Добірка наукової літератури з теми "Low-invasive procedure"

Background The David procedure is a well-known technique in selected patients with aortic root pathology. A minimally invasive approach in heart surgery increases open interest. Methods From 1991 to 2015, the David technique was performed in 296 patients in our unit. In 90 cases, operations were performed through partial upper sternotomy. The patient mean age was 57 ± 14 years in the minimally invasive group (n = 90) and 58 ± 14 years in the complete sternotomy group (n = 206; p = 0.2). The neosinus modification was performed in 80 patients (89%) in the minimally invasive group and in 79 patients (38%) in the complete sternotomy group (p < 0.01). Mean follow-up was 3 ± 2 years in the minimally invasive group and 8 ± 4 years in the complete sternotomy group. Results Thirty-day mortality was zero in the minimally invasive group and was 3% (n = 6) in the complete sternotomy group (p = 0.1). The need for packed red blood cells was significantly lower in the minimally invasive group (1.6 ± 3 U) than in the complete sternotomy group (3.7 ± 6 U; p < 0.01). Thirty late deaths (2% per patient-year) were observed in the complete sternotomy group versus zero in the minimally invasive group (p < 0.01). One patient (0.5% per patient-year) in the minimally invasive group and 12 patients (0.8% per patient-year) in the complete sternotomy group required reoperation in the follow-up period (p = 0.05). Conclusions Minimally invasive David technique for patients with ascending aortic aneurysm and aortic valve insufficiency offers a good solution with low perioperative blood transfusion rate. Our midterm results show low valve-related complications and reoperation rate. However, long-term follow-up of the minimally invasive group is necessary.

PurposeTo assess the prevalence and predictors of complications after prostate brachytherapy in a population-based sample of older men.Patients and MethodsWe analyzed claims for Medicare-enrolled men older than age 65 years living in Surveillance, Epidemiology, and End Results (SEER) surveillance areas diagnosed with prostate cancer from 1991 to 1999 who underwent brachytherapy as initial treatment.ResultsThere were 5,621 men who had brachytherapy with at least 2 years of follow-up. A complication diagnosis or invasive procedure occurred in 54.5% of men within 2 years, with 14.1% undergoing an invasive procedure. Urinary, bowel, and erectile morbidity rates were 33.8%, 21.0%, and 16.7%, respectively, and invasive procedure rates were 10.3%, 0.8%, and 4.0%, respectively. On multivariable analysis, combined urinary diagnoses and invasive procedures (obstruction, incontinence, bleeding, fistula) were associated with older age (P < .01), nonwhite race (odds ratio [OR], 1.30; P = .01), low income (OR, 1.74; P < .01), external-beam radiotherapy (EBRT; OR, 0.85; P = .01), androgen deprivation (OR, 1.31; P < .01), later year of brachytherapy (OR, 1.03/yr; P = .02), higher Charlson comorbidity score (P < .01), and prior transurethral resection of the prostate (OR, 1.65; P < .01). Bowel morbidity (bleeding/proctitis, injury) was associated with older age (P = .04), EBRT (OR, 1.46; P < .01), later year (OR, 1.04/yr; P < .01), higher Charlson score (P = .01), and inflammatory bowel disease (OR, 2.60; P < .01). Erectile morbidity was associated with younger age (P < .01), nonwhite race (OR, 1.37; P < .01), AD (OR, 1.18; P = .04), and later year (OR, 1.08/yr; P < .01). Invasive procedure rates declined with later year of brachytherapy (OR, 0.93/yr; P < .01).ConclusionMorbidity after prostate brachytherapy was common, though invasive procedures were required infrequently. Invasive procedures for complications declined during the 1990s, suggesting technical improvement with experience.

The diagnosis of stable ischemic heart disease begins with a careful clinical examination of the patient and non-invasive testing to identify the disease. Patients with very low and very high pretest probability should not undergo various non-invasive tests. Various non-invasive tests are available to assess the presence of coronary heart disease in patients with an intermediate probability of ischemic heart disease (15–65%). The combination of anatomical with functional non-invasive tests helps improve diagnostic capabili of the disease.

AbstractMinimally invasive cosmetic procedures are in increasing demand worldwide. Patients are constantly searching for office-based techniques that can help improve the signs of aging but without the morbidity of a surgical procedure. Thread lifting with polydioxanone (PDO) sutures is a cosmetic procedure where lax tissue is lifted and repositioned trying to create a more youthful looking facial contour. The threads are absorbable and come in different shapes and lengths. The rate of complications and the downtime of the procedure are low, which are something patients are looking for. Ideally, these procedures should be performed by trained specialists who have complete knowledge of the facial anatomy, thus enhancing and improving results. Thread lifting with PDO absorbable threads has become an excellent option for minimally invasive facial rejuvenation procedures with a high satisfaction among patients and very few complications. It is a new tool that can be introduced in the armamentarium of specialists who work in the field of facial plastic surgery and who can offer this option to their patients with improved outcomes.

Three horses undergoing general anaesthesia for orthopaedic procedures between August 2018 and January 2019 at Langford Veterinary Equine Services, Bristol University had falsely low arterial blood pressures due to damage of the non-disposable invasive arterial blood pressure transducer interface. The invasive arterial blood pressure transducer interface is not currently a component that is checked during the anaesthetic machine check prior starting a general anaesthetic procedure. Starting treatment for hypotension based on incorrect information due to faulty equipment can have severe negative consequences for the patient, such as extreme hypertension, increased myocardial workload and oxygen demand, and reduced perfusion of splanchnic and muscle tissue due to vasoconstriction. Therefore, we recommend routinely using the square wave test and checking the integrity of the blood pressure transducer interface before starting a general anaesthetic procedure, and when unexpected hypotensive readings are obtained and/or a state of hypotension is not responsive to treatment.

Abstract Introduction Contracture scars post-burn injury often develop in areas near joints and can restrict movement as well as cause cosmetic deformities.1,2 The goal of subcutaneous scar release is to maximize mobility and minimize the need for invasive procedures which can require more recovery time and cause less aesthetically pleasing outcomes, although this new minimally invasive technique may also be used in conjunction with invasive procedures or after more invasive reconstructions to yield the best functional and cosmetic outcome. Methods Retrospective data from May 2016 to July 2019 were collected and analyzed for 28 patients ranging from ages 6 to 68 years old that were diagnosed with a subcutaneous contracture in one or more areas of their body. The data recorded included demographics, procedure specifics and outcomes, patients’ assessments, and areas of which the procedure was most frequently done on. Results Of the data available, range of motion per site improved by 19.1 degrees. Average pain scores reported directly after the procedure were relatively low at 1.5 on a 10-point scale. Vancouver Scar Scale scores decreased by 0.6 from pre-operatively (10.7) to post-operatively (10.1). The most frequently occurring areas that subcutaneous scar release was done on was the neck (15), axilla (7), and shoulder (7). Overall, 83% of patients reported being very satisfied or satisfied with the outcome of their procedure. Conclusions Subcutaneous scar release improves burn patients’ range of mobility with less residual scarring and less recovery time than standard of care treatments for scar contractures.

Objective The Ozaki procedure for aortic valve reconstruction was reported in 2014 with low mortality, a highly reproducible rate and a good midterm result. However, the procedure still requires conventional sternotomy to be accomplished. The aim of the study was to start an initial evaluation for the feasibility of the minimally invasive approach in combination with the Ozaki technique. Methods From January 06, 2017, to January 12, 2017, nine patients with severe aortic valve diseases underwent minimally invasive Ozaki procedure through an upper ministernotomy. The pericardium was harvested endoscopically using three trocars in different intercostal spaces. Then, a ministernotomy was performed and the Ozaki procedure was accomplished in a similar manner to the conventional technique. We analyzed the in-hospital mortality and complications of this group. Results The mean age was 47.4 years and 55.6% patients were female. The predominant pathology was chronic rheumatic valve disease (66.7%) and other patients were diagnosed with a bicuspid aortic valve. The mean aortic cross-clamp time was 106.8 minutes, the mean cardiopulmonary bypass time was 153.6 minutes, the mean ventilation time was 8.4 hours, and the mean intensive care unit time was 1.6 days. No mortality was recorded in our series, no conversion to full sternotomy was required, one patient experienced right hemothorax requiring drainage, and one patient required valve replacement. Intraoperative transesophageal echocardiography and predischarge transthoracic echocardiography showed five competent valves and three valves with trivial regurgitation, and no stenosis was detected. Conclusions Ministernotomy combined with Ozaki procedure might be feasible, as well as an alternative to conventional sternotomy. This approach is associated with low mortality and morbidity and may be beneficial in younger populations.

Background: Approximately 10–15% of patients on DOACs have to interrupt their anticoagulant before an invasive procedure every year. The perioperative management and monitoring of DOACs have proved to be challenging, as differences in patients’ status and in the invasiveness of each procedure develop different situations that need a tailored therapeutic approach to each patient’s needs. Methods: This review aims to summarize current evidence on the perioperative management of DOACs in patients undergoing a vascular surgical procedure focusing with a practical approach on three key clinical questions: (i) can we stop DOAC therapy before the vascular procedure? (ii) is bridging therapy necessary? and (iii) which is the best perioperative strategy for interruption and resumption of the anticoagulant therapy? Results: No specific data exist for the perioperative management of vascular surgery patients on DOACs, as most studies include low number of such patients. Therapeutic strategy on how to handle DOACs perioperatively must be based on their half-life, the bleeding risk of the invasive procedures, and on the thromboembolic risk of the patient. Renal function plays a crucial role in such situations, increasing thromboembolic and bleeding risk. In general, DOACs should be stopped 2 days for high bleed risk, 1 day for low risk and should be resumed 48-72 hrs after high risk, 24 hrs after low-risk procedure. Bridging is almost never needed. Conclusion: Further perioperative research studies on patients undergoing vascular surgery are needed to confirm whether currently accepted therapeutic perioperative strategy is appropriate for these patients.

Transfusions are among the most common medical procedures in the intensive care unit. Several randomized controlled trials (RCT) indicate that restrictive red cell transfusion practice using a haemoglobin of <7g/dL is safe in critically-ill patients. Although similar RCT are not available for plasma or platelet transfusion guidelines, a large body of observational studies suggest that plasma transfusion for an invasive procedure has not been shown to be of benefit in patients with INR <2.0. Similarly, in thrombocytopenic patients, the target platelet count for bleeding or for an invasive procedure is 50,000/µl. Viral transmission risk has become exceedingly low. Other risks such as transfusion-associated circulatory overload and, to a lesser extent, transfusion-related acute lung injury, are much more common. Storage of red cells does not seem to be associated with adverse clinical outcomes. Alternatives using haemostatic agents, salvaged blood, and adherence to evidence-based transfusion guidelines probably reduce the need for transfusion in critically-ill patients.

This chapter, found in the cancer screening and management section of the book, provides a succinct synopsis of a key study examining the management of lung nodules detected by computed tomography and their risk of developing into lung cancer. This summary outlines the study methodology and design, major results, limitations and criticisms, related studies and additional information, and clinical implications. Virtual colonoscopy, using a primary 3D approach for polyp detection, was shown to be a minimally invasive procedure that is an accurate method for screening average-risk individuals. The likelihood of a clinically significant adenoma being missed on virtual colonoscopy was extremely low given the high negative predictive value. In addition to outlining the most salient features of the study, a clinical vignette and imaging example are included in order to provide relevant clinical context.

Histologic bone abnormalities begin very early in the course of chronic kidney disease. The KDIGO guidelines recommend that bone disease in patients with chronic kidney disease should be diagnosed on the basis of bone biopsy examination, with bone histomorphometry. They have also proposed a new classification system (TMV), using three key features of bone histology—turnover, mineralization, and volume—to describe bone disease in these patients. However, bone biopsy is still rarely performed today, as it involves an invasive procedure and highly specialized laboratory techniques. High-turnover bone disease (osteitis fibrosa cystica) is mainly related to secondary hyperparathyroidism and is characterized by increased rates of both bone formation and resorption, with extensive osteoclast and osteoblast activity, and a progressive increase in peritrabecular marrow space fibrosis. On the other hand, low-turnover (adynamic) bone disease involves a decline in osteoblast and osteoclast activities, reduced new bone formation and mineralization, and endosteal fibrosis. The pathophysiological mechanisms of adynamic bone include vitamin D deficiency, hyperphosphataemia, metabolic acidosis, inflammation, low oestrogen and testosterone levels, bone resistance to parathyroid hormone, and high serum fibroblast growth factor 23. Mixed uraemic osteodystrophy describes a combination of osteitis fibrosa and mineralization defect. In the past few decades, an increase in the prevalence of mixed uraemic osteodystrophy and adynamic bone disease has been observed.

This book is a detailed, evidence-based reference on the field of integrative geriatric medicine. It is intended for all healthcare providers and advocates who work with the geriatric population—in outpatient settings and nursing homes, assisted and independent living facilities, and senior community centers. In addition, it will provide valuable information for leaders and politicians who are involved with implementing policies and procedures for the care of elderly patients and who are looking for safer, less costly, and more patient-centered approaches. Integrative geriatrics is a new field of medicine that advocates for a whole-person, patient-centered, primarily non-pharmacological approach to medical care of the elderly. Most current geriatric practices overprescribe medications and procedures and underutilize non-pharmacological, low-cost, high-touch methods. Patients, however, often show reluctance toward these standard practices because they often involve invasive interventions. The practice of integrative geriatrics is rooted in lifestyle interventions, such as nutrition, movement therapies, and mind-body and spirituality approaches, that allow patients to take a different path to their health, one that utilizes pharmaceuticals and invasive procedures only when safer integrative approaches are not available or not effective.

This chapter provides an overview of the prevalence, pathophysiology, assessment, and clinical management of dyspnea, also known as shortness of breath or air hunger. This chapter describes the current understanding of the pathophysiology of dyspnea, potential causative factors, and evidence-based pharmacologic and nonpharmacologic management. Assessment of dyspnea is outlined using a biopsychosocial approach, emphasizing the understanding that dyspnea is a subjective experience, the severity of which is guided by patient perception. Evidence-based pharmacologic and nonpharmacologic interventions are offered. Guidelines for the use of opioids and benzodiazepines, invasive procedures such as tunneled catheters, and low-tech strategies such as fans to lessen the distress of dyspnea are included.

Three different guidelines of the European Society of Cardiology cover the field of percutaneous coronary interventions. Their main recommendations are the following: All patients with an ST-segment elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention as soon as possible after the first medical contact. Thrombolysis can be used as an alternative reperfusion therapy if the time delay to primary percutaneous coronary intervention is more than 2 hours. Patients with very high-risk non-ST-segment elevation acute coronary syndromes (recurrent or ongoing chest pain, profound or dynamic electrocardiogram changes, major arrhythmias, or haemodynamic instability) should undergo urgent coronary angiography within less than 2 hours after the initial hospital admissionAll moderate- to high-risk (GRACE score >140 or at least one primary high-risk criterion) non-ST-segment elevation acute coronary syndromes patients should undergo coronary angiography before discharge; the ideal timing is within 24 hours after admission for high-risk groups, and within 72 hours for moderate-risk groups. Other patients with recurrent symptoms or at least one high-risk criterion should undergo coronary angiography within 72 hours of first presentation. Low-risk non-ST-segment elevation acute coronary syndromes may be treated conservatively, and the indication for an invasive evaluation can be done, based on the evidence of ischaemia during exercise stress testing. Stents should be used during all percutaneous coronary intervention procedures, whenever technically feasible. Second-generation drug-eluting stents do not increase stent thrombosis and can be safely used in the ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome settings. Triple pharmacotherapy, consisting of aspirin, thienopyridine antiplatelet agent, and anticoagulation with heparin or bivalirudin, should be used in all percutaneous coronary intervention procedures, with glycoprotein IIb/IIIa inhibitors added in patients with a high thrombus burden and low bleeding risk.

Three different guidelines of the European Society of Cardiology cover the field of percutaneous coronary interventions. Their main recommendations are the following: All patients with an ST-segment elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention as soon as possible after the first medical contact. Thrombolysis can be used as an alternative reperfusion therapy if the time delay to primary percutaneous coronary intervention is more than 2 hours. Patients with very high-risk non-ST-segment elevation acute coronary syndromes (recurrent or ongoing chest pain, profound or dynamic electrocardiogram changes, major arrhythmias, or haemodynamic instability) should undergo urgent coronary angiography within less than 2 hours after the initial hospital admissionAll moderate- to high-risk (GRACE score >140 or at least one primary high-risk criterion) non-ST-segment elevation acute coronary syndromes patients should undergo coronary angiography before discharge; the ideal timing is within 24 hours after admission for high-risk groups, and within 72 hours for moderate-risk groups. Other patients with recurrent symptoms or at least one high-risk criterion should undergo coronary angiography within 72 hours of first presentation. Low-risk non-ST-segment elevation acute coronary syndromes may be treated conservatively, and the indication for an invasive evaluation can be done, based on the evidence of ischaemia during exercise stress testing. Stents should be used during all percutaneous coronary intervention procedures, whenever technically feasible. Second-generation drug-eluting stents do not increase stent thrombosis and can be safely used in the ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome settings. Triple pharmacotherapy, consisting of aspirin, thienopyridine antiplatelet agent, and anticoagulation with heparin or bivalirudin, should be used in all percutaneous coronary intervention procedures, with glycoprotein IIb/IIIa inhibitors added in patients with a high thrombus burden and low bleeding risk.

This chapter focuses on the economic data available for cardiovascular (CV) imaging. The total costs of testing are substantively lower than those associated with invasive procedures. There are several ongoing randomized trials, such as the PROMISE trial, that may further add to our evidence base on the cost implications of CV imaging. Data for stress nuclear cardiology supports its utility in terms of a high prognostic accuracy and that this test is economically attractive; notably for patients with a high likelihood of coronary artery disease. Data also supports that this benefit does not only include patients with known coronary artery disease but also the high likelihood subsets of the elderly or functionally impaired where ischemic findings play a fundamental role in ischemia-guided management. Importantly, more recent data support that alternative testing strategies have reduced cost in subsets of patients including lower risk women with stable chest pain and in the acute evaluation of low risk chest pain in the ED. Negative evidence is extremely important for the field of CV imaging and this more recent data should be embraced as defining our limitations in nuclear cardiology.

Three different guidelines of the European Society of Cardiology cover the field of percutaneous coronary interventions. Their main recommendations are the following:All patients with an ST-segment elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention as soon as possible after the first medical contact. Thrombolysis can be used as an alternative reperfusion therapy if the time delay to primary percutaneous coronary intervention is more than 2 hoursPatients with very high-risk non-ST-segment elevation acute coronary syndromes (recurrent or ongoing chest pain, profound or dynamic electrocardiogram changes, major arrhythmias, or haemodynamic instability) should undergo urgent coronary angiography within less than 2 hours after the initial hospital admissionAll moderate- to high-risk (GRACE score >140 or at least one primary high-risk criterion) non-ST-segment elevation acute coronary syndromes patients should undergo coronary angiography before discharge; the ideal timing is within 24 hours after admission for high-risk groups, and within 72 hours for moderate-risk groupsOther patients with recurrent symptoms or at least one high-risk criterion should undergo coronary angiography within 72 hours of first presentationLow-risk non-ST-segment elevation acute coronary syndromes may be treated conservatively, and the indication for an invasive evaluation can be done, based on the evidence of ischaemia during exercise stress testingStents should be used during all percutaneous coronary intervention procedures, whenever technically feasible. Second-generation drug-eluting stents do not increase stent thrombosis and can be safely used in the ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome settingsTriple pharmacotherapy, consisting of aspirin, thienopyridine antiplatelet agent, and anticoagulation with heparin or bivalirudin, should be used in all percutaneous coronary intervention procedures, with glycoprotein IIb/IIIa inhibitors added in patients with a high thrombus burden and low bleeding risk

Three different guidelines of the European Society of Cardiology cover the field of percutaneous coronary interventions. Their main recommendations are the following:All patients with an ST-segment elevation myocardial infarction should undergo immediate coronary angiography and percutaneous coronary intervention as soon as possible after the first medical contact. Thrombolysis can be used as an alternative reperfusion therapy if the time delay to primary percutaneous coronary intervention is more than 2 hoursPatients with very high-risk non-ST-segment elevation acute coronary syndromes (recurrent or ongoing chest pain, profound or dynamic electrocardiogram changes, major arrhythmias, or haemodynamic instability) should undergo urgent coronary angiography within less than 2 hours after the initial hospital admissionAll moderate- to high-risk (GRACE score >140 or at least one primary high-risk criterion) non-ST-segment elevation acute coronary syndromes patients should undergo coronary angiography before discharge; the ideal timing is within 24 hours after admission for high-risk groups, and within 72 hours for moderate-risk groupsOther patients with recurrent symptoms or at least one high-risk criterion should undergo coronary angiography within 72 hours of first presentationLow-risk non-ST-segment elevation acute coronary syndromes may be treated conservatively, and the indication for an invasive evaluation can be done, based on the evidence of ischaemia during exercise stress testingStents should be used during all percutaneous coronary intervention procedures, whenever technically feasible. Second-generation drug-eluting stents do not increase stent thrombosis and can be safely used in the ST-segment elevation myocardial infarction and non-ST-segment elevation acute coronary syndrome settingsTriple pharmacotherapy, consisting of aspirin, thienopyridine antiplatelet agent, and anticoagulation with heparin or bivalirudin, should be used in all percutaneous coronary intervention procedures, with glycoprotein IIb/IIIa inhibitors added in patients with a high thrombus burden and low bleeding risk

AbstractThe human species is biologically distinguished by low fertility. In fact, with each menstrual cycle, a couple at the peak of their reproductive capacity has only about a 30% chance of conceiving. The WHO states infertility as “a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected intercourse.”Assisted reproductive technology (ART) consists of all treatments or procedures that include the in vitro handling of both human oocytes and sperm or of embryos, for the purpose of establishing a pregnancy.The techniques are usually divided into three broad categories: First level techniques: Intrauterine and Intracervical Insemination (IUI/ICI), the simpler and less invasive ones, such as intrauterine insemination (IUI) with or without Intracervical Insemination (ICI) ovarian stimulation. Second level techniques: the more complex and more invasive ones that can be performed under local anesthesia or deep sedation, which differ from the basic techniques as they involve manipulation of female and male gametes and because they require in vitro fertilization. Among these techniques the IVF (In Vitro Fertilization and Embryo Transfer), ICSI (Intracytoplasmic Sperm Injection), and the possible cryopreservation of male and female gametes and embryos. Third level techniques procedures that require general anesthesia with intubation, including: laparoscopic egg retrieval, intra-tubal transfer of male and female gametes (GIFT), zygotes (ZIFT) and /or embryos (TET) laparoscopically; microsurgical sampling of gametes from the testicle: Testicular Sperm Extraction (TESE), Microsurgical Testicular Sperm Extraction (microTESE), Testicular Sperm Aspiration (TESA); microsurgical sampling of gametes from the epididymides: Percutaneous Epididymal Sperm Aspiration (PESA) and Microsurgical Epididymal Sperm Aspiration (MESA). In all assisted reproduction techniques, the seminal fluid receives a treatment able to induce capacitation “in vitro” so that the activated spermatozoa, at the threshold of the acrosomal reaction, can interact with the mature oocytes. Preimplantation Genetic Screening (PGS) and Preimplantation Genetic Diagnosis (PGD) are highly specialized procedures which involve removing three to four cells from a 5–6 day old blastocyst and testing them for chromosomal abnormalities prior to transferring the embryo into a woman’s uterus. According to data reported from the European IVF-Monitoring Consortium (EIM) for the European Society of Human Reproduction and Embryology (ESHRE), the clinical pregnancy rates (PR) per aspiration and per transfer are 28.0% and 34.8%, respectively. After ICSI, the corresponding rates are 24% and 33.5%. ART can alleviate the burden of infertility on individuals and families, but it can also present challenges to public health as evidenced by the high rates of multiple delivery, preterm delivery, and low birth-weight delivery experienced with ART.

Preoperative non-invasive testing aims to provide informed choices about the appropriateness of surgery, guide perioperative management, and assess the long-term risk of a cardiac event through identification of left ventricular dysfunction, heart valve abnormalities, and myocardial ischaemia. Preoperative non-invasive testing is not recommended routinely, but it should be considered in patients in whom initial clinical evaluation indicates increased risk for perioperative cardiac complications and who are scheduled for intermediate- or high-risk surgery. Pharmacological stress testing combined with myocardial perfusion imaging or echocardiography is more suitable than physical exercise for the detection of myocardial ischaemia in patients with limited exercise tolerance that is common in the preoperative setting. Alternatively, non-invasive coronary computed tomography angiography can identify obstructive coronary artery disease. A negative stress testing with imaging or the absence of high-risk coronary anatomy on computed tomography angiography is associated with a low incidence of perioperative cardiac events, but the positive predictive value is relatively low, that is, the risk is relatively low despite a positive result. In patients with extensive stress-induced ischaemia or extensive obstructive coronary artery disease detected by non-invasive testing, individualized perioperative management is recommended considering the potential benefit of the proposed surgical procedure, weighed against the predicted risk of adverse outcome.

Stereo-EEG (SEEG)-guided radiofrequency thermocoagulation (thermo-SEEG), is a stereotactic lesioning procedure in which the SEEG electrodes are used to deliver a radiofrequency current. This technique offers drug-resistant epileptic patients undergoing phase 2 investigations the possibility to benefit from lesions of the ictal onset zone without any additional invasive stereotactic procedure. A SEEG recording site can be considered eligible for thermo-SEEG if bipolar recordings through two adjacent contacts of the same electrode, located in cortical grey matter, show evidence of either spike-wave discharges or low-amplitude fast pattern at the onset of seizures. Electrical stimulations are systematically performed during video-SEEG recording sessions to avoid possible side-effects of a lesion. After 1-year follow-up, 45.6% of patients show greater than 50% improvement in terms of seizure frequency and 11.9% are seizure-free. Moreover, thermo-SEEG is safer than conventional surgery, with only a 3.2% rate of side-effects, which are almost always transient, including the expected ones.

This chapter reviews the complications that can occur after minimally invasive surgical fusion of the sacroiliac joint, focusing on infection and neurovascular injuries and their prevention and treatment. The sacroiliac joint has been identified as a potential pain generator in 15% to 30% of chronic low back pain and post-laminectomy syndrome patients. Minimally invasive sacroiliac joint fusion via the lateral approach is effective and better tolerated than the open surgical approach. Most of the current studies have focused on efficacy and patient satisfaction as opposed to the safety profile of the procedure. There is a dearth of literature regarding the safety of minimally invasive sacroiliac joint fusion. Over the past few years, a novel posterior approach to sacroiliac joint fusion has become more common that theoretically is safer and potentially as efficacious as the lateral approach.

Brain tumours show a low prevalence as compared to other cancer pathologies. Their impact, both in individual and social terms, far outweighs such low prevalence. Their anatomical specificity also makes them difficult to explore and treat. The use of biopsies is limited to extreme cases due to the risks involved in the surgical procedure, and non-invasive measurements are the standard for diagnostic exploration. The usual measurement techniques come in the modalities of imaging and spectroscopy. In this chapter, the authors analyze magnetic resonance spectroscopy (MRS) data from an international database and illustrate the importance of data preprocessing prior to diagnostic classification.

Sacroiliac joint fusion has become a mainstay of the treatment of low back pain for both surgeons and interventionalists. This chapter discusses proper patient selection for both open and minimally invasive sacroiliac joint fusion techniques. Topics covered are indications and contraindications for surgery as well as imaging modalities that the provider can use to ascertain the integrity of the sacroiliac joint when fusion is being considered. It is important to assess each patient’s psychiatric history and current psychiatric symptoms, weigh the benefits and the risks of the procedure, and then use clinical judgment before proceeding with surgery. A brief overview of the two most common surgical approaches (lateral and posterior), along with survivorship data, is provided. Other patient considerations include bone density, previous lumbar spine surgery, smoking history, and comorbidities such as diabetes mellitus.

Endovascular neurosurgery has evolved dramatically since the first description of aneurysm coiling in 1991 and is now employed as a primary treatment strategy for managing a multitude of cerebrovascular pathologies, including aneurysms, arteriovenous malformations (AVMs), and acute ischemic stroke. The endovascular approach offers an attractive, minimally invasive alternative for aneurysm treatment with low procedure-related morbidity and mortality. The durability and long-term efficacy of endovascular interventions is continuously evolving, especially with the introduction of newer coils, stents, and flow-diversion techniques. Endovascular management of AVMs can be used for presurgical embolization, preradiosurgical intervention, or palliative embolization or as a primary treatment for curative embolization, depending on the characteristics of the lesion. Advances in endovascular management of acute stroke have further increased the therapeutic window of recombinant tissue plasminogen activator administration using the intraarterial route and have led to the introduction of new devices for clot removal and vessel recanalization.

Bladder substitution following radical cystectomy for urothelial cancer (transitional cell carcinoma) has become increasingly common and in many centers has evolved to become the standard method of urinary diversion. Orthotopic neobladder has been a commonly used option for urinary diversion since the 1980s. Advantages of this type of diversion are the ability to avoid an ostomy, voiding function similar to the native bladder, and improved cosmesis. Robotic intracorporeal neobladder creation has demonstrated similar outcomes to open technique and represents a promising minimally invasive diversion for the future. The Studer pouch is widely used nowadays, yet there are still some drawbacks. Therefore, we designed a technique that would offer an orthotopic ureteroileal anastomosis by using a two chimney modification. This modification is simple to handle, safe and free of ureteric stricture or reflux. With low stricture rates, this modified procedure of ureterointestinal anastomosis, is worthy of further promotion.

Trigeminal neuralgia is a debilitating neuropathic condition characterized by recurrent paroxysms of shock-like pain across the distribution of the trigeminal nerve, often brought on by innocuous stimuli. Available therapies presently include symptomatic management using anti-convulsant drugs and invasive surgical procedures to target the pathogenic drivers of disease or ablate the trigeminal nerve. Radiosurgery is a treatment modality that offers a minimally invasive, low-risk alternative that has promising clinical utility in the management of refractory trigeminal neuralgia. Radiosurgical approaches like Gamma Knife (GKS) and Cyberknife (CK) utilize image-guided, algorithm-defined dose contouring to disrupt pathogenic pain signaling by delivering targeted amounts of radiation along different points on the trigeminal nerve. This chapter reviews the structure of radiotherapy paradigms, treatment protocol, major outcomes, associated risks, relative clinical utility, and areas of further research that underlie the use of CK and GKS in managing trigeminal neuralgia.

The generation of plasmin from plasminogen by plasminogen activators (fibrinolytic agents) induces a variety of effects in addition to dissolving fibrin strands, degrading fibrinogen, and inhibiting tissue factor pathway and factor VIII. It also, in high concentrations, causes platelet activation. Thus, fibrinolytic agents have both prothrombotic and antihemostatic properties—the latter of which is often augmented by the concomitant use of anticoagulants and platelet antagonists (see Chapter 12). Bleeding is the most common complication of fibrinolytic (and adjunctive antithrombotic) therapy. The most important predictors of nonintracranial hemorrhage are older age, invasive procedures, low body weight, and female sex (de Jaegre et al, 1992; GISSI 2 Investigators, 1990; GUSTO-III Investigators, 1997; INJECT Investigators, 1995). Predictors of intracranial hemorrhage include age (>65 years), low body weight (<70 kg), hypertension on admission, and alteplase (vs. streptokinase) (GUSTO-III Investigators, 1997). The approach to patient management in cases of fibrinolytic-induced bleeding is summarized in Figure 30.1. It is important to consider antithrombotic agents that may concomitantly increase hemorrhagic potential. Factor VIIa (recombinant; NovoSeven) represents a treatment alternative for life-threatening hemorrhagic complications.

Treatment for deeply seated brain tumors requires developing articulated surgical robots that are capable of navigating through narrow spaces with minimal damage to the surrounding tissues. These robots need to be low-cost to make them patient-specific as well as to reduce the health-care cost. This in turn requires lowering the manufacturing costs of the robots so that robots can be discarded after the surgical procedure. Injection molding is a mass manufacturing process for making low-cost plastic parts. We have developed a four degree-of-freedom surgical robot with multiple joints that can be manufactured using injection molding. We have designed a novel compliant mechanism to provide multiple articulated joints. The robot is currently actuated with servo motors located outside the robot that drive the joints using passive cables. Cables are routed through the robot to reduce the cross coupling between the joints and enable independent joint actuation. By detaching the actuation from the robot structure, we have made the robot suitable for operating under continuous magnetic resonance imaging (MRI).

A relatively recent and non invasive method for characterizing thermal fields generated by high intensity focused ultrasound (HIFU) transducers is Magnetic Resonance (MR) Thermometry method. However, noise signals generated by external RF sources infiltrate the scanner orifice and limit its ability to measure temperature rise during the heating or ablation phase. In this study, MRI monitored HIFU ablations are performed on freshly excised porcine liver samples, at varying sonication times, 20, 30 and 40 s at a constant acoustic intensity level of 1244 W/cm2. Temperature rise during the procedure is measured using Proton Resonant Frequency MR thermometry. Preliminary experiments without an adequate noise filter, failed to record temperature rise during the heating phase. A low pass R-C filter circuit is subsequently incorporated into the experimental set up to prevent infiltration of noise signals in the MRI orifice. This modified RC filter enables measurement of temperature rise during the heating phase followed by temperature decay during cooling. The measured data is within 12% agreement with the temperature rise computed by solving the acoustic and heat equations.

Abstract Laparoscopic surgery is a common minimally invasive procedure typically used in intestinal surgery. Several small incisions are made to allow specialized instruments to be inserted and operated in an inflated abdomen. There is limited mobility in these procedures and additional training must be completed for surgeons to become proficient. To increase the freedom of motion and reduce the required skill for the surgeon, the novel single incision, free motion (SIFM) laparoscopic surgical system is introduced. This device will allow for free motion of the tools with a single incision inside the body, using electromagnets, hydraulic, and motor actuation. Using a low friction material, an electromagnet on the outside of the skin translates the tool inside the body. Hydraulic and motor actuation allows for further control of the tool under the skin by tilting, extending and retraction. Experimentation was performed to measure the frictional forces of different materials gliding over porcine skin tissue. The results show that of the tested materials, Teflon performed the best with high consistency and low coefficients of friction across a range of pressures. Future work will explore magnetic force and actuation to work with the low friction materials of SIFM.

Irreversible electroporation (IRE) is a new non-thermal focal tissue ablation technique that uses low-energy electric pulses to destabilize cell membranes, thus achieving tissue death [1]. The procedure is minimally invasive and is performed through small electrodes inserted into the tissue with pulse delivery of about one minute. The pulses create an electric field that induces an increase in the resting transmembrane potential (TMP) of the cells [1]. Depending on the magnitude of the induced TMP, the electric pulses can have no effect, transiently increase membrane permeability, or cause cell death [1]. Our group has confirmed the safety of the procedure in brain with three experimental dogs [2]. We also treated a canine patient with IRE and radiation therapy for a non-resectable, high-grade glioma, resulting in complete remission of the tumor at four months [3].

Irreversible electroporation (IRE) is a new minimally invasive non-thermal focal ablation technique that has been used for the treatment of spontaneous tumors in canine and human patients [1–4]. The procedure involves placing electrodes into or around a tumor and delivering a series of low energy electric pulses to kill tumor tissue with sub-millimeter resolution. The pulses generate an electric field that alters the resting transmembrane potential (TMP) of the cells [1]. Depending on the magnitude of the induced TMP, the electric pulses can have no effect, transiently increase membrane permeability, or cause cell death [1].

Irreversible electroporation (IRE) is a new minimally invasive non-thermal focal ablation technique that has been used for the treatment of spontaneous tumors in canine and human patients [1, 2]. The procedure typically involves placing two electrodes into or around a tumor and delivering a series of low energy electric pulses to kill tumor tissue with sub-millimeter resolution. The pulses generate an electric field that alters the resting transmembrane potential (TMP) of the cells. Depending on the magnitude of the induced TMP, the electric pulses can have no effect, reversibly increase membrane permeability, or cause cell death in the case of IRE.

Non-thermal irreversible electroporation (IRE) is a new, minimally invasive technique that has shown great promise for the ablation of tumors [1]. The procedure involves placing electrodes into or around a targeted tissue and delivering a series of low energy (intense but short) electric pulses for approximately one minute. These pulses induce irreversible structural changes in the cell membranes of the targeted tissue that lead to cell death. Because IRE affects only a single molecular component of the treated area, the cell membrane, it is the first true molecular surgery. IRE has the ability to create complete and predictable cell ablation with a sharp transition between normal and necrotic tissue.

Arterial diseases are a common cause of death in the western world. The last two decades has seen vast improvements in scanning, screening, prognosis and symptom recognition, resulting in a greater number of treatments. A common treatment procedure used is bypass grafting which currently utilize synthetic graft materials, internal thoracic artery, and autologous vein. These treatments are invasive surgical procedures and can have low patency. An alternative treatment for these conditions is endovascular surgery. However these devices have problems such as restenois, migration and stent fracture. Improved design and drug elution have been utilized to enhance the performance, with limited success. The application of Tissue engineering scaffolds to enhance device performance has had limited studies. A Number of studies have looked at Small Intestine Submucosa in stenting applications [1, 2]. One study implanted an ECM (SIS) stent-graft into 8 sheep. The study concluded that the ECM stent graft successfully treated simple and ruptured AAA’s. Another study investigated a stent graft arrangement in the femoral arteries of sheep. The study found that SIS coated stent preformed better than that of PTFE covered stent grafts.

Minimally invasive surgery (MIS) is known to be a difficult procedure to master due to its complexity, compared to traditional open surgery. Therefore, an objective and quantitative assessment tool is highly required in MIS, which can be used for determining surgeon’s skills, evaluating educational programs and providing subjects with unbiased feedback. The goal of this paper is to review various assessment methods, summarize capabilities of the methods, and suggest future possible improvements. Specifically, this paper categorize existing methods into two groups: the first and the most well known group focuses on the analysis of surgical motions, and the other group uses force and torque as a key metric. Specifically, motion analysis includes tracking the body, tool, or hand motions of a surgeon, either from teleoperated robotic systems or surgical simulators using different sensors like wireless or electromagnetic motion tracking sensors, video-glove-based input devices, optical tracking system, or magnetic tracking technologies. Sometimes data explored form this method is synchronized with eye-gaze data (what a surgeon looks at while operating), or videographic data. Using motion analysis actually the number of movements, rate of movements, total path length, movement variability, time taken to complete the operation, average or peak velocity are considered for assessing surgical skills. On the other hand, the methods in the second group assess the skills based on force and toque data that surgeons apply through surgical instruments. More specifically, these methods use different kind of sensors placed on the grasper. Different force and torque measurement systems, hidden-Markov-model-based analysis, simulated models with criteria, and Virtual reality have been developed, allowing for the quantification of the performance of surgeons. Although, each method has its own advantageous, and according to the kind of surgical task and evaluation, these methods can be used successfully to assess surgical skills, to provide predictive validity for each of these methods more study is needed. Also, future works should improve the efficiency of each method and move toward automated, low-cost and real time assessment methods.

Background Lung cancer is the number one cause of cancer death worldwide.(1) It is the fifth most commonly diagnosed cancer in Australia (12,741 cases diagnosed in 2018) and the leading cause of cancer death.(2) The number of years of potential life lost to lung cancer in Australia is estimated to be 58,450, similar to that of colorectal and breast cancer combined.(3) While tobacco control strategies are most effective for disease prevention in the general population, early detection via low dose computed tomography (LDCT) screening in high-risk populations is a viable option for detecting asymptomatic disease in current (13%) and former (24%) Australian smokers.(4) The purpose of this Evidence Check review is to identify and analyse existing and emerging evidence for LDCT lung cancer screening in high-risk individuals to guide future program and policy planning. Evidence Check questions This review aimed to address the following questions: 1. What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? 2. What is the evidence of potential harms from lung cancer screening for higher-risk individuals? 3. What are the main components of recent major lung cancer screening programs or trials? 4. What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Summary of methods The authors searched the peer-reviewed literature across three databases (MEDLINE, PsycINFO and Embase) for existing systematic reviews and original studies published between 1 January 2009 and 8 August 2019. Fifteen systematic reviews (of which 8 were contemporary) and 64 original publications met the inclusion criteria set across the four questions. Key findings Question 1: What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? There is sufficient evidence from systematic reviews and meta-analyses of combined (pooled) data from screening trials (of high-risk individuals) to indicate that LDCT examination is clinically effective in reducing lung cancer mortality. In 2011, the landmark National Lung Cancer Screening Trial (NLST, a large-scale randomised controlled trial [RCT] conducted in the US) reported a 20% (95% CI 6.8% – 26.7%; P=0.004) relative reduction in mortality among long-term heavy smokers over three rounds of annual screening. High-risk eligibility criteria was defined as people aged 55–74 years with a smoking history of ≥30 pack-years (years in which a smoker has consumed 20-plus cigarettes each day) and, for former smokers, ≥30 pack-years and have quit within the past 15 years.(5) All-cause mortality was reduced by 6.7% (95% CI, 1.2% – 13.6%; P=0.02). Initial data from the second landmark RCT, the NEderlands-Leuvens Longkanker Screenings ONderzoek (known as the NELSON trial), have found an even greater reduction of 26% (95% CI, 9% – 41%) in lung cancer mortality, with full trial results yet to be published.(6, 7) Pooled analyses, including several smaller-scale European LDCT screening trials insufficiently powered in their own right, collectively demonstrate a statistically significant reduction in lung cancer mortality (RR 0.82, 95% CI 0.73–0.91).(8) Despite the reduction in all-cause mortality found in the NLST, pooled analyses of seven trials found no statistically significant difference in all-cause mortality (RR 0.95, 95% CI 0.90–1.00).(8) However, cancer-specific mortality is currently the most relevant outcome in cancer screening trials. These seven trials demonstrated a significantly greater proportion of early stage cancers in LDCT groups compared with controls (RR 2.08, 95% CI 1.43–3.03). Thus, when considering results across mortality outcomes and early stage cancers diagnosed, LDCT screening is considered to be clinically effective. Question 2: What is the evidence of potential harms from lung cancer screening for higher-risk individuals? The harms of LDCT lung cancer screening include false positive tests and the consequences of unnecessary invasive follow-up procedures for conditions that are eventually diagnosed as benign. While LDCT screening leads to an increased frequency of invasive procedures, it does not result in greater mortality soon after an invasive procedure (in trial settings when compared with the control arm).(8) Overdiagnosis, exposure to radiation, psychological distress and an impact on quality of life are other known harms. Systematic review evidence indicates the benefits of LDCT screening are likely to outweigh the harms. The potential harms are likely to be reduced as refinements are made to LDCT screening protocols through: i) the application of risk predication models (e.g. the PLCOm2012), which enable a more accurate selection of the high-risk population through the use of specific criteria (beyond age and smoking history); ii) the use of nodule management algorithms (e.g. Lung-RADS, PanCan), which assist in the diagnostic evaluation of screen-detected nodules and cancers (e.g. more precise volumetric assessment of nodules); and, iii) more judicious selection of patients for invasive procedures. Recent evidence suggests a positive LDCT result may transiently increase psychological distress but does not have long-term adverse effects on psychological distress or health-related quality of life (HRQoL). With regards to smoking cessation, there is no evidence to suggest screening participation invokes a false sense of assurance in smokers, nor a reduction in motivation to quit. The NELSON and Danish trials found no difference in smoking cessation rates between LDCT screening and control groups. Higher net cessation rates, compared with general population, suggest those who participate in screening trials may already be motivated to quit. Question 3: What are the main components of recent major lung cancer screening programs or trials? There are no systematic reviews that capture the main components of recent major lung cancer screening trials and programs. We extracted evidence from original studies and clinical guidance documents and organised this into key groups to form a concise set of components for potential implementation of a national lung cancer screening program in Australia: 1. Identifying the high-risk population: recruitment, eligibility, selection and referral 2. Educating the public, people at high risk and healthcare providers; this includes creating awareness of lung cancer, the benefits and harms of LDCT screening, and shared decision-making 3. Components necessary for health services to deliver a screening program: a. Planning phase: e.g. human resources to coordinate the program, electronic data systems that integrate medical records information and link to an established national registry b. Implementation phase: e.g. human and technological resources required to conduct LDCT examinations, interpretation of reports and communication of results to participants c. Monitoring and evaluation phase: e.g. monitoring outcomes across patients, radiological reporting, compliance with established standards and a quality assurance program 4. Data reporting and research, e.g. audit and feedback to multidisciplinary teams, reporting outcomes to enhance international research into LDCT screening 5. Incorporation of smoking cessation interventions, e.g. specific programs designed for LDCT screening or referral to existing community or hospital-based services that deliver cessation interventions. Most original studies are single-institution evaluations that contain descriptive data about the processes required to establish and implement a high-risk population-based screening program. Across all studies there is a consistent message as to the challenges and complexities of establishing LDCT screening programs to attract people at high risk who will receive the greatest benefits from participation. With regards to smoking cessation, evidence from one systematic review indicates the optimal strategy for incorporating smoking cessation interventions into a LDCT screening program is unclear. There is widespread agreement that LDCT screening attendance presents a ‘teachable moment’ for cessation advice, especially among those people who receive a positive scan result. Smoking cessation is an area of significant research investment; for instance, eight US-based clinical trials are now underway that aim to address how best to design and deliver cessation programs within large-scale LDCT screening programs.(9) Question 4: What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Assessing the value or cost-effectiveness of LDCT screening involves a complex interplay of factors including data on effectiveness and costs, and institutional context. A key input is data about the effectiveness of potential and current screening programs with respect to case detection, and the likely outcomes of treating those cases sooner (in the presence of LDCT screening) as opposed to later (in the absence of LDCT screening). Evidence about the cost-effectiveness of LDCT screening programs has been summarised in two systematic reviews. We identified a further 13 studies—five modelling studies, one discrete choice experiment and seven articles—that used a variety of methods to assess cost-effectiveness. Three modelling studies indicated LDCT screening was cost-effective in the settings of the US and Europe. Two studies—one from Australia and one from New Zealand—reported LDCT screening would not be cost-effective using NLST-like protocols. We anticipate that, following the full publication of the NELSON trial, cost-effectiveness studies will likely be updated with new data that reduce uncertainty about factors that influence modelling outcomes, including the findings of indeterminate nodules. Gaps in the evidence There is a large and accessible body of evidence as to the effectiveness (Q1) and harms (Q2) of LDCT screening for lung cancer. Nevertheless, there are significant gaps in the evidence about the program components that are required to implement an effective LDCT screening program (Q3). Questions about LDCT screening acceptability and feasibility were not explicitly included in the scope. However, as the evidence is based primarily on US programs and UK pilot studies, the relevance to the local setting requires careful consideration. The Queensland Lung Cancer Screening Study provides feasibility data about clinical aspects of LDCT screening but little about program design. The International Lung Screening Trial is still in the recruitment phase and findings are not yet available for inclusion in this Evidence Check. The Australian Population Based Screening Framework was developed to “inform decision-makers on the key issues to be considered when assessing potential screening programs in Australia”.(10) As the Framework is specific to population-based, rather than high-risk, screening programs, there is a lack of clarity about transferability of criteria. However, the Framework criteria do stipulate that a screening program must be acceptable to “important subgroups such as target participants who are from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, people from disadvantaged groups and people with a disability”.(10) An extensive search of the literature highlighted that there is very little information about the acceptability of LDCT screening to these population groups in Australia. Yet they are part of the high-risk population.(10) There are also considerable gaps in the evidence about the cost-effectiveness of LDCT screening in different settings, including Australia. The evidence base in this area is rapidly evolving and is likely to include new data from the NELSON trial and incorporate data about the costs of targeted- and immuno-therapies as these treatments become more widely available in Australia.

Background PHS (pulmonary hypertension syndrome, ascites syndrome) is a serious cause of loss in the broiler industry, and is a prime example of an undesirable side effect of successful genetic development that may be deleteriously manifested by factors in the environment of growing broilers. Basically, continuous and pinpointed selection for rapid growth in broilers has led to higher oxygen demand and consequently to more frequent manifestation of an inherent potential cardiopulmonary incapability to sufficiently oxygenate the arterial blood. The multifaceted causes and modifiers of PHS make research into finding solutions to the syndrome a complex and multi threaded challenge. This research used several directions to better understand the development of PHS and to probe possible means of achieving a goal of monitoring and increasing resistance to the syndrome. Research Objectives (1) To evaluate the growth dynamics of individuals within breeding stocks and their correlation with individual susceptibility or resistance to PHS; (2) To compile data on diagnostic indices found in this work to be predictive for PHS, during exposure to experimental protocols known to trigger PHS; (3) To conduct detailed physiological evaluations of cardiopulmonary function in broilers; (4) To compile data on growth dynamics and other diagnostic indices in existing lines selected for susceptibility or resistance to PHS; (5) To integrate growth dynamics and other diagnostic data within appropriate statistical procedures to provide geneticists with predictive indices that characterize resistance or susceptibility to PHS. Revisions In the first year, the US team acquired the costly Peckode weigh platform / individual bird I.D. system that was to provide the continuous (several times each day), automated weighing of birds, for a comprehensive monitoring of growth dynamics. However, data generated were found to be inaccurate and irreproducible, so making its use implausible. Henceforth, weighing was manual, this highly labor intensive work precluding some of the original objectives of using such a strategy of growth dynamics in selection procedures involving thousands of birds. Major conclusions, solutions, achievements 1. Healthy broilers were found to have greater oscillations in growth velocity and acceleration than PHS susceptible birds. This proved the scientific validity of our original hypothesis that such differences occur. 2. Growth rate in the first week is higher in PHS-susceptible than in PHS-resistant chicks. Artificial neural network accurately distinguished differences between the two groups based on growth patterns in this period. 3. In the US, the unilateral pulmonary occlusion technique was used in collaboration with a major broiler breeding company to create a commercial broiler line that is highly resistant to PHS induced by fast growth and low ambient temperatures. 4. In Israel, lines were obtained by genetic selection on PHS mortality after cold exposure in a dam-line population comprising of 85 sire families. The wide range of PHS incidence per family (0-50%), high heritability (about 0.6), and the results in cold challenged progeny, suggested a highly effective and relatively easy means for selection for PHS resistance 5. The best minimally-invasive diagnostic indices for prediction of PHS resistance were found to be oximetry, hematocrit values, heart rate and electrocardiographic (ECG) lead II waves. Some differences in results were found between the US and Israeli teams, probably reflecting genetic differences in the broiler strains used in the two countries. For instance the US team found the S wave amplitude to predict PHS susceptibility well, whereas the Israeli team found the P wave amplitude to be a better valid predictor. 6. Comprehensive physiological studies further increased knowledge on the development of PHS cardiopulmonary characteristics of pre-ascitic birds, pulmonary arterial wedge pressures, hypotension/kidney response, pulmonary hemodynamic responses to vasoactive mediators were all examined in depth. Implications, scientific and agricultural Substantial progress has been made in understanding the genetic and environmental factors involved in PHS, and their interaction. The two teams each successfully developed different selection programs, by surgical means and by divergent selection under cold challenge. Monitoring of the progress and success of the programs was done be using the in-depth estimations that this research engendered on the reliability and value of non-invasive predictive parameters. These findings helped corroborate the validity of practical means to improve PHT resistance by research-based programs of selection.