measure (SSIM). In our institutional dataset, our proposed L‐DM decreased the MAE from 101.47 to 37.87 HU and increased the PSNR from 24.97 to 29.89 dB, the NCC from 0.81 to 0.97, and the SSIM from 0.80 to 0.93. In the public dataset, our proposed L‐DM decreased the MAE from 173.65 to 58.95 HU, while increasing the PSNR, NCC, and SSIM from 13.07 to 24.05 dB, 0.68 to 0.94, and 0.41 to 0.88, respectively. Conclusions: The proposed L‐DM significantly improved sCT image quality compared to the pre‐correction CBCT and three mainstream generative models. Our model can benefit CBCT‐based IGRT and other potential clinical applications as it increases the HU accuracy and decreases the artifacts from input CBCT images. [ABSTRACT FROM AUTHOR]

Objective: The prone positioning (PP) strategy has been considered as a feasible treatment for intubated coronavirus disease 2019 (COVID-19) patients with acute respiratory distress syndrome (ARDS). However, the optimal duration of PP remains uncertain. This meta-analysis aims to assess the efficacy and safety of extended PP (EPP) on patients with ARDS due to COVID-19. Materials and methods: The Cochrane Library databases, Embase, and Pubmed were systematically searched from inception until September 21, 2023. The primary outcomes were the mortality and the change of PaO2:FiO2 ratio; the secondary outcome was the incidence of complications (pressure injuries, facial edema, loss of endotracheal tube, loss of vascular access, etc). The random effects model was used to analyze the data. Results: Eight studies were eligible for inclusion in the meta-analysis. All studies had a low risk of bias. Compared to the standard prone position group, EPP could improve the PaO2:FiO2 ratio (mean deviation [MD], 9.13; 95% confidence intervals [CI] 0.29-17.96; P =.04; χ2 = 1.12, I2 = 0%). No significant difference was found in the mortality (odds ratios [OR] 0.90; 95% CI 0.67-1.22; P =.49; χ2 = 5, I2 = 0%). However, patients treated with the EPP were associated with an increasing incidence rate of pressure injuries (OR 1.47; 95% CI 1.08-2.01; P =.01; χ2 = 4.37, I2 = 0%) compared to standard care. Conclusions: Our results demonstrated that the EPP could be an effective strategy to improve the PaO2:FiO2 ratio without detrimental effects on mortality in intubated patients with COVID-19. Given the limited number of randomized controlled trials (RCTs), further high-quality RCTs are needed to confirm the results. INPLASY registration number: INPLASY202390072 [ABSTRACT FROM AUTHOR]

BACKGROUND: The use of prone position (PP) has been widespread during the COVID-19 pandemic. Whereas it has demonstrated benefits, including improved oxygenation and lung aeration, the factors influencing the response in terms of gas exchange to PP remain unclear. In particular, the association between baseline quantitative computed tomography (CT) scan results and gas exchange response to PP in invasively ventilated subjects with COVID-19 ARDS is unknown. The present study aimed to compare baseline quantitative CT results between subjects responding to PP in terms of oxygenation or CO2 clearance and those who did not. METHODS: This was a single-center, retrospective observational study including critically ill, invasively ventilated subjects with COVID-19-related ARDS admitted to the ICUs of Niguarda Hospital between March 2020-November 2021. Blood gas samples were collected before and after PP. Subjects in whom the PaO2 /FIO2 increase was ≥ 20 mm Hg after PP were defined as oxygen responders. CO2 responders were defined when the ventilatory ratio (VR) decreased during PP. Automated quantitative CT analyses were performed to obtain tissue mass and density of the lungs. RESULTS: One hundred twenty-five subjects were enrolled, of which 116 (93%) were O2 responders and 51 (41%) CO2 responders. No difference in quantitative CT characteristics and oxygen were observed between responders and non-responders (tissue mass 1,532 ± 396 g vs 1,654 ± 304 g, P = .28; density -544 ± 109 HU vs -562 ± 58 HU P = .42). Similar findings were observed when dividing the population according to CO2 response (tissue mass 1,551 ± 412 g vs 1,534 ± 377 g, P = .89; density -545 ± 123 HU vs -546 ± 94 HU, P = .99). CONCLUSIONS: Most subjects with COVID-19-related ARDS improved their oxygenation at the first pronation cycle. The study suggests that baseline quantitative CT scan data were not associated with the response to PP in oxygenation or CO2 in mechanically ventilated subjects with COVID-19-related ARDS. [ABSTRACT FROM AUTHOR]

Image-guided biopsy is an integral step in the diagnosis and management of suspicious image-detected breast or axillary lesions, allowing for accurate diagnosis and, if indicated, treatment planning. Tissue sampling can be performed under guidance of a full spectrum of breast imaging modalities, including stereotactic, tomosynthesis, sonographic, and MRI, each with its own set of advantages and limitations. Procedural planning, which includes consideration of technical, patient, and lesion factors, is vital for diagnostic accuracy and limitation of complications. The purpose of this paper is to review and provide guidance for breast imaging radiologists in selecting the best procedural approach for the individual patient to ensure accurate diagnosis and optimal patient outcomes. Common patient and lesion factors that may affect successful sampling and contribute to postbiopsy complications are reviewed and include obesity, limited patient mobility, patient motion, patients prone to vasovagal reactions, history of anticoagulation, and lesion location, such as proximity to vital structures or breast implant. [ABSTRACT FROM AUTHOR]

Emergency Medical Services (EMS) and law enforcement (LE) frequently work as a team in encounters with individuals experiencing acute behavioral emergencies manifesting with severe agitation and aggression. The optimal management is a rehearsed, coordinated effort by law enforcement and EMS providing the necessary interventions to address behaviors that endanger the patient, the responders, and the public. The purpose of this document is to provide guidance and direction in the shared responsibility of managing and caring for a person displaying behavioral instability with irrational, agitated, and/or violent behavior. This is a discussion of the roles of law enforcement, 9-1-1 call centers (hereafter referred to as the Emergency Call Centers or "ECCs"), Fire, and EMS. A coordinated and unified response enhances the safety and effective management of potentially serious situations posed by individuals experiencing such acute behavioral emergencies. This paper provides the framework for an approach endorsed by NAEMSP, IACP, and the IAFC. [ABSTRACT FROM AUTHOR]

Background: Reduced muscle mass upon admission and development of muscle wasting are frequent in critically ill patients, and linked to unfavorable outcomes. Muscle ultrasound is a promising instrument for evaluating muscle mass. We summarized the findings of lower limb muscle ultrasound values and investigated how the muscle ultrasound parameters of the examination or the patient characteristics influence the results. Methods: Systematic review and meta-analysis of studies of lower limb ultrasound critically ill adults. PubMed, CINAHL, Embase, PEDro and Web of Science were searched. PRISMA guidelines were followed, and studies evaluated with the appropriate NIH quality assessment tool. A meta-analysis was conducted to compare the values at admission, short and long follow-up during ICU stay, and the association between baseline values and patient characteristics or ultrasound parameters was investigated with a meta-regression. Results: Sixty-six studies (3839 patients) were included. The main muscles investigated were rectus femoris cross-sectional area (RF-CSA, n = 33/66), quadriceps muscle layer thickness (n = 32/66), and rectus femoris thickness (n = 19/66). Significant differences were found in the anatomical landmark and ultrasound settings. At ICU admission, RF-CSA ranged from 1.1 [0.73–1.47] to 6.36 [5.45–7.27] cm2 (pooled average 2.83 [2.29–3.37] cm2) with high heterogeneity among studies (I2 = 98.43%). Higher age, higher BMI, more distal landmark and the use of probe compression were associated with lower baseline muscle mass. Conclusions: Measurements of muscle mass using ultrasound varied with reference to patient characteristics, patient position, anatomical landmarks used for measurement, and the level of compression applied by the probe; this constrains the external validity of the results and highlights the need for standardization. Study registration: PROSPERO CRD42023420376. [ABSTRACT FROM AUTHOR]

ABSTRACT Background and Objectives Methods Results Conclusion Preterm infants need nutritional support due to their premature digestive system, undeveloped anatomy and functional limitations. Neonatal positioning in the proper position is one of the nurses' main principles that affect the residual volume. We performed our systematic review and network meta‐analysis to determine the best feeding position for preterm infants in reducing gastric residual volume and increasing the rate of gastric emptying.We systematically searched PubMed, Cochrane, CINHAL, Scopus and Web of Science from their inception to August 2023. We included studies that assess the effect of different feeding positions for preterm infants on gastric residuals. The Cochrane risk of bias tool (ROB2) appraised the included clinical trials. Cohort studies were assessed by the NIH tool and quasi‐experimental studies by the relevant items from (Downs and Black) checklist. RevMan Version 5.4 was used for analysing the pooled data. Our study included a frequentist network meta‐analysis of the aggregate data to obtain network estimates for the outcomes of interest. Network meta‐analysis was done using R software.We included 16 studies with 1139 premature infants, comparing six preterm feeding positions. The pooled MD and 95% CI for GRV at 30 min for right lateral, prone, right anterior oblique and left lateral compared to supine position were as follows: (−12.08 [−20.09, −4.07]), (−11.14 [−18.26, −4.01]), (−9.02 [−21.66, 3.61]) and (−0.18 [−7.87, 7.5]), respectively. Moreover, the pooled MD and 95% CI for GRV at 180 min for right lateral, prone and left lateral compared to supine position were as follows: (−0.69 [−1.29, −0.09]), (−0.56 [−1.22, 0.1]) and (0.09 [−0.63, 0.81]), respectively. Nevertheless, the pooled MD and 95% CI for GRV at 120 min for right anterior oblique, prone, right lateral and left lateral compared to supine position were as follows: (−6.09 [−11.33, −0.86]), (−5.07 [−7.71, −2.43]), (−3.08 [−5.89, −0.27]) and (−0.44 [−3.41, 2.53]), respectively.We concluded that the best nursing position after preterm infants feeding for lower gastric residuals and higher gastric emptying rate is the right lateral position after 30 and 180 min post‐feeding. Also, the right anterior oblique was the best after 120 min. Although the prone position can lower the GRV better than the left lateral and supine positions, it is not advisable to use this position because it raises the SIDS risk. Our results could help healthcare professionals to provide the appropriate positioning of preterm infants. [ABSTRACT FROM AUTHOR]

Background: IV access is a commonly performed procedure that is often taught based on tradition rather than evidence. The effect of arm retroflexion on vein width, either alone or in combination with a tourniquet or general anesthesia (GA), remains unclear. In this case, the sonographically measured vein width is a surrogate parameter for the success of the puncture. Methods: Prospective, cross-sectional study involving 57 patients scheduled for surgery in general anesthesia. We analyzed the impact of arm retroflexion, tourniquet, general anesthesia, and their combinations on the antebrachial veins in supine patients by ultrasound. Measurements were taken awake and during general anesthesia, each with and without the application of a tourniquet, and in three different arm positions (0°, 30°, and max° retroflexion) each. Data are presented as median and interquartile range [IQR]. Results: Tourniquet application (AT) had the greatest single effect on Cubital vein outer diameter compared to the baseline value of all measures (3.9 mm [3.4–5.1]; 4.8 mm [4.1–5.7], P = 0.001, r = 0.515). This effect was surpassed by the combination of AT and GA (5.1 mm [4.6–6.6], P = 0.001, r = 0.889). In contrast, retroflexion alone did not result in an increase at either 30° (4.2 mm [3.7–5.1], p = 1.0, r = 0.12) or max° (4.2 mm [3.6–4.9], p = 0.72, r = 0.23). With GA and AT, no further enlargement was measurable by 30° (5.4 mm [4.6–6.6], p = 1.0, r = 0.15) or max° (5.4 mm [4.6–6.6], p = 1.0, r = 0.07) retroflexion compared to GA-AT-0° (5.1 mm [4.6–6.6], p = 1.0, r = 0.15). Conclusions: This study provides evidence that retroflexion of the arm in supine patients, whether alone or in addition to a tourniquet or general anesthesia, does not have any additional effect on vein width as a surrogate parameter for successful IV success. It shows for the first time that general anesthesia effectively increases vein diameter. Trial registration: DRKS00029603 (date of registration 07.07.2022). [ABSTRACT FROM AUTHOR]

Chylous leakage is an uncommon and serious clinical condition, especially occurring after retroperitoneal operations. Here, we report a case of cervical chylous leakage combined with chylothorax in a 57‐year‐old woman postretroperitoneal surgery, and our conservative approach led to resolution/clinical improvement. The causes of this rare complication are discussed. We considered that the venous thrombosis, the increased intra‐abdominal pressure, or the patient positioning during the surgery may lead to the chylous particles leakage and chylothorax. Because of its rarity, we hope this case report will improve clinicians' understanding of cervical chylous leakage combined with chylothorax and provide suitable treatment options for future clinical reference. [ABSTRACT FROM AUTHOR]

An outbreak of OXA-23-producing carbapenem-resistant Acinetobacter baumannii amongst ICU-patients with COVID-19 likely occurred by transmission through inanimate surfaces, potentially facilitated by a contaminated positioning pillow shared between patients. Subsequent rapid spread may have been caused by exposure to respiratory secretions contaminating healthcare worker's gloves and gowns during prone positioning. [ABSTRACT FROM AUTHOR]

The diaphragm is the primary muscle of respiration. Here, we disclose a fascinating patient's perspective that led, by clinical reasoning alone, to a novel mechanism of spontaneous respiratory arrests termed diaphragm cramp-contracture (DCC). Although the 7-year-old boy survived its paroxysmal nocturnal "bearhug pain apnea" episodes, essentially by breathing out to breathe in, DCC could cause sudden unexpected deaths in children, especially infants. Diaphragm fatigue is central to the DCC hypothesis in SIDS. Most, if not all, SIDS risk factors contribute to it, such as male sex, young infancy, rebreathing, nicotine, overheating and viral infections. A workload surge by a roll to prone position or REM-sleep inactivation of airway dilator or respiratory accessory muscles can trigger pathological diaphragm excitation (e.g., spasms, flutter, cramp). Electromyography studies in preterm infants already show that diaphragm fatigue and sudden temporary failure by transient spasms induce apneas, hypopneas and forced expirations, all leading to hypoxemic episodes. By extension, prolonged spasm as a diaphragm cramp would induce sustained apnea with severe hypoxemia and cardiac arrest if not quickly aborted. This would cause a sudden, rapid, silent death consistent with SIDS. Moreover, a unique airway obstruction could develop where the hypercontracted diaphragm resists terminal inspiratory efforts by the accessory muscles. It would disappear postmortem. SIDS autopsy evidence consistent with DCC includes disrupted myofibers and contraction band necrosis as well as signs of agonal breathing from obstruction. Screening for diaphragm injury from hypoxemia, hyperthermia, viral myositis and excitation include serum CK-MM and skeletal troponin-I. Active excitation could be visualized on ultrasound or fluoroscopy and monitored by respiratory inductive plethysmography or electromyography. [ABSTRACT FROM AUTHOR]

Background: Esophageal schwannoma is an extremely rare esophageal submucosal tumor. We report a case of a hybrid surgery for a large esophageal schwannoma that had extended from the cervical to the upper thoracic esophagus by using thoracoscopic and cervical approaches. Case presentation: A 58-year-old male was referred to our hospital for further examination and treatment of dysphagia and weight loss over the past 6 months. Upper gastrointestinal endoscopy revealed a 5.7-cm submucosal tumor from the cervical esophagus to the upper thoracic esophagus. The submucosal tumor was diagnosed as esophageal schwannoma by endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA). Contrast-enhanced CT showed that the tumor had not invaded surrounding organs. Since the tumor extended from the cervical esophagus to the upper thoracic esophagus, we decided that it should be resected by not only the cervical but also the thoracoscopic approach. In operation, the patient was first placed in the prone position, and a thoracoscopic dissection of the upper thoracic esophagus containing the tumor was performed from the surrounding area. After changing the patient's position from prone to supine, a cervical skin incision was performed, and we underwent the tumor enucleation. After enucleation, the esophageal wall was thinned, so the right sternocleidomastoid muscle was used to reinforce the esophageal wall. The tumor size of the specimen was 60 × 52 × 42 mm. The postoperative course was uneventful, and the patient was discharged on the 22nd day after surgery. Conclusions: Enucleation of a large esophageal schwannoma from the cervical to the upper thoracic esophagus could be safely performed using both thoracoscopic and cervical approaches. The sternocleidomastoid muscle flap is useful in the occasion considering stenosis by muscular layer suture. [ABSTRACT FROM AUTHOR]

Background: Neurosurgery performed in the semi-sitting position provides advantages for certain procedures. However, this approach is associated with potential complications, particularly venous air embolism. Due to typically negative venous pressure at the wound site, air can be drawn into the veins. This risk is especially high in patients presenting with an intra- or extracardiac right-to-left-shunt. Transoesophageal echocardiography can be used to detect a patent foramen ovale or other possible pulmonary-systemic shunt before placing the patient in the sitting position. Case presentation: In this report, we present two young patients undergoing scheduled microsurgical vestibular schwannoma removal in a semi-sitting position who were diagnosed with congenital heart defects during routine perioperative assessment to detect possible intracardiac right-to-left shunts, using pre- and intraoperative transesophageal echocardiography (TEE) and additionally conducting an agitated saline bubble study under Valsalva manoeuvre. Patient A was diagnosed with a persistent left superior vena cava and Patient B with an unroofed coronary sinus (UCS). These findings confronted the anesthesiological and surgical teams with difficult individual decisions regarding further perioperative management. Conclusions: Perioperative transesophageal echocardiography is a diagnostic tool to both detect intraoperative position-related air embolisms and to rule out intracardiac right-to-left shunts, e.g. a patent foramen ovale, in order to decide for or against a (semi-)sitting position. Depending on the surgical circumstances a semi-sitting positioning of patients presenting with an intracardiac right-to-left-shunt, e.g. a PFO, can be feasible in individual cases if there is an implemented therapeutic algorithm to immediately terminate significant venous air entry. However, since certain other intra- or extracardiac right-to-left-shunts, such as here presented PLSVC or UCS, are rare, there is no definitive way of estimating the amount of entered air through detected shunts or anomalous vessels. Therefore, it is recommended to avoid a (semi-)sitting position in favour of a lateral or prone position for a patient undergoing intracranial surgery, once the perioperative TEE shows air bubbles in the left atrium or ventricle whose origins cannot be defined solely through TEE for certain in order to ensure patient safety by minimizing the risk of intraoperative paradoxical air embolisms. [ABSTRACT FROM AUTHOR]

Introduction: An immobile patient cannot be weighed on a stand-on weighing machine, i.e., a bathroom scale. They have to get weighed while lying, which is not easy. The main objective of this research is to design a medical apparatus that measures the patient's weight in a lying condition. To achieve this the apparatus is designed as a stretcher to carry the patient in and around the hospital. Methods: The stretcher has four load cells to measure the patient's weight; it can bear a weight of 500 kg and has a self-weight of 20 kg. A Microcontroller unit (MCU) is embedded into the apparatus to weigh the patient lying on it. The stretcher comprises the top frame, middle frame, and base frame. The top frame can be detached and mounted back to the middle frame; this will help the medical personnel shift the patients from a medical bed. The middle frame is a plate structure where the four load cells are mounted at the corners of the lower plate. The upper plate functions as a pressure plate on the load cell. The base plate has four heavy-duty wheels that can bear the load. The middle frame and base frame, together, form a single structure, giving mobility to the structure. A control panel is employed with reset, tare, and on-off buttons to control the embedded platform. The LCD panel on the side of the apparatus shows the weight when the patient is placed on top of the apparatus. Results and discussion: A prototype trolley equipped with a wireless data logging system was tested on 10 healthy participants. The device accurately measured weight within ±50 g across a scale range of 2-140 kg, with data captured every 30 s over a 5-min testing period. Wireless communication was successfully demonstrated over a 100-m range. The important add-on feature of this work is the apparatus is connected to the internet, transforming it into an IoT-based medical device. [ABSTRACT FROM AUTHOR]

Purpose: To investigate in a feasibility study the combination of [18F]FDG whole-body (WB) positron emission tomography-magnetic resonance (PET-MR), including an integrated breast MR within a single protocol for locoregional and distant staging in breast cancer patients. Methods: Consecutive patients with breast cancer diagnoses according to conventional imaging modalities (full-field digital mammography (FFDM) and ultrasound (US)) were prospectively included. All patients underwent [18F]FDG WB PET-MR, including an integrated dedicated breast MR (prone position) and WB PET-MR (supine position) protocol. Results of [18F]FDG WB PET-MR, including integrated breast MR, versus conventional imaging modalities were compared. Results: From April 2021–April 2022, 28 patients were included. On conventional imaging, cT1-2 breast cancer was present in 22 (FFDM) and 23 (US) out of 28 patients. With regard to clinical nodal status, eight patients were considered cN0, eighteen cN1 (1-3 suspicious lymph nodes), and two patients were cN2 (four suspicious axillary lymph nodes/internal mammary lymph node metastasis). [18F]FDG WB PET-MR, including an integrated breast MR protocol, upstaged clinical tumor status in two patients and clinical nodal status in nine patients according to both [18F]FDG WB PET-MR and breast MR findings. In addition, distant metastases were detected in three patients (liver/bone), and another patient was diagnosed with a synchronous primary tumor (lung cancer). Conclusion: [18F]FDG WB PET-MR, including an integrated breast MR within a single protocol in breast cancer patients, is feasible and provides a promising new approach in breast cancer patients with regard to locoregional and distant staging. Critical relevance statement: [18F]FDG whole-body PET-MR, including an integrated breast MR protocol, is feasible and allows locoregional and distant staging within a single imaging exam in breast cancer patients. Key Points: [18F]FDG PET-MR allows the combination of breast MR and whole-body staging. Therefore, a single protocol of whole-body [18F]FDG PET-MR, including an integrated breast MRI, is investigated. [18F]FDG PET-MR, including an integrated breast MR is feasible and can be considered in daily clinical practice. [ABSTRACT FROM AUTHOR]

Background: The operating room is a high-risk environment where proper patient positioning is crucial for minimizing injury and ensuring optimal access to surgical sites. This process requires effective collaboration among surgical team members, particularly operating room nurses who play a vital role in patient safety. Despite advancements in technology, challenges such as pressure injuries persist, with a significant incidence rate. Video-based training (VBT) emerges as a promising educational tool, enhancing knowledge retention and fostering a learner-centered approach. This study aims to evaluate the impact of VBT on adherence to surgical positioning standards, highlighting its potential to improve safety protocols in the operating room. Methods: In this clinical trial, 62 qualified operating room nurses (50 women, 12 men, average age: 28.90 ± 3.75 years) were randomly divided into control and intervention group (n = 31 in each group). The control group only received positioning recommendations, but in the intervention group, in addition to the recommendations, video-based surgical positioning training was performed for 1 month, at least 3 times a week. The performance of nurses in both groups was evaluated through a researcher-made checklist at baseline and post-intervention. Results: Based on findings, there was no significant difference between the two groups in compliance with surgical positioning standards at baseline (p = 0.07). However, after the intervention, compliance scores significantly improved in the VBT group compared to the control group (p < 0.001). The VBT group showed a mean improvement of 62.12 points, while the control group improved by 10.77 points (p < 0.001). Conclusions: This preliminary study demonstrated a notable improvement in compliance with surgical positioning standards among operating room nurses following VBT intervention. Despite the promising results, the small sample size and preliminary nature of the research necessitate further studies to confirm these findings and assess long-term outcomes. These initial insights highlight the potential of innovative training methods in enhancing surgical practices. [ABSTRACT FROM AUTHOR]

Objectives: To present our technique of diagnostic CT-guided ischiofemoral space injection and report on pain response, complications, and associated imaging findings in young patients with ischiofemoral impingement (IFI). Methods: Retrospective case series of patients with a clinical diagnosis of IFI that underwent CT-guided IFS injection with local anesthetic in a prone position with the feet in maximum internal rotation between 06/2019 and 04/2021. The response was evaluated using maximum subjective pain evaluation on a 0–10 visual analog scale (VAS) during a standardized pre- and postinterventional clinical examination. Patient charts and radiographic imaging data were reviewed to report associated imaging findings and subsequent surgeries. Results: Eleven patients (13 hips, 9 females) with a median age of 31 years (interquartile range; IQR: 25–37 years) were included. Median baseline VAS was 7 points (IQR: 5–8) with a pain reduction of 5 points (IQR: 5–7 points, p = 0.001) after the injection. One patient reported transient ischial nerve paresthesia, otherwise, no complications occurred. Quadratus femoris muscle edema was present in 85% (11 of 13 hips). Excessively high femoral torsion (11/13 hips, 85%) and cam deformities (8/13 hips, 62%) were the most common osseous deformities. Eight of 13 hips (62%) underwent subsequent surgery for IFI. Conclusion: CT-guided diagnostic injection of the ischiofemoral space is safe and feasible. In young IFI patients, diagnostic IFS injections have the potential to improve the differential diagnosis of hip pain and to inform decision-making with regard to a possible benefit of joint-preserving hip surgery. Critical relevance statement: In young patients with hip pain, diagnosis of IFI can be challenging due to concomitant pathologies. Furthermore, surgical treatment in these patients is controversial. In this context, CT-guided diagnostic infiltrations of the ischiofemoral space may facilitate not only the initial diagnosis of IFI, but could also improve surgical decision-making. Key Points: CT-guided diagnostic injection of local anesthetic in the ischiofemoral space is safe. In young patients with IFI, it leads to subjective pain reduction. In young patients with concomitant osseous deformities, it may improve surgical decision-making. [ABSTRACT FROM AUTHOR]

Background Aim Study Design and Methods Results Conclusions Relevance to Clinical Practice Position change and interventions to increase lung capacity should be considered in mechanically ventilated patients. The most effective of these is the prone position.This systematic review and meta‐analysis aimed to determine the effects of the prone position on respiratory parameters and outcomes and to guide nurses working in the intensive care unit.This systematic review‐meta‐analysis was conducted in accordance with the Preferred Reporting in Systematic Reviews and Meta‐Analyses guideline. ScienceDirect, CINAHL, Academic Search Complete (EBSCOhost), MEDLINE, EMBASE, Web of Science, Cochrane and PubMed databases were searched between January 2022 and January 2023 to access studies related to prone position in COVID‐19 patients.Twenty‐three studies were included. This meta‐analysis shows that a prone position is feasible and can achieve improvements in gas exchange. Prone position increases PaO2/FiO2 in the majority of patients followed with a diagnosis of COVID‐19 and severe hypoxemic.The study has shown that the prone position is effective in improving patients' respiratory function and oxygenation.The results presented in this article support the notion that the prone position can be an effective strategy in the clinical management of COVID‐19 patients. [ABSTRACT FROM AUTHOR]

Colonoscopy is a commonly performed procedure in the United Kingdom and the gold standard for diagnosis and therapy in the gastrointestinal tract. Increased levels of pain during colonoscopy have been associated with reduced completion rates and difficulties in maintaining attendance for repeat procedures. Multiple factors play a role in causing discomfort intra-procedurally: patient factors, such as gender, anatomy and pre-procedure anxiety; operator factors, such as patient position and level of experience and other factors, such as bowel preparation and total procedure time. A literature search was performed to identify papers that explained how patient, operator and endoscopy factors influenced pain and discomfort in endoscopy. A further search then also identified papers describing solutions to pain and discomfort that have been explored. After review of the literature, key methods are selected and discussed in this paper. Solutions and aids that can resolve and improve pain and discomfort include endoscopic methods such as variable stiffness and ultrathin scopes. Operator improvements in techniques and ergonomics alongside the use of newer technologies such as propelled endoscopy, computer-assisted endoscopy and task distraction. To improve patient experience and outcomes, the investigation and research into improving techniques to reduce pain is crucial. This review aims to identify the modifiable and non-modifiable factors associated with intra-procedural discomfort during colonoscopy. We discuss established methods of improving pain during colonoscopy, in addition to newer technologies to mitigate associated discomfort. [ABSTRACT FROM AUTHOR]

Background: Prone position has been proven to improve ventilation and oxygenation in infants. Currently, there are few reports of early prone position ventilation after pediatric liver transplantation. Here, we present our experience with prone position in an infant following living donor liver transplantation, in an attempt to improve oxygenation. Case presentation: An 8-month-old boy, 7.5 kg, experienced two failed extubations that presented with Type II respiratory failure due to dyspnea, potentially caused by consolidation and airway secretions. To prevent the third failure of extubation, prone position ventilation was implemented after the third extubation on the 11th postoperative day. Oxygenation increased after each prone position session with no signs of transplant liver ischemia or other adverse outcomes. Following two days of continuous prone position, airway secretions decreased, and the infant was discharged from the ICU. The third extubation procedure was successful. Conclusions: Prone position ventilation may be effective in this infant without adverse events, indicating that early prone position is not absolutely contraindicated after pediatric liver transplantation. Therefore, more reasonable prone position strategies should be sought in infants undergoing liver transplantation. [ABSTRACT FROM AUTHOR]

A minimally invasive surgery (MIS) is the standard of care for surgical treatment in gynecological oncology. Robotic surgery is increasingly being used in this domain. Anesthetic considerations are related to the specific procedure, robotic approach per se, adjuvant chemotherapy, radiotherapy, and patient-specific concerns. Evidence-based practices encompass a balance of preoperative, intraoperative, and postoperative evidence-based goals. A summary of these key aspects of perioperative care for women undergoing MIS can enhance surgical outcomes in gynecological oncology. [ABSTRACT FROM AUTHOR]

Background: Prone position ventilation (PPV) is recommended for patients with COVID‐19 induced severe Adult Respiratory Distress Syndrome (ARDS) and is used for patients supported with V‐V ECMO as well. The purpose of this study was to describe the use of PPV in these patients focusing on physiological effects with the hypothesis that PPV could reduce oxygen need and improve dynamic compliance. Methods: This study was a nationwide retrospective analysis of all COVID‐19 patients in Denmark from March 2020 – December 2021 with severe ARDS and need of V‐V ECMO support. Data on the number of patients treated with PPV, number of PPV sessions, timing, the time spent in prone position, pulmonary physiological response types with analysis of variables affecting the response are reported. Results: Out of 68 patients 44 were treated with 220 PPV sessions and a positive clinical response was observed in 80% of patients but only in 45% of sessions. On a single session level, increased compliance was observed in 38% and increased oxygenation in only 15% of 220 sessions, with within‐patient heterogeneity. Higher dynamic compliance at the beginning of a PPV session was associated with a lower delta change in dynamic compliance during PPV. The response to a PPV session could not be predicted by the response in the prior session. Dynamic compliance did not change during the ECMO course. Conclusion: Eighty percent of patients responded positively during a PPV session, but this was not associated with overall pulmonary improvement. On a single patient level, responses were heterogenous and only 45% of sessions resulted in clinical improvement. Response in dynamic compliance was associated with starting values of compliance. [ABSTRACT FROM AUTHOR]

Background: Undesirable injuries during the intraoperative period, such as pressure injuries caused by improper positioning, medical devices, or adhesive tapes, can lead to patient harm and decreased satisfaction. This study aims to identify the risk factors of pressure injuries during the intraoperative period and the characteristics of these injuries. Methods: A retrospective case‑control study was conducted at King Khaled University Hospital in Riyadh, Saudi Arabia. Data were collected from the hospital incident reporting system and electronic medical records for incidents reported from January 1, 2022 to December 31, 2022. Inclusion criteria consisted of all patients with a reported pressure injury, including pressure ulcers, medical adhesive‑related skin injuries, or medical device‑related pressure injuries, occurring at least once during surgery. Results: Among the 113 patients, 57 (50.44%) had intraoperative pressure injuries (cases), while 56 (49.56%) did not (controls). The most common locations for pressure injuries were the lips (33.33%). Most of these injuries were classified as Medical Adhesive‑Related Skin Injury (61.40%). Stage 1 injuries were observed in 47 cases (82.46%), while Stage 2 injuries were observed in 10 cases (17.54%). Duration of surgery and device tightness were identified as significant risk factors (P < 0.001). Conclusion: This case‑control study identified the duration of surgery and device tightness as significant risk factors for intraoperative pressure injuries. The findings emphasize the importance of implementing evidence‑based prevention strategies. Healthcare professionals should prioritize staff education and training, while future research should focus on conducting prospective, multicenter studies and developing risk assessment tools and innovative medical devices. [ABSTRACT FROM AUTHOR]

A key best practice to prevent and treat pressure injuries (PIs) is to ensure at-risk individuals are repositioned regularly. Our team designed a non-contact position detection system that predicts an individual's position in bed using data from load cells under the bed legs. The system was originally designed to predict the individual's position as left-side lying, right-side lying, or supine. Our previous work suggested that a higher precision for detecting position (classifying more than three positions) may be needed to determine whether key bony prominences on the pelvis at high risk of PIs have been off-loaded. The objective of this study was to determine the impact of categorizing participant position with higher precision using the system prediction F1 score. Data from 18 participants was collected from four load cells placed under the bed legs and a pelvis-mounted inertial measurement unit while the participants assumed 21 positions. The data was used to train classifiers to predict the participants' transverse pelvic angle using three different position bin sizes (45°, ~30°, and 15°). A leave-one-participant-out cross validation approach was used to evaluate classifier performance for each bin size. Results indicated that our prediction F1 score dropped as the position category precision was increased. [ABSTRACT FROM AUTHOR]

Background/Objectives: Airway management techniques, including mask ventilation and tracheal intubation, are vital across medical settings. However, these procedures can be challenging, especially when environmental conditions are less than ideal. This study explores how the height of the operating table affects the difficulty of anesthesia techniques involving mask ventilation and tracheal intubation. Methods: Twenty anesthesiologists participated in this study. We assessed the difficulty of procedures such as mask ventilation, Macintosh laryngoscopy, and video laryngoscopy using McGRATH and AWS, on a four-level scale. The operating table's height was adjusted at four points: the operator's umbilicus, the inferior margin of the 12th rib, the xiphoid process, and the nipple. Results: Mask ventilation was easiest at the operating table's height aligned with the inferior margin of the 12th rib. Conversely, direct laryngoscopic exposure was perceived as easier at higher table heights, with nipple height being optimal. The McGRATH laryngoscopy showed consistent difficulty across table heights, whereas the AWS tended to be somewhat more difficult at greater heights. Conclusions: The optimal bed height for video laryngoscopy coincided with that for mask ventilation. Video laryngoscopy offers enhanced flexibility in optimal patient positioning compared to Macintosh laryngoscopy, contributing to its advantages in tracheal intubation procedures. [ABSTRACT FROM AUTHOR]

Background: Since robotic pancreaticoduodenectomy (R-PD) has emerged as a promising technique for treating periampullary tumors, optimal surgical views across various stages of the surgery are vital. This study aimed to describe the evolution and optimization of the multiple scope transition (MST) method using comprehensive videos and illustrations, particularly from the perspective of the patient-side assistants, to enhance the efficiency and safety of R-PD through its different phases. Methods: We retrospectively analyzed 61 patients who underwent R-PD from April 2021 to May 2023. Results: The median total operation duration was 599 min (415–840 min). The median scope transition times for redocking from the left to central lower position, transition from the central lower to upper position, and port-hopping from the central to right position were 169 s (53–725 s), 55 s (26–165 s), and 120 s (41–260 s), respectively. Owing to the advancements in the scope transition procedures, these scope transition times became shorter with an increase in the number of experiences. No intraoperative complications relevant to scope transition was reported, and the incidence of significant postoperative complications greater than Grade IIIa of the Clavien–Dindo classification was 8.2%. Conclusion: We reported the established role and evolution of the MST method from the standpoint of the patient-side assistants. The comfortable surgical field expansion provided by the MST method can ensure the safe and widespread application of R-PD. [ABSTRACT FROM AUTHOR]

Background: The ergonomic advantages and potential challenges that robotic surgery poses to the well-being of surgeons are mainly unexplored. The most recent surgical robot introduced on the European market is the Hugo™ RAS System by Medtronic. This study aims to evaluate the ergonomic benefits of the Hugo™ RAS System, which is available in our training laboratory, CeMIT (Center for Medical Innovation and Technology Cologne). Methods and procedures: Using the previously established Cologne Ergonomic Measurement Setup for Robotic Surgery (CEMRobSurg), we measured three parameters related to ergonomic posture from subjects with different levels of surgical expertise (laypeople, medical students, surgical residents, and expert robotic surgeons). The heart rate was measured continuously using a polar band. The noise level was measured while using the Hugo™ RAS System, and automated photographs using our locally developed methodology were captured of the participant every 2 s to assess body posture. The ergonomic measurements were conducted while the subject performed the same standardized robotic training exercises (Peg Board, Rope Walk, and Ring Walk). Results: A total of 53 participants were enrolled in this study. The average noise level during all measurements was 54.87 dB. The highest stress level was measured in surgical residents with a sympathetic nervous system index (SNS index) of 1.15 (min − 1.43, max 3.56). The lowest stress level was measured in robotic experts with an SNS index of 0.23 (min − 0.18, max 0.91). We observed a risk-prone positioning of the neck and elbow in medical students (mean 39.6° and 129.48°, respectively). Robotic experts showed a risk positioning in the knee and hip region (mean 107.89° and 90.31°, respectively). Conclusion: This is the first study to analyze and objectify the ergonomic posture of medical students, surgical trainees, surgeons, and laypeople using the open console, modular Hugo™ RAS System. Our findings offer recommendations for operating surgeons and allow for a comparative analysis between the different robotic systems. Further evaluations in real-time operative scenarios will follow. [ABSTRACT FROM AUTHOR]

Background: The evidence for the benefits of early mobilization in intensive care is growing. Early mobilization differs from most other interventions in intensive care since the patient's participation is requested. What kind of challenges this entails for the intensive care clinicians, and what is crucial in successful early mobilization from their perspective, is sparsely explored and was therefore the purpose of this study. Methods: Semi-structured interviews were held with 17 intensive care clinicians, seven nurses, five assistant nurses and five physiotherapists. The interviews were analyzed with a phenomenographic methodology. Findings: Four descriptive categories emerged: 1) Taking responsibility; 2) Taking the patient's perspective; 3) Time or not time to mobilize; and 4) The "know-how" of early mobilization. Early mobilization was perceived as an important and crucial part of intensive care. It includes positioning and sensory stimulation, which could be used to re-orientate the patient and prevent delirium. The patients' experiences were considered individual with a mix of strong emotions. Despite the stated significance of early mobilization, different conceptions were expressed about the right time, some of them based on concerns for the patient, and some due to safety concerns. In the optimal active mobilization to upright positions there was an emphasis on careful preparation and patient involvement, including negotiation and active participation. Conclusions: The importance of early mobilization is indisputable. Successful early mobilization is achieved by applying a person-centered approach, involving the patient as an active partner. Early mobilization comprises positioning and sensory stimulation and should be included in the daily planning of patient care. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to compare the effect of a pressure-controlled strategy allowing non-synchronised unassisted spontaneous ventilation (PC-SV) to a conventional volume assist-control strategy (ACV) on the outcome of patients with acute respiratory distress syndrome (ARDS). Methods: Open-label randomised clinical trial in 22 intensive care units (ICU) in France. Seven hundred adults with moderate or severe ARDS (PaO2/FiO2 < 200 mmHg) were enrolled from February 2013 to October 2018. Patients were randomly assigned to PC-SV (n = 348) or ACV (n = 352) with similar objectives of tidal volume (6 mL/kg predicted body weight) and positive end-expiratory pressure (PEEP). Paralysis was stopped after 24 h and sedation adapted to favour patients' spontaneous ventilation. The primary endpoint was in-hospital death from any cause at day 60. Results: Hospital mortality [34.6% vs 33.5%, p = 0.77, risk ratio (RR) = 1.03 (95% confidence interval [CI] 0.84–1.27)], 28-day mortality, as well as the number of ventilator-free days and organ failure-free days at day 28 did not differ between PC-SV and ACV groups. Patients in the PC-SV group received significantly less sedation and neuro-muscular blocking agents than in the ACV group. A lower proportion of patients required adjunctive therapy of hypoxemia (including prone positioning) in the PC-SV group than in the ACV group [33.1% vs 41.3%, p = 0.03, RR = 0.80 (95% CI 0.66–0.98)]. The incidences of pneumothorax and refractory hypoxemia did not differ between the groups. Conclusions: A strategy based on PC-SV mode that favours spontaneous ventilation reduced the need for sedation and adjunctive therapies of hypoxemia but did not significantly reduce mortality compared to ACV with similar tidal volume and PEEP levels. [ABSTRACT FROM AUTHOR]

Background: Laryngeal mask airway (LMA) has been increasingly used for airway management; however, LMA insertion can be difficult and cause adverse effects. Therefore, the rapid, safe, and effective insertion of LMA is necessary. This study aimed to compare the efficacy of the standard method with that of the 30° curved tongue depressor-aided technique for LMA insertion to determine the superior technique. Methods: This study included 154 patients aged 18–70 years (American Society of Anesthesiologists class I or II) scheduled for general anesthesia. The patients were randomly assigned to the standard LMA insertion group (Group C, n = 77) or the 30° curved tongue depressor-aided LMA insertion group (Group T, n = 77). The primary outcome evaluated was the first-attempt success rate. The secondary outcomes were the second-attempt success rate, insertion time, fiberoptic position grade, oropharyngeal leak pressure (OPLP), and adverse events. Results: The first-attempt success rate was significantly higher in Group T than in Group C (97.40% vs. 88.31%, P = 0.029). The second-attempt success rate (P = 0.209), insertion time (P = 0.340), fiberoptic position grade (P = 0.872), and OPLP (P = 0.203) were slightly improved in Group T; however, there was no statistical significance. Bleeding events were reduced in Group T than in Group C (6.49% vs. 14.29%); however, there was no statistical significance. The incidence of sore throat symptoms was significantly reduced in Group T than in Group C (5.19% vs. 15.58%, P = 0.035). Conclusions: The curved tongue depressor-aided technique significantly improved the first-attempt success rate of LMA insertion and reduced the incidence of sore throat symptoms. Trial registration: KCT0004964; Registered at https://cris.nih.go.kr on April 27, 2020. [ABSTRACT FROM AUTHOR]

Background: The actual significance of prehospital immobilization of the cervical spine in severely injured trauma patients remains unclear. In view of possible negative implications, such as an increase in intracranial pressure due to the application of a rigid cervical spine orthosis, the long-term use must be critically questioned. Further studies are required to justify the long-term use of a rigid cervical spine orthosis in the prehospital setting. Objective: Comparative measurements of the mobility of the cervical spine during immobilization using a vacuum mattress with or without the additional application of a rigid cervical spine orthosis after positioning on the stretcher were carried out. Material and methods: Biomechanical measurements of the movement of the cervical spine were carried out by attaching inertial measurement units to a test person during the loading and unloading process in a modern ambulance and during the journey along a predefined parkour. The test person on whom the measurements were carried out was immobilized on a vacuum mattress with the option of lateral fixation of the head and chin and forehead strap on an electrohydraulic stretcher. The complete standard monitoring was set up to simulate as realistic a transport of a severely injured patient as possible. A total of 30 test runs were realized. In one half of the tests, the cervical spine was additionally immobilized using a rigid orthosis and in the other half a cervical spine orthosis was not used. For each of the 30 tests, the angles, axial rotation, lateral bending and flexion/extension as well as the first and second derivatives were considered for loading, transport and unloading and the parameters mean deviation from the zero position, size of the swept angle range and maximum were calculated for each test run. Results: Statistically significant differences were only found for some biomechanical parameters in the sagittal plane (flexion and extension). No significant differences were found for the measured parameters in the other directions of movement (axial rotation, lateral flexion). In general, only very small angular deflections were measured both in the tests with the cervical spine orthosis and without the cervical spine orthosis (on average in the range of 1–2° for axial rotation and flexion/extension and up to 3° for lateral flexion). Conclusion: If immobilization is carried out correctly using a vacuum mattress with the option of lateral stabilization of the head and chin and a forehead strap on an electrohydraulic stretcher with a loading system, there are no relevant advantages with respect to the restriction of movement of the cervical spine by the additional use of a rigid cervical spine orthosis for the loading and unloading process or during the transport in a modern ambulance. It could therefore be advantageous to remove the rigid cervical spine orthosis initially applied for the rescue of the patient at the scene after the patient has been positioned on the vacuum mattress and stretcher to avoid potential negative effects of the rigid cervical spine orthosis for the period of transportation to the hospital. [ABSTRACT FROM AUTHOR]

Background: The ramped position facilitates mask ventilation and endotracheal intubation in patients with obesity. This study aimed to determine whether the ramped position improves supraglottic airway (SGA) insertion in patients with obesity. Methods: In this prospective, randomized, single-center trial, 48 obese patients undergoing elective surgery were randomized into either ramped or sniffing position groups. The Ambu® AuraGainTM (Ambu A/S), a second-generation SGA, was used. The primary outcome was the time required for the AuraGain insertion. Secondary outcomes included ease and number of insertion attempts, oropharyngeal leak pressure (OLP), and complications. The number needed to treat (NNT) was calculated to ensure ease of insertion. Results: The time required for the AuraGain insertion was significantly shorter in the ramped group than in the sniffing group (13.0 [11.0, 16.0] vs. 24.0 [21.0, 28.0], P < 0.001). The insertion was easier in the ramped group than in the sniffing group (23/24 vs. 13/24, NNT = 2.4 [95% CI, 1.6, 5.0], P = 0.003). The first-attempt success rate was higher in the ramped group than in the sniffing group, although the difference was not statistically significant (22/24 vs. 18/24, P = 0.319). The OLP and postoperative complication rates were not significantly different between the groups. Conclusions: The ramped position reduced the time required for the AuraGain insertion in obese patients while providing comparable airway sealing without increasing adverse events. Therefore, a ramped position may be a more suitable option for SGA insertion in this population. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to identify a safe and effective method to assist older adults with pneumonia in tolerating the prone position for a longer duration. Methods: This was a randomized, controlled, double-blinded study performed at the Shanghai Fourth People's Hospital. Eighty patients with pneumonia aged ≥ 65 years were included. The patients were able to spontaneous breath in the prone position and were administered intravenous dexmedetomidine or an isotonic sodium chloride solution. The cumulative daily durations of prone positioning for all patients in the two groups were recorded. The primary outcome was the percentage of patients who completed ≥ 9 h/day in the prone position. The secondary outcomes included the incidence of complications in the prone position and patient outcomes. Results: Eighty patients were included (average age: 79.6 ± 8.9 years). The percentage of patients who completed ≥ 9 h/day in the prone position was significantly higher in the dexmedetomidine group than in the placebo group (P = 0.011). The percentage of patients who completed ≥ 12 h/day in the prone position was also significantly greater in the dexmedetomidine group than in the placebo group (P = 0.008). There were no significant differences in other variables between the two groups. Conclusions: The results of this study demonstrate that intravenous dexmedetomidine injection can significantly prolong the duration of spontaneous breathing in the prone position in elderly pneumonia patients without obvious adverse events. We provide a safe and effective method to help patients with pneumonia, especially those with delirium or cognitive impairment, who cannot tolerate the length of time needed for spontaneous breathing in the prone position to be effective. Trial registration: The study was registered with the Chinese Clinical Trial Center (registration number: ChiCRT2300067383) on 2023-01-05. [ABSTRACT FROM AUTHOR]

Robotic spine surgery, utilizing 3D imaging and robotic arms, has been shown to improve the accuracy of pedicle screw placement compared to conventional methods, although its superiority remains under debate. There are few studies evaluating the accuracy of 3D navigated versus robotic-guided screw placement across lumbar levels, addressing anatomical challenges to refine surgical strategies and patient safety. This study aims to investigate the pedicle screw placement accuracy between 3D navigation and robotic arm-guided systems across distinct lumbar levels. A retrospective review of a prospectively collected registry. Patients undergoing fusion surgery with pedicle screw placement in the prone position, using either via 3D image navigation only or robotic arm guidance. Radiographical screw accuracy was assessed by the postoperative computed tomography (CT) according to the Gertzbein-Robbins classification, particularly focused on accuracy at different lumbar levels. Accuracy of screw placement in the 3D navigation (Nav group) and robotic arm guidance (Robo group) was compared using Chi-squared test/Fisher's exact test with effect size measured by Cramer's V, both overall and at each specific lumbosacral spinal level. A total of 321 patients were included (Nav, 157; Robo, 189) and evaluated 1210 screws (Nav, 651; Robo 559). The Robo group demonstrated significantly higher overall accuracy (98.6 vs 93.9%; p<.001, V=0.25). This difference of no breach screw rate was signified the most at the L3 level (No breach screw: Robo 91.3 vs 57.8%, p<.001, V=0.35) followed by L4 (89.6 vs 64.7%, p<.001, V=0.28), and L5 (92.0 vs 74.5%, p<.001, V=0.22). However, screw accuracy at S1 was not significant between the groups (81.1 vs 72.0%, V=0.10). This study highlights the enhanced accuracy of robotic arm-guided systems compared to 3D navigation for pedicle screw placement in lumbar fusion surgeries, especially at the L3, L4, and L5 levels. However, at the S1 level, both systems exhibit similar effectiveness, underscoring the importance of understanding each system's specific advantages for optimization of surgical complications. [ABSTRACT FROM AUTHOR]

Otitis media is a disease that commonly occurs in infants. Various risk factors have been reported. Sleep position has been reported to be associated with various diseases. There is no report on the relationship between otitis media and sleep position. We examined the incidence of otitis media and sleep position in infants. We used data from the Japan Environment Children's Study. We used multivariate logistic analysis to examine the relationship between sleep position and the incidence of otitis media in infants aged up to 6 months. In addition, we conducted a stratified analysis based on whether the child was able to turn over in bed at 6 months of age. The study population comprised 85,731 participants. The incidence of otitis media by sleep position was significantly higher when the infant was in the prone position compared to any other position (adjusted odds ratio, 1.206; 95 %CI, 1.038–1.401). Stratified analysis of turning showed that otitis media was more common in the prone position in all groups. In the current study, infants aged 6 months or younger who slept in the prone position were more likely to have otitis media. Sleep position interview and guidance on changing sleep position may be useful for the prevention of otitis media. [ABSTRACT FROM AUTHOR]