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BACKGROUND: Cervical paragangliomas (CPG) are slow-growing tumours, most of which are highly vascular, making surgical resection challenging. Preoperative embolisation of afferent arteries has been recommended to facilitate operative dissection, reduce perioperative blood loss, and shorten the duration of the operation. However, there is conflicting evidence on the benefits of preoperative embolisation on surgical outcomes, operative time, and bleeding. OBJECTIVES: The objective of this study was to compare the perioperative parameters and outcomes like duration of surgery, blood transfusion, duration of stay in the ICU, cranial nerve injuries, and postoperative stroke between patients who underwent excision of CPGs with and without preoperative embolisation. METHODS: This is a retrospective study conducted at the Division of Vascular Surgery, Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. The study included a review of the medical records of 32 patients who underwent excision of CPGs. Patients who underwent surgical resection without preoperative embolisation (SR) were compared with those who underwent surgical resection with embolisation (SREMB). Statistical analysis was done in R statistical software (R Foundation for Statistical Computing, Vienna, Austria). Categorical variables were reported in absolute numbers and percentages continuous variables were compared with an unpaired Mann-Whitney U test. The chi-square test was used to compare the categorical data. RESULTS: Out of 32 patients included in this study, 13 (40.6%) patients were included in the SREMB group. Between the two groups, there were no significant differences in operative time (120 vs. 150 minutes; p = 0.59), blood transfusion requirement (0.69 vs. 0.37 units; p = 0.39) and ICU stays (1 vs. 1; p = 0.56). Postoperative cranial nerve injury was significantly more in the SREMB group (6 vs 1; p = 0.01) but stroke (0 vs 2; p = 0.50) was not statistically significant between the two groups. CONCLUSION: In this study, we found that there was insufficient evidence to support routine preoperative embolisation in CPG. Hence, preoperative embolisation should only be used in a very select group of patients.
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The prevalence of ineffective corrective surgeries for ocular motor disorders calls for a robotic eye platform in aiding ophthalmologists to better understand the biomechanisms of human eye movement. This letter presents the first hardware design and implementation of a 2-DOF robotic eye driven by super-coiled polymer (SCP) artificial muscles. While our previous work designed and simulated a deep deterministic policy gradient (DDPG) learning-based controller that requires full-state feedback of the SCP-driven robotic eye, measuring the temperature states of the slender SCPs is generally impractical for the ubiquitously aimed robot. To address this predicament, this letter proposes a reduced-order state observer to estimate the temperature of SCPs given the kinematic measurements. Combining the designed observer and the learning-based controller, the closed-loop output feedback control is implemented on the robotic eye prototype to examine its performance on three classical types of eye movements: visual fixation, saccadic pursuit, and smooth pursuit. The experimental results are presented which successfully validate the observer-based output control of the SCP-driven robotic eye.
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Successful revascularization and restoration of blood flow to one of the pedal arteries is the mainstay to prevent major limb amputation. Here, we report a rare case of successful bypass to the inframalleolar ankle collateral artery in a middle-aged female with rheumatoid arthritis presenting with gangrene of the toes of the left foot. A computed tomography angiography (CTA) demonstrated normal infrarenal aorta, common iliac, external iliac, and common femoral arteries on the left side. The left superficial femoral, popliteal, tibial, and peroneal arteries were occluded. Extensive collateralization was noted in the left thigh and leg, with distal reformation in large ankle collateral. A successful bypass was done using from the common femoral artery to the ankle collateral using the great saphenous vein harvested from the same limb. At a one-year follow-up, the patient was symptom-free, and a CTA showed a patent bypass graft.
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IntroductionPublished evidence of venous thrombotic complications of COVID-19 is lacking from India. This case series consists of twenty-nine adult patients who were COVID -19 positive and treated for Deep Vein Thrombosis (DVT) during the second wave of the COVID-19 pandemic, in India. The study was aimed at analyzing patient demographics of patients with DVT and the outcome of Catheter-Directed Thrombolysis (CDT) in COVID positive patients. Material and Methods: Patients who developed DVT while or after being COVID positive were managed between February and April 2021 at the institution of the first two authors and were included in this retrospective study. Demographic, clinical data, laboratory data, and treatment given were analyzed. All patients were followed up for 3 months with a Villalta score. Results: There were a total of 29 patients (12 male and 17 female) included in the study with a mean age of 47 ± 17 years. The average time of presentation from being COVID positive was 17.8 ± 3.6 days and one patient developed DVT after becoming Covid negative. All but one patient had lower limb involvement, with 42.8% having proximal and 57.2% distal DVT. All patients with Iliofemoral and two with Femoropopliteal DVT were treated with catheter-di thrombolysis and the other 15 patients were managed with anticoagulation alone. No re-thrombosis was observed in the thrombolysis group. Overall average Villalta score at 3 months was 10.7 ± 2.1 with a score of 10.58 ± 2.1 in the anticoagulation-only group and 10.85 ± 2.3 in the CDT group. Conclusion: COVID-19 seems to be an additional risk factor in the development of DVT. The outcome of such patients, treated by thrombolysis appears to be similar to non-COVID patients. In this, observational experience of the authors suggests that CDT could be offered to COVID positive patients with symptomatic Iliofemoral DVT with good outcomes and an acceptable post-intervention Villalta score.
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COVID-19 , Trombosis de la Vena , Adulto , COVID-19/complicaciones , Catéteres , Femenino , Humanos , Vena Ilíaca , Masculino , Persona de Mediana Edad , Pandemias , Estudios Retrospectivos , SARS-CoV-2 , Terapia Trombolítica/efectos adversos , Resultado del Tratamiento , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/tratamiento farmacológico , Trombosis de la Vena/etiologíaRESUMEN
BACKGROUND: Technical errors are the most common preventable cause of recurrence after high ligation and stripping procedures for the treatment of great saphenous vein incompetence. Ultrasound-assisted varicose vein surgery (UAVS) uses intraoperative ultrasound during high ligation and stripping to minimize such failures, although no data have been reported regarding its use during open surgery. The present study compared the short-term outcomes of UAVS and endovenous laser ablation (EVLA) with a 1470-nm laser. METHODS: The present prospective randomized study was conducted from January 2019 to December 2019. We compared 40 patients who had undergone UAVS under regional anesthesia with an equal number of patients who had undergone EVLA under tumescent anesthesia. Both groups received 1 week of standardized postoperative analgesia. The improvements in the pain score, venous clinical severity score, and recurrence at 6 months and 1 year were studied. RESULTS: No significant differences were found in either clinical or radiologic great saphenous vein recurrence after UAVS compared with EVLA at 1 year. The mean pain score at 8 hours after the procedure was higher in the UAVS group (3.7 ± 1.2 vs 2.9 ± 1.0; P = .03). At 1 week, the score was higher in the EVLA group (1.8 ± 0.7 vs 1.4 ± 0.5; P = .01). At 6 months, the venous clinical severity score had improved from 9.2 ± 3.7 to 2.4 ± 1.4 in the UAVS group and from 9.3 ± 3.2 to 2.1 ± 0.8 in the EVLA group (P = .64). At 1 year, the corresponding scores were 1.3 ± 0.7 and 1.4 ± 0.6 (P = .21). CONCLUSIONS: UAVS has high technical success, making it a suitable alternative to EVLA using a 1470-nm laser.
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Terapia por Láser , Vena Safena/cirugía , Ultrasonografía Intervencional , Várices/cirugía , Procedimientos Quirúrgicos Vasculares , Insuficiencia Venosa/cirugía , Adulto , Anciano , Femenino , Humanos , India , Terapia por Láser/efectos adversos , Ligadura , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Valor Predictivo de las Pruebas , Estudios Prospectivos , Recurrencia , Vena Safena/diagnóstico por imagen , Vena Safena/fisiopatología , Factores de Tiempo , Resultado del Tratamiento , Várices/diagnóstico por imagen , Várices/fisiopatología , Procedimientos Quirúrgicos Vasculares/efectos adversos , Insuficiencia Venosa/diagnóstico por imagen , Insuficiencia Venosa/fisiopatología , Adulto JovenRESUMEN
With increasing ocular motility disorders affecting human eye movement, the need to understand the biomechanics of the human eye rises constantly. A robotic eye system that physically mimics the human eye can serve as a useful tool for biomedical researchers to obtain an intuitive understanding of the functions and defects of the extraocular muscles and the eye. This paper presents the design, modeling, and control of a two degree-of-freedom (2-DOF) robotic eye, driven by artificial muscles, in particular, made of super-coiled polymers (SCPs). Considering the highly nonlinear dynamics of the robotic eye system, this paper applies deep deterministic policy gradient (DDPG), a machine learning algorithm to solve the control design problem in foveation and smooth pursuit of the robotic eye. To the best of our knowledge, this paper presents the first modeling effort to establish the dynamics of a robotic eye driven by SCP actuators, as well as the first control design effort for robotic eyes using a DDPG-based control strategy. A linear quadratic regulator-type reward function is proposed to achieve a balance between system performances (convergence speed and tracking accuracy) and control efforts. Simulation results are presented to demonstrate the effectiveness of the proposed control strategy for the 2-DOF robotic eye.
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Procedimientos Quirúrgicos Robotizados , Robótica , Simulación por Computador , Humanos , Dinámicas no Lineales , Seguimiento Ocular UniformeRESUMEN
A rapidly growing field of aquatic bio-inspired soft robotics takes advantage of the underwater animals' bio-mechanisms, where its applications are foreseen in a vast domain such as underwater exploration, environmental monitoring, search and rescue, oil-spill detection, etc. Improved maneuverability and locomotion of such robots call for designs with higher level of biomimicry, reduced order of complex modeling due to continuum elastic dynamics, and challenging robust nonlinear controllers. This paper presents a novel design of a soft robotic fish actively actuated by a newly developed kind of artificial muscles-super-coiled polymers (SCP) and passively propelled by a caudal fin. Besides SCP exhibiting several advantages in terms of flexibility, cost and fabrication duration, this design benefits from the SCP's significantly quicker recovery due to water-based cooling. The soft robotic fish is approximated as a 3-link representation and mathematically modeled from its geometric and dynamic perspectives to constitute the combined system dynamics of the SCP actuators and hydrodynamics of the fish, thus realizing two-dimensional fish-swimming motion. The nonlinear dynamic model of the SCP driven soft robotic fish, ignoring uncertainties and unmodeled dynamics, necessitates the development of robust/intelligent control which serves as the motivation to not only mimic the bio-mechanisms, but also mimic the cognitive abilities of a real fish. Therefore, a learning-based control design is proposed to meet the yaw control objective and study its performance in path following via various swimming patterns. The proposed learning-based control design employs the use of deep-deterministic policy gradient (DDPG) reinforcement learning algorithm to train the agent. To overcome the limitations of sensing the soft robotic fish's states by designing complex embedded sensors, overhead image-based observations are generated and input to convolutional neural networks (CNNs) to deduce the curvature dynamics of the soft robot. A linear quadratic regulator (LQR) based multi-objective reward is proposed to reinforce the learning feedback of the agent during training. The DDPG-based control design is simulated and the corresponding results are presented.
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OBJECTIVE: The common side effects of endovenous laser ablation (EVLA) are pain and discomfort in the treated leg. We compared the pain and outcomes after EVLA using a 1470-nm laser with bare tip or radial fibers in the treatment of incompetent great saphenous veins (GSVs). METHODS: A total of 86 patients with primary varicose veins of the GSV were randomized to treatment using a 1470-nm laser and bare fiber (BF; n = 43) or radial fiber (RF; n = 43) during a 12-month period from January to December 2019. Patients were assessed clinically and using venous Doppler ultrasonography at 24 hours, 1 week, and 1 month. The periprocedural parameters and short-term outcomes of pain after the procedure, improvement in the Venous Clinical Severity Score (VCSS), and vein occlusion at 1 month were compared and analyzed. RESULTS: The linear endovenous energy density (65.7 J/cm vs 65.2 J/cm), tumescent local anesthetic solution used (627.4 mL vs 661.4 mL), treated GSV length, and number of hook phlebectomies were similar in both groups. The pain score at 8 hours (2.77 vs 2.70) and 1 week (2.81 vs 2.74) were similar in the BF and RF groups, respectively. The improvement in the VCSS was significant in both groups and was slightly better in the BF group, although the difference was not statistically significant. Both fiber types had 100% efficacy in terms of closure of the treated vein at 1 month. CONCLUSIONS: EVLA using a 1470-nm laser with a BF had similar outcomes in the short term compared with a RF of the same wavelength. Both fibers were associated with significant improvement in the VCSS at 1 month.
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Terapia por Láser , Fibras Ópticas , Vena Safena/cirugía , Insuficiencia Venosa/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Escala Visual AnalógicaRESUMEN
Most patients with diffuse coronary disease require endarterectomy for revascularization. In view of the high morbidity and mortality associated with coronary endarterectomy, patch angioplasty and reconstruction of the coronary artery was developed. We retrospectively evaluated 104 patients who underwent mammary artery patch angioplasty of the left anterior descending coronary artery. The procedure consisted of laying open the entire diseased segment of the coronary artery and patching it with an in-situ left internal mammary artery onlay patch, without endarterectomy, in an off-pump procedure. One (0.9%) patient died, 2 (1.8%) suffered perioperative myocardial infarction, and an intraaortic balloon pump was used in 2. The mean blood loss was 224 mL. Intensive care unit stay was 2.5 days, and hospital stay was 7.8 days. At 1-year follow-up, most patients were in New York Heart Association functional class I. Follow-up angiography was carried out in 16 patients and showed good patency of all anastomoses. Arterial patch reconstruction of the left anterior descending coronary artery can be performed safely and effectively in an off-pump procedure, with excellent early and intermediate results.
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Puente de Arteria Coronaria/métodos , Enfermedad Coronaria/cirugía , Arterias Mamarias/trasplante , Procedimientos de Cirugía Plástica/métodos , Angiografía Coronaria , Enfermedad Coronaria/diagnóstico por imagen , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Surgery for diffuse coronary artery disease requires coronary reconstruction with or without endarterectomy. Considering the immediate and late postoperative problems of coronary endarterectomy, many surgeons now prefer coronary reconstruction without endarterectomy. Patch reconstruction of the diseased coronary artery with either the internal mammary artery or another conduit is an attractive option. This article describes the technique of long mammary patch reconstruction of the left anterior descending coronary artery without endarterectomy as an off-pump procedure.
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Puente de Arteria Coronaria Off-Pump/instrumentación , Puente de Arteria Coronaria Off-Pump/métodos , Enfermedad de la Arteria Coronaria/cirugía , Vasos Coronarios/cirugía , Arterias Mamarias/trasplante , Procedimientos de Cirugía Plástica/instrumentación , Procedimientos de Cirugía Plástica/métodos , Endarterectomía , Femenino , Humanos , Masculino , Resultado del TratamientoRESUMEN
Tuberculosis rarely figures in the list of thymic masses. We hereby report a case of thymic tuberculosis successfully managed with surgical excision and antituberculouschemotherapy.
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Enfermedades Linfáticas/microbiología , Timo/microbiología , Tuberculosis/patología , Adulto , Antibacterianos/uso terapéutico , Biopsia , Humanos , Enfermedades Linfáticas/tratamiento farmacológico , Enfermedades Linfáticas/patología , Masculino , Timo/patología , Tuberculosis/tratamiento farmacológicoRESUMEN
Aortoiliac disease often coexists with coronary artery disease. It is not uncommon to subject a patient to two separate interventions. We report two cases in which in simultaneous off-pump coronary artery bypass grafting was done with an ascending aortobifemoral bypass graft through the ventral abdominal route without any additional morbidity. Combining a technically simple method of limb bypass with an off-pump cardiac surgery is a promising procedure for revascularization of myocardium and lower limbs. We discuss the merits of combining an off-pump coronary artery bypass grafting procedure with a limb bypass.
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SUMMARY: : Suprahepatic inferior vena caval (IVC) injuries are rare but carry nearly a 100% mortality rate. The main problem with its surgical management is the technical difficulty in draining the IVC during cardiopulmonary bypass. In this report, an efficient method of IVC drainage for repair of the IVC on cardiopulmonary bypass is described.