A task and performance analysis of endoscopic submucosal dissection (ESD) surgery

BACKGROUND: ESD is an endoscopic technique for en bloc resection of gastrointestinal lesions. ESD is a widely-used in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for objective ESD training and assessment. In this work, we performed task and performance analysis of ESD surgeries. METHODS: We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, marking, injection, circumferential cutting, dissection, intraprocedural complication management, and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics. We measured task times and scores of 16 ESD surgeries performed by four different endoscopic surgeons. RESULTS: The average time of the marking, injection, and circumferential cutting phases are 203.4 (σ: 205.46), 83.5 (σ: 49.92), 908.4 s. (σ: 584.53), respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 s (σ: 908.43). We also performed correlation analysis (Pearson's test) among the performance scores of the tasks. There is a moderate positive correlation (R = 0.528, p = 0.0355) between marking scores and total scores, a strong positive correlation (R = 0.7879, p = 0.0003) between circumferential cutting and submucosal dissection and total scores. Similarly, we noted a strong positive correlation (R = 0.7095, p = 0.0021) between circumferential cutting and submucosal dissection and marking scores. CONCLUSIONS: We elaborated ESD tasks and developed quantitative performance metrics used in analysis of actual surgery performance. These ESD metrics will be used in future validation studies of our VESS simulator

Learning for a Change: Exploring the Relationship Between Education and Sustainable Development

Whether we view sustainable development as our greatest challenge or a subversive litany, every phase of education is now being urged to declare its support for education for sustainable development (ESD). In this paper, we explore the ideas behind ESD and, building on work by Foster and by Scott and Gough, we argue that it is necessary now to think of two complementary approaches: ESD 1 and ESD 2. We see ESD 1 as the promotion of informed, skilled behaviours and ways of thinking, useful in the short-term where the need is clearly identified and agreed, and ESD 2 as building capacity to think critically about what experts say and to test ideas, exploring the dilemmas and contradictions inherent in sustainable living. We note the prevalence of ESD 1 approaches, especially from policy makers; this is a concern because people rarely change their behaviour in response to a rational call to do so, and more importantly, too much successful ESD 1 in isolation would reduce our capacity to manage change ourselves and therefore make us less sustainable. We argue that ESD 2 is a necessary complement to ESD 1, making it meaningful in a learning sense. In this way we avoid an either-or debate in favour of a yes-and approach that constantly challenges us to understand what we are communicating, how we are going about it and, crucially, why we are doing it in the first place

Safety and efficacy of endoscopic submucosal dissection for rectal neoplasia: a multicenter North American experience.

Background and aims  Rectal lesions traditionally represent the first lesions approached during endoscopic submucosal dissection (ESD) training in the West. We evaluated the safety and efficacy of rectal ESD in North America. Methods  This is a multicenter retrospective analysis of rectal ESD between January 2010 and September 2018 in 15 centers. End points included: rates of en bloc resection, R0 resection, adverse events, comparison of pre- and post-ESD histology, and factors associated with failed resection. Results  In total, 171 patients (median age 63 years; 56 % men) underwent rectal ESD (median size 43 mm). En bloc resection was achieved in 141 cases (82.5 %; 95 %CI 76.8-88.2), including 24 of 27 (88.9 %) with prior failed endoscopic mucosal resection (EMR). R0 resection rate was 74.9 % (95 %CI 68.4-81.4). Post-ESD bleeding and perforation occurred in 4 (2.3 %) and 7 (4.1 %), respectively. Covert submucosal invasive cancer (SMIC) was identified in 8.6 % of post-ESD specimens. There was one case (1/120; 0.8 %) of recurrence at a median follow-up of 31 weeks; IQR: 19-76 weeks). Older age and higher body mass index (BMI) were predictors of failed R0 resection, whereas submucosal fibrosis was associated with a higher likelihood of both failed en bloc and R0 resection. Conclusion  Rectal ESD in North America is safe and is associated with high en bloc and R0 resection rates. The presence of submucosal fibrosis was the main predictor of failed en bloc and R0 resection. ESD can be considered for select rectal lesions, and serves not only to establish a definitive tissue diagnosis but also to provide curative resection for lesions with covert advanced disease

Entanglement sudden death in qubit-qutrit systems

We demonstrate the existence of entanglement sudden death (ESD), the complete loss of entanglement in finite time, in qubit-qutrit systems. In particular, ESD is shown to occur in such systems initially prepared in a one-parameter class of entangled mixed states and then subjected to local dephasing noise. Together with previous results, this proves the existence of ESD for some states in all quantum systems for which rigorously defined mixed-state entanglement measures have been identified. We conjecture that ESD exists in all quantum systems prepared in appropriate bipartite states.Comment: 10 pages. To appear in Physics Letters

Quantum error correction may delay, but also cause, entanglement sudden death

Dissipation may cause two initially entangled qubits to evolve into a separable state in a finite time. This behavior is called entanglement sudden death (ESD). We study to what extent quantum error correction can combat ESD. We find that in some cases quantum error correction can delay entanglement sudden death but in other cases quantum error correction may cause ESD for states that otherwise do not suffer from it. Our analysis also shows that fidelity may not be the best measure to compare the efficiency of different error correction codes since the fidelity is not directly coupled to a state's remaining entanglement.Comment: 3 figure

Physics of electro-thermal effects in ESD protection devices

Damage in ESD protection devices can be caused by high local temperatures resulting from heat generation by an ESD pulse. In order to obtain physical insight into the process that leads to permanent damage, device simulations of coupled thermal and electrical behaviour have been performed. Additional to the potential and the electron and hole concentrations the lattice temperature is solved as a variable. Simulations of ESD pulses (forward bias) applied to a diode have been performed. The discharge mechanism could be visualised by using the coupled thermal/electrical model. Locations with considerable temperature rise that eventually lead to damage can be extracted from the calculated temperature distributions. Protection devices with optimum electrical and thermal characteristics can be designed by adjusting doping profiles and layout parameters. The buried layer of the protection device does not contribute in conducting current at high current levels. Therefore the buried layer is not functional in diodes that are subjected to ESD in forward bias. Measurements determining the ESD vulnerability of protection devices with and without buried layer confirm this fact

Two devices for analysis of nystagmus

Electromechanical Slope Computer /ESC/ and Electronic Summation Device /ESD/ facilitates rapid analysis of nystagmus records. The ESC reads out the slope and time of each nystagmus wave form. The ESD provides much faster analysis than the ESC. It provides an immediate analog display and digital display of analyzed nystagmus