Structured cost analysis of robotic TME resection for rectal cancer:a comparison between the da Vinci Si and Xi in a single surgeon's experience

Background: Robotic-assisted surgery by the da Vinci Si appears to benefit rectal cancer surgery in selected patients, but still has some limitations, one of which is its high costs. Preliminary studies have indicated that the use of the new da Vinci Xi provides some added advantages, but their impact on cost is unknown. The aim of the present study is to compare surgical outcomes and costs of rectal cancer resection by the two platforms, in a single surgeon’s experience. Methods: From April 2010 to April 2017, 90 robotic rectal resections were performed, with either the da Vinci Si (Si-RobTME) or the da Vinci Xi (Xi-RobTME). Based on CUSUM analysis, two comparable groups of 40 consecutive Si-RobTME and 40 consecutive Xi-RobTME were obtained from the prospectively collected database and used for the present retrospective comparative study. Data costs were analysed based on the level of experience on the proficiency–gain curve (p–g curve) by the surgeon with each platform. Results: In both groups, two homogeneous phases of the p–g curve were identified: Si1 and Xi1: cases 1–19, Si2 and Xi2: cases 20–40. A significantly higher number of full RAS operations were achieved in the Xi-RobTME group (p < 0.001). A statistically significant reduction in operating time (OT) during Si2 and Xi2 phase was observed (p < 0.001), accompanied by reduced overall variable costs (OVC), personnel costs (PC) and consumable costs (CC) (p < 0.001). All costs were lower in the Xi2 phase compared to Si2 phase: OT 265 versus 290 min (p = 0.052); OVC 7983 versus 10231.9 (p = 0.009); PC 1151.6 versus 1260.2 (p = 0.052), CC 3464.4 versus 3869.7 (p < 0.001). Conclusions: Our experience confirms a significant reduction of costs with increasing surgeon’s experience with both platforms. However, the economic gain was higher with the Xi with shorter OT, reduced PC and CC, in addition to a significantly larger number of cases performed by the fully robotic approach

Operative blood loss and use of blood products after full robotic and conventional low anterior resection with total mesorectal excision for treatment of rectal cancer

To date, no studies have investigated the estimated blood loss (EBL) after full robotic low anterior resection (R-LAR) in a case-matched model, comparing it with the conventional open approach (O-LAR). Forty-nine patients in the R-LAR and 105 in the O-LAR group were matched for age, gender, BMI (body mass index), ASA (American Society of Anesthesiology) class, tumor–node–metastasis (TNM) classification and UICC (Union for International Cancer Control) stage, distance of the lower edge of the tumor from the anal verge, presence of comorbidities, and preoperative hemoglobin (Hb). EBL was significantly higher in the O-LAR group (P < 0.001); twelve units of packed red blood cells were globally transfused in the O-LAR group, compared to one unit only in the R-LAR (P = 0.051). A significantly higher postoperative Hb drop (3.0 vs. 2.4 g/dL, P = 0.015) was registered in the O-LAR patients. The length of hospital stay was much lower for the R-LAR group (8.4 vs. 12.4 days, P < 0.001). The number of harvested lymph nodes (17.4 vs. 13.5, P = 0.006) and extent of distal margin (2.9 vs. 1.9 cm, P < 0.001) were significantly higher in the R-LAR group. Open surgery was confirmed as the sole variable significantly associated (P < 0.001) with blood loss (odds ratio = 4.41, 95% CI 2.06–9.43). It was a confirmed prognosticator of blood loss (P = 0.006) when a preoperative clinical predictive model was built, using multivariate analysis (odds ratio = 3.95, 95% CI 1.47–10.6). In conclusion, R-LAR produced less operative blood loss and less drop in postoperative hemoglobin when compared to O-LAR. Other clinically relevant outcomes were similar or superior to O-LAR

Effects of cadmium and phenanthrene mixtures on aquatic fungi and microbially mediated leaf litter decomposition

This version does not correspond to the published one. To access the final version go to: http://www.springerlink.com/content/t8t302617003m078/Urbanization and industrial activities have contributed to widespread contamination by metals and polycyclic aromatic hydrocarbons, but the combined effects of these toxics on aquatic biota and processes are poorly understood. We examined the effects of cadmium (Cd) and phenanthrene on the activity and diversity of fungi associated with decomposing leaf litter in streams. Leaves of Alnus glutinosa were immersed for 10 days in an unpolluted low-order stream in northwest Portugal to allow microbial colonization. Leaves were then exposed in microcosms for 14 days to Cd (0.06–4.5 mg L−1) and phenanthrene (0.2 mg L−1) either alone or in mixture. A total of 19 aquatic hyphomycete species were found sporulating on leaves during the whole study. The dominant species was Articulospora tetracladia, followed by Alatospora pulchella, Clavatospora longibrachiata, and Tetrachaetum elegans. Exposure to Cd and phenanthrene decreased the contribution of A. tetracladia to the total conidial production, whereas it increased that of A. pulchella. Fungal diversity, assessed as denaturing gradient gel electrophoresis fingerprinting or conidial morphology, was decreased by the exposure to Cd and/or phenanthrene. Moreover, increased Cd concentrations decreased leaf decomposition and fungal reproduction but did not inhibit fungal biomass production. Exposure to phenanthrene potentiated the negative effects of Cd on fungal diversity and activity, suggesting that the co-occurrence of these stressors may pose additional risk to aquatic biodiversity and stream ecosystem functioning.The Portuguese Foundation for the Science and Technology supported this work (POCI/MAR/56964/2004) and S. Duarte (SFRH/BPD/47574/2008

Integration of robotic surgery into routine practice and impacts on communication, collaboration, and decision making: A realist process evaluation protocol

Background: Robotic surgery offers many potential benefits for patients. While an increasing number of healthcare providers are purchasing surgical robots, there are reports that the technology is failing to be introduced into routine practice. Additionally, in robotic surgery, the surgeon is physically separated from the patient and the rest of the team, with the potential to negatively impact teamwork in the operating theatre. The aim of this study is to ascertain: how and under what circumstances robotic surgery is effectively introduced into routine practice; and how and under what circumstances robotic surgery impacts teamwork, communication and decision making, and subsequent patient outcomes. Methods and design: We will undertake a process evaluation alongside a randomised controlled trial comparing laparoscopic and robotic surgery for the curative treatment of rectal cancer. Realist evaluation provides an overall framework for the study. The study will be in three phases. In Phase I, grey literature will be reviewed to identify stakeholders' theories concerning how robotic surgery becomes embedded into surgical practice and its impacts. These theories will be refined and added to through interviews conducted across English hospitals that are using robotic surgery for rectal cancer resection with staff at different levels of the organisation, along with a review of documentation associated with the introduction of robotic surgery. In Phase II, a multi-site case study will be conducted across four English hospitals to test and refine the candidate theories. Data will be collected using multiple methods: the structured observation tool OTAS (Observational Teamwork Assessment for Surgery); video recordings of operations; ethnographic observation; and interviews. In Phase III, interviews will be conducted at the four case sites with staff representing a range of surgical disciplines, to assess the extent to which the results of Phase II are generalisable and to refine the resulting theories to reflect the experience of a broader range of surgical disciplines. The study will provide (i) guidance to healthcare organisations on factors likely to facilitate successful implementation and integration of robotic surgery, and (ii) guidance on how to ensure effective communication and teamwork when undertaking robotic surgery

Experimental study of thermal behavior of batteries for electric car

In the electric vehicles market the need for advanced storage systems that allow fast and very fast charging and discharging has highlighted, in order to offer competitive products. The necessity of fast discharging in normal exercise of electric vehicle requires new specific storage systems. In fact increasing the amperage, losses increases, with production of heat that can lead to thermal instability with catastrophic consequences. Further the fast charging can induce stress that reduces battery. This paper deal with the thermal characterization of lithium-ions batteries with lithium-iron phosphate (LFP) cathode technology, prismatic and pouch type; and lithium-ions batteries with nickel-cobalt-manganese (NMC) cathode technology, pouch type. It is presented a comparison between different geometries (for the same chemistry) and between different chemistry (for the same geometry), covering the different types of batteries currently used in most automotive and stationary applications. For this purpose the charge and discharge currents used to test the batteries are based on specifications defined by the manufacturer. The tests were performed on a facility where such batteries are subject to charge/discharge cycles with current intensity gradually increasing, reaching maximum values declared by their manufacturers: during the cycles, electrical parameters are recorded together the acquisition of thermal behaviour using both thermocouples and infrared camera. From the analysis of the data obtained it is possible: to define the thermal behaviour of each type of batteries, to carry out a comparison of the different types, to identify critical points related to the geometry or chemistry and to assess the need for cooling during operation. The presence of hot spots seems to be independent on the geometry used; on the contrary the wear of the cell over time determines the onset of hot spots on the surface of the battery (as detected by tests performed on cells NMC). With regard to the different chemical, using new cells, it is possible to deduce that: • LFP cells do not reach temperatures exceeding safety range even if subject to discharge over the maximum specified by the manufacturer • NMC cells reach temperatures that exceed the safety range at maximum discharge rate specified by the manufacturer

Experimental evaluation of heat transfer coefficient for nanofluids

The paper reports the results of heat transfer experimental tests on nanofluids. Measurements were performed in a two-loop test rig for immediate comparison of the thermal performances of the nanofluid with the base-fluid. The convective heat transfer was evaluated in a circular pipe heated with uniform heat flux and with flow regimes from laminar to turbulent. Tests have been performed to compare the heat transfer capability of nanofluids and water at the same velocity or Reynolds number , and they have been compared with values calculated from widely used correlations. In particular ten different nanofluids and three base fluids (in addition to the water) have been used. The analysis of the experimental data shows a different behavior depending on the parameter used in the comparison, and, as a consequence, the addition of nanoparticles to the heat transfer fluid can result advantageous or not, depending on the specific point of view. Furthermore some classical correlations have been used to estimate the heat transfer coefficients, and the analysis shows that they are able to provide good agreement with the experimental data both for the nanofluid and water

Experimental and numerical analysis of a PCM for more uniform battery temperatures

This work presents an experimental and simulation analysis of a small-scale phase-change material (PCM) set-up containing A46 paraffin wax . The main objective is to understand the solidification and melting process of the PCM with the aim of placing the same PCM around an electric battery in order to guarantee more stable and uniform temperatures during the charging or discharging of the battery. In first place, the experimental set-up including the PCM and the instrumentation is presented. The experimental device has been designed to measure the transient temperatures that occur in a volume of PCM when the lower face is subjected to a heat flow or a set temperature. A heater is located under a copper block and the PCM is in the upper part (with a melting temperature of 46°C and a latent heat of 155 kJ / kg). An experimental campaign has been designed based on different heating rates, and the successive cooling and solidification is also measured. Subsequently, the main characteristics of the model are explained. A CFD model has been developed in Fluent and the main parameters are given. Finally, the experimental results are compared with the simulations for different tests. The results indicate the complexity of the melting process, which involves heat and mass transfer on a vertical direction, whereas in the solidification process the vertical PCM temperatures can be better reproduced

Panus Tigrinus: a valuable fungus for decontamination purpose of both wastewaters and solid wastes

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