Search results for: knee replacement surgery

Authors: Ratna Farida Soenarto, Anas Alatas, Made Ryan Kharmayani

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Background: Conventional ultrafiltration (CUF) system was shown to be helpful in reducing anti-inflammatory mediators for patients who underwent open heart surgery. Additionally, modified ultrafiltration (MUF) has been shown to reduce anti-inflammatory mediators further while reducing interstitial fluid volume at the same time. However, there has been minimal data concerning the efficacy of combining both ultrafiltration methods. This study aims to compare inflammation marker, vascular resistance, and cardiac index on CUF+MUF patients with CUF only patients undergoing open heart surgery. Method: This is a single blind randomized controlled trial on patients undergoing open heart surgery between June 2021 - October 2021 in CiptoMangunkusumo National Referral Hospital and Jakarta Heart Hospital. Patients wererandomized using block randomization into modified ultrafiltration following conventional ultrafiltration (CUF+MUF) and conventional ultrafiltration (CUF) only. Outcome assessed in this study were 24-hoursinterleukin-6 levels, systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), and cardiac index. Results: A total of 38patients were included (19 CUF+MUF and 19 CUF subjects). There was no difference in postoperative IL-6 level between groups (p > 0.05).No difference in PVR was observed between groups.Higher difference in SVR was observed in CUF+MUF group (-646 vs. -261dyn/s/cm-5, p < 0.05). Higher cardiac index was observed on CUF+MUF group (0.93 vs. 0.48, p < 0.05). Conclusion: Patients undergoing open heart surgery with modified ultrafiltration following conventional ultrafiltration had similar systemic inflammatory response and better cardiac response than those having conventional ultrafiltration.

Keywords: open-heart, CUF, MUF, SVR, PVR, IL-6

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Authors: Naruemon Prapasuwannakul, Supitcha Boonchai, Nawapat Pengpengpit

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The aim of this study was to determine physicochemical and sensory properties of germinated brown rice ice cream as affected by replacement of cream, milk, stabilizer, and emulsifier with green coconut pulp. Five different formulations of ice cream were performed. Regular formulation of ice cream consisted of GBR juice, milk cream, milk powder, stabilizer, emulsifier, sucrose and salt. Replacing of cream, milk, stabilizer, and emulsifier with coconut pulp resulted in an increase in viscosity and overrun, but a decrease in hardness, melting rate, lightness (l*) and redness (a*). However, there was no significant difference among all formulations on any sensory attributes. The results also showed that the ice cream with replacement of coconut pulp contained less fat and protein than those of the regular ice cream. The findings suggested that green coconut pulp can be used as alternative ingredient to replace fat, milk stabilizer and emulsifier even in a high carbohydrate ice cream formulation.

Keywords: ice cream, germinated brown rice, coconut pulp, milk, cream

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Authors: Nitesh Kumar, Adel Elrasheed, Antonio Gagliardilugo

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Introduction and aims: PRP has been increasing in popularity over the past decade. It is used in many facets of medicine and dentistry such as osteoarthritis, hair loss, skin rejunavation, healing of tendons after injury. Due to the increasing popularity of PRP in third molar surgery in dentistry, this study aims to identify the role of platelet rich plasma and its function in third molar surgery. Methodology: Three databases were chosen to source the articles for review: pubmed, science direct, and Cochrane. The keywords “platelet rich plasma”, “third molar extraction” and “wisdom tooth extraction” and literature review were used to search for relevant articles. Articles that were not in English were omitted and only systematic reviews relevant to the study were collected. All systematic reviews abstracts pertinent to the study were read by two reviewers to avoid bias. Results/statistics: 20 review articles were obtained of which 13 fulfilled the criteria. The Amstar tool validified the strength of these review articles. There is strong evidence in the literature that PRP in third molar surgery decreases post op pain, swelling and recovery time. 20 review articles were obtained of which 13 fulfilled the criteria. The Amstar tool validified the strength of these review articles. There is strong evidence in the literature that PRP in third molar surgery decreases post op pain, swelling and recovery time. Conclusions/clinical relevance: Platelet rich plasma plays a crucial role in patient recovery following the extraction of third molars and should be considered and offered as a routine part of third molar therapy.

Keywords: PRP, third molar, extractions, wisdom teeth

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Authors: Amal A. Mashali, Omar Eltaweel, Elerian Ekladious

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Stature of an individual has an important role in identification, which is often required in medico-legal practice. The estimation of stature is an important step in the identification of dismembered remains or when only a part of a skeleton is only available as in major disasters or with mutilation. There is no published data on anthropological data among Jordanian population. The present study was designed in order to find out relationship of stature to some anthropometric measures among a sample of Jordanian population and to determine the most accurate and reliable one in predicting the stature of an individual. A cross sectional study was conducted on 336 adult healthy volunteers , free of bone diseases, nutritional diseases and abnormalities in the extremities after taking their consent. Students of Faculty of Medicine, Mutah University helped in collecting the data. The anthropometric measurements (anatomically defined) were stature, humerus length, hand length and breadth, foot length and breadth, foot index and knee height on both right and left sides of the body. The measurements were typical on both sides of the bodies of the studied samples. All the anthropologic data showed significant relation with age except the knee height. There was a significant difference between male and female measurements except for the foot index where F= 0.269. There was a significant positive correlation between the different measures and the stature of the individuals. Three equations were developed for estimation of stature. The most sensitive measure for prediction of a stature was found to be the humerus length.

Keywords: foot index, foot length, hand length, humerus length, stature

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Authors: Abdoullah Namdar, Fadzil Mat Yahaya

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The waste agriculture materials cause environment pollution, recycle of these materials help sustainable development. This study focused on the impact of used oil palm shell ash on the compressive and flexural strengths of cement mortar. Two different cement mortar mixes have been designed to investigate the impact of oil palm shell ash on strengths of cement mortar. Quantity of 4% oil palm shell ash has been replaced in cement mortar. The main objective of this paper is, to modify mechanical properties of cement mortar by replacement of oil palm ash in it at early age of seven days. The results have been revealed optimum quantity of oil palm ash for replacement in cement mortar. The deflection, load to failure, time to failure of compressive strength and flexural strength of all specimens have significantly been improved. The stress-strain behavior has been indicated ability of modified cement mortar in control stress path and strain. The micro property of cement paste has not been investigated.

Keywords: minerals, additive, flexural strength, compressive strength, modulus of elasticity

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Authors: R. Boudjelthia

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The aim of this study is to determine the influence of mix composition of concrete as the content of water and cement, water–binder ratio, and the replacement of fly ash on the durability of self compacting concrete (SCC) by using artificial neural networks (ANNs). To achieve this, an ANNs model is developed to predict the durability of self compacting concrete which is expressed in terms of chloride ions permeability in accordance with ASTM C1202-97 or AASHTO T277. Database gathered from the literature for the training and testing the model. A sensitivity analysis was also conducted using the trained and tested ANN model to investigate the effect of fly ash on the durability of SCC. The results indicate that the developed model is reliable and accurate. the durability of SCC expressed in terms of total charge passed over a 6-h period can be significantly improved by using at least 25% fly ash as replacement of cement. This study show that artificial neural network have strong potentialas a feasible tool for predicting accurately the durability of SCC containing fly ash.

Keywords: artificial neural networks, durability, chloride ions permeability, self compacting concrete

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Authors: Estelle Démoulin, Dionysios Adamopoulos, Tornike Sologashvili, Mathieu Van Steenberghe, Jalal Jolou, Haran Burri, Christoph Huber, Mustafa Cikirikcioglu

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Background & objective: Mitral valve surgeries are mainly performed by median sternotomy with conventional direct atriotomy. Good exposure to the mitral valve is challenging, especially for acute pathologies, where left atrium dilation does not occur. Other atriotomies, such as transseptal or superior septal, are used as they allow better access and visualization. Peri- and postoperative outcomes of these three different left atriotomies were compared. Methods: Patients undergoing mitral valve surgery between January 2010 and December 2020 were included and divided into three groups: group 1 (conventional direct, n=115), group 2 (transseptal, n=33) and group 3 (superior septal, n=59). To improve the sampling size, all patients underwent mitral valve surgery with or without associated procedures (CABG, aortic-tricuspid surgery, Maze procedure). The study protocol was approved by SwissEthics. Results: No difference was shown for the etiology of mitral valve disease, except endocarditis, which was more frequent in group 3 (p = 0.014). Elective surgeries and isolated mitral valve surgery were more frequent in group 1 (p = 0.008, p = 0.011) and aortic clamping and cardiopulmonary bypass were shorter (p = 0.002, p<0.001). Group 3 had more emergency procedures (p = 0.011) and longer lengths of intensive care unit and hospital stay (p = 0.000, p = 0.003). There was no difference in permanent pacemaker implantation, postoperative complications and mortality between the groups. Conclusion: Mitral valve surgeries can be safely performed using those three left atriotomies. Conventional direct may lead to shorter aortic clamping and cardiopulmonary bypass times. Superior septal is mostly used for acute pathologies, and it does not increase postoperative arrhythmias and permanent pacemaker implantation. However, intensive care unit and hospital lengths of stay were found to be longer in this group. In our opinion, this outcome is more related to the pathology and type of surgery than the incision itself.

Keywords: Mitral valve surgery, cardiac surgery, atriotomy, Operative outcomes

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Authors: A. J. Shah, Neeraj Kumar Sahu

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Reactive powder concrete (RPC) is high performance and high strength concrete which composes of very fine powdered materials like cement, sand, silica fume and quartz powder. It also constitutes steel fibre (optional) and super-plasticizer. The present study investigates the performance of reactive powder concrete with fly ash as a replacement of cement under hot water and normal water curing conditions. The replacement of cement with fly ash is done at 10%, 20%, 30% and 40%. To compare the results of cement replaced RPC and traditional RPC, the performance of various mixes is evaluated by compressive strength, flexural strength, split tensile strength and durability. The results show that with increasing percentage of fly ash, improvement in durability is observed and a slight decrease in compressive strength and flexural strength is also observed. It is observed that specimen under hot water curing showed 15 to 20 % more strength than specimens under normal water curing.

Keywords: high strength concrete, the flexural strength of RPC, compressive strength of RPC, durability

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Authors: T. S. Ramesh Babu, D. Neeraja

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This research work revealed that effect of Natural admixture (NAD) on Conventional Concrete (CC) and Class F Fly Ash(FA) blended concrete. Broiler hen egg white albumen and yellow yolk were used as Natural Admixture. Cement was replaced by Class F fly ash at various levels of 0%, 25%, 35%, 45% and 55% by its mass and NAD was added to concrete at different replacement dosages of 0%, 0.25%, 0.5%, 0.75% and 1.00% by its volume to water content and liquid to binder ratio was maintained at 0.5. For all replacement levels of FA and NAD, the mechanical properties viz unit weight, compressive strength, splitting tensile strength and modulus of elasticity of CC and Class F fly ash (FA) were studied at 7, 28, 56 and 112 days. From the results, it was concluded that 0.25% of NAD dosage was considered as optimum dosage for both CC and class F fly ash blended concrete. The studies revealed that 35% Class F fly ash blended concrete mix is concluded as optimum mix and 55% Class F fly ash blended concrete mix is concluded as economical mix with 0.25% NAD dosage.

Keywords: Class F fly ash, compressive strength, modulus of elasticity, natural admixture, splitting tensile strength, unit weight

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Authors: Arun Prasad

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Background: Robotic Bariatric Surgery is a good option for the super obese where laparoscopy demands challenging technical skills. Gastric bypass can be difficult due to inability of the robot to work in two quadrants at the same time. Lonroth technique of gastric bypass involves a totally supracolic surgery where all anastomosis are done in one quadrant only. Methods: We have done 78 robotic gastric bypass surgeries using the modified Lonroth technique. The robot is docked above the head of the patient in the midline. Camera port is placed supra umbilically. Two ports are placed on the left side of the patient and one port on the right side of the patient. An assistant port is placed between the camera port and right sided robotic port for use of stapler. Gastric pouch is made first followed by the gastrojejunostomy that is a four layered sutured anastomosis. Jejuno jejunostomy is then performed followed by a leak test and then the jejunum is divided. A 150 cm biliopancreatic limb and a 75 cm alimentary limb are finally obtained. Mesenteric and Petersen’s defects are then closed. Results: All patients had a successful robotic procedure. Mean time taken in the first 5 cases was 130 minutes. This reduced to a mean of 95 minutes in the last five cases. There were no intraoperative or post operative complications. Conclusions: While a hybrid technique of partly laparoscopic and partly robotic gastric bypass has been done at many centres, we feel using the modified Lonroth technique, a totally robotic gastric bypass surgery fully utilizes the potential of robotic bariatric surgery.

Keywords: robot, bariatric, totally robotic, gastric bypass

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Authors: Visith Siriphuwanun, Yodying Punjasawadwong, Suwinai Saengyo, Kittipan Rerkasem

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Objective: To determine incidences and factors associated with perioperative cardiac arrest in trauma patients who received anesthesia for emergency surgery. Design and setting: Retrospective cohort study in trauma patients during anesthesia for emergency surgery at a university hospital in northern Thailand country. Patients and methods: This study was permitted by the medical ethical committee, Faculty of Medicine at Maharaj Nakorn Chiang Mai Hospital, Thailand. We clarified data of 19,683 trauma patients receiving anesthesia within a decade between January 2007 to March 2016. The data analyzed patient characteristics, traumas surgery procedures, anesthesia information such as ASA physical status classification, anesthesia techniques, anesthetic drugs, location of anesthesia performed, and cardiac arrest outcomes. This study excluded the data of trauma patients who had received local anesthesia by surgeons or monitoring anesthesia care (MAC) and the patient which missing more information. The factor associated with perioperative cardiac arrest was identified with univariate analyses. Multiple regressions model for risk ratio (RR) and 95% confidence intervals (CI) were used to conduct factors correlated with perioperative cardiac arrest. The multicollinearity of all variables was examined by bivariate correlation matrix. A stepwise algorithm was chosen at a p-value less than 0.02 was selected to further multivariate analysis. A P-value of less than 0.05 was concluded as statistically significant. Measurements and results: The occurrence of perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was 170.04 per 10,000 cases. Factors associated with perioperative cardiac arrest in trauma patients were age being more than 65 years (RR=1.41, CI=1.02–1.96, p=0.039), ASA physical status 3 or higher (RR=4.19–21.58, p < 0.001), sites of surgery (intracranial, intrathoracic, upper intra-abdominal, and major vascular, each p < 0.001), cardiopulmonary comorbidities (RR=1.55, CI=1.10–2.17, p < 0.012), hemodynamic instability with shock prior to receiving anesthesia (RR=1.60, CI=1.21–2.11, p < 0.001) , special techniques for surgery such as cardiopulmonary bypass (CPB) and hypotensive techniques (RR=5.55, CI=2.01–15.36, p=0.001; RR=6.24, CI=2.21–17.58, p=0.001, respectively), and patients who had a history of being alcoholic (RR=5.27, CI=4.09–6.79, p < 0.001). Conclusion: Incidence of perioperative cardiac arrest in trauma patients receiving anesthesia for emergency surgery was very high and correlated with many factors, especially age of patient and cardiopulmonary comorbidities, patient having a history of alcoholic addiction, increasing ASA physical status, preoperative shock, special techniques for surgery, and sites of surgery including brain, thorax, abdomen, and major vascular region. Anesthesiologists and multidisciplinary teams in pre- and perioperative periods should remain alert for warning signs of pre-cardiac arrest and be quick to manage the high-risk group of surgical trauma patients. Furthermore, a healthcare policy should be promoted for protecting against accidents in high-risk groups of the population as well.

Keywords: perioperative cardiac arrest, trauma patients, emergency surgery, anesthesia, factors risk, incidence

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Authors: Benmalek M. Larbi, R. Harbi, S. Boukor

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This paper reports an experimental work that aimed to investigate the effects of clay brick waste, as part of fine aggregate, on rendering mortar performance. The brick, in crushed form, was from a local brick manufacturer that was rejected due to being of-standard. It was used to replace 33.33 %, 50 %, 66.66 % and 100 % by weight of the quarry sand in mortar. Effects of the brick replacement on the mortar key properties intended for wall plastering were investigated; these are workability, compressive strength, flexural strength, linear shrinkage, water absorption by total immersion and by capillary suction. The results showed that as the brick replacement level increased, the mortar workability reduced. The linear shrinkage increases over time and decreases with the introduction of brick waste. The compressive and flexural strengths decrease with the increase of brick waste because of their great water absorption.

Keywords: clay brick waste, mortar, properties, quarry sand

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Authors: Ceren Ince, Berkay Zafer Erdem, Shahram Derogar, Nabi Yuzer

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Fibre cement plates, often used in construction, generally are made using quartz as an inert material, cement as a binder and cellulose as a fibre. This paper first of all investigates the mechanical properties and durability of fibre cement plates when quartz is both partly and fully replaced with diatomite. Diatomite does not only have lower density compared to quartz but also has high pozzolanic activity. The main objective of this paper is the investigation of the effects of supplementary cementing materials (SCMs) on the short and long term mechanical properties and durability characteristics of fibre cement plates prepared using diatomite. Supplementary cementing materials such as ground granulated blast furnace slug (GGBS) and fly ash (FA) are used in this study. 10, 20, 30 and 40% of GGBS and FA are used as partial replacement materials to cement. Short and long term mechanical properties such as compressive and flexural strengths as well as capillary absorption, sorptivity characteristics and mass were investigated. Consistency and setting time at each replacement levels of SCMs were also recorded. The effects of using supplementary cementing materials on the carbonation and sulphate resistance of fibre cement plates were then experimented. The results, first of all, show that the use of diatomite as a full or partial replacement to quartz resulted in a systematic decrease in total mass of the fibre cement plates. The reduction of mass was largely due to the lower density and finer particle size of diatomite compared to quartz. The use of diatomite did not only reduce the mass of these plates but also increased the compressive strength significantly as a result of its high pozzolanic activity. The replacement levels of both GGBS and FA resulted in a systematic decrease in short term compressive strength with increasing replacement levels. This was essentially expected as the total heat of hydration is much lower in GGBS and FA than that of cement. Long term results however, indicated that the compressive strength of fibre cement plates prepared using both GGBS and FA increases with time and hence the compressive strength of plates prepared using SCMs is either equivalent or more than the compressive strength of plates prepared using cement alone. Durability characteristics of fibre cement plates prepared using SCMs were enhanced significantly. Measurements of capillary absorption and sopritivty characteristics were also indicated that the plates prepared using SCMs has much lower permeability compared to plates prepared cement alone. Much higher resistance to carbonation and sulphate attach were observed with plates prepared using SCMs. The results presented in this paper show that the use of SCMs does not only support the production of more sustainable construction materials but also enhances the mechanical properties and durability characteristics of fibre cement plates.

Keywords: diatomite, fibre, strength, supplementary cementing material

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Authors: Daniela Magalhaes, Jorge Pedro, Pedro Souteiro, Joao S. Neves, Sofia Castro-Oliveira, Vanessa Guerreiro, Rita Bettencourt- Silva, Maria M. Costa, Ana Varela, Joana Queiros, Paula Freitas, Davide Carvalho

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Introduction: Obesity is an independent risk factor for renal dysfunction. Our aims were: (1) evaluate the impact of bariatric surgery (BS) on renal function; (2) clarify the factors determining the postoperative evolution of the glomerular filtration rate (GFR); (3) access the occurrence of oxalate-mediated renal complications. Methods: We investigated a cohort of 1448 obese patients who underwent bariatric surgery. Those with basal GFR (GFR0) < 30mL/min or without information about the GFR 2-year post-surgery (GFR2) were excluded. Results: We included 725 patients, of whom 647 (89.2%) women, with 41 (IQR 34-51) years, a median weight of 112.4 (IQR 103.0-125.0) kg and a median BMI of 43.4 (IQR 40.6-46.9) kg/m2. Of these, 459 (63.3%) performed gastric bypass (RYGB), 144 (19.9%) placed an adjustable gastric band (AGB) and 122 (16.8%) underwent vertical gastrectomy (VG). At 2-year post-surgery, excess weight loss (EWL) was 60.1 (IQR 43.7-72.4) %. There was a significant improve of metabolic and inflammatory status, as well as a significant decrease in the proportion of patients with diabetes, arterial hypertension and dyslipidemia (p < 0.0001). At baseline, 38 (5.2%) of subjects had hyperfiltration with a GFR0 ≥ 125mL/min/1.73m2, 492 (67.9%) had a GFR0 90-124 mL/min/1.73m2, 178 (24.6%) had a GFR0 60-89 mL/min/1.73m2, and 17 (2.3%) had a GFR0 < 60 mL/min/1.73m2. GFR decreased in 63.2% of patients with hyperfiltration (ΔGFR=-2.5±7.6), and increased in 96.6% (ΔGFR=22.2±12.0) and 82.4% (ΔGFR=24.3±30.0) of the subjects with GFR0 60-89 and < 60 mL/min/1.73m2, respectively ( p < 0.0001). This trend was maintained when adjustment was made for the type of surgery performed. Of 321 patients, 10 (3.3%) had a urinary albumin excretion (UAE) > 300 mg/dL (A3), 44 (14.6%) had a UAE 30-300 mg/dL (A2) and 247 (82.1%) has a UAE < 30 mg/dL (A1). Albuminuria decreased after surgery and at 2-year follow-up only 1 (0.3%) patient had A3, 17 (5.6%) had A2 and 283 (94%) had A1 (p < 0,0001). In multivariate analysis, the variables independently associated with ΔGFR were BMI (positively) and fasting plasma glucose (negatively). During the 2-year follow-up, only 57 of the 725 patients had transient urinary excretion of calcium oxalate crystals. None has records of oxalate-mediated renal complications at our center. Conclusions: The evolution of GFR after BS seems to depend on the initial renal function, as it decreases in subjects with hyperfiltration, but tends to increase in those with renal dysfunction. Our results suggest that BS is associated with improvement of renal outcomes, without significant increase of renal complications. So, apart the clear benefits in metabolic and inflammatory status, maybe obese adults with nondialysis-dependent CKD should be referred for bariatric surgery evaluation.

Keywords: albuminuria, bariatric surgery, glomerular filtration rate, renal function

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Authors: Ramanish Ravishankar, Azar Hussain, Mahmoud Loubani, Mubarak Chaudhry

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Background and Aims: Currently, there are no strict guidelines in cardiopulmonary bypass temperature management in cardiac surgery not involving the aortic arch. This study aims to compare patient outcomes undergoing mild hypothermia and normothermia. The aim of this study was to compare patient outcomes between mild hypothermia and normothermia undergoing on-pump cardiac surgery not involving the aortic arch. Methods: This was a retrospective cohort study from January 2015 until May 2023. Patients who underwent cardiac surgery with cardiopulmonary bypass temperatures ≥32oC were included and stratified into mild hypothermia (32oC – 35oC) and normothermia (>35oC) cohorts. Propensity matching was applied through the nearest neighbour method (1:1) using the risk factors detailed in the EuroScore using RStudio. The primary outcome was mortality. Secondary outcomes included post-op stay, intensive care unit readmission, re-admission, stroke, and renal complications. Patients who had major aortic surgery and off-pump operations were excluded. Results: Each cohort had 1675 patients. There was a significant increase in overall mortality with the mild hypothermia cohort (3.59% vs. 2.32%; p=0.04912). There was also a greater stroke incidence (2.09% vs. 1.13%; p=0.0396) and transient ischaemic attack (TIA) risk (3.1% vs. 1.49%; p=0.0027). There was no significant difference in renal complications (9.13% vs. 7.88%; p=0.2155). Conclusions: Patient’s who underwent mild hypothermia during cardiopulmonary bypass have a significantly greater mortality, stroke, and transient ischaemic attack incidence. Mild hypothermia does not appear to provide any benefit over normothermia and does not appear to provide any neuroprotective benefits. This shows different results to that of other major studies; further trials and studies need to be conducted to reach a consensus.

Keywords: cardiac surgery, therapeutic hypothermia, neuroprotection, cardiopulmonary bypass

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Authors: Tzu-Hao Li, Shie-Liang Hsieh, Han-Chieh Lin, Ying-Ying Yang

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TNF superfamily-stimulated pathogenic cascades and macrophage (M1)/kupffer cells (KC) polarization are important in the pathogenesis of ischemia-reperfusion (IR) liver injury in animals with hepatic steatosis (HS). Decoy receptor 3 (DcR3) is a common upstream inhibitor of the above-mentioned pathogenic cascades. The study evaluated whether modulation of these DcR3-related cascades was able to protect steatotic liver from IR injury. Serum and hepatic DcR3 levels were lower in patients and animals with HS. Accordingly, the effects of pharmacologic and genetic DcR3 replacement on the IR-related pathogenic changes were measured. Significantly, DcR3 replacement protected IR-Zucker(HS) rats and IR-DcR3-Tg(HS) mice from IR liver injury. The beneficial effects of DcR3 replacement were accompanied by decreased serum/hepatic TNF, soluble TNF-like cytokine 1A (TL1A), Fas ligand (Fas-L) and LIGHT, T-helper-cell-1 cytokine (INF) levels, neutrophil infiltration, M1 polarization, neutrophil-macrophage/KC-T-cell interaction, hepatocyte apoptosis and improved hepatic microcirculatory failure among animals with IR-injured steatotic livers. Additionally, TL1A, Fas-L, LIGHT and TLR4/NFB signals were found to mediate the DcR3-related protective effects of steatotic livers from IR injury. Using multimodal in vivo and in vitro approaches, we found that DcR3 was a potential agent to protect steatotic livers from IR injury by simultaneous blocking the multiple IR injury-related pathogenic changes.

Keywords: Decoy 3 receptor, ischemia-reperfusion injury, M1 polarization, TNF superfamily

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Authors: Eunjoo Lee

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Background: As the number of surgeries increases, the incidence of adverse events is likely to become more prevalent. Patients who are somewhat knowledgeable about surgery-related adverse events are more likely to engage in safety initiatives to prevent them. Objectives: To evaluate the impact of a smartphone application developed during the study to enhance patients’ knowledge of surgery-related adverse events during hospitalization. Design: Non-randomized, one group, measured pre- and post-intervention. Participants: Thirty-six hospitalized patients admitted to the orthopedics unit of a general hospital in South Korea. Methods. First, a smartphone application to enhance patients’ knowledge of surgery-related adverse events was developed through an iterative process, which included a literature review, expert consultation, and pilot testing. The application was installed on participants’ smartphones, and research assistants taught the participants to use it. Twenty-five true/false questions were used to assess patients’ knowledge of preoperative precautions (eight items), surgical site infection (five items), Foley catheter management (four items), drainage management (four items), and anesthesia-related complications (four items). Results: Overall, the percentage of correct answers increased significantly, from 57.02% to 73.82%, although answers related to a few specific topics did not increase that much. Although the patients’ understanding of drainage management and the Foley catheter did increase substantially after they used the smartphone application, it was still relatively low. Conclusions: The smartphone application developed during this study enhanced the patients’ knowledge of surgery-related adverse events during hospitalization. However, nurses must make an additional effort to help patients to understand certain topics, including drainage and Foley catheter management. Relevance to clinical practice: Insufficient patient knowledge increases the risk of adverse events during hospitalization. Nurses should take active steps to enhance patients’ knowledge of a range of safety issues during hospitalization, in order to decrease the number of surgery-related adverse events.

Keywords: patient education, patient participation, patient safety, smartphone application, surgical errors

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Authors: Wei Xu, Abdo S. Haidar, Jianxin Gao

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Prosthetic socket is a component that connects the residual limb of an amputee with an artificial prosthesis. It is widely recognized as the most critical component that determines the comfort of a patient when wearing the prosthesis in his/her daily activities. Through the socket, the body weight and its associated dynamic load are distributed and transmitted to the prosthesis during walking, running or climbing. In order to achieve a good-fit socket for an individual amputee, it is essential to obtain the biomechanical properties of the residual limb. In current clinical practices, this is achieved by a touch-and-feel approach which is highly subjective. Although there have been significant advancements in prosthetic technologies such as microprocessor controlled knee and ankle joints in the last decade, the progress in designing a comfortable socket has been rather limited. This means that the current process of socket design is still very time-consuming, and highly dependent on the expertise of the prosthetist. Supported by the state-of-the-art sensor technologies and numerical simulations, a new socket design system is being developed to help prosthetists achieve rapid design of comfortable sockets for above knee amputees. This paper reports the research work related to establishing biomechanical models for socket design. Through numerical simulation using finite element method, comprehensive relationships between pressure on residual limb and socket geometry were established. This allowed local topological adjustment for the socket so as to optimize the pressure distributions across the residual limb. When the full body weight of a patient is exerted on the residual limb, high pressures and shear forces between the residual limb and the socket occur. During numerical simulations, various hyperplastic models, namely Ogden, Yeoh and Mooney-Rivlin, were used, and their effectiveness in representing the biomechanical properties of soft tissues of the residual limb was evaluated. This also involved reverse engineering, which resulted in an optimal representative model under compression test. To validate the simulation results, a range of silicone models were fabricated. They were tested by an indentation device which yielded the force-displacement relationships. Comparisons of results obtained from FEA simulations and experimental tests showed that the Ogden model did not fit well the soft tissue material indentation data, while the Yeoh model gave the best representation of the soft tissue mechanical behavior under indentation. Compared with hyperplastic model, the result showed that elastic model also had significant errors. In addition, normal and shear stress distributions on the surface of the soft tissue model were obtained. The effect of friction in compression testing and the influence of soft tissue stiffness and testing boundary conditions were also analyzed. All these have contributed to the overall goal of designing a good-fit socket for individual above knee amputees.

Keywords: above knee amputee, finite element simulation, hyperplastic model, prosthetic socket

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Authors: Allaire Eric, Hauet Pascal, Floresco Jean, Beley Sebastien, Sussman Helene, Virag Ronald

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Background: Caverno-venous leakage (CVL) is devastating, although barely known disease, the first cause of major physical impairment in men under 25, and responsible for 50% of resistances to phosphodiesterase 5-inhibitors (PDE5-I), affecting 30 to 40% of users in this medication class. In this condition, too early blood drainage from corpora cavernosa prevents penile rigidity and penetration during sexual intercourse. The role of conservative surgery in this disease remains controversial. Aim: Assess complications and results of combined open surgery and embolization for CVL. Method: Between June 2016 and September 2021, 133 consecutive patients underwent surgery in our institution for CVL, causing severe erectile dysfunction (ED) resistance to oral medical treatment. Procedures combined vein embolization and ligation with microsurgical techniques. We performed a pre-and post-operative clinical (Erection Harness Scale: EHS) hemodynamic evaluation by duplex sonography in all patients. Before surgery, the CVL network was visualized by computed tomography cavernography. Penile EMG was performed in case of diabetes or suspected other neurological conditions. All patients were optimized for hormonal status—data we prospectively recorded. Results: Clinical signs suggesting CVL were ED since age lower than 25, loss of erection when changing position, penile rigidity varying according to the position. Main complications were minor pulmonary embolism in 2 patients, one after airline travel, one with Factor V Leiden heterozygote mutation, one infection and three hematomas requiring reoperation, one decreased gland sensitivity lasting for more than one year. Mean pre-operative pharmacologic EHS was 2.37+/-0.64, mean pharmacologic post-operative EHS was 3.21+/-0.60, p<0.0001 (paired t-test). The mean EHS variation was 0.87+/-0.74. After surgery, 81.5% of patients had a pharmacologic EHS equal to or over 3, allowing for intercourse with penetration. Three patients (2.2%) experienced lower post-operative EHS. The main cause of failure was leakage from the deep dorsal aspect of the corpus cavernosa. In a 14 months follow-up, 83.2% of patients had a clinical EHS equal to or over 3, allowing for sexual intercourse with penetration, one-third of them without any medication. 5 patients had a penile implant after unsuccessful conservative surgery. Conclusion: Open surgery combined with embolization for CVL is an efficient approach to CVL causing severe erectile dysfunction.

Keywords: erectile dysfunction, cavernovenous leakage, surgery, embolization, treatment, result, complications, penile duplex sonography

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Authors: Lamia Bensissaid

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Goals: Endometriosis affects 6 to 10% of women of childbearing age. 17 to 44% of them have ovarian endometriomas. Medical and surgical treatments represent the two therapeutic axes with which PMA can be associated. Laparoscopic intraperitoneal ovarian cystectomy is described as the reference technique in the management of endometriomas by learned societies (CNGOF, ESHRE, NICE). However, it leads to a significant short-term reduction in the AMH level and the number of antral follicles, especially in cases of bilateral cystectomy, large cyst size or cystectomy after recurrence. Often, the disease is at an advanced stage with several surgical patients. Most have adhesions, which increase the risk of surgical complications and suboptimal resection and, therefore recurrence of the cyst. These results led to a change of opinion towards a conservative approach. Sclerotherapy is an old technique which acts by fibrinoid necrosis. It consists of injecting a sclerosing agent into the cyst cavity. Results : Recurrence was less than 15% for a 12-month follow-up; these rates are comparable to those of surgery. It does not seem to have a negative impact on ovarian reserve, but this is not sufficiently evaluated. It has an advantage in IVF pregnancy rates compared to cystectomy, particularly in cases of recurrent endometriomas. It has the advantages: · To be done on an outpatient basis. · To be inexpensive. · To avoid sometimes difficult and iterative surgery: · To allow an increase in pregnancy rates and the preservation of the ovarian reserve compared to iterative surgery. · of great interest in cases of bilateral endometriomas (kissing ovaries) or recurrent endometriomas. Conclusions: Ethanol sclerotherapy could be a good alternative to surgery.

Keywords: Endometrioma, Sclerotherapy, infertility, Ethanol

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Authors: Rebin Mzhda Mohammed, Hoshmand Ali Hama Agha

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Excess skin, often consequential to substantial weight loss or the aging process, introduces physical discomfort, obstructs daily activities, and undermines an individual's self-esteem. As these challenges become increasingly prevalent, the need to explore viable solutions grows in significance. Extra skin removal surgery, colloquially known as body contouring surgery, has emerged as a compelling intervention to ameliorate the physical and psychological burdens of excess skin. This study undertakes a comprehensive review to illuminate the intricacies of extra skin removal surgery, encompassing its diverse procedures, associated risks, benefits, and psychological implications on patients. The methodological approach adopted involves a systematic and exhaustive review of pertinent scholarly literature sourced from reputable databases, including PubMed, Google Scholar, and specialized cosmetic surgery journals. Articles are meticulously curated based on their relevance, credibility, and recency. Subsequently, data from these sources are synthesized and categorized, facilitating a comprehensive understanding of the subject matter. Qualitative analysis serves to unravel the nuanced psychological effects, while quantitative data, where available, are harnessed to underpin the study's conclusions. In terms of major findings, the research underscores the manifold advantages of extra skin removal surgery. Patients experience a notable improvement in physical comfort, amplified mobility, enhanced self-confidence, and a newfound ability to don clothing comfortably. Nonetheless, the benefits are juxtaposed with potential risks, encompassing infection, scarring, hematoma, delayed healing, and the challenge of achieving symmetry. A salient discovery is the profound psychological impact of the surgery, as patients consistently report elevated body image satisfaction, heightened self-esteem, and a substantial enhancement in overall quality of life. In summation, this research accentuates the pivotal role of extra skin removal surgery in ameliorating the intricate interplay of physical and psychological difficulties posed by excess skin. By elucidating the diverse procedures, associated risks, and psychological outcomes, the study contributes to a comprehensive and informed comprehension of the surgery's multifaceted effects. Therefore, individuals contemplating this transformative surgical option are equipped with comprehensive insights, ultimately fostering informed decision-making, guided by the expertise of medical professionals.

Keywords: extra skin removal surgery, body contouring, abdominoplasty, brachioplasty, thigh lift, body lift, benefits, risks, psychological effects

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Authors: Samar Mousa, Rebecca Shirley

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Injuries to the hand account for 20% of all emergency department attendances, with an estimated annual treatment cost of over £100 million in the UK. Functional impairments as a result of hand injuries often necessitate absence from employment, resulting in reduced productivity estimated to incur an additional £600m loss to the UK economy. Appropriate and early management is vital to preserve anatomy, prevent stiffness and allow function. The initial assessment and management of hand injuries are usually undertaken by junior staff, many of whom have little or no training or experience in splinting hand fractures. In our plastic surgery department at Stoke Mandeville hospital Buckinghamshire trust, we carried out an audit project to detect errors in hand splinting in the period between April 2022 and July 2022 and find out measures to support junior doctors, nurses and hand therapists in providing the best possible care for hand trauma patients. Our standards were The British Society for Surgery of the Hand (BSSH) standard of care in hand trauma, AO surgery reference and Stoke Mandeville hospital hand therapy mini protocol Feb 2022 During the period of 4 months, 5 cases were identified. Two cases of wrong splint choice, two cases of early removal of the splint and one tight splint that required change. In order to avoid those mistakes, a training program was given to junior doctors and nurses in collaboration with the hand therapy team regarding ways of splinting the hand in different injuries like fractures, tendons injuries, muscle injuries and ligamentous injuries. In addition to, a poster hung in the examination rooms and theatres to help junior doctors reach the correct decision.

Keywords: splinting, hand trauma, plastic surgery, tendon injury, hand fracrture

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Authors: M. F. M. Ali, A. R. Ismail, B. M. Deros

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Soccer is very popular and ranked as the top sports in the world as well as in Malaysia. Although soccer sport in Malaysia is currently professionalized, but it’s plunging achievements within recent years continue and are not to be proud of. After review, the Malaysian soccer players are still weak in terms of kicking techniques. The instep kick is a technique, which is often used in soccer for the purpose of short passes and making a scoring. This study presents the 3D biomechanics analysis on a soccer player during performing instep kick. This study was conducted to determine the optimization value for approach angle, distance of supporting leg from the ball and ball internal pressure respect to the knee angular velocity of the ball on the kicking leg. Six subjects from different categories using dominant right leg and free from any injury were selected to take part in this study. Subjects were asked to perform one step instep kick according to the setting for the variables with different parameter. Data analysis was performed using 3 Dimensional “Qualisys Track Manager” system and will focused on the bottom of the body from the waist to the ankle. For this purpose, the marker will be attached to the bottom of the body before the kicking is perform by the subjects. Statistical analysis was conducted by using Minitab software using Response Surface Method through Box-Behnken design. The results of this study found the optimization values for all three parameters, namely the approach angle, 53.6º, distance of supporting leg from the ball, 8.84sm and ball internal pressure, 0.9bar with knee angular velocity, 779.27 degrees/sec have been produced.

Keywords: biomechanics, instep kick, soccer, optimization

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Authors: Majid Farsadrouh Rashti, Amir Shafiee Kisomi, Parisa Jahani

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The direct ethanol fuel cells (DEFCs) are contemplated as a promising energy source because, In addition to being used in portable electronic devices, it is also used for electric vehicles. The synthesis of bimetallic nanostructures due to their novel optical, catalytic and electronic characteristic which is precisely in contrast to their monometallic counterparts is attracting extensive attention. Galvanic replacement (sometimes is named to as cementation or immersion plating) is an uncomplicated and effective technique for making nanostructures (such as core-shell) of different metals, semiconductors, and their application in DEFCs. The replacement of galvanic does not need any external power supply compared to electrodeposition. In addition, it is different from electroless deposition because there is no need for a reducing agent to replace galvanizing. In this paper, a fast method for the palladium (Pd) wire nanostructures synthesis with the great surface area through galvanic replacement reaction utilizing copper nanowires (CuNWS) as a template by the assistance of ultrasound under room temperature condition is proposed. To evaluate the morphology and composition of Pd@ Copper nanowires/MultiWalled Carbon nanotubes-Chitosan, emission scanning electron microscopy, energy dispersive X-ray spectroscopy were applied. In order to measure the phase structure of the electrocatalysts were performed via room temperature X-ray powder diffraction (XRD) applying an X-ray diffractometer. Various electrochemical techniques including chronoamperometry and cyclic voltammetry were utilized for the electrocatalytic activity of ethanol electrooxidation and durability in basic solution. Pd@ Copper nanowires/MultiWalled Carbon nanotubes-Chitosan catalyst demonstrated substantially enhanced performance and long-term stability for ethanol electrooxidation in the basic solution in comparison to commercial Pd/C that demonstrated the potential in utilizing Pd@ Copper nanowires/MultiWalled Carbon nanotubes-Chitosan as efficient catalysts towards ethanol oxidation. Noticeably, the Pd@ Copper nanowires/MultiWalled Carbon nanotubes-Chitosan presented excellent catalytic activities with a peak current density of 320.73 mAcm² which was 9.5 times more than in comparison to Pd/C (34.2133 mAcm²). Additionally, activation energy thermodynamic and kinetic evaluations revealed that the Pd@ Copper nanowires/MultiWalled Carbon nanotubes-Chitosan catalyst has lower compared to Pd/C which leads to a lower energy barrier and an excellent charge transfer rate towards ethanol oxidation.

Keywords: core-shell structure, electrocatalyst, ethanol oxidation, galvanic replacement reaction

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Authors: Ayat E. Ali, Christeen R. Aziz, Merna A. Helmy, Mohammed M. Malek, Sherif H. El-Gohary

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Goal: Purpose of the project was to make a plastic surgery prediction by using pre-operative images for the plastic surgeries’ patients and to show this prediction on a screen to compare between the current case and the appearance after the surgery. Methods: To this aim, we implemented a software which used data from the internet for facial skin diseases, skin burns, pre-and post-images for plastic surgeries then the post- surgical prediction is done by using K-nearest neighbor (KNN). So we designed and fabricated a smart mirror divided into two parts a screen and a reflective mirror so patient's pre- and post-appearance will be showed at the same time. Results: We worked on some skin diseases like vitiligo, skin burns and wrinkles. We classified the three degrees of burns using KNN classifier with accuracy 60%. We also succeeded in segmenting the area of vitiligo. Our future work will include working on more skin diseases, classify them and give a prediction for the look after the surgery. Also we will go deeper into facial deformities and plastic surgeries like nose reshaping and face slim down. Conclusion: Our project will give a prediction relates strongly to the real look after surgery and decrease different diagnoses among doctors. Significance: The mirror may have broad societal appeal as it will make the distance between patient's satisfaction and the medical standards smaller.

Keywords: k-nearest neighbor (knn), face detection, vitiligo, bone deformity

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Authors: Juliane P. De Oliveira, Carlos H. Dos Santos, Marcia Shoji, Maria E. C. Ferreira, Natalia U. Yamaguchi

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The construction sector is considered a major generator of environmental impacts due to the high consumption of natural resources and waste generation. Thus, this article aims to evaluate the performance of a concrete produced by the partial and total replacement of natural coarse aggregate by recycled coarse aggregate, derived from the concrete residue of buildings and demolitions. The study was made by comparing the compressive strength and absorption of three different concrete traces, keeping the water/cement factor of 0.60 and changing only the proportions of recycled coarse aggregate between 0%, 50% and 100%. Traces 50% and 100% obtained good results by comparing the actual specific mass, because the material used is lighter to the natural coarse aggregate. It was concluded that the concrete produced with recycled aggregates, even with inferior results, can be used where it is not needed a structural function, giving an adequate destination to the construction and demolition waste and consequently reducing the extraction and consumption of natural resources.

Keywords: green concrete, recycled aggregate, recycling, sustainable development

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Authors: Rajan Goyal, S. Lamba, S. Annapoorni

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The indirect exchange coupled system consists of two ferromagnetic layers separated by non-magnetic spacer layer. The type of exchange coupling may be either ferro or anti-ferro depending on the thickness of the spacer layer. In the present work, the strength of exchange coupling in FePt/Al₂O₃/Fe₃Pt has been investigated by varying the thickness of the spacer layer Al₂O₃. The FePt/Al₂O₃/Fe₃Pt trilayer structure is fabricated on Si <100> single crystal substrate using sputtering technique. The thickness of FePt and Fe₃Pt is fixed at 60 nm and 2 nm respectively. The thickness of spacer layer Al₂O₃ was varied from 0 to 16 nm. The normalized hysteresis loops recorded at room temperature both in the in-plane and out of plane configuration reveals that the orientation of easy axis lies along the plane of the film. It is observed that the hysteresis loop for ts=0 nm does not exhibit any knee around H=0 indicating that the hard FePt layer and soft Fe₃Pt layer are strongly exchange coupled. However, the insertion of Al₂O₃ spacer layer of thickness ts = 0.7 nm results in appearance of a minor knee around H=0 suggesting the weakening of exchange coupling between FePt and Fe₃Pt. The disappearance of knee in hysteresis loop with further increase in thickness of the spacer layer up to 8 nm predicts the co-existence of ferromagnetic (FM) and antiferromagnetic (AFM) exchange interaction between FePt and Fe₃Pt. In addition to this, the out of plane hysteresis loop also shows an asymmetry around H=0. The exchange field Hex = (Hc↑-HC↓)/2, where Hc↑ and Hc↓ are the coercivity estimated from lower and upper branch of hysteresis loop, increases from ~ 150 Oe to ~ 700 Oe respectively. This behavior may be attributed to the uncompensated moments in the hard FePt layer and soft Fe₃Pt layer at the interface. A better insight into the variation in indirect exchange coupling has been investigated using recoil curves. It is observed that the almost closed recoil curves are obtained for ts= 0 nm up to a reverse field of ~ 5 kOe. On the other hand, the appearance of appreciable open recoil curves at lower reverse field ~ 4 kOe for ts = 0.7 nm indicates that uncoupled soft phase undergoes irreversible magnetization reversal at lower reverse field suggesting the weakening of exchange coupling. The openness of recoil curves decreases with increase in thickness of the spacer layer up to 8 nm. This behavior may be attributed to the competition between FM and AFM exchange interactions. The FM exchange coupling between FePt and Fe₃Pt due to porous nature of Al₂O₃ decreases much slower than the weak AFM coupling due to interaction between Fe ions of FePt and Fe₃Pt via O ions of Al₂O₃. The hysteresis loop has been simulated using Monte Carlo based on Metropolis algorithm to investigate the variation in strength of exchange coupling in FePt/Al₂O₃/Fe₃Pt trilayer system.

Keywords: indirect exchange coupling, MH loop, Monte Carlo simulation, recoil curve

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Authors: Chang Su Woo, Hyun Sung Park

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Useful lifetime evaluations of rail-pads were very important in design procedure to assure the safety and reliability. It is, therefore, necessary to establish a suitable criterion for the replacement period of rail pads. In this study, we performed properties and accelerated heat aging tests of rail pads considering degradation factors and all environmental conditions including operation, and then derived a lifetime prediction equation according to changes in hardness, thickness, and static spring constants in the Arrhenius plot to establish how to estimate the aging of rail pads. With the useful lifetime prediction equation, the lifetime of e-clip pads was 2.5 years when the change in hardness was 10% at 25°C; and that of f-clip pads was 1.7 years. When the change in thickness was 10%, the lifetime of e-clip pads and f-clip pads is 2.6 years respectively. The results obtained in this study to estimate the useful lifetime of rail pads for high speed trains can be used for determining the maintenance and replacement schedule for rail pads.

Keywords: rail pads, accelerated test, Arrhenius plot, useful lifetime prediction, mechanical engineering design

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Authors: Chiung-Yun Chang, Po-Chou Chen, Jiun-Shiang Tzeng, Ka-Wai Mac, Chia-Chi Hsiao, Jo-Chi Jao

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This study aimed to measure R2* relaxation rates in the liver of New Zealand White (NZW) rabbits. R2* relaxation rate has been widely used in various hepatic diseases for iron overload by quantifying iron contents in liver. R2* relaxation rate is defined as the reciprocal of T2* relaxation time and mainly depends on the composition of tissue. Different tissues would have different R2* relaxation rates. The signal intensity decay in Magnetic resonance imaging (MRI) may be characterized by R2* relaxation rates. In this study, a 1.5T GE Signa HDxt whole body MR scanner equipped with an 8-channel high resolution knee coil was used to observe R2* values in NZW rabbit’s liver and muscle. Eight healthy NZW rabbits weighted 2 ~ 2.5 kg were recruited. After anesthesia using Zoletil 50 and Rompun 2% mixture, the abdomen of rabbit was landmarked at the center of knee coil to perform 3-plane localizer scan using fast spoiled gradient echo (FSPGR) pulse sequence. Afterward, multi-planar fast gradient echo (MFGR) scans were performed with 8 various echo times (TEs) (2/4/6/8/10/12/14/16 ms) to acquire images for R2* calculations. Regions of interest (ROIs) at liver and muscle were measured using Advantage workstation. Finally, the R2* was obtained by a linear regression of ln(SI) on TE. The results showed that the longer the echo time, the smaller the signal intensity. The R2* values of liver and muscle were 44.8  10.9 s-1 and 37.4  9.5 s-1, respectively. It implies that the iron concentration of liver is higher than that of muscle. In conclusion, R2* is correlated with iron contents in tissue. The correlations between R2* and iron content in NZW rabbit might be valuable for further exploration.

Keywords: liver, magnetic resonance imaging, muscle, R2* relaxation rate

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Authors: Diane Ghanem, Whitney Kagabo, Rebecca Engels, Uma Srikumaran, Babar Shafiq

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Hospitalist co-management of orthopaedic surgery patients is a growing trend across the country. It was created as a collaborative effort to provide overarching care to patients with the goal of improving their postoperative care and decreasing in-hospital medical complications. The aim of this project is to provide a guide for implementing and optimizing a hospitalist co-management service in orthopaedic surgery. Key leaders from the hospitalist team, orthopaedic team and quality, safety and service team were identified. Multiple meetings were convened to discuss the comanagement service and determine the necessary building blocks behind an efficient and well-designed co-management framework. After meticulous deliberation, a consensus was reached on the final service agreement and a written guide was drafted. Fundamental features of the service include the identification of service stakeholders and leaders, frequent consensus meetings, a well-defined framework, with goals, program metrics and unified commands, and a regular satisfaction assessment to update and improve the program. Identified pearls for co-managing orthopaedic surgery patients are standardization, timing, adequate patient selection, and two-way feedback between hospitalists and orthopaedic surgeons to optimize the protocols. Developing a service agreement is a constant work in progress, with meetings, discussions, revisions, and multiple piloting attempts before implementation. It is a partnership created to provide hospitals with a streamlined admission process where at-risk patients are identified early, and patient care is optimized regardless of the number or nature of medical comorbidities. A wellestablished hospitalist co-management service can increase patient care quality and safety, as well as health care value.

Keywords: co-management, hospitalist co-management, implementation, orthopaedic surgery, quality improvement

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