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Gavin Wright, Paul Hatfield, Carmel Loughrey, Beatrice Reiner, and Peter Bownes

duration of each shot needed to deliver the prescribed dose. In addition to creating a plan of suitable dosimetric quality, another important consideration during treatment planning is the minimization of treatment time, that is, the total duration of all shots in the plan. As well as benefiting patient throughput, minimizing treatment time improves patient comfort by reducing the time spent immobilized on the treatment couch, and additionally can reduce time demands on staff supporting the service. Studies have compared the treatment efficiency of different models of

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Roee Ber, Dennis London, Samya Senan, Yasmin Youssefi, David H. Harter, John G. Golfinos, and Donato Pacione

expertise to base our workflow design on proven combat aviation practices. We hypothesize that the adoption of this workflow through a technological platform will increase compliance and improve sustainability. We report the widespread implementation of this workflow through a mobile app in a single institution and its effect on safety, efficiency, and education in neurosurgery cases. Methods Ethical Approval This study qualifies as a quality improvement activity and does not involve human subjects. Implementation of the Workflow Prior to this study

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Amol Raheja, Shashwat Mishra, Kanwaljeet Garg, Varidh Katiyar, Ravi Sharma, Vivek Tandon, Revanth Goda, Ashish Suri, and Shashank S. Kale

–10 Although there are a few clinical studies and a single cadaveric study demonstrating the effectiveness of 3D exoscopes, 11 to our knowledge there has been no study to date comparing the impact of the 3D exoscope versus the 2D exoscope or the operating microscope on surgical proficiency and workflow efficiency. Hence, we conceptualized this controlled laboratory setting experimental study to objectively compare the impact of these visualization tools on accuracy, efficiency of task completion, and dexterity using a structured skills assessment module. Methods Study

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Ilya V. Ulasov, Angel A. Rivera, Yu Han, David T. Curiel, Zeng B. Zhu, and Maciej S. Lesniak

. Recombinant adenoviruses are an attractive vehicle for gene therapy, and most of the adenoviral vectors used against malignant brain tumors are derived from human Ad5. Although preliminary studies have shown that Ad5 vectors are more effective than retroviral vectors 28 and recent preclinical and clinical studies have shown promising results, 5 , 8 , 21 , 28 , 29 , 36 , 40 continued efforts to improve transduction efficiency and transgene expression in tumor cells, while simultaneously decreasing endogenous binding to normal brain cells, are likely to enhance the clinical

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Carlos E. Sanchez, Travis S. Tierney, John T. Gale, Kambiz N. Alavian, Ayguen Sahin, Jeng-Shin Lee, Richard C. Mulligan, and Bob S. Carter

AAV2 only provides efficient neuronal transduction at the injection site, 27 CED, first developed by Oldfield and Bankiewicz, 1–3 , 6 , 9 , 11 , 13 , 21 has emerged as an important tool for delivering large vector volumes to the CNS of patients with Parkinson disease 7 , 16 , 23 and certain lysosomal storage disorders. 26 , 37 In addition to enhancing viral delivery methods, higher CNS-specific transduction efficiency has been achieved by cross-packaging AAV2 genomes recombinantly with endogenous AAV capsid sequences from human (AAV2/1 and AAV2/5) 15 , 30 and

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Ronald L. Wolf, Robert J. Ivnik, Kathryn A. Hirschorn, Frank W. Sharbrough, Gregory D. Cascino, and W. Richard Marsh

✓ Decreased memory and learning efficiency may follow left temporal lobectomy. Debate exists as to whether the acquired deficit is related to the size of the surgical resection. This study addresses this question by comparing changes in cognitive performance to the extent of resection of both mesial temporal structures and lateral cortex.

The authors retrospectively reviewed 47 right-handed patients who underwent left temporal lobectomy for medically intractable seizures. To examine the effects of the extent of mesial resection, the patients were divided into two groups: those with resection at the anterior 1 to 2 cm of mesial structures versus those with resection greater than 2 cm. To examine the effects of the extent of lateral cortical resection, patients were again divided into two groups: those with lateral cortex resections of 4 cm or less versus those with resections greater than 4 cm.

Statistical analyses showed no difference in cognitive outcome between the groups defined by the extent of mesial resection. Likewise, no difference in cognitive outcome was seen between the groups defined by the extent of lateral cortical resection. Associated data analyses did, however, reveal a negative correlation of cognitive change with patient age at seizure onset. These results showed that the neurocognitive consequences of extended mesial resections were similar to those of limited mesial resections, and that the neurocognitive consequences of extended lateral cortical resections were similar to those of limited lateral cortical resections. The risk of cognitive impairment depends more on age at seizure onset than on the extent of mesial or lateral resection.

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Vin-Cent Wu, Tao-Min Huang, Chih-Chung Shiao, Chun-Fu Lai, Pi-Ru Tsai, Wei-Jie Wang, Hui-Yu Huang, Kuo-Chuan Wang, Wen-Je Ko, Kwan-Dun Wu, and NSARF Group

ICP compared with CVVH. 30 On the other hand, CVVH can increase the patient tolerance to volume removal and preserved myocardial contractility 35 and cause fewer changes in ICP and cerebral perfusion pressure than intermittent hemodialysis due to smaller changes in plasma osmolality and cardiovascular stability based on the convective transport. 8 However, the necessary use of anticoagulation is a shortcoming of CVVH in critical patients with brain hemorrhage. Later on, a hybrid form of intermittent RRT termed SLED was developed. 42 Sustained low-efficiency

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Eric Z. Herring, Matthew R. Peck, Caroline E. Vonck, Gabriel A. Smith, Thomas E. Mroz, and Michael P. Steinmetz

S pine surgery in the United States continues to grow at a steady rate, and surgical volume over the last decade has exceeded the supply of spine surgeons. 16 , 17 For this reason, it is imperative for spine surgeons to maximize efficiency within their practice and critically evaluate the outpatient clinic. Over half of all outpatient visits in the United States are to specialists, and evaluating the appropriate indication for a visit request (i.e., surgical yield, in the case of visits to surgeons) is critical. 1 Currently, there are many health care

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Laura B. Ngwenya, Catherine G. Suen, Phiroz E. Tarapore, Geoffrey T. Manley, and Michael C. Huang

OBJECTIVE

Blood loss and moderate anemia are common in patients with traumatic brain injury (TBI). However, despite evidence of the ill effects and expense of the transfusion of packed red blood cells, restrictive transfusion practices have not been universally adopted for patients with TBI. At a Level I trauma center, the authors compared patients with TBI who were managed with a restrictive (target hemoglobin level > 7 g/dl) versus a liberal (target hemoglobin level > 10 g/dl) transfusion protocol. This study evaluated the safety and cost-efficiency of a hospital-wide change to a restrictive transfusion protocol.

METHODS

A retrospective analysis of patients with TBI who were admitted to the intensive care unit (ICU) between January 2011 and September 2015 was performed. Patients < 16 years of age and those who died within 24 hours of admission were excluded. Demographic data and injury characteristics were compared between groups. Multivariable regression analyses were used to assess hospital outcome measures and mortality rates. Estimates from an activity-based cost analysis model were used to detect changes in cost with transfusion protocol.

RESULTS

A total of 1565 patients with TBI admitted to the ICU were included in the study. Multivariable analysis showed that a restrictive transfusion strategy was associated with fewer days of fever (p = 0.01) and that patients who received a transfusion had a larger fever burden. ICU length of stay, ventilator days, incidence of lung injury, thromboembolic events, and mortality rates were not significantly different between transfusion protocol groups. A restrictive transfusion protocol saved approximately $115,000 annually in hospital direct and indirect costs.

CONCLUSIONS

To the authors’ knowledge, this is the largest study to date to compare transfusion protocols in patients with TBI. The results demonstrate that a hospital-wide change to a restrictive transfusion protocol is safe and cost-effective in patients with TBI.

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Allen L. Ho, Eric S. Sussman, Arjun V. Pendharkar, Scheherazade Le, Alessandra Mantovani, Alaine C. Keebaugh, David R. Drover, Gerald A. Grant, Max Wintermark, and Casey H. Halpern

. This is, at least in part, due to familiarity with existing stereotactic technology and logistical concerns related to implementing a new stereotactic system outside the comfort of the traditional OR setting. As the popularity of and indications for MRgLITT continue to grow, it is essential to critically assess its limitations and obstacles and identify modifications that may optimize the efficacy and efficiency of this technology. Here, we review our experience with 2 stereotactic platforms for laser fiber placement: 1) the Vertek Biopsy Solution (Medtronic), used