JUDE LAWRENCE S.

JACALAN N-411 B2
Regional Protocols Improve Quality of Care for Aortic Dissection
Patients
ScienceDaily (Aug. 10, 2010) — Using a standardized protocol within a
regional health network, a multidisciplinary acute aortic dissection (AAD)
program resulted in a 43 percent reduction in time to diagnosis for all AAD
patients over the course of five years, according to a study published in the
July edition of Circulation: Cardiovascular Quality and Outcomes, an
American Heart Association journal.
While the incidence rate of AAD is rare -- approximately three cases per 100,000 persons annually --
these patients have an in-hospital mortality rate of 26 percent, and for those patients with type A aortic
dissection, the mortality risk is 1 percent to 2 percent per hour until emergency surgical repair is
performed. "It is therefore critical that AAD be recognized promptly and that surgical care be provided
expeditiously," according to background information of the study.
"Aortic dissection has a much higher mortality rate than more prolific disease states, such as severe heart
attacks," explained Kevin M. Harris, MD, who is co-director of the Acute Aortic Dissection Program at the
Minneapolis Heart Institute® at Abbott Northwestern Hospital in Minneapolis, Minn.
The International Registry of Acute Aortic Dissection (IRAD) estimates that the average time between an
emergency room arrival and the diagnosis of acute aortic dissections is 4.3 hours.
In an effort to accelerate the time between hospital arrival to diagnosis and diagnosis to intervention,
Harris and his colleagues at the Minneapolis Heart Institute® and Minneapolis Heart Institute Foundation
established quality improvement protocols and standardized care measures throughout 32 community
hospitals in Minnesota, North Dakota and western Wisconsin. As part of an ongoing AAD educational
program, the participating facilities received more than 60 lectures and training sessions on AAD and
received program-related protocols and toolkits.
During the study, the researchers examined 101 patients with aortic dissection -- 68 percent of whom had
aortic dissection affecting the ascending aorta (Type A) and 76 percent were transferred to the aortic
dissection center from community hospitals.
Overall, the study showed that the system-wide education and coordination efforts resulted in a 43
percent reduction in time to diagnosis for all cases of AAD and a 55 percent reduction in the time from
diagnosis to intervention in surgically managed type A patients.
"The time was reduced from 279 minutes to 160 minutes, which equates to a two-hour time savings," said
Dr. Harris.
The researchers also reported a 30 percent decrease between the time a patient was diagnosed with
aortic dissection and the time they presented to the operating room. "The times prior to use of the
protocols were 728 minutes compared to 360 minutes after implementation of the protocols, and we've
cut the time of transfer from arrival to the operating room basically in half," said Dr. Harris.
The study authors noted that no new technologies or significant financial costs were required to
implement the program. "This systematic approach to AAD care represents a new paradigm for the
treatment of this life-threatening condition," they concluded.

http://www.sciencedaily.com/releases/2010/08/100810094611.htm
Better Surgery With New Surgical Robot With Force Feedback
ScienceDaily (Sep. 29, 2010) — Robotic surgery makes it possible to perform
highly complicated and precise operations. Surgical robots have limitations,
too. For one, the surgeon does not 'feel' the force of his incision or of his pull
on the suture, and robots are also big and clumsy to use. Therefore TU/e
researcher Linda van den Bedem developed a much more compact surgical
robot, which uses 'force feedback' to allow the surgeon to feel what he or she
is doing.
Van den Bedem intends to market Sofie, the 'Surgeon's Operating Force-feedback Interface Eindhoven'.
One of the distinctive properties of Sofie is the 'force feedback', i.e. 'tactile feedback' in the joysticks with
which the surgeon operates. This counter pressure enables a surgeon to feel exactly what force he
applies when making a suture or pushing aside a bit of tissue. The finishing touch of this, the control of
the force feedback, is being developed.
Moreover, Sofie is quite compact and hence less of an obstacle in the operating theater and above the
patient. Its small dimensions come with an added bonus: Sofie's slave is not on the floor, but is mounted
on the operating table. This averts the need of resetting everything when the operating table and the
patient are moved or tilted. Further, Sofie makes it possible to approach an organ from different sides and
can even operate 'around the corner'. Van den Bedem built the robot with assistance from TU/e's
technical department. The university has patented this know-how.
The researcher expects that it will definitely take some five years or so before Sofie can really be put on
the market.
Van den Bedem last week obtained her PhD degree at TU/e for a new type of surgical robot, Sofie. More
specifically: she was awarded the title for the 'slave' of the robot, the robotic section performing the
operation at the table. Van den Bedem built a prototype for this. The other components Sofie consists of
are a master, the surgeon's 'control panel', with driven joysticks.

http://www.sciencedaily.com/releases/2010/09/100928083848.htm
Studies Identify Complications in Women Undergoing
Mastectomy and Immediate Breast Reconstruction
ScienceDaily (Sep. 27, 2010) — About half of women who require radiation
therapy after they have had a mastectomy and immediate breast
reconstruction develop complications that necessitate a return to the operating
room, but pre- or post-mastectomy chemotherapy does not appear to be
associated with the need for additional procedures, according to two reports in
the September issue of Archives of Surgery, one of the JAMA/Archives
journals.
An increasing number of women are undergoing mastectomy as a treatment for breast cancer or as a
means to prevent cancer if they have a genetic predisposition, according to background information in the
articles. Previously, most women underwent mastectomy and then radiation or chemotherapy, followed by
a second procedure for breast reconstruction after completing therapy. However, many treatment facilities
now offer the option of having breast reconstruction at the same time as mastectomy. Studies suggest
immediate reconstruction is safe and has potential psychological and aesthetic benefits.
Rates of radiation therapy after mastectomy are also increasing. In one article, Dara Christante, M.D., and
colleagues at Oregon Health & Science University Knight Cancer Institute, Portland, studied 302
mastectomy patients with stage I to III breast cancer treated between 2000 and 2008, identified via an
institutional cancer registry. Of the 302 women, 152 had breast reconstructions, including 131 that were
immediate; 183 (60 percent) underwent biopsies to detect malignancy in their lymph nodes, of whom 108
(59 percent) had a negative finding; and 100 underwent postmastectomy irradiation to the chest wall.
"Postmastectomy irradiation and immediate breast reconstruction were each indentified as strong
independent predictors of complications," the authors write. "Postmastectomy irradiation tripled the risk
for an unplanned return to the operating room and immediate breast reconstruction increased that risk
eight-fold. The combination of immediate breast reconstruction and postmastectomy irradiation resulted in
nearly one of two patients returning to the operating room with complications compared with 7 percent of
patients who received postmastectomy irradiation but did not undergo reconstruction."
Patients are typically counseled to avoid immediate breast reconstruction if they may be at risk of needing
radiation therapy, the authors note. However, among patients in the current study, seven of 39 (20
percent) who were considered low-risk enough to have immediate reconstruction required irradiation after
final pathology reports were available.
"Therefore, predicting postmastectomy irradiation more accurately would permit avoidance of immediate
breast reconstruction and its postmastectomy irradiation-associated complications, potentially decreasing
the rate of unplanned operations," the authors write. "Conversely, some women are unnecessarily
directed away from immediate breast reconstruction because of an overestimation of their risk for
postmastectomy irradiation. In this series, 12 of 22 patients (55 percent) who underwent delayed
reconstruction did not undergo postmastectomy irradiation."
Knowledge of lymph node status significantly contributed to the ability to predict postmastectomy
irradiation, the authors note. Therefore, women considering immediate breast reconstruction might wish
to have a sentinel lymph node biopsy performed prior to mastectomy. "Patients with a negative sentinel
lymph node would be reassured that their risk with immediate breast reconstruction is low," the authors
conclude. "Patients with a positive sentinel lymph node would be identified as having a higher,
quantifiable risk of meeting postmastectomy irradiation indications."
In another article, Anne Warren Peled, M.D., and colleagues at Helen Diller Family Comprehensive
Cancer Center, University of California, San Francisco, studied 163 women who underwent mastectomy
and immediate breast reconstruction between 2005 and 2007. Of these, 57 received chemotherapy
before their surgery and 41 received chemotherapy post-operatively; all were followed for an average of
19.2 months to monitor postoperative complications.
Overall, 31 percent of patients had a complication requiring a return to the operating room. This rate did
not differ based on whether women received chemotherapy before surgery, after or not at all.
Postoperative infections developed in 18 patients (44 percent) who received chemotherapy after surgery,
compared with 13 patients (23 percent) who received chemotherapy before surgery and 16 patients (25
percent) who did not receive any chemotherapy.
"Although systemic chemotherapy has been thought to increase wound-related complications, our study
demonstrates that risk of non-infectious postoperative complications is not increased after mastectomy
and immediate breast reconstruction among women who receive chemotherapy," the authors conclude.
"Additionally, the timing of chemotherapy in relation to mastectomy did not have a significant impact on
surgical outcomes. However, the wound infection rate was significantly higher in patients who had
received adjuvant [postoperative] chemotherapy and in some cases resulted in delay of chemotherapy."
"These results suggest a possible benefit for pre-operative administration of chemotherapy in those
patients who require chemotherapy, even in women who will undergo mastectomy, and they support the
use of immediate reconstruction in this patient population."

http://www.sciencedaily.com/releases/2010/09/100920172632.htm

Awake Sedation for Brain Surgery May Shorten Hospital Stay

ScienceDaily (June 19, 2010) — The recovery time and cost of brain-tumor
surgery might both be reduced if surgery is performed while patients are
awake during part of the procedure, according to a new study conducted at
The Ohio State University Comprehensive Cancer Center-Arthur G. James
Cancer Hospital and Richard J. Solove Research Institute.
The study, published online June 18 in the Journal of Neurosurgery, examined the outcomes of 39
patients treated for glioma, a type of brain tumor that affects about 20,000 Americans annually. The
doctors wanted to learn if surgeries that used conscious sedation -- in which patients are initially
anesthetized but restored to consciousness during surgery on the brain itself -- had outcomes different
from those using more traditional general anesthesia.
"Our data suggest that patients who received conscious sedation had shorter hospital stays than those
receiving general anesthesia, and that this reduced the cost of treatment," says study leader Dr. E.
Antonio Chiocca, professor and chair of neurological surgery and Dardinger Family Endowed Chair in
Oncological Neurosurgery.
"This finding needs to be validated with a randomized prospective clinical trial, but if it holds true, it would
mean that changing our current way of delivering anesthesia for these patients could allow them to leave
the hospital sooner and save resources."
Neurosurgeons usually reserve conscious sedation for patients with tumors located near the brain's
speech and sensorimotor centers, Chiocca says. The method was originally conceived as early as the
1950s to avoid or minimize the accidental damaging of these centers. Since then, additional studies have
indicated that conscious sedation can result in more complications than procedures using general
anesthesia, while others appear to show the opposite
To investigate the question, Chiocca and his colleagues studied the outcomes of 20 cases that used
conscious sedation during surgery for stage II, III or IV gliomas and compared them with 19 cases that
used general anesthesia.
The investigators evaluated each patient for the number of days they remained in the hospital and for the
cost of four items that directly related to the surgery: the cost of the operating room, of anesthesia, of
neurosurgical intensive care and of the hospital room. Each patient was also evaluated for neurological
complications.
No significant differences were found in the percentage of complications. Regarding the four costs
examined by the investigators, the expense associated with the operating room and anesthesia were the
same in both groups, and both groups spent a similar period in neurosurgical intensive care. Patients
receiving conscious sedation, however, had shorter hospital stays after leaving intensive care than did
patients receiving general anesthesia, for a total of 3.5 days and 4.6 days respectively.
The shorter hospital stay led to an average 36 percent decrease in post-intensive-care direct cost for
cases receiving conscious sedation compared with those receiving general anesthesia.
"Overall," Chiocca says, "our findings suggest that glioma resection under conscious sedation is
associated with shorter hospital stays and reduced inpatient expenses compared with the same surgery
under general anesthesia."
http://www.sciencedaily.com/releases/2010/06/100618171250.htm

Synthetic FlexBone Could Help Speed Bone Transplant Recovery

ScienceDaily (Oct. 25, 2010) — With a failure rate as high as 50 percent,
bone tissue grafts pose a significant obstacle to orthopedic surgeons
attempting to repair complex fractures or large areas of bone loss, such as
those often caused by trauma and cancer. Current synthetic substitutes rarely
possess the bone-like properties needed for successful grafting and are often
difficult for surgeons to manipulate in the operating room. In response to these
challenges, researchers at UMass Medical School have developed an easy-
to-produce, inexpensive, synthetic bone material called FlexBone.
Building upon previous development of a material that combines a key mineral found in bone
(nanocrystalline hydroxyapatite) with a hydrogel similar to that used in contact lenses, Jie Song, PhD,
assistant professor of orthopedics & physical rehabilitation and cell biology, and a team of graduate
students and orthopedic surgeons, along with their collaborators at the University of Michigan, have
created a bone substitute that can be press-fit into a bony lesion.
"Functionally sophisticated synthetic materials don't have to be complicated to manufacture or difficult to
reproduce," said Dr. Song. "Our idea was to create an inexpensive, off-the-shelf product that can be
easily manipulated in the operating room to fill large bone voids and facilitate the tissue repair." Research
published online ahead of print in Tissue Engineering Part A describes the efficacy of the FlexBone as a
synthetic bone substitute in repairing large bone defects in animal models.
In large, complex bone voids caused by trauma or tumor removal, stabilization with traditional metal
plates and other internal and external fixation devices often isn't enough to facilitate healing. In many
cases, surgeons turn to bone tissue grafts to bridge the gap left by the break, transplanting bone from
another donor. Complications from infection, immune response or incomplete union between the
transplanted and host tissue, however, result in almost 50 percent of these procedures failing. Synthetic
substitutes, meanwhile, do not have the necessary bone-like properties to make them an ideal alternative.
David Ayers, MD, the Arthur M. Pappas, MD, Chair in Orthopedics and chair and professor of orthopedics
& physical rehabilitation said, "FlexBone has a bone mineral content approaching that of human bone,
enabling the elastic FlexBone material to be cut and shaped prior to surgery or intraoperatively and then
pressed into a bone gap. When used in conjunction with traditional fixation techniques, the FlexBone
material provides ideal scaffolding for new bone growth."
The density of the FlexBone material also allows surgeons to pre-drill channels in it, allowing for bone
marrow from adjacent bone to migrate and penetrate. This helps to attract progenitor cells that are critical
to new bone formation.
Beyond the benefits of its physical properties, FlexBone has also proved to be an ideal material for
speeding recovery. "What makes FlexBone so ideal for healing large bone gaps is that it absorbs and
retains the proteins associated with the natural healing process from the surrounding tissue once
implanted," said Song. "This helps accelerate healing." Conversely, it can also be loaded with therapeutic
agents, such as protein factors and antibiotics that can facilitate faster healing and fight infection through
localized and controlled delivery over a sustained period of time.
"Because of this combination of factors, our study shows that FlexBone, combined with a protein growth
factor in a dose 100 times less than what currently needed, was able to heal a large, long bone defect
that would not heal on its own in a short period of time," said Song. "This material has enormous potential
to solve a major problem that orthopedic surgeons face when reconstructing large bone deficits in the
skeleton."
"Its ability to deliver growth factors and antibiotics to the patient and the handling characteristics
simplifying the surgical procedure combine to make this material very exciting," said Dr. Ayers.
Song and Ayers would like to next test the safety and efficacy of the material in large animals, which they
hope will pave the way for future clinical trials.
http://www.sciencedaily.com/releases/2010/10/101022123755.htm

Children's Agitation After Surgery May Be Preventable

ScienceDaily (Oct. 10, 2010) — Temporary combativeness after surgery -- a
complication affecting up to half of anesthetized children -- may be
preventable with drugs that decrease epinephrine production, according to a
Medical College of Georgia pediatric anesthesiologist.
"Some children wake up after surgery and begin crying and become combative," said Dr. Ivan Florentino,
associate professor of anesthesiology and perioperative medicine and pediatrics at MCG. "They are often
extremely frightened, disoriented and refuse to be comforted, even after being reunited with their parents.
Some even hallucinate and become so agitated that they have to be restrained."
Those reactions, called emergence delirium, may result from a brain dysfunction that increases the
release of hormones that prompt "fight-or-flight," a sympathetic nervous system reaction. The findings are
being presented at the 50th Honduran National Congress of Anesthesiology Oct. 8-9.
Preschool-aged children and those with behavioral problems and developmental delays are more prone
to emergence delirium because their sympathetic nervous system is often already hyperactive, Florentino
said. "Some types of anesthesia increase the release of the stress hormone norepinephrine in the brain,"
he said.
Animal studies suggest traditional inhaled anesthetics are the most common culprits for emergence
delirium. Newer drugs, such as those that bind to cells that release epinephrine, can reduce the incidence
when given before or with anesthesia.
The disorder can create a challenge for parents and post-anesthesia care providers. Children can
become so agitated that they pull out IVs and surgical drains, which can lead to complications such as
increased bleeding at the surgical site, he said.
"Preventing this as much as possible is a way to improve children's experience with the operating room
and anesthesia," Florentino said. "People used to be simply concerned about whether the patient woke
up from surgery. Now the practice has shifted to focus on a better experience for the patients and their
families."

http://www.sciencedaily.com/releases/2010/10/101008105714.htm