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PubMed2004

Verification of the change blindness phenomenon while managing critical events on a combat information display.

Change blindness occurs when humans are unable to detect significant changes in objects and scenes after their attention is momentarily diverted. Because change blindness is relevant in many applied settings, the current study investigated the phenomenon in the context of tasks performed by naval command and control system personnel. Operators of such systems are often heavily loaded with concurrent visual search, situation assessment, voice communications, and control-display manipulation tasks at large, physically dispersed tactical situation displays. As the operators' attention shifts from one display to another, it creates an opportunity for changes to occur on unattended screens with potentially negative consequences. Our results show that on a display containing 8 objects of interest, considerable change blindness was demonstrated in that participants required 2 or more selections to correctly identify a changed object on nearly 1/3 of the test trials. Further, operator performance on 15% of the trials was equivalent to randomly guessing with replacement after making 3 incorrect selections. This research underscores the need for developing effective countermeasures to the change blindness phenomenon. Actual or potential uses of this research include interface design of computer workstations for military, nuclear power industry, air traffic control, crisis response center, and hospital emergency room applications.

Attention↗
PubMed2006

A guide to the positioning of brainstem implants using intraoperative electrical auditory brainstem responses.

The number of electrodes that elicit usable auditory sensations with an auditory brainstem implant varies significantly between subjects. For those with only very few, movement of the array by only a few millimetres could make a significant improvement to their outcome, but yet the point at which this is normally discovered is during activation, weeks after the surgery. The number of the electrodes that are able to stimulate the auditory system can be more reliably assured by the use of electrophysiologic guidance in the placement of the implanted electrode array. This chapter describes a procedure for the use of electrophysiology to aid placement in the operating room. The procedure involves stimulating the individual electrodes and recording electrical auditory brainstem responses (EABR) as an aid in positioning the electrode array. This procedure makes it possible to position the majority of electrodes over the surface of the cochlear nucleus thus minimising stimulation of other cranial nerves, which might result in undesirable side effects. Correctly positioned electrodes elicit an EABR response with between 1 and 4 peaks with average latencies approximately (in ms) 0.7 (0.4-0.9), 1.5 (1.2-1.9), 2.7 (2.1-3.4) and 3.7 (3.4-4.0). These waves likely correspond to waves III-VI of the traditional ABR (and wave II if an excitable stump of the auditory nerve is present). No further peaks within a 10-ms window should be seen nor should activation of other cranial nerves occur. The response to stimulation of bipolar combinations of electrodes covering lateral, medial and distal positions provide information about the insertion depth. In individuals with a large lateral recess, measuring other combinations may assist in sideways and rotational orientation of the electrode array.

Auditory Brain Stem Implants↗
PubMedDate not supplied

[Classification of laser irradiation and safety measures].

The use of lasers in medicine and especially surgery is rapidly expanding in many disciplines from clinical laboratory to the office practice and operating room. It is essential that users of this powerful tool have knowledge of their potential hazards and the measures to protect patients and personnel against injuries or undesired effects. Below, we have included information about the way lasers are classified; the development of protective standards; the current status of protection standards that apply to lasers, especially those used in medicine/surgery; the specific kinds of hazards associated with medical/surgical applications; and the measures by which hazards have been controlled. Since laser technology is still a young field, it is likely that problems unknown at present will occur and methodologies for controlling hazards will evolve. The American National Standards Committee produced the first consensus standard Z136.1 in 1973. The Standard was revised in 1976 to accommodate differences in biological effects for different wavelengths in the visible spectrum. The ANSI Standard has been revised again in 1980, and currently (1984) there are two additional standards in preparation, Z136.2 and 136.3, which treat the safe use of light-emitting diodes and the safe use of lasers in the health care environment, respectively. Most surgical and medical lasers are Class III or IV. Some lasers have a Class IV therapy level beam plus a Class I or II alignment beam. When using lasers, it is possible to generate incandescence or fluorescence in an irradiated object. This can occur even with protective eyewear, because the correlated radiations are usually of a different wavelength. Generally, this should not be a problem when beams are directed at biological material. However, hazard could be caused by lasers designed to produce fluorescence. Control of correlative radiation in a laser system is required in the federal regulations. Hazards of lasers may be grouped as those to the eye, skin and associated hazards, fire, x-rays, electrical, fumes, toxic materials, etc. Effects on tissue are governed by the following factors:--the energy or power density of the beam;--the absorption in tissue at the laser wavelength;--the time the beam is held at a given area.;--the protective effects of heat removal by thermal conduction and by circulation. Eye hazards include thermal burns or acoustical disruption (shock waves) from high-powered or high-energy beams in the visible and near infrared wavelengths. Direct beam exposure or specular or diffuse reflaction from these very high-power lasers can also cause injuries to other parts of the retina. For example, beams can directly penetrate through the sclera and cause retinal injury. Near ultraviolet (less than 400 hm) and far infrared (.3000 hm including CO2 lasers) can cause moderate to severe corneal burns. Far ultraviolet (200-315 nm), mid infrared (1400-3000 nanometers) can cause welders' flash or snow blindness and chronic exposure could cause cataract, and exposure to ultraviolet rays may be carcinogenic. For CO2 lasers, the far infrared radiation is attenuated by plastic goggles, or by glasses, or quartz. Other eyewear with special filters is used for different lasers. The whole personnel who may be exposed to direct beams, specular reflections, and many times diffuse reflections must wear protective eyewear. In all cases the surgeon and others viewing the procedure through the endoscope need glasses or suitable protective lenses installed in the endoscope. Persons who are not viewing the beam may not need to wear protective glasses with the same level of optical density. Glasses may be selected to provide protection for lasers operating in the visible wavelength to the point where the normal aversion response could protect the individual.

Eye Injuries↗
PubMedDate not supplied

Hospital disaster management simulation system.

INTRODUCTION: Theoretically, simulation of disastrous situations has many advantages in that it prepares hospital staff to cope with the real scenario. It is a challenge to create the database and custom-making a friendly software while still keeping it representative of a real situation. This article describes experience with developing and implementing the use of simulation software as a drilling technique used by Israeli hospitals. METHODS: The application was developed using SIMAN/ARENA software. Knowledge and a database for a basic multi-casualty incident (MCI) were developed in the pilot phase. It contains detailed descriptions of the casualties which can be compared with the real hospital capabilities (staff and infrastructure). A consensus committee decided the crucial model issues and established the thresholds for quality performance indicators. Interfaces to the each hospital's information management systems (IMS) were developed and the various output documents of each exercised step were updated. Before drilling, the hospital managerial staff received notice and had to prepare the data on the anticipated resources required. The simulation staff, as well as representatives from the hospitals, then conducted the limited scale drill (LSD). RESULTS: During the LSD, the trained hospital staff were given two types of input: 1) copies of reports on patients entering the stations and had to enter them into its IMS; and 2) timed telephone notifications of problems in each station. During a 90 minutes drill, there were about 15 timely reports and 20 telephone problems. The evaluation of the LSD were based mainly on the following: 1) observing the staff solving various problems; 2) constructing a detailed picture of the situation; and 3) measuring the effectiveness of the hospital IMS. The drill ended with a discussion. Lessons are drawn from each drill in order to find methods for optimizing the conduct of the hospital. An animation tool proved to be useful in describing bottle necks in emergency room, diagnostic department, and operating rooms. CONCLUSIONS: Simulation techniques and a preparatory limited scale drill have advantages in evaluating and improving preparedness of hospitals for managing an MCI before a full scale drill is carried out.

Computer Simulation↗
PubMed1979

Health problems of anaesthetists and their families in the West Midlands.

A survey of all anaesthetists in the West Midlands region--that is, 10% of all the anaesthetists in England and Wales--showed that one in 10 of their children had been referred to a consultant because of a congenital or nonacquired anomaly. Abortions among anaesthetists' families were also common but more so when the mother was an anaesthetist. The anomalies were concentrated particularly in the central nervous system and musculoskeletal system, and girls were worst affected. The mean birth weights were below normal, more so when the mothers were anaesthetists. Girls with anomalies were particularly underweight. Other effects observed were unexpected infertility, cancer both in the adults and in the children, and, possibly, impaired intellectual development in the children. Many anaesthetising areas were inadequately ventilated, and scavenging devices despite their inefficiency are recommended as a stopgap measure. The results of the study closely resemble those of other studies with similar high response rates to requests for information.

Abnormalities, Drug-Induced↗
PubMed2006

Update on bispectral index monitoring.

Since 1997, bispectral index (BIS; Aspect Medical Systems Inc., Natick, MA) has been in clinical practice and a wealth of experimental research has accumulated on its use. Originally, the device was approved only for monitoring hypnosis and has now received an indication for reducing the incidence of intraoperative awareness during anesthesia. Numerous studies have documented the ability of BIS to reduce intermediate outcomes such as hypnotic drug administration, extubation time, postoperative nausea and shortened recovery room discharge. Two recent large-scale outcome studies using BIS (one randomized controlled trial and one prospective, nonrandomized historical cohort study) identified an approximately 80% reduction in the incidence of recall after anesthesia. BIS provides clinicians with unique information that can be used to tailor hypnotic drug doses to individual patient requirements. BIS does not predict movement or hemodynamic response to stimulation, nor will it predict the exact moment consciousness returns. This review will also discuss other BIS applications including use in pediatrics, intensive care and for procedural sedation. Some limitations exist to the use of BIS and it is not useful for some individual hypnotic agents (ketamine, dexmedetomidine, nitrous oxide, xenon, opioids). BIS technology is moving out of the operating room and into diverse environments where conscious and deep sedation are provided. Anesthesiologists need to be actively involved in promoting patient safety and helping transition this technology into broader use.

Adult↗
PubMed1993

Non-invasive magnetocardiographic localization of ventricular pre-excitation in the Wolff-Parkinson-White syndrome using a realistic torso model.

This study was performed to evaluate the accuracy of magnetocardiography in non-invasive localization of the ventricular pre-excitation site in patients suffering from the Wolff-Parkinson-White (WPW) syndrome. Twelve WPW patients were studied, in whom the pre-excitation caused serious supraventricular arrhythmias refractory to drug therapy. Magnetocardiographic measurements were performed in a magnetically shielded room, and non-invasive localization was computed from preprocessed magnetic signals using a current dipole source in a realistically shaped digital torso. All patients underwent intra-operative multicatheter mapping and subsequent dissection of the accessory atrioventricular connection. The intra-operative localization results were marked on magnetic resonance images of the heart, where magnetocardiographic results were also superimposed to allow comparison. The average of the three-dimensional differences between the magnetocardiographic and the invasive results was 2.1 +/- 0.9 cm. In all cases, the computed localization result was in the same or adjacent anatomical region as the intra-operative result. The present results show that the magnetocardiographic method using a realistic torso model is capable of localizing pre-excitation sites with sufficient accuracy to provide extra information so that non-pharmacological therapeutic interventions can be applied.

Adult↗
PubMedDate not supplied

Hemodynamic and thermal responses to head and neck cooling in men and women.

Personal cooling systems are used to alleviate symptoms of multiple sclerosis and to prevent increased core temperature during daily activities. The objective of this study was to determine the operating characteristics and the physiologic changes produced by short term use of one commercially available thermal control system. A Life Support Systems, Inc. Mark VII portable cooling system and a liquid cooling helmet were used to cool the head and neck regions of 12 female and 12 male subjects (25-55 yr) in this study. The healthy subjects, seated in an upright position at normal room temperature (approximately 21 degrees C), were tested for 30 min with the liquid cooling garment operated at its maximum cooling capacity. Electrocardiograms and scalp and intracranial blood flows were recorded periodically during each test sequence. Scalp, right and left ear, and oral temperatures and cooling system parameters were logged every 5 min. Scalp, right and left ear canal, and oral temperatures were all significantly (P <0.05) reduced by 30 min of head and neck cooling. Oral temperatures decreased approximately 0.2-0.6 degrees C after 30 min and continued to decrease further (approximately 0.1-0.2 degrees C) for a period of approximately 10 min after removal of the cooling helmet. Intracranial blood flow decreased significantly (P < 0.05) during the first 10 min of the cooling period. Both right and left ear temperatures in the women were significantly lower than those of the men during the cooling period. These data indicate that head and neck cooling may be used to reduce core temperature to that needed for symptomatic relief of both male and female multiple sclerosis patients. This study quantifies the operating characteristics of one liquid cooling garment as an example of the information needed to compare the efficiency of other garments operated under different test conditions.

Adult↗
PubMed2000

The legal implications of healthcare communications: what every pain physician needs to know.

Accurate and sensitive communication of health care information is essential to effective patient management in the pain clinic, operating room, other health care settings. However, information relating to the health care status of a patient is sensitive and may be embarrassing or damaging if it falls into the wrong hands. Ethical cannons of medicine and statutory provisions have emphasized the obligation of the physician to safeguard patient confidences. However, threats to the confidentiality of medical information abound and are even more significant in our age of instantaneous communication characterized by the growing use of email, facsimile, and the Internet. This article outlines legal issues relating to communication in three key areas of health care law: confidentiality/breach of privacy, informed consent, and defamation. The major principles of the law in these areas are discussed and case studies are used to illustrate key points and give simple preventive strategies to help steer the delicate balance between sharing important healthcare information and protecting sensitive patient information.

Communication↗
PubMed1997

Clinical process cost analysis.

BACKGROUND: New systems of reimbursement are exerting enormous pressure on clinicians and hospitals to reduce costs. Using cheaper supplies or reducing the length of stay may be a satisfactory short-term solution, but the best strategy for long-term success is radical reduction of costs by reengineering the processes of care. However, few clinicians or institutions know the actual costs of medical care; nor do they understand, in detail, the activities involved in the delivery of care. Finally, there is no accepted method for linking the two. METHODS: Clinical process cost analysis begins with the construction of a detailed flow diagram incorporating each activity in the process of care. The cost of each activity is then calculated, and the two are linked. This technique was applied to Diagnosis Related Group 75 to analyze the real costs of the operative treatment of lung cancer at one institution. RESULTS: Total costs varied between $6,400 and $7,700. The major driver of costs was personnel time, which accounted for 55% of the total. Forty percent of the total cost was incurred in the operating room. The cost of care decreased progressively during hospitalization. CONCLUSIONS: Clinical process cost analysis provides detailed information about the costs and processes of care. The insights thus obtained may be used to reduce costs by reengineering the process.

Cost Control↗
PubMed2006

Application of LIBS to the in-line process control of liquid high-alloy steel under pressure.

A process optimization and control system called VAI-CON Chem has been developed that uses laser-induced breakdown spectroscopy (LIBS) to quasi-continuously chemically analyze liquid high-alloy steel under pressure. The beam from a Nd:YAG laser, located on safe ground and operating at its fundamental wavelength, is guided by a mirror system to a process tuyere below bath level. Passing through the approximately 1.5 m long tuyere, the beam is then focused onto the steel bath. Light emitted from the induced plasma passes back through the tuyere, which is coupled to a fiber optic cable that carries the information over a distance of approximately 10 m back to an Echelle spectrometer located beside the laser. Calibrations were performed using the complete system, located in a laboratory, during system testing. An induction furnace was used to simulate the AOD converter, wherein the samples were molten and superheated to a temperature of approximately 1600 degrees C and kept at a pressure of approximately 1.7 bar under an argon atmosphere. Twelve different high alloyed reference samples taken from normal AOD production with Fe concentrations of >48 wt.% and non-Fe element concentrations of up to 25 wt.% were available for calibration. The mean residual deviations (defined as the square root of the variance of the concentration ratios determined by LIBS and the reference element concentration ratios) obtained were close to those reported for other comparable high-alloy samples that were investigated at room temperature under normal atmospheric pressure.

Journal Article↗
PubMed1976

Advances in animal care technology at the National Center for Toxicological Research.

The research purpose of the NCTR as it relates to animal care emphasizes the improvement of protocols for safety assessments, the study of irreversible lesions, and the use of valid animal models. The development, building, and operation of the "A" Barrier were described. The "A" Barrier is a complex of equipment, instrumentation, and rooms with controlled entry designed to prevent introduction of microoranisms or environmental factors into the SPF animal colonies. Support facilities such as computer controls and pathology were also described. The first experimental compound being tested is 2-acetylaminofluorene (2-AAF) which will be administered to a total of 25,000 mice in some 72 different treatment groups at 7 dose levels. The desired end-product of the center is to produce a series of tests which can be done quickly, efficiently, and economically and allow for a realistic estimate of risk to man of suspected toxic chemicals.

Animal Feed↗
PubMed2001

Effects of chronic exposure to anaesthetic gases on some immune parameters.

A cross-sectional survey was carried out to evaluate the relation between occupational exposure to low levels of anaesthetic gases (nitrous oxide and isoflurane) and immune parameters. Fifty-one anaesthetists were recruited among different Services of Anaesthesiology and Reanimation. The control group consisted of non-exposed physicians, similar for gender, age, and job grade. Total number of lymphocytes, lymphocyte subpopulations and the natural killer (NK) cytotoxic activity were measured. Information on personal and professional characteristics and on short- and long-term exposure was collected. Percentages of T cells (CD3) decreased significantly in anaesthetists compared to controls, whereas numbers of NK cells (CD16+ CD3-) increased. After correction for confounders, short-term (last 2 weeks) exposure was associated with a decrease in percentages of total T and T helper (CD4) cells. Furthermore, T helper percentages were significantly reduced with increasing individual exposure score evaluated on the basis of working days and levels of anaesthetic gases in operating rooms. A significant X-ray-associated increase of numbers and percentages of NK cells was lastly observed. Despite limited present exposure to anaesthetic gases, a specific derangement in lymphocyte subpopulations, with T lymphocytes more affected than B, has been observed.

Adult↗
PubMed1999

Knowledge optimization theory and application to point-of-care testing.

Point-of-care testing is defined as testing at or near the site of patient care wherever that medical care is needed. The number and types of tests available at the point of care are increasing dramatically. Point-of-care testing provides test results to the clinical team immediately, usually within a therapeutic turnaround time of five minutes. Immediacy of data is a primary benefit, but we must evaluate when, why, and where point-of-care testing should be used because in most cases this new modality is more expensive than conventional testing in clinical laboratories. Knowledge optimization integrates key components of testing, patient focusing, performance, and test clusters, in concert with synthesis of temporal and diagnostic-therapeutic process information that the physician can assimilate quickly and act on to improve patient outcomes. We identify through literature searches, meta-analysis, and documented outcomes results, the optimal applications of point-of-care testing in critical care and other medical settings. The basis for optimality is improved medical and/or economic outcomes. Results show that point-of-care testing is strongly justified for emergency resuscitations under any circumstances, in critical care, such as the operating room and intensive care unit, and in disease management. Long-range implications are: (1) the point-of-care testing trend will accelerate; (2) viable optimization tools include integrative strategies, clinical algorithms, care paths, and performance maps; (3) attention should be focused on rapid communication and understanding of critical results; and (4) enhanced human interfaces are crucial for efficient medical decision making and efficacious patient therapy.

Artificial Intelligence↗
PubMed2006

The role of computed tomography in endoscopic sinus surgery: a review of 10 years' practice.

CT scans from 100 patients undergoing endoscopic sinus surgery (ESS) were primarily re-examined in order to assess the quality of the radiological examinations and the information it could provide years later. The material comprised the cases of patients who had undergone ESS by one surgeon (AD) in the 1990s. The indications for surgery were acute recurrent or chronic sinus infections, polyposis of the nasal and paranasal cavities, mucoceles and sinogenic headache. All examinations were described using a scheme modified according to Stoney et al., evaluating the opacity/mucosal thickening, drainage/pathways, the lateral nasal walls, septum and other bony walls. This study has been re-evaluated and an additional group of 20 patients consecutively operated on in 2002/2003 has been added. The initial radiological examinations often proved incomplete, with insufficient descriptions of either the drainage/pathways, the lateral nasal wall or the septum and bony walls, which all are structures of great value to evaluate preoperatively for the endoscopic surgeon. The operative findings correlated well with the CT if taken between 4-6 weeks before the operation. The structural pathology correlated with preoperative endoscopic findings independently of the time lapse between the scans taken and the date of surgery. The development and the gradual implementation of the picture archiving and communication system (PACS) certainly represent huge advantages in radiological assessment. The need for CT scans to be available in the operating room calls for specific computer installations to make PACS readily available peroperatively and in an easily workable way for the surgeon.

Adult↗
PubMed2004

[Significance of transesophageal echocardiography in daily clinical practice].

Transesophageal echocardiography (TEE) has opened a new window to the heart. Its success rate is impressive. In less than 2 decades it has become an integral part of pediatric and adult cardiology as well as cardiac surgery and anesthesiology. The range of indications has broadened since its introduction almost 20 years ago. The combination of unique morphological and hemodynamic information of exceptional diagnostic quality and the possibility to use this diagnostic method as a bedside tool in the intensive care unit and the operating room guarantee that this diagnostic modality will maintain its firm place in the diagnostic armamentarium of cardiologists and anesthesiologists, besides novel and emerging imaging modalities such as cardiac magnetic resonance imaging (MRI) and multislice computed tomography (MSCT). Technical improvements in transducer technology and the development of miniaturized matrix transducers may, in the near future, allow real-time three-dimensional viewing of the heart even from the esophagus. It is anticipated that this will further increase the diagnostic potential of the technique and its importance for guiding of therapeutic procedures.

Critical Care↗
PubMed1995

Cost analysis of point-of-care laboratory testing in a community hospital.

Point-of-care testing (POCT) is a means of providing patient services more rapidly. Most evaluations of bedside laboratory testing devices have emphasized analytical performance in tertiary care settings. In contrast, the authors compare the operating cost of POCT for glucose and an electrolyte/glucose/blood urea nitrogen chemistry panel with the cost of central laboratory stat testing in a 204-bed community hospital. In scenarios studied, POCT costs exceed central laboratory stat costs from 1.1 to 4.6 times. The more POCT is used, the greater the excess costs compared to the central laboratory. Cost analysis demonstrates that the investment in acquiring automated transport and data management systems for the authors' hospital was far less expensive than POCT for both an individual stat test and on an annual cost basis. The authors urge fiscal caution before indiscriminately implementing POCT.

Blood Chemical Analysis↗
PubMed1998

Comparison of cost and clinical outcome between transcatheter coil occlusion and surgical closure of isolated patent ductus arteriosus.

OBJECTIVE: The objective of this study was to compare the cost (measured as resource utilization by the institution) and clinical effectiveness of transcatheter coil occlusion and surgical patent ductus arteriosus (PDA) closure. Similar comparisons have been made previously with other devices no longer in use in the United States. No such comparison has been made for coil occlusion, which has been performed increasingly since 1992. METHODS: All patients who underwent either coil or surgical closure of uncomplicated PDA at our institution between August 1993 and June 1996 were retrospectively identified. Patients were included in the study if they were eligible for either closure technique. Thus, they had a restrictive PDA (not associated with pulmonary hypertension) and no overt evidence of congestive heart failure. Patients were excluded if they had other significant cardiac or noncardiac problems. Total procedural and recovery costs (including labor, material, equipment, and overhead) incurred by the provider were determined using a cost accounting system called Transition Systems, Inc. To define further how costs differed for the two techniques, total costs were subdivided into the categories of professional, technical, inpatient hospital stay, postprocedure testing, and supplies and other miscellaneous costs. PDA closure rates and associated complications also were compared. Follow-up information was sought from outpatient visits to our institution or by contacting the referring physicians. RESULTS: A total of 39 patients were identified, 3 of whom were excluded because of coexisting medical problems. The study group consisted of 36 patients; 24 underwent PDA coil occlusion and 12 surgical closure. Mean age and weight were 8.8 years and 28.5 kg for the coil patients, and 7.3 years and 32.8 kg for the surgical patients. Median procedural duration was 150 minutes for the coil group and 165 minutes for the surgical group. The total cost to the institution of coil occlusion was significantly lower than that of surgical closure ($5273 vs $8509). The largest difference lay in the cost of hospital stay ($398 vs $2566) and in the professional costs ($1506 vs $2782). Technical costs were similar ($2156 for coil, $2151 for surgery), although use of the catheterization laboratory per unit of time was more expensive than use of the operating room ($800 vs $400 per hour). Additional technical costs of the surgical procedure related to general anesthesia and postoperative care made up the difference. No patient in either group had a residual PDA murmur at hospital discharge or thereafter. Follow-up echocardiography was performed in all coil occlusion patients, and tiny residual leaks were detected in 17%. Only 42% of the surgical patients had postoperative echocardiography; none had residual leaks. There were no deaths or major complications in either group. CONCLUSIONS: Transcatheter coil occlusion is as effective and less costly than surgical closure if silent residual leaks are not considered clinically significant. This information may be used increasingly in patient care decisions in the current era of managed medical care.

Adolescent↗