Child's heart printed in 3D to aid complex surgery

Louisville Kentucky cardiothoracic surgeon Erle Austin has performed successful heart repair surgery on a 14 month old infant named Roland Lian Cung Bawi, heart surgery on such a young patient is not unheard of, of course, what's new is that Austin was able to map out his surgical approach using a nearly exact model of the patients heart, it had been printed on a 3D printer.

Erle Austin

Young Roland had been born with four congenital heart defects—doctors had known since before he was born that his heart had problems.

Fixing them all would prove to be a challenge. When it came time to plan the surgery, Austin consulted with other surgeons and found each of them had different ideas on the best way to fix the heart.

The ideal approach would involve the least amount of cutting and suturing—but that can be hard to plan using only conventional scanning techniques.

Looking for more precision, Austin turned to the engineering school at the University of Louisville, they'd been researching different kinds of 3D printing technology.

Researchers at the University worked with radiologists at Kosair Children's Hospital to create a means for converting data from a CT scan of Roland's heart to data that could be used with a 3D printer.

The two seemed a perfect match as CT scanning uses the same basic idea as 3D printing, it takes pictures of slices and puts them together on a computer screen to form a whole, and 3D printing is achieved by laying down one layer or "slice" of material at a time.

The 3D printing team used a MakerBot Replicator 2X, to print the heart (in three pieces) at twice its normal size, they also used a flexible type of plastic filament known as "Ninja Flex" instead of ABS.

Ninja Flex allowed the surgeon to bend the finished heart in ways that resembled a real human heart.

Printing the heart took approximately 20 hours at a cost of roughly $600.

Austin told local news reporters that the printed heart let him plan the surgery in ways he'd never experienced before, it allowed for a single surgery (this past February 10) and greatly reduced cutting and suturing, which ultimately led to a much quicker recovery for Roland, who by all accounts is now doing just fine.

Consciousness Signature: Awareness Warnings during surgery

Anaesthesia wearing off mid-operation is not just the stuff of nightmares – it occurs in around 0.2 per cent of surgeries globally. Keeping tabs on the brain during surgery could stop this.

Indirect signs of consciousness such as changes in heart rate, blood pressure and muscle tone can be tracked during surgery but more reliable indicators are not currently available.

"It's slightly frightening that millions are given anaesthesia every year and the anaesthetist has no way of knowing with certainty that the patient is unconscious," says Tony Absalom at the University of Groningen in the Netherlands.

To look for a more concrete signature that could be monitored during surgery, Emery Brown at the Massachusetts Institute of Technology and his team attached an EEG cap with 64 electrodes to the heads of 10 adults.

They used this to measure changes in brain activity across multiple brain regions as unconsciousness was induced using a general anaesthetic.

As the volunteers lost and regained consciousness they were asked to press a button whenever they heard a click or a spoken word, allowing brain activity to be matched to different stages of wakefulness.

By constructing a montage of the activity from different parts of the brain, the team identified recognisable patterns that corresponded to different levels of consciousness, allowing them to tell when someone was waking up.

Mysterious sleep
EEG monitoring during surgery is carried out in about 2 per cent of hospitals in the UK, but only three or four electrodes are used, in a strip across the forehead.

This looks at just one brain region, however, and so can only give you a probability of unconsciousness, not a conclusive answer, says Absalom.

"You don't want something that says a patient is probably asleep. You want to know 'Are they or aren't they?'"

Using more electrodes, as Brown has done, should shore this up. Although applying more electrodes means the patient's head must be shaved and a conductive gel applied.

"The mechanisms underlying anaesthesia remain a mystery," says Ram Adapa at the University of Cambridge. But these results support the idea that anaesthesia affects the communication and synchronisation between brain regions, he says. "It is yet another piece of the jigsaw puzzle."

However, Adapa notes that it may be a while before the technique can be used in a clinical setting. EEG measurements are very sensitive to mechanical and electrical interference, he says, "and the operating room environment is unfortunately burdened by both."

Journal reference: 
Electroencephalogram signatures of loss and recovery of consciousness from propofol PNAS, 10.1073/pnas.1221180110

Arsenal DARPA Foam: Saving Wounded Soldiers

Researchers working on a foam designed to limit internal bleeding of soldiers injured on the battlefield have received $15.5m (£9.6m) from the US military to continue their work.

The foam is formed by two liquids, injected into the body, which mix, expand and harden to create an internal dressing.

Arsenal Medical's product is funded by the Pentagon's Darpa research unit.

One UK surgeon said it could help those far away from a medical facility but the technology is still in early pre-clinical stages. It has already been tested on pigs but not humans.

The firm hopes that the polyurethane polymer foam will help control internal bleeding for at least an hour, increasing the survival chances of troops wounded on the battlefield.

Polyurethane foams are already widely used inside the metal and plastic walls of refrigerators or for thermal insulation.

Brian Holloway - DARPA

Once a wounded soldier is transferred to receive proper medical attention, the foam can be easily removed in minutes in a solid block.

According to the pre-clinical data presented at the 2012 annual meeting of the American Association for the Surgery of Trauma (AAST) in Kauai, Hawaii, the foam raised survival rates for liver injuries after three hours from 8% to 72%, and reduced blood loss sixfold.

"If testing bears out, the foam technology could affect up to 50% of potentially survivable battlefield wounds," said Brian Holloway of Darpa.

Dangerous haemorrhage
Abdominal injuries were especially dangerous, said Dr Michael Walsh, a surgeon at the Royal London Hospital, because traditional methods of stopping blood loss such as compression pads or tourniquets could not be applied.

"Currently for internal bleeding in the abdomen and chest there is nothing that is done pre-hospital to stop the bleeding," he said.

"The best policy currently is for the pre-hospital team to recognise the potential for internal bleeding and to transfer the patient to one of our now designated major trauma centres for rapid assessment and early surgery to stop the bleeding."

He said that the foam technology could be useful to control haemorrhages when a patient was far from a medical facility, or in the case of multiple injuries with competing priorities for treatment.

For example, a severe head injury could be treated once major internal bleeding in the abdomen had been stabilised but, he added, that more research was needed to "demonstrate the safety and efficacy of this product over and above current standards of care for internal bleeding".

Staff would also have to be trained to administer it properly but shows great promise.

The device still needs to be approved by the US Food and Drug Administration.

Diabetes, Weight Loss Surgery Works Better Than Medicine

Two studies have found that weight-loss operations worked much better than the standard therapies for Type 2 diabetes in obese and overweight people whose blood sugar was out of control. 

Those who had surgery, which stapled the stomach and rerouted the small intestine, were much more likely to have a complete remission of diabetes, or to need less medicine, than people who were given the typical regimen of drugs, diet and exercise.

The surgery also helped many to lower their blood pressure and cholesterol.

The new studies, published on Monday by The New England Journal of Medicine, are the first to rigorously compare medical treatment with these particular stomach and intestinal operations as ways to control diabetes. 

Doctors had been noticing for years that weight-loss operations, also called bariatric surgery, could sometimes get rid of Type 2 diabetes. But they had no hard data.

Experts say better treatments are desperately needed for the disease.

“Type 2 diabetes is one of the fastest growing epidemics in human history,” according to an editorial published with the two studies.

The question is whether major surgery, with its risks and complications, should be more widely used. 

Some surgeons and obesity experts are pushing to establish a role for the surgeries in treating diabetes, not just obesity, while other experts say more research is needed.

The president for medicine and science for the American Diabetes Association, Dr. Vivian Fonseca, said the two studies were “not game changers” because they were relatively small.

The disease, which causes high blood sugar, is linked to obesity and often becomes harder to manage as it progresses. It can bring devastating complications like heart disease, strokes, blindness, amputations and kidney failure.

In the United States, the number of diabetes cases has tripled in the past 30 years to more than 20 million, according to the Centers for Disease Control and Prevention. Most of the cases are Type 2. Type 1, far less common, is not linked to obesity.

Researchers said the operations used in the studies help control diabetes not just because they make people lose weight — a known treatment for the disease — but because the changes in anatomy alter the levels of gut hormones that affect the metabolism of sugars and fats.

Artificial Heart: Would you accept having no pulse?

We do not actually need a pulse to stay alive, we just require a means to ensure that bloody flow is continually circulated through the body. Doctors Bud Frazier and Billy Cohn created a new, continuous-flow artificial heart based on these principles, the continuous-flow left ventricular assist device (VLAD).

By using two turbines to replace the muscle of the heart, the system keeps blood moving continually by mimicking the heart’s pumping rhythm, without recreating the pulse.

Although it in no way looks like a natural organ, the device has so far been tested on 50 calves, and its first human subject, Craig Lewis, can be considered a success at the least as a temporary measure.

After being given a maximum of 12 hours to live due to a plethora of medical conditions, the surgery was performed to take out his original heart and replace it with the 10,000 RPM artificial alternative.

Within 48 hours, Lewis was able to sit up, speak, and even sketched. Although he passed away 5 weeks later, the causes are reportedly to have been due to his original conditions and the artificial device would never have been able to eradicate these issues, but it did allow him to live longer and say his goodbyes.

Since Lewis, several other patients have been fitted with the devices.

Cohn and Frazier’s continuous-flow left ventricular assist device was previously placed in a calf named Meeko, who lived on to lead a normal life after having his heart taken out and replaced with the turbines.

The surgery was performed by cutting the heart free, sewing collars of rubberized Dacron onto the atria, and then connecting the turbines on to the collars before activation.

Creating an artificial heart has been difficult up until now, as many metal and plastic experiments have resulted in the wearing out of material, and an inability to beat, mimicking the human pulse for more than 18 months.

Currently, there are other developments within artificial heart development, including the ‘Total Artificial Heart’ made by Arizona-based SynCardia Systems Inc., which replaces ventricles and a number of valves instead of taking out the entire organ.

However, it does require toting around a 12 pound external engine to power the heart, and according to the second patient to receive the operation, John Martino, it is extremely loud and is only a measure for patients who are waiting for a transplant rather than a permanent solution.

This new VLAD technology has the potential to help patients with conditions such as terminal heart disease in the future, and as the scientists themselves say, may mean we are a step closer to a ‘perfect’ artificial heart.

Cohn says that: “I think we’re on the verge, right now, of solving the artificial-heart problem for good. All we had to do was get rid of the pulse.”

CANADA's NeuroArm: Robotic Arm Provides Healing Touch

The delicate touch that successfully removed an egg-shaped tumor from Paige Nickason's brain got a helping hand from a world-renowned arm -- a robotic arm, that is.

The technology that went into developing neuroArm, the world's first robot capable of performing surgery inside magnetic resonance machines, was born from the Canadarm (developed by MDA for the US Space Shuttle Program), as well as Canadarm2 and Dextre, the Canadian Space Agency's family of space robots performing the heavy-lifting and maintenance on board the International Space Station.

neuroArm began with the search for a solution to a surgical dilemma: how to make difficult surgeries easier or impossible surgeries possible. MDA worked with a team led by Dr. Garnette Sutherland at the University of Calgary to develop a highly precise robotic arm that works in conjunction with the advanced imaging capabilities of MRI systems.

Surgeons needed to be able to perform surgeries while a patient was inside a magnetic resonance (MRI) machine, which meant designing a robot that was as dexterous as the human hand but even more precise and tremor-free.

Operating inside the MRI also means it had to be entirely made from non-magnetic materials (for instance, no steel) so that it would not be affected by the MRI's magnetic field or adversely affect the MRI's images.

The project team developed novel ways to control the robot's movements and give the robot's operator a sense of touch, both essential so that the surgeon can precisely control the robot and can feel what is happening during the surgery.

Since Paige Nickason's surgery in 2008, neuroArm has been used to successfully treat dozens more patients. The neuroArm technology has since been purchased by IMRIS Inc. a private publicly traded medical device manufacturer based in Winnipeg, Manitoba.

MDA and IMRIS are advancing the design to commercialise a two-armed version of the system to allow surgeons to see detailed three-dimensional images of the brain, as well as surgical tools and hand controllers that allow the surgeon to feel tissue and apply pressure when they operate.

A clinical trial led by Dr. Sutherland is currently underway at Calgary's Foothills hospital using the first generation of the robot on a group of 120 patients. IMRIS anticipates being in a position to seek regulatory approval for the robot as early as 2012.

Alternative Energy - Lipo-diesel illegal in some states

In November 2008 the Beverly Hills surgeon Craig Alan Bittner suddenly closed his thriving liposuction practice and fled to South America. Why? Bittner had been using the extracted fat of patients as "lipo-diesel" to fuel the SUVs of himself and his girlfriend, and was therefore violating state laws on medical waste.

Research finds surgery outperforms drug therapy in treatment of benign prostatic hyperplasia

Research finds surgery outperforms drug therapy in treatment of benign prostatic hyperplasia — Science Blog

A 17-year-long community study looking at symptoms of enlarged prostate in over 2,000 men age 40 to 79 years suggests that surgery for benign prostatic hyperplasia (BPH) offers more relief from incontinence and obstruction symptoms than treatment from drug-based therapy, according to a new study by researchers at Mayo Clinic. The researchers presented their results today at the annual meeting of the American Urological Association.

Overall, results show:

* Urinary incontinence was a common condition, coexisting with BPH/lower urinary tract symptoms.
* In the community setting, patients with the highest symptom scores were most likely to receive surgical intervention.
* Symptoms stabilised and did not get worse after treatment of all kinds.
* Patients who underwent transurethral resection of the prostate (TURP) had the greatest decrease in both symptoms and incontinence compared to other treatment groups. Pre-TURP the incontinence rate was 64.5 percent and post-TURP it was 41.9 percent.

Significance
The findings provide large-sample, long-term data comparing the effectiveness of medical versus surgical treatments in a large, general population, as compared to small, select clinical populations of men. “Our data fills a gap in the research record that can be used by physicians and patients to evaluate management options,” says Amy Krambeck, M.D., Mayo Clinic urologist and lead study investigator. “Because it’s a large community-based study of more than 2,100 men, it includes the entire broad range of male health. This suggests the results are stronger in terms of being generalised and applied to other men.”

Background
BPH and lower urinary tract symptoms, such as frequent urge to urinate or leakage, are common. By age 60, an estimated 50 percent of all men suffer from enlarged prostate symptoms; by age 90, about 80 percent do. Multiple treatments exist but data comparing drug therapy to surgery are lacking, making clinical decisions vulnerable to subjective factors.

About the Study
From 1990 through 2007, the study enrolled 2,184 healthy men, age 40-79, living in Olmsted County, Minn., All participants completed surveys every other year about their urinary symptoms and the treatments they received. From this information, the investigators examined urinary problems and incontinence before and after different types of treatment.

Results showed that of the 2,184 men:

* 1,574 (72%) received no treatment for BPH symptoms.
* 307 (14%) took alpha adrenergic receptor blockers (α-ARs).
* 195 (9%) took the medication 5-alpha-reductase inhibitors (ARIs).
* 23 (1%) received surgical laser vaporization.
* 85 (4%) received surgical transurethral resection of the prostate (TURP).

Comments Dr. Krambeck: “After intervention, the greatest improvement in symptom score was seen in the TURP group, followed by laser vaporisation, then the drugs, 5 alpha reductase inhibitors and alpha adrenergic receptor blockers.

Only the surgical TURP group reported a decrease in incontinence – pre-TURP the incontinence rate was 64.5 percent and post-TURP it was 41.9 percent.”

This reduction in incontinence rates is significant when compared to the increase in reported incontinence in the patients receiving both forms of medical therapy and no change in symptoms for patients receiving laser vaporization.

Industrial robot hones virtual autopsies - New Scientist

Industrial robot hones virtual autopsies - New Scientist

THE small industrial robot that dominates the room is in many ways much like any other. A robotic arm smoothly wields grippers and probes - always accurate and never tired. But rather than working on cars or computers, this robot is processing human corpses.

A team of forensic pathologists at the University of Bern in Switzerland reckon it could make autopsies more accurate and also less distressing for families.

The researchers are already pioneers of virtual autopsies, or "virtopsies", which use non-invasive imaging of a body inside and out rather than the radical post-mortem surgery typically used to determine cause of death.

Now they are using a robot, dubbed Virtibot, to carry out parts of that process, making it more reliable - and standardised.

Their virtopsies combine 3D imaging of a body's surface with a CT scan of its interior anatomy. The result is a faithful, high-resolution virtual double of the corpse (see diagram). This double can be used to accurately determine what killed someone. And it's a more tactful approach: only needle biopsies are used to sample tissues, leaving a body essentially undamaged.

This virtual body-double can be used to accurately determine what killed a person "Currently, organs are taken out and sliced for analysis of tumours and lesions, but if something is overlooked you have no chance of seeing it again," says team member Lars Ebert. "All you have afterwards is a huge pile of organ slices."

By automating virtopsies, he now hopes to free the post-mortem from the influence of the unavoidable human failings of pathologists, which can affect conclusions about cause of death.

"Too much of an investigator's autopsy results depend on their ability to describe in a report what they see - and they may overlook things," says Ebert. "We want to make the whole procedure more objective and generate digitally stored data that can be re-examined 20 or 30 years later."

Questions: When is the best time to go under the Knife?

Questions

1. Is it safer to have elective surgery first thing in the morning rather than in late afternoon, when doctors and nurses might be tired?



2. For the same reason, is it smarter to schedule surgery earlier in the workweek than later?



3. Is it better to avoid having elective surgery in July and August, when a new crop of residents has just started training?



4. Also, is it foolish to have elective surgery when the moon is full and, tradition has it, people can go a little off-kilter?

Answers

No, no, no and no, according to a Cleveland Clinic study that found timing isn't anything, at least when it comes to elective coronary bypass surgery.

The authors of the study, published today in the journal Anesthesiology, write that they decided to focus on elective heart bypass surgery because, thanks to "well-established protocols (for bypass surgery), there is much less variability than with other procedures." Plus, they write, "hospitals closely track morbidity and mortality for this operation", which is very encouraging. I am presuming that this is in an attempte to reduce it.

Daniel Sessler, an anesthesiologist who chairs the Cleveland Clinic's department of outcomes research, says he and his co-authors hope to examine whether timing affects other types of elective surgery, but they expect to find the same thing.

The researchers analysed the results of 18,597 elective bypass surgeries at the Cleveland Clinic from 1993 to 2006. Most were performed between 7 a.m. and 5 p.m. on weekdays. None of the time factors — hour, day, month or phase of moon — made any difference in the outcomes of the operations.

"Fatigue is well-known to impair performance," Sessler says, citing its role in plane and car crashes. "It's highly plausible that fatigue would impair the performance of medical personnel."

But, he says, just because doctors or nurses are fatigued and make mistakes doesn't necessarily mean patients suffer. "Hospitals have extensive systems in place to minimize the consequences of any error," he says.

I hope this has answered some of your questions but I suspect it may have raised a few more!