Potential Applications of Three-Dimensional Printing in the Hospital Network: An Exploratory Study

Potential Applications of Three-Dimensional Printing in the Hospital Network: An Exploratory Study Bruce Schmidt, Emily Iobst, Philip Horlacher, Michael Pasquale MD, Martin Martino MD Abstract This study sought to explore and evaluate the potential benefits of investing in an on-site three-dimensional (3D) printer for use by the Lehigh Valley Hospital Network (LVHN). Preliminary research was conducted to first determine where and how three-dimensional printing is being utilized in healthcare currently. Interviews were conducted with LVHN physicians and other personnel in an effort to identify cost-effective applications of this technology that could be implemented into the network in a practical manner. Using information gathered from interviews, a general survey was created and administered to 190 physicians in the Department of Surgery at LVHN to both evaluate the degree of interest in 3D printing technology within the network and identify which applications would be most valuable to the physicians. Three main areas of use were identified: 3D model production for preoperative visualization, 3D model production for surgical simulation training and education, and medical device prototyping. The results of the study indicate that the purchase of a 3D printer would be beneficial and utilized by health network personnel. Further education on the capabilities of a 3D printer to the health network personnel is encouraged in order to maximize the profitability of the printer. Keywords Three-dimensional printing, rapid prototyping, patient outcomes, 3D model, custom implants, surgical training Introduction Three-dimensional (3D) printing or rapid prototyping is a process of additive manufacturing that produces physical 3D objects from digital 3D models or other electronic data sources. The process involves the successive layering of many thin sheets of a material (“3D printing”). The object produced can be of virtually any shape or geometry, and composed of a variety of materials including plastics, metals, and resins (Kurenov, Ionita, Sammons, & Demmy, 2015). The size, quality, and degree of detail of the object are dependent upon the printer model, the type of material being used, and the software. Recent advancements in the capabilities of 3D printing technology have allowed for increased integration into the healthcare industry, specifically the surgical arena. Rapid prototyping techniques are being used in conjunction with common medical imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) for the production of anatomic models and customizable implant devices based on patient data (Kurenov, Ionita, Sammons, & Demmy, 2015). Three main steps are standard in transforming the raw imaging data into a solid 3D model: obtainment of CT or MRI image, generation of Computer-aided Design (CAD) drawing using CAD software, and the printing of the solid 3D model (Rengier et al., 2010). In terms of medical applications, physicians across many specialties at institutions around the world are utilizing rapid prototyping as a diagnostic tool for patient cases with complex anatomical anomalies (Tam, Latham, Brown, & Jakeways, 2014; Igami et al., 2014). In these cases, the use of prototype models can improve diagnostic quality, aid in preoperative planning, and provide intraoperative navigation (Kurenov, Ionita, Sammons, & Demmy, 2015; Yang et al., 2015; Azuma et al., 2014). The benefits associated with the utilization of patient-based models for preoperative planning have been proven in spine, maxillofacial, thoracic, cardiovascular, kidney, lung, and liver surgeries (Yang et al., 2015; Azuma et al., 2014; Kurenov, Ionita, Sammons, & Demmy, 2015; Tam, Latham, Brown, & Jakeways, 2014; Komai et al., 2014; Gildea, 2014; Igami et al., 2014). These models are also used as training tools for teaching and practicing surgical procedures outside the operating room (Stone et al., 2015; Kurenov, Ionita, Sammons, & Demmy, 2015). In addition to models, 3D printing is playing a role in medical prosthesis and custom implant design. Its application in hip, femoral, knee joint, and maxillofacial reconstructive surgeries is well documented (Rengier et al., 2010). In this study, the potential benefits of investing in an on-site 3D printer for use by the Lehigh Valley Hospital Network (LVHN) are explored and evaluated. As an institution that performed over 35,000 surgeries in the past year, LVHN is an ideal market for 3D printing technology. As rapid prototyping becomes increasingly standard in the healthcare industry, such technology is becoming less of a novelty and more of a necessity. In order for LVHN to continue to lead the region in patient care, it is imperative for the network to consider and investigate this technology. Methodology A multi-step procedure consisting of preliminary research, individual interviews, and electronic surveying was followed in order to identify applications of 3D printing being used in healthcare currently, determine which applications could be implemented into LVHN in a practical manner, and evaluate the potential benefits and costs associated with those applications. A prototype model based on patient data was printed using standard industry methods at LVPG Plastic and Reconstructive Surgery. The feasibility and costs of the printing process for the prototype were examined. MEDLINE was searched between January 1, 2010 and June 1, 2015 using the keyword “three-dimensional printing.” This keyword was combined using “AND” with the following terms: “surgery” and “hospital.” The term “rapid prototyping” was searched separately. Additionally, the institutional websites of the top ten hospitals in the U.S. (as ranked in U.S. News & World Report for 2015-2016) were searched in terms of applications of 3D printing. Only studies that have put 3D printing technology into clinical practice were considered. Individual unstructured interviews were conducted with eight LVHN employees. Those employees consisted of physicians, surgical education coordinators, and Information Services (IS) staff. Discussions were focused on cost-effective applications of 3D printing that could be implemented given the resources at LVHN. Notes from the interviews were used in the creation of an electronic survey. The survey was administered to 190 physicians in the Department of Surgery via email. It consisted of three questions: 1. Would a 3D printer be a valuable addition to LVHN? 2a. Do you have any ideas for how 3D printing would enhance your practice currently? 2b. If yes [to 2a], in which of the following areas? The options given for question 2b are listed in Figure 4. Responses were received via email and recorded on a data sheet. Graphical analysis of the survey responses was performed (Figures 2,3,4). No incentive was offered for completing the survey. A model of a patient’s skull with a severe facial fracture was produced by acquiring a CT scan of the patient and converting the 2D image into a digital 3D model using commercial CAD software. A custom implant was designed to correct the fracture using the software as well. The CAD model was generated as a stereolithography (STL) file. The STL file was then sent to a 3D printing vendor for fabrication of the physical model. Patient consent was obtained through HIPPA media release form. The costs associated with the process of vendor printing were noted and compared to the costs of using an on-site printer (Figure 5). Results Based on the preliminary research and individual interviews, three main applications of 3D printing were established: 3D model production for preoperative planning, 3D model production for surgical simulation training and education, and medical device prototyping. The results of the survey provided information about the degree of interest in the purchase of a 3D printer at LVHN as well as where and how network personnel would utilize the technology. 20 out of 190 physicians responded to the survey. Of the sample that participated, 76% of the respondents believe a 3D printer would be a valuable asset in the health network while 14% believe it would not be; 10% were uncertain as to whether or not a 3D printer would be beneficial (Figure 2). 72% of the respondents had ideas for how 3D printing technology would enhance their practice currently; 14% did not have any ideas while the remaining 14% were uncertain (Figure 3). For those that did have ideas, preoperative planning was the most popular application receiving 12 votes. Surgical training and device prototyping received 7 and 8 votes respectively (Figure 4). Respondents were allowed to vote for more than one application. The average cost for a standard 3D printer with the capabilities to produce clinically accurate prototypes using plastics and other resins is approximately $150,000. The average cost for CAD software and licensing is$1,500. These are both one-time costs. The average cost of materials is anywhere from $50 to$100 depending on the type of material. Vendor charges can be anywhere from $500 to$2,500 depending on the manufacturer and the desired prototype to be printed (Figure 5). These costs are general averages based on current market prices for the printing of a plastic skull. Discussion Based on the preliminary research, interviews, and electronic survey, the addition of a 3D printer at LVHN would be beneficial and utilized by hospital staff across several departments. Although survey participation was low (~11%), a decisive majority of physicians in that small sample view 3D printing technology as a potential asset in the areas of preoperative planning, surgical training and education, and medical device prototyping. It is important to note that a relatively significant portion of physicians were uncertain of the capabilities of a 3D printer. Educating hospital staff on the capabilities of this technology would allow for increased use and thus increased profitability. With the help of patient-specific models created using 3D printing technology, LVHN surgeons would be able to simulate complicated surgical steps for complex cases in advance thus allowing them to foresee intraoperative complications. This may result in reduced operating times, less blood loss and transfusion volumes, decreased amount of time the patient is under anesthesia, and shortened length of hospital stay. All of these factors contribute to a more cost-effective use of the operating room as well as improved patient outcomes. These models could also be beneficial in demonstrating and explaining surgical procedures to patients and their families (Kurenov, Ionita, Sammons, & Demmy, 2015; Rengier et al., 2010). Rapid prototyping models could be used as valuable educational tools for use in the Surgical Educational Center by surgical residents and SELECT medical students. These simulated models would allow for safe training of surgical procedures in a realistic manner without the risk of harm to a patient (Stone et al., 2015). Techniques using a multi-material 3D printer to create translucent organ models with realistic visual and tactile sense feedbacks have already been proven successful (Komai et al., 2014). In terms of medical prosthesis and implant design, a 3D printer would allow orthopedic and reconstructive surgeons at LVHN the ability to create custom implants for their patients. The need for customized implants is apparent in cases where patients are outside the standard range with respect to prosthesis size, or have condition-specific special requirements. Custom implants offer improved surgical outcomes and reduced operating time because of patient-specific fitting that matches individual anatomical needs (Rengier et al., 2010). Cost comparison between vendor printing and on-site printing emphasizes the cost-effectiveness of having an on-site printer in the health network versus outsourcing the prints. To produce a model of certain dimensions and materials using a commercial vendor costs substantially more than it would cost to print the same model on-site. This finding is consistent with another study that reported a vendor cost of two to three times the overall cost for printing model pulmonary arteries on-site (Kurenov, Ionita, Sammons, & Demmy, 2015). This study was successful in uncovering the potential benefits of an on-site 3D printer through preliminary research, provider interviews, and a standardized survey. Results showed that a 3D printer would be advantageous for preoperative planning, surgical simulation training and education, and medical device prototyping. In conclusion, investing in a 3D printer is supported as a potential cost-effective way for LVHN to remain on the cutting edge of medical technology as well as improve surgical training and patient outcomes. Acknowledgements Randolph Wojcik, Jr., MD Christian Caputo References Azuma, M., Yanagawa, T., Ishibashi-Kanno, N., Uchida, F., Ito, T., Yamagata, K., . . . Bukawa, H. (2014). Mandibular reconstruction using plates prebent fit rapid prototyping 3-dimensional printing models ameliorates contour deformity. Head & Face Medicine, 10(45), 1-8. doi: 10.1186/1746-160X-10-45 Gildea, T. (2014, Winter). 3D printing: Innovation allows customized airway stents. Respiratory Exchange.12-13 Komai, Y., Sugimoto, M., Kobayashi, T., Ito, M., Sakai, Y., & Saito, N. (2014). Patient-based 3D printed organ model provides tangible surgical navigation: A novel aid to clampless partial nephrectomy. The Journal of Urology, 191(4S), e488. Kurenov, S.N., Ionita, C., Sammons, D., & Demmy, T.L. (2015). Three-dimensional printing to facilitate anatomic study, device development, simulation, and planning in thoracic surgery. The Journal of Thoracic and Cardiovascular Surgery, 149(4), 973-979. http://dx.doi.org/10.1016/j.jtcvs.2014.12.059 Rankin, T.M., Mailey, B., Cucher, D., Giovinco, N.A., Armstrong, D.G., & Gosman, A. (2014). Use of 3D printing for auricular template molds in first stage microtia. Plastic and Reconstructive Surgery, 134(4S-1), 16-17 Rengier, F., Mehndiratta, A., von, T.-K. H., Zechmann, C. M., Unterhinninghofen, R., Kauczor, H.-U., & Giesel, F. L. (2010). 3D printing based on imaging data: review of medical applications. International Journal of Computer Assisted Radiology and Surgery : a Journal for Interdisciplinary Research, Development and Applications of Image Guided Diagnosis and Therapy, 5(4), 335-341. Stone, J., Candela, B., Alleluia, V., Fazili, A., Richards, M., Feng, C., . . . Ghazi, A. (2015). A novel technique for simulated surgical procedures using 3D printing technology [Abstract]. The Journal of Urology, 193(4S), e270. Tam, M., Latham, T., Brown, J.R.I., & Jakeways, M. (2014). Use of a 3D printed hollow aortic model to assist EVAR planning in a case with complex neck anatomy: Potential of 3D printing to improve patient outcome. Journal of Endovascular Therapy, 21, 760-762. doi: 10.1583/14-4810L.1 Igami, T., Nakamura, Y., Hirose, T., Ebata, T., Yokoyama, Y., Sugawara, G., . . . Nagino, M. (2014). Application of a three-dimensional print of a liver in hepatectomy for small tumors invisible by intraoperative ultrasonography: Preliminary experience. World Journal of Surgery, 38, 3163-3166. doi: 10.1007/s00268-014-2740-7 Yang, M., Li, C., Li, Y., Zhao, Y., Wei, X., Zhang, G., . . . Li, M. (2015). Application of 3D rapid prototyping technology in posterior corrective surgery for Lenke 1 adolescent idiopathic scoliosis patients. Medicine, 94(8), 1-8. doi: 10.1097/MD.0000000000000582 3D printing. (n.d.). In Oxford Dictionaries online. Retrieved from http://www.oxforddictionaries.com/us/definition/american_english/3D-printing Appendix Figure 4. Graphical representation of results for question 2b. Figure 5. Overview of 3D printing process including cost comparison between on-site printing and vendor printing for the production of a model skull. Figure 3. Graphical representation of results for question 2a. Figure 2. Graphical representation of results for question 1

Cognitive–Behavioral Therapy for Physical and Emotional Disturbances in Adolescents with Polycystic Ovary Syndrome: A Pilot Study

Objective To evaluate the feasibility and effectiveness of an enhanced cognitive–behavioral therapy (CBT), Primary and Secondary Control Enhancement Training (PASCET-PI-2), for physical (obesity) and emotional (depression) disturbances in adolescents with polycystic ovary syndrome (PCOS). Method In an open trial, 12 adolescents with PCOS, obesity, and depression underwent eight weekly sessions and three family-based sessions of CBT enhanced by lifestyle goals (nutrition and exercise), physical illness narrative (meaning of having PCOS), and family psychoeducation (family functioning). Results Weight showed a significant decrease across the eight sessions from an average of 104 kg (SD = 26) to an average of 93 kg (SD = 18), t(11) = 6.6, p <.05. Depressive symptoms on the Children's Depression Inventory significantly decreased from a mean of 17 (SD = 3) to a mean of 9.6 (SD = 2), t(11) = 16.8, p <.01. Conclusion A manual-based CBT approach to treat depression in adolescents with PCOS and obesity appears to be promising