Cardiac rehabilitation after cardiac surgery:An important underutilized treatment strategy

Physical inactivity remains in high levels after cardiac surgery,reaching up to 50%.Patients present a significant loss of functional capacity,with prominent muscle weakness after cardiac surgery due to anesthesia,surgical incision,duration of cardiopulmonary bypass,and mechanical ventilation that affects their quality of life.These complications,along with pulmonary complications after surgery,lead to extended intensive care unit(ICU)and hospital length of stay and significant mortality rates.Despite the well-known beneficial effects of cardiac rehabilitation,this treatment strategy still remains broadly underutilized in patients after cardiac surgery.Prehabilitation and ICU early mobilization have been both showed to be valid methods to improve exercise tolerance and muscle strength.Early mobilization should be adjusted to each patient’s functional capacity with progressive exercise training,from passive mobilization to more active range of motion and resistance exercises.Cardiopulmonary exercise testing remains the gold standard for exercise capacity assessment and optimal prescription of aerobic exercise intensity.During the last decade,recent advances in healthcare technology have changed cardiac rehabilitation perspectives,leading to the future of cardiac rehabilitation.By incorporating artificial intelligence,simulation,telemedicine and virtual cardiac rehabilitation,cardiac surgery patients may improve adherence and compliance,targeting to reduced hospital readmissions and decreased healthcare costs.

Developing an evidence-based and theory informed intervention to involve families in patients care after surgery: A quality improvement project

Objectives: In the post-surgical setting,active involvement of family caregivers has the potential to improve patient outcomes by prevention of surgical complications that are sensitive to fundamental care.This paper describes the development of a theoretically grounded program to enhance the active involvement of family caregivers in fundamental care for post-surgical patients.Methods: We used a quality improvement project following a multi-phase design.In Phase 1,an iterative method was used to combine evidence from a narrative review and professionals' preferences.In Phase 2,the logic model underlying the program was developed guided by four steps: (1) confirm situation,intervention aim,and target population;(2) documented expected outcomes,and outputs of the intervention;(3) identify and describe assumptions,external factors and inputs;and (4) confirm intervention components.Results: Phase 1 identified a minimum set of family involvement activities that were both supported by staff and the narrative review.In Phase 2,the logic model was developed and includes (1) the inputs (e.g.educational-and environmental support),(2) the ultimate outcomes (e.g.reduction of postoperative complications),(3) the intermediate outcomes (e.g.behavioural changes),and (4) immediate outcomes (e.g.improved knowledge,skills and attitude).Conclusions: We demonstrated how we aimed to change our practice to an environment in which family caregivers were stimulated to be actively involved in postoperative care on surgical wards,and how we took different factors into account.The description of this program may provide a solid basis for professionals to implement the family involvement program in their own setting.

Augmented reality technology for preoperative planning and intraoperative navigation during hepatobiliary surgery: A review of current methods

Background: Augmented reality(AR) technology is used to reconstruct three-dimensional(3D) images of hepatic and biliary structures from computed tomography and magnetic resonance imaging data, and to superimpose the virtual images onto a view of the surgical field. In liver surgery, these superimposed virtual images help the surgeon to visualize intrahepatic structures and therefore, to operate precisely and to improve clinical outcomes.Data Sources: The keywords "augmented reality", "liver", "laparoscopic" and "hepatectomy" were used for searching publications in the Pub Med database. The primary source of literatures was from peer-reviewed journals up to December 2016. Additional articles were identified by manual search of references found in the key articles.Results: In general, AR technology mainly includes 3D reconstruction, display, registration as well as tracking techniques and has recently been adopted gradually for liver surgeries including laparoscopy and laparotomy with video-based AR assisted laparoscopic resection as the main technical application. By applying AR technology, blood vessels and tumor structures in the liver can be displayed during surgery,which permits precise navigation during complex surgical procedures. Liver transformation and registration errors during surgery were the main factors that limit the application of AR technology.Conclusions: With recent advances, AR technologies have the potential to improve hepatobiliary surgical procedures. However, additional clinical studies will be required to evaluate AR as a tool for reducing postoperative morbidity and mortality and for the improvement of long-term clinical outcomes. Future research is needed in the fusion of multiple imaging modalities, improving biomechanical liver modeling,and enhancing image data processing and tracking technologies to increase the accuracy of current AR methods.

Enhanced recovery after surgery:Current research insights and future direction

Since the concept of enhanced recovery after surgery(ERAS)was introduced in the late 1990 s the idea of implementing specific interventions throughout the perioperative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol,leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery,rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes,described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS,e.g.,the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better,more reliable patient outcomes.

Three-dimensional printing: review of application in medicine and hepatic surgery

Three-dimensional(3D) printing(3DP) is a rapid prototyping technology that has gained increasing recognition in many different fields. Inherent accuracy and low-cost property enable applicability of 3DP in many areas, such as manufacturing, aerospace,medical, and industrial design. Recently, 3DP has gained considerable attention in the medical field. The image data can be quickly turned into physical objects by using 3DP technology. These objects are being used across a variety of surgical specialties. The shortage of cadaver specimens is a major problem in medical education. However, this concern has been solved with the emergence of 3DP model. Custom-made items can be produced by using 3DP technology. This innovation allows 3DP use in preoperative planning and surgical training. Learning is difficult among medical students because of the complex anatomical structures of the liver. Thus, 3D visualization is a useful tool in anatomy teaching and hepatic surgical training. However,conventional models do not capture haptic qualities. 3DP can produce highly accurate and complex physical models. Many types of human or animal differentiated cells can be printed successfully with the development of 3D bio-printing technology. This progress represents a valuable breakthrough that exhibits many potential uses, such as research on drug metabolism or liver disease mechanism. This technology can also be used to solve shortage of organs for transplant in the future.

Introduction of new techniques and technologies in surgery: Where is transanal total mesorectal excision today?

The introduction of new surgical techniques and technologies has traditionally been unregulated.In many settings surgeons frequently adopt novel procedures without following a structured program of implementation or supervision.The appearance of innovative technology played a pivotal role in the advancement of new surgical techniques during the industrial revolution.Innovation has been an essential component of surgical development,which led to contemporary surgical techniques such as minimally invasive surgery.Different initiatives have been developed to guide the safe introduction of new surgical techniques and other procedures.Those include comprehensive concepts such as the Idea,Development,Exploration,Assessment,Long-term study framework,which could be particularly relevant when reflecting on the novel transanal total mesorectal excision(taTME),introduced a decade ago.This relatively novel and complex procedure promised to overcome some of the major limitations of traditional surgical approaches for rectal cancer.According to the Idea,Development,Exploration,Assessment,Long-term study framework,taTME is in the phase of exploration,where there is an existing and increasing number of reports being published as the experience grows.The current management of rectal cancer is in a state of radical evolution,with multiple options that were not previously available.Ta TME is only one technique amongst many which could be part of a rectal cancer surgeon’s armamentarium;however,it requires further rigorous study and evaluation.

The impact of new technology on surgery for colorectal cancer

Advances in technology continue at a rapid pace and affect all aspects of life, including surgery. We have reviewed some of these advances and the impact they are having on the investigation and management of colorectal cancer. Modern endoscopes, with magnifying, variable stiffness and localisation capabilities are making the primary investigation of colonic cancer easier and more acceptable for patients.Imaging investigations looking at primary, metastatic and recurrent disease are shifting to digital data sets, which can be stored, reviewed remotely, potentially fused with other modalities and reconstructed as 3 dimensional (3D) images for the purposes of advanced diagnostic interpretation and computer assisted surgery. They include virtual colonoscopy, trans-rectal ultrasound, magnetic resonance imaging, positron emission tomography and radioimmunoscintigraphy. Once a colorectal carcinoma is diagnosed, the treatment options available are expanding. Colonic stents are being used to relieve large bowel obstruction, either as a palliative measure or to improve the patient's overall condition before definitive surgery. Transanal endoscopic microsurgery and minimally invasive techniques are being used with similar outcomes and a lower mortality, morbidity and hospital stay than open trans-abdominal surgery. Transanal endoscopic microsurgery allows precise excision of both benign and early malignant lesions in the mid and upper rectum. Survival of patients with inoperable hepatic metastases following radiofrequency ablation is encouraging. Robotics and telemedicine are taking surgery well into the 21(st) century. Artificial neural networks are being developed to enable us to predict the outcome for individual patients. New technology has a major impact on the way we practice surgery for colorectal cancer.

Mini-invasive surgery for colorectal cancer

Laparoscopic techniques have been extensively used for the surgical management of colorectal cancer during the last two decades. Accumulating data have demonstrated that laparoscopic colectomy is associated with better short-term outcomes and equivalent oncologic outcomes when compared with open surgery. However, some controversies regarding the oncologic quality of mini-invasive surgery for rectal cancer exist. Meanwhile, some progresses in colorectal surgery, such as robotic technology, single-incision laparoscopic surgery, natural orifice specimen extraction, and natural orifice transluminal endoscopic surgery, have been made in recent years. In this article, we review the published data and mainly focus on the current status and latest advances of mini-invasive surgery for colorectal cancer.

Hemodynamic Changes during Off-Pump Coronary Ar-tery Bypass Graft Surgery: Experience Using Pericardial Bands for Target Stabilization

Background: The off-pump coronary artery bypass graft surgery (OPCAB) may produce significant hemodynamic instability necessitating conversion to on-pump surgery. This study evaluated the hemodynamic parameters in patients undergoing OPCAB using pericardial bands for stabilization of the coronary target sites. Methods: In 250 patients undergoing OPCAB the hemodynamic parameters including continuous cardiac output and systemic venous oxygen saturation (SvO2) were recorded at baseline after pericardiotomy, during each coronary artery anastomosis at 3, 5, 10, 15 min, and after release of the pericardial bands used for target stabilization. Vasopressors were used to maintain mean arterial pressure (MAP) > 60 mmHg. Results: SvO2 and cardiac index (CI) decreased significantly after target stabilization and during all coronary anastomoses with greater decreases noted during obtuse marginal branch of left circumflex (OM) anastomosis. The MAP and heart rate were maintained without significant change but central venous pressure increased significantly during all coronary anastomoses. The significant increase in pulmonary capillary wedge pressure and mean pulmonary artery pressure were noted only during anastomosis of the left anterior descending artery. The highest dose of vasopressor was used during OM anastomosis. Conclusions: During OPCAB surgery using pericardial bands for coronary target stabilization, MAP was maintained constantly, but SvO2 and CI decreased immediately after target stabilization and reduced further during all coronary artery anastomoses. During OM anastomosis SvO2 and CI were significantly lower as compared to that of LAD and right coronary artery. Careful monitoring and management of hemodynamic variables are warranted to avoid conversion to on-pump technique.

Post-operative morbidity after neoadjuvant chemotherapy and resection for gallbladder cancer: A national surgical quality improvement program analysis

BACKGROUND Gallbladder cancer is the most common malignancy of the biliary tract.Neo-adjuvant chemotherapy(NACT)has improved overall survival by enabling R0 resection.Currently,there is no consensus of guidelines for neoadjuvant therapy in gallbladder cancer.As investigations continue to analyze the regimen and benefit of NACT for ongoing care of gallbladder cancer patients,we examined American College of Surgeons National Surgical Quality Improvement Program(NSQIP)database to determine if there was higher morbidity among the neo-adjuvant group within the 30-day post-operative period.We hypothesized patients who underwent NACT were more likely to have higher post-operative morbidity.AIM To investigate the 30-day post-operative morbidity outcomes between patients who received NACT and underwent surgery and patients who only had surgery.METHODS A retrospective analysis of the targeted hepatectomy NSQIP data between 2015 and 2019 was performed to determine if NACT in gallbladder cancer increased the risk for post-operative morbidity(bile leak,infection rate,rate of converting to open surgery,etc.)compared to the group who only had surgery.To calculate the odds ratio for the primary and secondary outcomes,a crude logistic regression was performed.RESULTS Of the 452 patients,52 patients received NACT prior to surgery.There were no statistically significant differences in the odds of morbidity between the two groups,including bile leak[odds ratio(OR),0.69;95%confidence interval(95%CI):0.16-2.10;P=0.55],superficial wound infection(OR,0.58;95%CI:0.03-3.02;P=0.61),and organ space wound infection(OR,0.63;95%CI:0.18-1.63;P=0.61).CONCLUSION There was no significant difference in the risk of 30-day post-operative morbidity between the NACT and surgery group and the surgery only group.

Hotspots and difficulties of biliary surgery in older patients

With the accelerated aging society in China,the incidence of biliary surgical diseases in the elderly has increased significantly.The clinical characteristics of these patients indicate that improving treatment outcomes and realizing healthy aging are worthy of attention.How to effectively improve the treatment effect of geriatric biliary surgical diseases has attracted widespread attention.This paper reviews and comments on the hotspots and difficulties of biliary surgery in older patients from six aspects:(1)higher morbidity associated with an aging society,(2)prevention and control of pre-operative risks,(3)extending the indications of laparoscopic surgery,(4)urgent standardization of minimally invasive surgery,(5)precise technological progress in hepatobiliary surgery,and(6)guarantee of peri-operative safety.It is of great significance to fully understand the focus of controversy,actively make use of its favorable factors,and effectively avoid its unfavorable factors,for further improving the therapeutic effects of geriatric biliary surgical diseases,and thus benefits the vast older patients with biliary surgical diseases.Accordingly,a historical record with the highest age of 93 years for laparoscopic transcystic common bile duct exploration has been created by us recently.

Integration of an enhanced recovery after surgery program for patients undergoing pituitary surgery

Evidence-based enhanced recovery after surgery(ERAS)programs aim to improve patient outcomes and shorten hospital stays.The objective of this study is to describe the development,implementation,and evolution of an ERAS protocol to optimize the perioperative management for patients undergoing endoscopic skull base surgery for pituitary tumors.A systematic review of the literature was performed,best practices were discussed with stakeholders,and institutional guidelines were established and implemented.Key performance indicators(KPI)were measured and patient-reported outcome surveys were collected.The ERAS protocol was introduced successfully at our institution.We describe the process of initiation of the program and the perioperative management of our patients.We demonstrated the feasibility of integration of ERAS protocols for pituitary tumors with multidisciplinary engagement,with a particular emphasis on the use of data informatics and metrics to monitor outcomes.We expect that this approach will translate to improved quality of care for these often-complex patients.

Technological Analysis on Improvement of Hydraulic Cylinder Structure

Hydraulic equipment is widely applied in the fields of engineering construction, manufacture and mining. As the core component of hydraulic equipment, hydraulic cylinder will directly affect the whole operation of hydraulic equipment. This paper will analyze the improvement of hydraulic cylinder structure and expect to enhance its reliability and stability.

地基处理技术现状与发展

近年来我国的基础设施建设规模不断扩大,坚实的地基是确保工程建设安全与韧性的关键。因此,地基处理技术与工程品质之间的关联性愈发受到关注,这促进了地基处理技术的持续进步与发展,进而不断涌现出新的理论、技术和设备。文章简要阐述了地基处理的分类方法与发展特点,回顾了各类地基处理技术的研究现状,具体介绍了近年来复合地基技术、排水固结法、土工合成材料、高聚物注浆、固化剂、特殊土地基、大面积高填方地基和抗震地基处理技术等方面的新进展,归纳总结了地基处理智能设备、设计理论、评价方法和规范编制的发展情况。在现阶段信息化浪潮不断来袭、可持续发展作为永恒主题的新形势下,提出了地基处理技术应不懈追求“韧性、绿色、智能、人文”的品质提升的核心议题,探讨了地基处理行业各个方面的发展方向与未来展望,以期为地基处理领域的研究与技术人员提供参考和借鉴。

高质量发展下中国工业企业碳减排路径选择

管理改进与技术创新是工业企业实现高质量减排的两大关键路径。运用Shapley值分解方法实证测度了技术创新与管理改进对工业企业碳减排技术进步效率的贡献作用。结果发现,整体上技术创新与管理改进的贡献率分别为28.45%和71.55%,并且二者贡献率在不同类型特征企业之间存在明显差异。随着企业技术进步水平、雇佣规模和能耗水平的提升,技术创新的贡献率逐步递减,而管理创新的贡献率则呈现递增趋势。首次对企业管理改进与技术创新对碳排放效率的贡献进行测度,为优化“双碳”目标政策与指导企业减排行动提供有益参考。

新时代我国发起成立国际科技组织:机理、问题与路径

在科技自立自强成为国家发展战略目标与任务的大背景下,“发起成立国际科技组织”作为新时代我国国际科技交流合作新的重要形态,能够使我国在激烈的国际科技竞争中掌握战略主动。基于机理分析,我国发起成立的国际科技组织在组织属性、组织行为等维度上应具备实体化、公共化、国际化、法制化等基本要件。针对存在的主要问题,我国需要制定相关战略性整体规划、营造更开放的政策环境、出台更细化的成立审批要求和流程。在路径选择上,我国发起成立国际科技组织应遵循坚持独立自主、用好国际资源、选准学科领域、使用战略科学家等根本原则,同时,应基于自身优势和战略需求、突出组织特色和互补能力,通过组织创新的价值体现避免出现组织拥挤现象。

冲击破岩钻井提速技术研究现状与发展建议

提高钻井速度不仅是提高我国油气效益开发及深地勘探等方面的重要技术手段,同时对保障国家能源安全意义重大。冲击破岩钻井技术在国内外油田现场应用并获得了良好的提速效果,持续开展此类技术攻关有望攻克当下我国深地高温高压硬岩地层进尺低、提速难的技术痛点。介绍和分析了轴向冲击、扭力冲击和轴-扭耦合冲击辅助钻头破岩钻进技术方面的实践及发展动态。结合冲击破岩钻井技术现状,阐明了冲击辅助钻头破岩力学原理是冲击破岩钻井提速技术的关键问题,综述了国内外研究学者在冲击辅助钻头破岩物理实验、理论模型和数值模拟等研究方法上取得的科学进展。针对冲击破岩钻井提速技术的发展提出了相关建议,即加强在材料结构优化设计、智能化控制、多元技术融合和井场应用优化等方面的研究力度,为我国能源高效开发做出贡献。

工程教育认证理念下电力电子技术课程思政教学改革研究

在浙江理工大学电力电子技术课程学情基础上,引入工程教育认证理念,提出电力电子技术课程思政教学改革思路和方法。首先制定融合工程教育认证理念和课程思政的教学新目标,其次根据思政教育新目标对电力电子技术的教学内容进行改革,接着提出电力电子技术课程思政教育的教学新方法,最后引入多元考评手段,形成有效的持续改进机制。通过电力电子技术课程思政教育教学改革,力求达到思想教育润物无声的效果。

红土镍矿酸浸渣综合利用进展

近年来随着不锈钢及新能源用镍需求的增长,红土镍矿湿法提镍工艺得到更多应用,相应的红土镍矿酸浸渣堆存量也迅速增加,对此类固废进行科学消纳和资源综合利用迫在眉睫。针对红土镍矿酸浸渣有害元素硫、有价金属铁含量高的特点进行综合利用新技术、新装备研究对红土镍矿湿法冶金工业的持续发展具有重要的理论和现实意义。主要介绍红土镍矿酸浸渣的湿法冶金形成过程及其成分组成和物理化学性质,较为系统地梳理了红土镍矿酸浸渣在尾矿坝堆积、地下压滤回填和深海填埋等直接处理方法,提取利用铁、铬、铝、稀土等有价金属资源,消纳制备硅藻土、陶粒、矿物纤维等建筑材料、制备锂电池电极、沸石等高附加值材料综合利用技术上的研究进展,展望了红土镍矿酸浸渣流态化提铁降硫技术及装备的发展前景。

混合现实技术在口腔颌面部肿瘤诊疗中的应用

口腔颌面部肿瘤是口腔颌面外科的常见疾病,以虚拟手术设计、手术导航为代表的数字化外科技术目前已成为口腔颌面部肿瘤外科诊治的主要辅助手段。然而,现有的数字化技术在三维可视化成像、术中手眼配合等方面仍存在提升空间。目前,以混合现实技术为代表的三维可视化技术已经在医学领域迅速发展和应用,通过将三维虚拟图像叠加到真实的手术环境中,可辅助实现医学影像实时立体呈现,已逐步应用于口腔颌面部肿瘤的诊治中。术前可基于影像数据构建肿瘤及其周边重要结构三维模型,在混合现实环境中,进行个性化术前评估和手术方案设计;术中将混合现实技术与手术导航技术相结合,可以在术区真实环境中实时显示三维虚拟模型,克服单纯使用导航技术的手眼协调问题,进一步提高口腔颌面部肿瘤手术的精确性和安全性。混合现实技术与远程互联网医疗技术相结合,还可以提供高质量的教学平台,推动地区口腔颌面外科诊疗水平的发展。混合现实技术的局限性主要在于术区影像遮挡、单纯使用时精度不足、配准时间长等。笔者结合国内外文献报道以及本课题组的临床实践,对混合现实技术在口腔颌面部肿瘤诊疗中的应用进行归纳与总结。