Challenging endoscopy reprocessing guidelines: a prospective study investigating the safe shelf life of flexible endoscopes in a tertiary gastroenterology unit.

Professional prac− tice guidelines for endoscope reprocessing re− commend reprocessing endoscopes between each case and proper storage following repro− cessing after the last case of the list. There is lim− ited empirical evidence to support the efficacy of endoscope reprocessing prior to use in the first case of the day; however, internationally, many guidelines continue to recommend this practice. The aim of this study is to estimate a safe shelf life for flexible endoscopes in a high−turnover gastroenterology unit. Materials and methods: In a prospective obser− vational study, all flexible endoscopes in active service during the 3−week study period were mi− crobiologically sampled prior to reprocessing be− fore the first case of the day (n = 200). The main outcome variables were culture status, organism cultured, and shelf life. Results: Among the total number of useable samples (n = 194), the overall contamination rate was 15.5 %, with a pathogenic contamination rate of 0.5 %. Mean time between last case one day and reprocessing before the first case on the next day (that is, shelf life) was 37.62 h (SD 36.47). Median shelf life was 18.8 h (range 5.27± 165.35 h). The most frequently identified organ− ism was coagulase−negative Staphylococcus, an environmental nonpathogenic organism. Conclusions: When processed according to es− tablished guidelines, flexible endoscopes remain free from pathogenic organisms between last case and next day first case use. Significant re− ductions in the expenditure of time and resources on reprocessing endoscopes have the potential to reduce the restraints experienced by high−turnover endoscopy units and improve ser− vice delivery.

Wide Field-of-view Microscopes and Endoscopes for Time-lapse Imaging and High-throughput Screening

Wide field-of-view (FOV) microscopy is of high importance to biological research and clinical diagnosis where a high-throughput screening of samples is needed. This thesis presents the development of several novel wide FOV imaging technologies and demonstrates their capabilities in longitudinal imaging of living organisms, on the scale of viral plaques to live cells and tissues.

The ePetri Dish is a wide FOV on-chip bright-field microscope. Here we applied an ePetri platform for plaque analysis of murine norovirus 1 (MNV-1). The ePetri offers the ability to dynamically track plaques at the individual cell death event level over a wide FOV of 6 mm × 4 mm at 30 min intervals. A density-based clustering algorithm is used to analyze the spatial-temporal distribution of cell death events to identify plaques at their earliest stages. We also demonstrate the capabilities of the ePetri in viral titer count and dynamically monitoring plaque formation, growth, and the influence of antiviral drugs.

We developed another wide FOV imaging technique, the Talbot microscope, for the fluorescence imaging of live cells. The Talbot microscope takes advantage of the Talbot effect and can generate a focal spot array to scan the fluorescence samples directly on-chip. It has a resolution of 1.2 μm and a FOV of ~13 mm². We further upgraded the Talbot microscope for the long-term time-lapse fluorescence imaging of live cell cultures, and analyzed the cells’ dynamic response to an anticancer drug.

We present two wide FOV endoscopes for tissue imaging, named the AnCam and the PanCam. The AnCam is based on the contact image sensor (CIS) technology, and can scan the whole anal canal within 10 seconds with a resolution of 89 μm, a maximum FOV of 100 mm × 120 mm, and a depth-of-field (DOF) of 0.65 mm. We also demonstrate the performance of the AnCam in whole anal canal imaging in both animal models and real patients. In addition to this, the PanCam is based on a smartphone platform integrated with a panoramic annular lens (PAL), and can capture a FOV of 18 mm × 120 mm in a single shot with a resolution of 100─140 μm. In this work we demonstrate the PanCam’s performance in imaging a stained tissue sample.

Scénarios pour un mode de gestion optimal des endoscopes à l’Hôpital Maisonneuve-Rosemont.

Travail dirigé

Industrial design in endoscopy : the development of a tissue and organ extractor

Throughout history, developments in medicine have aimed to improve patient quality of life, and reduce the trauma associated with surgical treatment. Surgical access to internal organs and bodily structures has been traditionally via large incisions. Endoscopic surgery presents a technique for surgical access via small (1 Omm) incisions by utilising a scope and camera for visualisation of the operative site. Endoscopy presents enormous benefits for patients in terms of lower post operative discomfort, and reduced recovery and hospitalisation time. Since the first gall bladder extraction operation was performed in France in 1987, endoscopic surgery has been embraced by the international medical community. With the adoption of the new technique, new problems never previously encountered in open surgery, were revealed. One such problem is that the removal of large tissue specimens and organs is restricted by the small incision size. Instruments have been developed to address this problem however none of the devices provide a totally satisfactory solution. They have a number of critical weaknesses: -The size of the access incision has to be enlarged, thereby compromising the entire endoscopic approach to surgery. - The physical quality of the specimen extracted is very poor and is not suitable to conduct the necessary post operative pathological examinations. -The safety of both the patient and the physician is jeopardised. The problem of tissue and organ extraction at endoscopy is investigated and addressed. In addition to background information covering endoscopic surgery, this thesis describes the entire approach to the design problem, and the steps taken before arriving at the final solution. This thesis contributes to the body of knowledge associated with the development of endoscopic surgical instruments. A new product capable of extracting large tissue specimens and organs in endoscopy is the final outcome of the research.

Pesquisa de segunda neoplasia em boca e orofaringe em pacientes portadores de carcinoma espinocelular (CEC) de esôfago, boca e orofaringe através de narrow band imaging (NBI)

Pós-graduação em Pesquisa e Desenvolvimento (Biotecnologia Médica) - FMB

MICROORGANISMS OF THE COCCIDIA SUBCLASS: RESISTANCE AND IMPLICATIONS FOR THE ASEPTIC PROCESSING OF HEALTHCARE PRODUCTS

This theoretical study proposes a reflection on the intrinsic resistance of the subclass Coccidia, particularly the genus Cryptosporidium, considered to be potential pathogens for immunocompromised patients, and the implications for nursing practice. Currently, the international and national guidelines support the chemical disinfection of digestive system endoscopes after their cleansing as a safe and effective procedure. However, studies show that microorganisms of the subclass Coccidia, namely Cryptosporidium, responsible for enteric infection, are more resistant than mycobacteria and are not inactivated by high-level disinfectants, except for hydrogen peroxide 6% and 7.5%, which are not currently available in Brazil. We conclude that the legislation should include this agent among test microorganisms for approving high-level disinfectants. Health authorities should make efforts to ensure that healthcare institutions have access to effective disinfectants against Cryptosporidium.

Micro-organismos da subclasse Coccidia: resistência e implicações para o processamento de materiais de assistência à saúde

Este estudo teórico propõe uma reflexão sobre a resistência intrínseca da subclasse Coccidia, particularmente o gênero Cryptosporidium, considerado como um agente potencialmente patogênico para pacientes imunocomprometidos, e suas repercussões na prática assistencial. Atualmente, as diretrizes internacionais e nacionais aprovam como procedimento seguro a desinfecção química de alto nível de endoscópios digestivos, após sua limpeza. No entanto, estudos evidenciaram que micro-organismos da subclasse Coccidia, especificamente o Cryptosporidium, responsável por infecção entérica, são mais resistentes que as micobactérias e não são inativados pelos desinfetantes químicos de alto nível, exceto pelo Peróxido de Hidrogênio a 6% e 7,5%, formulação ainda não disponível no Brasil. Conclui-se que a legislação deve incluir este agente entre os micro-organismos teste para aprovação de desinfetantes químicos de alto nível e que as autoridades sanitárias devem se esforçar para garantir que os estabelecimentos de assistência à saúde tenham acesso a produtos eficazes contra o Cryptosporidium.

Remoção de biofilme em canais de endoscópios: avaliação de métodos de desinfecção atualmente utilizados

Estudo experimental laboratorial que comparou a ação de cinco métodos de desinfecção na remoção de biofilme em endoscópios gastrintestinais. Foram utilizados como corpos de prova tubos novos transparentes de politetrafluoretileno (Teflon®) simulando os canais flexíveis dos endoscópios. Após limpeza prévia os tubos foram contaminados intencionalmente com Pseudomonas aeruginosa para formação de biofilme e submetidos à desinfecção. Como resultado, nenhum deles removeu 100% dos biofilmes. O que mais removeu fisicamente o biofilme foi o glutaraldeído 2% em processadora automática, provavelmente justificado pela dupla limpeza, já que o equipamento conta com essa fase no início do seu ciclo. O método que se mostrou menos eficiente para remoção de biofilme e outros resíduos foi água eletrolítica ácida. Esses resultados sugerem que a limpeza é mais impactante na remoção de biofilmes do que a desinfecção consecutiva, uma vez que o glutaraldeído, desinfetante da máquina que se mostrou mais eficiente, é um fixador de resíduos orgânicos.

Descripción de parámetros glóticos basados en el modelado de los pliegues vocales para la detección de patología de la voz

Las patologías de la voz se han transformado en los últimos tiempos en una problemática social con cierto calado. La contaminación de las ciudades, hábitos como el de fumar, el uso de aparatos de aire acondicionado, etcétera, contribuyen a ello. Esto alcanza más relevancia en profesionales que utilizan su voz de manera frecuente, como, por ejemplo, locutores, cantantes, profesores o teleoperadores. Por todo ello resultan de especial interés las técnicas de ayuda al diagnóstico que son capaces de extraer conclusiones clínicas a partir de una muestra de la voz grabada con un micrófono, frente a otras invasivas que implican la exploración utilizando laringoscopios, fibroscopios o videoendoscopios, técnicas en cualquier caso mucho más molestas para los pacientes al exigir la introducción parcial del instrumental citado por la garganta, en actuaciones consideradas de tipo quirúrgico. Dentro de aquellas técnicas se ha avanzado mucho en un período de tiempo relativamente corto. En lo que se refiere al diagnóstico de patologías, hemos pasado en los últimos quince años de trabajar principalmente con parámetros extraídos de la señal de voz –tanto en el dominio del tiempo como en el de la frecuencia– y con escalas elaboradas con valoraciones subjetivas realizadas por expertos a hacerlo también con parámetros procedentes de estimaciones de la fuente glótica. La importancia de utilizar la fuente glótica reside, a grandes rasgos, en que se trata de una señal vinculada directamente al estado de la estructura laríngea del locutor y también en que está generalmente menos influida por el tracto vocal que la señal de voz. Es conocido que el tracto vocal guarda más relación con el mensaje hablado, y su presencia dificulta el proceso de detección de patología vocal. Estas estimaciones de la fuente glótica han sido obtenidas a través de técnicas de filtrado inverso desarrolladas por nuestro grupo de investigación. Hemos conseguido, además, profundizar en la naturaleza de la señal glótica: somos capaces de descomponerla y relacionarla con parámetros biomecánicos de los propios pliegues vocales, obteniendo estimaciones de elementos como la masa, la pérdida de energía o la elasticidad del cuerpo y de la cubierta del pliegue, entre otros. De las componentes de la fuente glótica surgen también los denominados parámetros biométricos, relacionados con la forma de la señal, que constituyen por sí mismos una firma biométrica del individuo. También trabajaremos con parámetros temporales, relacionados con las diferentes etapas que se observan dentro de la señal glótica durante un ciclo de fonación. Por último, consideraremos parámetros clásicos de perturbación y energía de la señal. En definitiva, contamos ahora con una considerable cantidad de parámetros glóticos que conforman una base estadística multidimensional, destinada a ser capaz de discriminar personas con voces patológicas o disfónicas de aquellas que no presentan patología en la voz o con voces sanas o normofónicas. Esta tesis doctoral se ocupa de varias cuestiones: en primer lugar, es necesario analizar cuidadosamente estos nuevos parámetros, por lo que ofreceremos una completa descripción estadística de los mismos. También estudiaremos cuestiones como la distribución de los parámetros atendiendo a criterios como el de normalidad estadística de los mismos, ocupándonos especialmente de la diferencia entre las distribuciones que presentan sujetos sanos y sujetos con patología vocal. Para todo ello emplearemos diferentes técnicas estadísticas: generación de elementos y diagramas descriptivos, pruebas de normalidad y diversos contrastes de hipótesis, tanto paramétricos como no paramétricos, que considerarán la diferencia entre los grupos de personas sanas y los grupos de personas con alguna patología relacionada con la voz. Además, nos interesa encontrar relaciones estadísticas entre los parámetros, de cara a eliminar posibles redundancias presentes en el modelo, a reducir la dimensionalidad del problema y a establecer un criterio de importancia relativa en los parámetros en cuanto a su capacidad discriminante para el criterio patológico/sano. Para ello se aplicarán técnicas estadísticas como la Correlación Lineal Bivariada y el Análisis Factorial basado en Componentes Principales. Por último, utilizaremos la conocida técnica de clasificación Análisis Discriminante, aplicada a diferentes combinaciones de parámetros y de factores, para determinar cuáles de ellas son las que ofrecen tasas de acierto más prometedoras. Para llevar a cabo la experimentación se ha utilizado una base de datos equilibrada y robusta formada por doscientos sujetos, cien de ellos pertenecientes al género femenino y los restantes cien al género masculino, con una proporción también equilibrada entre los sujetos que presentan patología vocal y aquellos que no la presentan. Una de las aplicaciones informáticas diseñada para llevar a cabo la recogida de muestras también es presentada en esta tesis. Los distintos estudios estadísticos realizados nos permitirán identificar aquellos parámetros que tienen una mayor contribución a la hora de detectar la presencia de patología vocal. Alguno de los estudios, además, nos permitirá presentar una ordenación de los parámetros en base a su importancia para realizar la detección. Por otra parte, también concluiremos que en ocasiones es conveniente realizar una reducción de la dimensionalidad de los parámetros para mejorar las tasas de detección. Por fin, las propias tasas de detección constituyen quizá la conclusión más importante del trabajo. Todos los análisis presentes en el trabajo serán realizados para cada uno de los dos géneros, de acuerdo con diversos estudios previos que demuestran que los géneros masculino y femenino deben tratarse de forma independiente debido a las diferencias orgánicas observadas entre ambos. Sin embargo, en lo referente a la detección de patología vocal contemplaremos también la posibilidad de trabajar con la base de datos unificada, comprobando que las tasas de acierto son también elevadas. Abstract Voice pathologies have become recently in a social problem that has reached a certain concern. Pollution in cities, smoking habits, air conditioning, etc. contributes to it. This problem is more relevant for professionals who use their voice frequently: speakers, singers, teachers, actors, telemarketers, etc. Therefore techniques that are capable of drawing conclusions from a sample of the recorded voice are of particular interest for the diagnosis as opposed to other invasive ones, involving exploration by laryngoscopes, fiber scopes or video endoscopes, which are techniques much less comfortable for patients. Voice quality analysis has come a long way in a relatively short period of time. In regard to the diagnosis of diseases, we have gone in the last fifteen years from working primarily with parameters extracted from the voice signal (both in time and frequency domains) and with scales drawn from subjective assessments by experts to produce more accurate evaluations with estimates derived from the glottal source. The importance of using the glottal source resides broadly in that this signal is linked to the state of the speaker's laryngeal structure. Unlike the voice signal (phonated speech) the glottal source, if conveniently reconstructed using adaptive lattices, may be less influenced by the vocal tract. As it is well known the vocal tract is related to the articulation of the spoken message and its influence complicates the process of voice pathology detection, unlike when using the reconstructed glottal source, where vocal tract influence has been almost completely removed. The estimates of the glottal source have been obtained through inverse filtering techniques developed by our research group. We have also deepened into the nature of the glottal signal, dissecting it and relating it to the biomechanical parameters of the vocal folds, obtaining several estimates of items such as mass, loss or elasticity of cover and body of the vocal fold, among others. From the components of the glottal source also arise the so-called biometric parameters, related to the shape of the signal, which are themselves a biometric signature of the individual. We will also work with temporal parameters related to the different stages that are observed in the glottal signal during a cycle of phonation. Finally, we will take into consideration classical perturbation and energy parameters. In short, we have now a considerable amount of glottal parameters in a multidimensional statistical basis, designed to be able to discriminate people with pathologic or dysphonic voices from those who do not show pathology. This thesis addresses several issues: first, a careful analysis of these new parameters is required, so we will offer a complete statistical description of them. We will also discuss issues such as distribution of the parameters, considering criteria such as their statistical normality. We will take special care in the analysis of the difference between distributions from healthy subjects and the distributions from pathological subjects. To reach these goals we will use different statistical techniques such as: generation of descriptive items and diagramas, tests for normality and hypothesis testing, both parametric and nonparametric. These latter techniques consider the difference between the groups of healthy subjects and groups of people with an illness related to voice. In addition, we are interested in finding statistical relationships between parameters. There are various reasons behind that: eliminate possible redundancies in the model, reduce the dimensionality of the problem and establish a criterion of relative importance in the parameters. The latter reason will be done in terms of discriminatory power for the criterion pathological/healthy. To this end, statistical techniques such as Bivariate Linear Correlation and Factor Analysis based on Principal Components will be applied. Finally, we will use the well-known technique of Discriminant Analysis classification applied to different combinations of parameters and factors to determine which of these combinations offers more promising success rates. To perform the experiments we have used a balanced and robust database, consisting of two hundred speakers, one hundred of them males and one hundred females. We have also used a well-balanced proportion where subjects with vocal pathology as well as subjects who don´t have a vocal pathology are equally represented. A computer application designed to carry out the collection of samples is also presented in this thesis. The different statistical analyses performed will allow us to determine which parameters contribute in a more decisive way in the detection of vocal pathology. Therefore, some of the analyses will even allow us to present a ranking of the parameters based on their importance for the detection of vocal pathology. On the other hand, we will also conclude that it is sometimes desirable to perform a dimensionality reduction in order to improve the detection rates. Finally, detection rates themselves are perhaps the most important conclusion of the work. All the analyses presented in this work have been performed for each of the two genders in agreement with previous studies showing that male and female genders should be treated independently, due to the observed functional differences between them. However, with regard to the detection of vocal pathology we will consider the possibility of working with the unified database, ensuring that the success rates obtained are also high.

Translation of lectures delivered by Aurelio Bianchi ... on the phonendoscope and its practical application ...

Mode of access: Internet.

Discriminating contact in lumen with a moving flexible digit using fibre Bragg grating sensing elements

Minimal access procedures in surgery offer benefits of reduced patient recovery time and less pain, yet for the surgeon the task is more complex, as both tactile and visual perception of the working site is reduced. In this paper, experimental evidence of the performance of a novel sensing system embedded in an actuated flexible digit element is presented. The digit represents a steerable tip element of devices such as endoscopes and laparoscopes. This solution is able to discriminate types of contact and tissue interaction, and to feed back this information with the shape of the flexible digit. As an alternative to this information, force level, force distribution, and other quantifiable descriptors can also be evaluated. These can be used to aid perception in processes such as navigation and investigation of tissues through palpation. The solution is pragmatic, and by virtue of its efficient mechanical construction and a polymer construction, it offers opportunities for a disposable element with suitability for magnetic resonance imaging (MRI) and other scanning environments. By using only four photonics sensing elements, full perception of tissue contact and the shape of the actuated digit can be described in the feedback of this information. The distributive sensory method applied to the sensory signals relies on the coupled values of the sensory data transients of the four deployed sensing elements to discriminate tissue interaction directly in near real time.

Discriminating contact in lumen with a moving flexible digit using fibre Bragg grating sensing elements

Minimal access procedures in surgery offer benefits of reduced patient recovery time and less pain, yet for the surgeon the task is more complex, as both tactile and visual perception of the working site is reduced. In this paper, experimental evidence of the performance of a novel sensing system embedded in an actuated flexible digit element is presented. The digit represents a steerable tip element of devices such as endoscopes and laparoscopes. This solution is able to discriminate types of contact and tissue interaction, and to feed back this information with the shape of the flexible digit. As an alternative to this information, force level, force distribution, and other quantifiable descriptors can also be evaluated. These can be used to aid perception in processes such as navigation and investigation of tissues through palpation. The solution is pragmatic, and by virtue of its efficient mechanical construction and a polymer construction, it offers opportunities for a disposable element with suitability for magnetic resonance imaging (MRI) and other scanning environments. By using only four photonics sensing elements, full perception of tissue contact and the shape of the actuated digit can be described in the feedback of this information. The distributive sensory method applied to the sensory signals relies on the coupled values of the sensory data transients of the four deployed sensing elements to discriminate tissue interaction directly in near real time.