The scavenging of volatile anesthetic agents in the cardiovascular intensive care unit environment: a technical report

Purpose

The use of volatile-based sedation within critical care environments has been limited by difficulties of drug administration and safety concerns over environment pollution and staff exposure in an intensive care unit (ICU) with no scavenging. The aim of this study was to develop a simple scavenging system to be used with the Anesthesia Conserving Device (AnaConDa^®) and to determine whether or not ambient concentrations of residual anesthetic are within current acceptable limits.

Technical features

The scavenging system consists of two Deltasorb^® canisters attached to the ICU ventilator in series. AnaConDa is a miniature vaporizer designed to provide volatile-based sedation within an ICU. The first ten patients recruited into a larger randomized trial assessing outcomes after elective coronary graft bypass surgery were sedated within the cardiac ICU using either isoflurane or sevoflurane. Sedation was guided by the Sedation Agitation Scale, resulting in an end-tidal minimum anesthetic concentration of volatile agent ranging from 0.1-0.3. At one hour post ICU admission, infrared photometric analysis was used to assess environmental contamination at four points along the ventilator circuit and scavenging system and around the patient’s head. All measurements taken within the patient’s room were below 1 part per million, which satisfies criteria for occupational exposure.

Conclusions

This study shows that volatile agents can be administered safely within critical care settings using a simple scavenging system. Our scavenging system used in conjunction with the AnaConDa device reduced the concentration of environmental contamination to a level that is acceptable to Canadian standards and standards in most Western countries and thus conforms to international safety standards. The related clinical trial was registered at www.clinicaltrials.gov (NCT01151254).     

Bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis, seventy eight revisions using bone allografts with or without metal reinforcements

Purpose

The aim of the study was to assess bone graft incorporation after revision hip arthroplasty in patients with rheumatoid arthritis (RA).

Methods

We report an acetabular reconstruction using impacted, morselized, frozen, radiation sterilized bone allografts in 71 patients suffering from RA. There were sixty-six women and five men at a mean age of 57.5 years. Reconstruction was performed in 78 revision total hip arthroplasties (THAs) for aseptic loosening of acetabular component. The mean follow-up was five years and four months. In 38 cases, a revision was done with use of reinforcement devices.

Results

In four revised hips (10 %) without reinforcement implants, resorption of the allografts was noticed. All Mueller rings and 50 % of unscrews cages (Link, Howmedica) were revised because of aseptic loosening and bone graft resorption. In all of 17 hips with the Burch-Schneider cage, no measurable migration or bone allografts resorption occurred. There were no major general complications.

Conclusions

Acetabular reconstruction with use of morselized, frozen, radiation sterilized bone allografts and the Burch-Schneider cage can be highly successful in managing massive deficiency of acetabular bone stock in revision hip arthroplasty in RA patients.     

Measurement of active shoulder proprioception: dedicated system and device

Proprioception is an essential part of shoulder stability and neuromuscular control. The purpose of the study was the development of a precise system of shoulder proprioception assessment in the active mode (Propriometr). For that purpose, devices such as the electronic goniometer and computer software had been designed. A pilot study was carried out on a control group of 27 healthy subjects, the average age being 23.8 (22–29) in order to test the system. The result of the assessment was the finding of the error of active reproduction of the joint position (EARJP). EARJP was assessed for flexion, abduction, external and internal rotation. For every motion, reference positions were used at three different angles. The results showed EARJP to range in 3–6.1°. The proprioception evaluation system (propriometr) allows a precise measurement of active joint position sense. The designed system can be used to assess proprioception in both shoulder injuries and treatment. In addition, all achieved results of normal shoulders may serve as reference to be compared with the results of forthcoming studies.     

Nineteen-year single-center experience in 76 patients with penile cancer treated with high-dose-rate brachytherapy

PURPOSETo report the outcomes for 76 patients with penile cancer treated with high-dose-rate brachytherapy (HDR-BT) at a single institution.METHODSSeventy-six patients with penile cancer treated with HDR-BT in our department between October 1998 and September 2018 were analyzed. Seventy underwent interstitial HDR-BT (fractionation dose range of 3–3.5 Gy given twice a day with an interval of at least six hours between the fractions), and six underwent superficial treatment with mold applicators (fractionation dose range of 4–7 Gy given once or twice a week).RESULTSMedian follow-up was 76 months (7–204 months). In the whole group, 22/76 local failures (28.9%) were observed: 14/76 (18.4%) local recurrences and 8/76 (10.5%) cases of persistent disease. Median time to recurrence was 24 months (9–54 months). Inguinal lymph node metastases were observed in 18/76 cases (23.7%). Distant metastases occurred in 12/76 (15.8%) cases. Patients with local recurrence and persistent disease underwent salvage penectomies, except four who refused surgery and underwent a second course of interstitial HDR-BT. Five- and 10-year cause-specific survival were 85.0% and 77.8%, respectively. Local control at 5 and 10 years was 65.6%. Five- and 10-year penile preservation were 69.5% and 66.9%, respectively. There was no G3 or G4 acute toxicity. One urethral stenosis (1.3%) occurred in a patient with a T3 tumor and was treated successfully with dilatation.CONCLUSIONSHDR-BT provides good local control of penile cancer and is a good option for penis preservation therapy and in our experience achieves a penile preservation rate at 10 years of 66.9%.     

Reliability of measurements performed on two dimensional and three dimensional computed tomography in glenoid assessment for instability

Purpose

The main purpose of this study is to establish which of two methods is more reliable in glenoid assessment for instability in pre-operative planning. Accordingly, we have studied the intra- and inter-observer reliability of glenoid parameters with the use of two-dimensional (2D) and three-dimensional (3D) reconstructed computed tomography (CT) images.

Methods

One hundred glenoids were measured with the use of 2D-CT and 3D-CT (in 3D orientation) by two independent observers (one experienced and one inexperienced). Measurements were repeated after one week for 30 randomly selected glenoids.

Results

The intra-class correlation coefficient (ICC) for inter-observer reliability was significantly greater for 3D-CT (0.811 to 0.915) than for 2D-CT (0.523 to 0.925). All intra-observer reliability values for 3D-CT were near perfect (0.835 to 0.997), while those for 2D-CT were less reliable (0.704 to 0.960). A dependent t-test showed that, for both observers, almost all glenoid parameters (except R and d) differed significantly (p?<?0.05) between 2D and 3D measurement methods.

Conclusions

Therefore, it can be concluded that 3D glenoid reconstructions are more reliable for glenoid bone loss assessment than 2D-CT. The results suggest that quantifying a glenoid defect with the use of 2D image only—even if performed by an experienced orthopaedic surgeon—is prone to errors. Differences in measurements between and within observers can be explained by plane setting and identifying glenoid rim in 2D-CT. Accordingly, we recommend that glenoid measurements should be performed in 3D orientation using 3D reconstruction obtained from CT images for pre-operative assessments, which are crucial for surgical planning.

     

Prospective validation study of Cernea classification for predicting EMG alterations of the external branch of the superior laryngeal nerve

Purposes

Cernea classification is applied to describe the external branch of the superior laryngeal nerve (EBSLN). Using intraoperative neural monitoring we evaluated whether or not this classification is useful for predicting which EBSLN subtype has an increased risk of injury.

Methods

An analysis of 400 EBSLN. The identification of EBSLN was achieved with both cricothyroid muscle twitch and the glottis evoked electromyography response. We defined S1 initial EBSLN stimulation at identification and S2 final nerve stimulation achieved in the most cranial aspect of the nerve exposed above the area of surgical dissection after superior artery ligation.

Results

The mean S1 amplitude acquired was 259+/67 (180–421), 321 +/79 (192–391), 371 +/38 (200–551) μV, respectively, for type 1, 2A, 2B (p = 0.08). The S1 and S2 amplitudes were similar in type 1 (p = 0.3). The S1 and S2 determinations changed significantly in type 2A and 2B (p = 0.04 and 0.03). EBSLN which demonstrated a >25 % decreased amplitude in S2 increased significantly from Type 1 (4.9 %) to Type 2A (11.2 %) and 2B (18 %) (p = 0.01). None of type 1, 2.8 % type 2A and 3 % type 2B showed a loss of EBSLN conductivity. The latency determinations did not vary significantly for any parameter compared.

Conclusions

The Cernea classification was, therefore, found to predict the risk of EBSLN stress. We identified amplitude differences between S1 and S2 determinations in type 2A and 2B, thus confirming that surgical dissection in these subtypes is, therefore, extremely difficult to perform.

     

The analysis of densitometry image of bone tissue based on computer simulation of X-ray radiation propagation through plate model

In this work, we have presented an attempt at the computer modelling of the attenuation effect of X-ray radiation which occurs in the densitometry test. The purpose of the modelling is to examine the extent to which the parameters of the plate model of bone tissue affect bone mineral density (BMD) parameter. In the modelling the fundamental functions realised by a densitometry device have been taken into consideration. Certain necessary assumptions simplifying the computation of the complex physical processes that occur during the transition of X-ray radiation through an object have been made. In order to compute the image produced by interaction of radiation the attenuation law is applied. The modelling of an object consists in defining its dimensions and its material characteristics. In the presented simulation the material characteristics of the object are limited to its attenuation coefficient. A different value of the coefficient can be defined for each voxel. The result image is produced by the calculation of partial attenuation in the individual voxels. The levels of grey in the image represent the value of the computed radiation intensity which is recorded in the "detector" after transition through the object. The simulation has been performed for the plate model representing trabecular bone tissue with 0.1mm porosity compartments. The results of the simulation of the plate model are presented. It can be observed that for certain modelled porosity compartments the size, structure and spatial arrangement are not properly recorded in the two-dimensional "detector". The recorded simulation results may be found useful for explaining difference that has been noticed between the BMD obtained from the densitometry test and the bone susceptibility to fracture.     

Optimisation of Shrinkage and Strength on Thick Plate Part Using Recycled LDPE Materials

Achieving good quality of products from plastic injection moulding processes is very challenging, since the process comprises many affecting parameters. Common defects such as warpage are hard to avoid, and the defective parts will eventually go to waste, leading to unnecessary costs to the manufacturer. The use of recycled material from postindustrial waste has been studied by a few researchers. However, the application of an optimisation method by which to optimise processing parameters to mould parts using recycled materials remains lacking. In this study, Response Surface Methodology (RSM) and Particle Swarm Optimisation (PSO) methods were conducted on thick plate parts moulded using virgin and recycled low-density polyethylene (LDPE) materials (100:0, 70:30, 60:40 and 50:50; virgin to recycle material ratios) to find the optimal input parameters for each of the material ratios. Shrinkage in the x and y directions increased in correlation with the recycled ratio, compared to virgin material. Meanwhile, the tensile strength of the thick plate part continued to decrease when the recycled ratio increased. R30 (70:30) had the optimum shrinkage in the x direction with respect to R0 (100:0) material where the shrinkage increased by 24.49% (RSM) and 33.20% (PSO). On the other hand, the shrinkage in the y direction for R30 material increased by 4.48% (RSM) and decreased by 2.67% (PSO), while the tensile strength of R30 (70:30) material decreased by 0.51% (RSM) and 2.68% (PSO) as compared to R0 (100:0) material. Validation tests indicated that the optimal setting of processing parameter suggested by PSO and RSM for R0 (100:0), R30 (70:30), R40 (60:40) and R50 (50:50) was less than 10%.     

Research on Reduction of Selected Iron-Bearing Waste Materials

During the steel production process, nearly twice as many input materials are used as compared to finished products. This creates a large amount of post-production waste, including slag, dust, and sludge. New iron production technologies enable the reuse and recycling of metallurgical waste. This paper presents an investigation on the reduction of selected iron-bearing waste materials in a laboratory rotary furnace. Iron-bearing waste materials in the form of dust, scale, and sludge were obtained from several Polish metallurgical plants as research material. A chemical analysis made it possible to select samples with sufficiently high iron content for testing. The assumed iron content limit in waste materials was 40 wt.% Fe. A sieve analysis of the samples used in the subsequent stages of the research was also performed. The tests carried out with the use of a CO as a reducer, at a temperature of 1000 °C, allowed to obtain high levels of metallization of the samples for scale 91.6%, dust 66.9%, and sludge 97.3%. These results indicate that in the case of sludge and scale, the degree of metallization meets the requirements for charge materials used in both blast furnace (BF) and electric arc furnace (EAF) steelmaking processes, while in the case of reduced dust, this material can be used as enriched charge in the blast furnace process. Reduction studies were also carried out using a gas mixture of CO and H₂ (50 vol.% CO + 50 vol.% H₂). The introduction of hydrogen as a reducing agent in reduction processes meets the urgent need of reducing CO₂ emissions. The obtained results confirm the great importance and influence of the selection of the right amount of reducer on the achievement of a high degree of metallization and that these materials can be a valuable source of metallic charge for blast furnace and steelmaking processes. At an earlier stage of the established research program, experiments of the iron oxides reduction from iron-bearing waste materials in a stationary layer in a Tammann furnace were also conducted.