Samuel Rodriguez, MD

All Publications

• Small surgeries, big smiles: using virtual reality to reduce the need for sedation or general anesthesia during minor surgical procedures. Pediatric surgery international Taylor, J. S., Chandler, J. M., Menendez, M., Diyaolu, M., Austin, J. R., Gibson, M. L., Portelli, K. I., Caruso, T. J., Rodriguez, S., Chao, S. D. 2021

  Abstract

  PURPOSE: Children often require anesthesia for simple diagnostic and therapeutic procedures. The aim of this study was to evaluate the feasibility of using virtual reality (VR) to reduce sedation in children undergoing minor surgical procedures.METHOD: In this prospective, non-randomized clinical trial, pediatric patients at a free-standing children's hospital undergoing hormone implant placement, removal, or exchange were recruited to use VR and local anesthesia instead of procedural sedation or general anesthesia (GA). Patients were enrolled between November 2017 and March 2020, and were compared to historic controls who underwent similar procedures without VR between April 2016 and February 2020. Primary outcome measure was successful procedure completion without sedation or GA. Secondary measures included assessments of pain, fear and anxiety, patient compliance, procedural and recovery times.RESULTS: Twenty-eight patients underwent 29 procedures with VR. Hormone implants (72%), removals (7%), or exchanges (21%) were completed without GA, sedation or IV placement. Procedure lengths and pain scores were similar between VR patients and historic controls, but recovery times were significantly shorter in VR patients (18 vs 65min, p<0.001). Participant satisfaction scores were high, with 95% recommending VR to others.CONCLUSIONS: VR is a feasible alternative to sedation or GA for select pediatric patients undergoing minor surgical procedures.

  View details for DOI 10.1007/s00383-021-04955-6

  View details for PubMedID 34269867

• Commentary on A Body of Work: Painting a Decade of Gross Dissection. Academic medicine : journal of the Association of American Medical Colleges Rodriguez, S. n., Srivastava, S. n. 2018; 93 (3): 429

  View details for DOI 10.1097/01.ACM.0000531163.02389.da

  View details for PubMedID 29485506

• Bedside Entertainment and Relaxation Theater: size and novelty does matter when using video distraction for perioperative pediatric anxiety. Paediatric anaesthesia Rodriguez, S. n., Caruso, T. n., Tsui, B. n. 2017; 27 (6): 668–69

  View details for DOI 10.1111/pan.13133

  View details for PubMedID 28474813

• Interactive video game built for mask induction in pediatric patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Rodriguez, S. n., Tsui, J. H., Jiang, S. Y., Caruso, T. J. 2017

  View details for PubMedID 28646461

• The transfer of care. Anesthesia and analgesia Rodriguez, S. 2015; 120 (3): 687-?

  View details for DOI 10.1213/ANE.0000000000000592

  View details for PubMedID 25695585

• Response to the Letter to the Editor Regarding 'Let Kids Play: Using Virtual Reality as a Substitute for General Anesthesia for Minor Procedures in Pediatric Population'. Journal of pediatric surgery Salimi-Jazi, F., Sabapaty, A., Dalusag, K. S., Abrajano, C., Nguyen, J., Robinson, B., Caruso, T. J., Rodriguez, S., Hartman, G., Chao, S. D. 2024: 161685

  View details for DOI 10.1016/j.jpedsurg.2024.161685

  View details for PubMedID 39218727

• Awe Inducing Elements in Virtual Reality Applications: A Prospective Study of Hospitalized Children and Caregivers. Games for health journal He, E. M., Arshad, F., Li, B. S., Brinda, R., Ganesan, A., Zhang, L., Fehr, S., Renavikar, M., Rodriguez, S. T., Wang, E., Rosales, O., Caruso, T. J. 2024

  Abstract

  Background: Hospitalized pediatric patients and their caregivers often experience anxiety and fear, resulting in withdrawal and aggression. Despite virtual reality (VR) being a safe and effective anxiolytic, it is unknown what software design aspects contribute to its effectiveness. This prospective observational study evaluated which VR application elements increased awe, which is correlated with improved behavior and satisfaction. Methods: Patients aged 6 to 25 years and their caregivers at an academic pediatric hospital interacted with a custom VR application that compared design aspects, including environment, graphics fidelity, and presence of a motivational character. Outcomes investigated self-reported awe, vastness, accommodation, and engagement. Data were analyzed using repeated measure ANOVA tests and correlation analyses. Results: A total of 202 participants were enrolled, and 179 (88 pediatric patients, 91 adult caregivers) were included in the final analysis. A fictional environment was more effective at increasing awe in pediatric patients (P = 0.030) compared with a realistic environment. However, increased graphics fidelity was more effective at increasing awe in caregiver adults (P = 0.023) compared with low resolution graphics. Presence of a motivational character did not influence awe in either patients or caregivers (P = 0.432, P = 0.904, respectively). All measures of awe were positively correlated with application engagement (P < 0.005). Conclusion: In conclusion, when software developers design VR software for pediatric patients and their caregivers, fictional settings and increased graphic fidelity should be considered for pediatric patients and adults, respectively. Future studies will explore other VR elements in gameplay settings.

  View details for DOI 10.1089/g4h.2024.0050

  View details for PubMedID 39109578

• Virtual Reality Facilitated Exercise Increases Sympathetic Activity and Reduces Pain Perception: A Randomized Crossover Study. American journal of physical medicine & rehabilitation Rodriguez, S. T., Makarewicz, N., Wang, E. Y., Zuniga-Hernandez, M., Titzler, J., Jackson, C., Suen, M. Y., Rosales, O., Caruso, T. J. 2024

  Abstract

  Both virtual reality (VR) and exercise reduce pain while avoiding the risks of traditional pharmacotherapy. The aim of this study was to assess how VR-facilitated exercise modulates sympathetic activity and pain perception.Healthy adult volunteers were randomized by hand dominance and then subjected to a standardized cold pressor test while experiencing a VR application. After a 5-minute washout, participants were crossed-over and repeated the test on their other hand while undergoing a VR-facilitated exercise application. Sympathetic activation, pain sensation, and pain tolerance data were collected identically during both conditions.110 participants were analyzed. Sympathetic activity increased in both conditions but was higher in the VR-facilitated exercise condition (p < 0.0001). Pain sensation scores were initially higher with VR-facilitated exercise but dropped below the VR-only condition by the end of the intervention (p = 0.0175). There were no differences in pain tolerance between conditions (p = 0.18).The decrease in pain perception with VR-facilitated exercise condition compared to VR alone indicates VR-facilitated exercise can be a useful tool for managing pain. Though this effect did not translate into higher pain tolerance, VR-facilitated exercise may be a useful intervention in the setting of physical therapy or for patients with chronic pain.

  View details for DOI 10.1097/PHM.0000000000002550

  View details for PubMedID 38842101

• Augmented Reality Improves Pediatric Mask Induction: A Prospective, Matched Case-Control Study. Journal of patient experience Yun, R., He, E. M., Zuniga, M., Guo, N., Wang, E. Y., Ho, F., Pearson, M., Rodriguez, S. T., Caruso, T. J. 2024; 11: 23743735241241146

  Abstract

  Introduction: Pediatric perioperative anxiety is a significant problem during mask induction for general anesthesia. Immersive technologies, such as extended reality headsets, are a promising strategy for alleviating anxiety. Our primary aim was to investigate mask acceptance during inhalational induction utilizing augmented reality (AR). Methods: This was a prospective, matched case-control study at a quaternary academic hospital. Fifty pediatric patients using AR for mask induction were matched to 150 standard-of-care (SOC) controls. The primary outcome was measured with the Mask Acceptance Scale (MAS). Secondary outcomes of cooperation and emergent delirium (ED) were assessed. Results: MAS scores ≥2 occurred at 4% (95% CI [0, 9.4%]) with AR versus 19.3%, (95% CI [13%, 25.7%]) with SOC (RR 0.21, 95% CI [0.05, 0.84], P = .027). Ninety-eight percent of AR patients were cooperative versus 91.3% with SOC (P = .457). Zero percent had ED with AR versus 0.7% with SOC (P = 1.000). Conclusions: AR during mask induction improved mask acceptance compared to SOC. No relationship was observed between AR and cooperation or ED. Future research will investigate the integration of AR into clinical practice as a nonpharmacologic intervention.

  View details for DOI 10.1177/23743735241241146

  View details for PubMedID 38549806

  View details for PubMedCentralID PMC10976515

• A prospective, observational validation of HRAD±, a novel pediatric affect and cooperation scale. Journal of clinical anesthesia Yun, R., Qian, D., Wang, E., Zuniga, M., Forbes, T., Li, B., Rodriguez, S. T., Jackson, C., Caruso, T. J. 2024; 94: 111410

  Abstract

  STUDY OBJECTIVE: HRAD± was developed to quickly assess pediatric perioperative affect and cooperation. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to investigate the clinical utility of HRAD± as an affect and cooperation assessment tool for inhalational mask induction. Secondary aims examined inter-rater reliability (IRR) of HRAD± and predictive validity of induction HRAD± with emergence delirium.DESIGN: This was a prospective observational investigation.SETTING: We conducted this investigation at Lucile Packard Children's Hospital Stanford, an academic, quaternary care children's hospital in Northern California.PATIENTS: A total of 197 patients were included in this investigation. Children 1-14years of age, who underwent daytime procedures with inhalational induction of anesthesia and American Society of Anesthesiologists physical status I-III were eligible.INTERVENTIONS: During mask induction, two trained research assistants (RAs) independently scored the patient's affect and cooperation. After extubation, the same investigators observed the patient's emergence.MEASUREMENTS: RAs scored each mask induction using the following scales: HRAD±, modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC). Correlations were calculated to HRAD±. IRR of HRAD± between the RAs as well as predictive validity of HRAD± to Pediatric Anesthesia Emergence Delirium (PAED), Watcha and Cravero scales were calculated.MAIN RESULTS: HRAD± scores strongly correlated with mYPAS (r=0.840, p<0.0001) with moderate correlation to OSBD (r=0.685, p<0.0001) and ICC (-0.663, p<0.0001). IRR was moderate for the affect and cooperation portion of the HRAD± scale, respectively (kappa=0.595 [p<0.0001], kappa=0.478 [p<0.0001]). A weak correlation was observed with PAED (r=0.134 [p=0.0597]) vs HRAD±. No correlations were observed between Watcha (r=0.013 [p=0.8559]) and Cravero and HRAD± scales (r=0.002 [p=0.9767]).CONCLUSIONS: HRAD± is a clinically useful and simple scale for evaluating pediatric affect and cooperation during inhalational mask induction. Results demonstrate correlation with commonly utilized research assessment scales.

  View details for DOI 10.1016/j.jclinane.2024.111410

  View details for PubMedID 38340678

• Let Kids Play: Using Virtual Reality as a Substitute for General Anesthesia for Minor Procedures in Pediatric Population. Journal of pediatric surgery Salimi-Jazi, F., Sabapaty, A., Santos Dalusag, K., Abrajano, C., Nguyen, J., Robinson, B., Caruso, T. J., Rodriguez, S., Hartman, G., Chao, S. D. 2024

  Abstract

  In the pediatric population, virtual reality (VR) has been used as an adjunct to augment analgesia and reduce the need for opioids. In this study, we review our experience using VR in lieu of anesthesia or sedation to enable minor procedures in children.A retrospective chart review study was performed on patients who presented to our institution from 2019 to 2022 for hormone implant placement, exchange, or removal with VR distraction. Demographic and procedure information was recorded. The primary outcome was successful procedure completion without requiring pharmacologic sedation or analgesia.A total of 111 patients underwent the following minor procedures with VR and without anesthesia or sedation. Fourteen patients had multiple encounters resulting in a total of 126 encounters. The median age was 11 [6] years. 43 patients were female, 23 were female to male, 6 were non-binary, 7 were male, and 32 were male to female. 58 % had private insurance. Most common diagnosis was precocious puberty (54 %) followed by gender dysphoria (46 %). Most common procedure was implant placement (72 %). 69 % of procedures were performed in the clinic and 31 % in the OR. All procedures were completed without requiring the administration of additional sedation or anesthesia. None of the patients required intravenous catheter placement for the procedure. No intra-procedural complications were recorded.VR is a feasible option that can spare children from sedation or general anesthesia for minor procedures. VR may enable minor procedures in children to be successfully performed in clinic setting.

  View details for DOI 10.1016/j.jpedsurg.2024.01.002

  View details for PubMedID 38307749

• Reducing Preoperative Caregiver Anxiety With Virtual Reality: A Pragmatic, Randomized Controlled Study. Journal of patient experience Fonseca, A., Qian, D., Forbes, T., Li, B. S., Lee, C., Burdsall, K., Rodriguez, S., Jackson, C., Wang, E. Y., Caruso, T. J. 2024; 11: 23743735231220190

  Abstract

  Pediatric patients and their caregivers often experience perioperative anxiety. Interventions reduce caregiver anxiety improve cooperation and contribute to an improved patient experience. This study seeks to evaluate the efficacy of virtual reality (VR)-assisted mindfulness on perioperative caregiver anxiety. Participants were randomized into a standard of care (SOC) group, which included snacks but no technology-based distractions, or a VR group, which included snacks and a VR-guided meditation. Caregiver anxiety was measured before and after the intervention using the Visual Analogue Scale for Anxiety (VAS-A). Secondary aims explored participants' baseline anxiety with the State-Trait Anxiety Inventory (STAI). VR group participants completed a satisfaction survey. Linear regression models of VAS-A and STAI were used to compare group differences. Satisfaction survey results were reported with descriptive statistics. 26 participants were included, with 12 randomized to the SOC group and 14 to the VR group. VAS-A scores in the VR group were lower than those in the SOC group (p = .002). The STAI found no change in participants' state of anxiety in the SOC group (p = .7108), compared to a significant reduction (p = .014) in the VR group when controlling for anxiety traits. 12 of 14 caregivers in the VR group expressed satisfaction or strong satisfaction. This study supports the implementation of VR mindfulness as a method to reduce caregiver anxiety. VR use in the pediatric healthcare setting is safe and inexpensive, and the intervention had a high degree of participant satisfaction.

  View details for DOI 10.1177/23743735231220190

  View details for PubMedID 38188533

  View details for PubMedCentralID PMC10771051

• Virtual reality facilitated exercise improves pain perception: A crossover study. Journal of clinical anesthesia Rodriguez, S. T., Makarewicz, N., Wang, E. Y., Zuniga-Hernandez, M., Titzler, J., Jackson, C., Suen, M. Y., Rosales, O., Caruso, T. J. 2023; 91: 111257

  Abstract

  STUDY OBJECTIVE: Both virtual reality (VR) and exercise are recognized for their analgesic and anxiolytic properties. The purpose of this study is to evaluate the ability of VR-facilitated exercise to modulate pain.DESIGN: Within-subject cross-over clinical trial.SETTING: The Stanford Chariot Program conducted this study at Lucile Packard Children's Hospital Stanford (LCPHS).PATIENTS: Healthy participants meeting inclusion criteria were recruited by volunteer solicitation from LCPHS.INTERVENTIONS: Participants were randomized by hand dominance and subjected to a standardized cold pressor test with no VR or exercise. After a 5-min wash-out period, participants repeated the test on their other hand while experiencing a VR-facilitated exercise condition. Pain sensitivity, pain tolerance, and sympathetic activation data were collected during both conditions.MEASUREMENTS: Pain sensitivity was scored 0-10 and collected every 30s. Pain tolerance was recorded as the duration a participant could endure the painful stimuli. Sympathetic activation was measured by skin conductance response density (SCRD) and recorded in 30s epochs by a biosensor. In all analyses, data were nested by participant.MAIN RESULTS: Forty-one participants completed both interventions. Pain sensitivity was reduced in the VR-facilitated exercise condition (p<0.0001). There was no difference in pain tolerance between conditions. While both conditions resulted in an increase in sympathetic activity, SCRD was higher at all time points in the VR-facilitated exercise condition.CONCLUSIONS: The reduction in pain sensitivity indicates VR-facilitated exercise results in improved pain perception. VR-facilitated exercise may be especially useful for patients with chronic pain or other conditions requiring physical therapy, where pain may be exacerbated by exercise.

  View details for DOI 10.1016/j.jclinane.2023.111257

  View details for PubMedID 37708601

• Percutaneous cervical sympathetic block to treat cerebral vasospasm and delayed cerebral ischemia: a review of the evidence. Journal of neurointerventional surgery Bombardieri, A. M., Albers, G. W., Rodriguez, S., Pileggi, M., Steinberg, G. K., Heit, J. J. 2022

  Abstract

  Delayed cerebral ischemia (DCI) affects 30% of patients following aneurysmal subarachnoid hemorrhage (aSAH) and is a major driver of morbidity, mortality, and intensive care unit length of stay for these patients. DCI is strongly associated with cerebral arterial vasospasm, reduced cerebral blood flow and cerebral infarction. The current standard treatment with intravenous or intra-arterial calcium channel antagonist and balloon angioplasty or stent has limited efficacy. A simple treatment such as a cervical sympathetic block (CSB) may be an effective therapy but is not routinely performed to treat vasospasm/DCI. CSB consists of injecting local anesthetic at the level of the cervical sympathetic trunk, which temporarily blocks the innervation of the cerebral arteries to cause arterial vasodilatation. CSB is a local, minimally invasive, low cost and safe technique that can be performed at the bedside and may offer significant advantages as complementary treatment in combination with more conventional neurointerventional surgery interventions. We reviewed the literature that describes CSB for vasospasm/DCI prevention or treatment in humans after aSAH. The studies outlined in this review show promising results for a CSB as a treatment for vasospasm/DCI. Further research is required to standardize the technique, to explore how to integrate a CSB with conventional neurointerventional surgery treatments of vasospasm and DCI, and to study its long-term effect on neurological outcomes.

  View details for DOI 10.1136/jnis-2022-019838

  View details for PubMedID 36597947

• What every anesthesiologist should know about virtual reality. Paediatric anaesthesia Rodriguez, S., Caruso, T. J. 2022; 32 (12): 1276-1277

  View details for DOI 10.1111/pan.14464

  View details for PubMedID 36352521

• Use of virtual reality for targeted physical rehabilitation: Case report on managing functional motor disorder. Journal of pediatric rehabilitation medicine Nguyen, A. T., Hemphill, S., Donahue, B., Menendez, M., Rodriguez, S., Caruso, T. J. 2022

  Abstract

  Virtual reality (VR) technology has seen increasing use in physical rehabilitation and in the management of acute and chronic pain. Functional movement disorders (FMDs) are a source of disability with no known association to neurologic pathology, and patients are generally offered multidisciplinary treatment approaches to improve functional movement. However, patients who are not compliant with rehabilitation may have persistent FMD and long-term disability. Given VR's use in physical rehabilitation, it may serve as a useful adjunct for the management of FMD. Utilizing an application called MovementTM to create a playlist of targeted applications for the restoration of motor function and balance, this case study presents the application of VR as a tool to engage patients in physical therapy for the management of FMD. The VR games were selected to encourage movement while customization of levels within the games facilitated achievement of physical therapy goals. Physical rehabilitation aided by VR, when used in collaboration with a multidisciplinary care team, may be used to facilitate recovery from FMD.

  View details for DOI 10.3233/PRM-210009

  View details for PubMedID 36120795

• Virtual Reality Reduces Fear and Anxiety During Pediatric Orthopaedic Cast Room Procedures: A Randomized Controlled Trial. Journal of pediatric orthopedics Richey, A. E., Hastings, K. G., Karius, A., Segovia, N. A., Caruso, T. J., Frick, S., Rodriguez, S. 2022

  Abstract

  BACKGROUND: Virtual Reality (VR) has been used as a distraction tool in various medical settings to reduce pain and anxiety associated with procedures. This study evaluates the effectiveness of VR as a distraction tool for decreasing fear, anxiety, and pain in pediatric patients undergoing common outpatient orthopaedic procedures.METHODS: A total of 210 patients were recruited from a single orthopaedic clinic between October 2017 and July 2019. Patients were randomized to the VR group or to the control group (standard of care). Outpatient procedures included cast and/or pin removals. Primary outcome measures were collected preprocedure and postprocedure using validated surveys, and included: fear (Children's Fear Scale), anxiety (Children's Anxiety Meter-State), and pain (Numerical Rating Scale). Patients and caregivers in the VR group completed a satisfaction survey at the end of their appointment. Fear, anxiety, and pain scores between the 2 groups were analyzed using multivariable linear regression models, and the satisfaction survey was analyzed using descriptive statistics.RESULTS: One hundred twenty nine patients were included in the final analysis, with 85 patients in the VR group and 44 patients in the control group. During the procedure, patients in the VR group reported significantly lower average fear scores (P<0.001) and anxiety scores (P=0.003) as compared with controls. There were no differences between the groups in fear and anxiety scores before and after the procedure, or pain scores before, during, or after the procedure. Overall, patients and caregivers in the VR group reported high satisfaction scores, with 97% of patients and 95% of caregivers recommending this intervention to others.CONCLUSION: VR technology was found to be an effective distraction tool to improve fear and anxiety during cast removal procedures. Findings build on a body of evidence that supports the use of distraction tools in clinics, specifically pediatric orthopaedics, to improve fear and anxiety. The distraction tools can be easily translated into current practices.LEVEL OF EVIDENCE: Level I.

  View details for DOI 10.1097/BPO.0000000000002250

  View details for PubMedID 36040069

• Communication Skills Training Using Remote Augmented Reality Medical Simulation: a Feasibility and Acceptability Qualitative Study. Medical science educator Hess, O., Qian, J., Bruce, J., Wang, E., Rodriguez, S., Haber, N., Caruso, T. J. 2022: 1-10

  Abstract

  Introduction: Augmented reality (AR) has promise as a clinical teaching tool, particularly for remote learning. The Chariot Augmented Reality Medical (CHARM) simulator integrates real-time communication into a portable medical simulator with a holographic patient and monitor. The primary aim was to analyze feedback from medical and physician assistant students regarding acceptability and feasibility of the simulator.Methods: Using the CHARM simulator, we created an advanced cardiovascular life support (ACLS) simulation scenario. After IRB approval, preclinical medical and physician assistant students volunteered to participate from August to September 2020. We delivered augmented reality headsets (Magic Leap One) to students before the study. Prior to the simulation, via video conference, we introduced students to effective communication skills during a cardiac arrest. Participants then, individually and remotely from their homes, synchronously completed an instructor-led ACLS AR simulation in groups of three. After the simulation, students participated in a structured focus group using a qualitative interview guide. Our study team coded their responses and interpreted them using team-based thematic analysis.Results: Eighteen medical and physician assistant students participated. We identified four domains that reflected trainee experiences: experiential satisfaction, learning engagement, technology learning curve, and opportunities for improvement. Students reported that the simulator was acceptable and enjoyable for teaching trainees communication skills; however, there were some technical difficulties associated with initial use.Conclusion: This study suggests that multiplayer AR is a promising and feasible approach for remote medical education of communication skills during medical crises.Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01598-7.

  View details for DOI 10.1007/s40670-022-01598-7

  View details for PubMedID 35966166

• Quantifying virtual reality pain modulation in healthy volunteers: A randomized, crossover study. Journal of clinical anesthesia Neiman, N. R., Falkson, S. R., Rodriguez, S. T., Wang, E. Y., Hemphill, S. F., Khoury, M. E., Kist, M. N., Jackson, C. D., Caruso, T. J. 2022; 80: 110876

  Abstract

  STUDY OBJECTIVE: Virtual reality (VR) is an emerging tool to reduce pain and anxiety during procedures. Although VR's clinical benefits are reported, biometric data quantifying VR's effect on pain tolerance is lacking. We used time-lapse, subjective, and biometric data to evaluate VR's effect on modulating pain.DESIGN: Randomized, controlled crossover within-subject clinical trial.SETTING: This study was conducted in the Chariot Lab at Lucile Packard Children's Hospital and outdoors at Stanford University School of Medicine.PATIENTS: 156 healthy volunteers were included.INTERVENTIONS: Participants underwent pain-inducing ice immersions while connected to biometric sensors. Participants were randomized to immerse their dominant or non-dominant hand with VR or control (no VR) for one immersion, and then crossed-over to the other hand for the second immersion. We instructed participants to submerge their hand until they reached their pain tolerance or until four minutes elapsed.MEASUREMENTS: Outcomes included ice immersion duration, perceived pain scores, and skin conductance response density (SCRD), a marker of sympathetic arousal. We used survival analysis and mixed effects models to compare measurements with and without VR.MAIN RESULTS: 153 participants were included in the analysis. Participants with VR were 64% less likely to remove their hands from the ice bath throughout the immersion's duration compared to control (P<0.001). Participants with VR reported significantly lower pain scores after controlling for dominant hand treatment assignment, VR vs. no VR treatment order, and gender (P<0.001). SCRD increased as time progressed for both VR and control groups (P=0.047 combined), with no significant mean group differences.CONCLUSIONS: Participants with VR were more likely to survive the 4-min ice bath challenge longer and with lower levels of pain perception, supporting VR's effectiveness as a distraction tool during painful procedures. We observed no differences in sympathetic response when comparing VR to no VR.

  View details for DOI 10.1016/j.jclinane.2022.110876

  View details for PubMedID 35525050

• Augmented Reality as Sole Anxiolytic for Pediatric Inhalational Induction of General Anesthesia Sanofsky, B., Caruso, T. J., Zuniga, M., Rodriguez, S., Yun, R. LIPPINCOTT WILLIAMS & WILKINS. 2022: 81-84

  View details for Web of Science ID 000770094900043

• Real-time reorientation and cognitive load adjustment allow for broad application of virtual reality in a pediatric hospital. Journal of clinical and translational research Caruso, T. J., Fonseca, A., Barreau, A., Khoury, M., Menendez, M., Wang, E., Lawrence, K., Jackson, C., Rodriguez, S. 1800; 7 (6): 750-753

  Abstract

  Background: With a new generation of affordable portable virtual reality (VR), clinicians are discovering more utility for VR, while also identifying opportunities for improvement, such as the inability to reorient the horizon line during repositioning or transport, or modulate cognitive load in real time.Aim: At our institution, this lack of functionality prohibited or decreased VR usage in some clinical scenarios such as dressing changes with dynamic positioning. The purpose of this brief report is to describe the development and use of a VR application that is optimized for the healthcare setting and report historical effects of patients who utilized VR as supplement to Child Life procedures. Eligible affects per chart review included Happy, Relaxed, Anxious, Distressed, Unable to Assess.Materials and Methods: Given the need for real-time reorientation and cognitive load modulation, we created the Space Pups VR application. The experience was launched as part of the Stanford Chariot Program in the summer of 2017, and its usage was tracked through the electronic medical record and a VR application dashboard. Chart review was queried from 3 January 2018 to 9 August 2021 for pediatric patients who used VR with real-time reorientation and cognitive load modulation as a supplement to their Child Life interventions.Results: The Space Pups experience has been successfully used in a variety of settings, including perioperative care, vascular access, wound care, and ENT clinic, a total of 1696 times. Patients ranged from 6 years to 18-year old, with no reports of side effects. Significant results (P<0.001) were observed pre- and post-VR use for affect improvements in Happy, Relaxed, and Anxious, but not for Distressed.Conclusions: The ability to reorient VR experiences in real time has increased functionality where other applications have failed.Relevance for Patients: While more studies are needed to quantify the anxiolytic and pain-reducing effect of Space Pups, our report demonstrates the feasibility of this VR experience as a non-pharmacological modality to safely increase patient cooperation in a wide variety of clinical settings.

  View details for PubMedID 34988325

• Use of Bedside Entertainment and Relaxation Theater (BERT) to Reduce Fear and Anxiety Associated With Outpatient Procedures in Pediatric Orthopaedics. Journal of pediatric orthopedics Richey, A. E., Khoury, M., Segovia, N. A., Hastings, K. G., Caruso, T. J., Frick, S., Rodriguez, S. 2021

  Abstract

  BACKGROUND: The aim of the present study was to evaluate the effectiveness of the Bedside Entertainment and Relaxation Theater (BERT) on fear, anxiety, and pain outcomes in pediatric orthopaedic patients associated with cast removal and/or pin removal in the outpatient clinic setting.METHODS: A total of 66 pediatric patients between the ages of 2 and 6 undergoing clinic procedures were recruited for this study and randomized into the control group or the intervention (BERT) group. Patients in the control group received standard of care during the cast room procedure; patients in the BERT group were given headphones and watched a movie on a projector during the procedure. Fear, anxiety, and pain were measured before and after the procedure. Procedures included cast removal, pin removal, or a combination of the 2.RESULTS: Patients in the BERT group reported less fear and anxiety overall after the procedure than patients in the control group (P=0.009, 0.015). Adjusting for procedure type (ie, pin removal), patients in the BERT group reported a 0.67 point decrease (95% confidence interval: 0.04, 1.30) on the fear scale after the procedure (P=0.039) and a 1.81 point decrease (95% confidence interval: 0.04, 3.59) on the anxiety scale associated with the procedure (P=0.045), compared with the control group. Patients and caregivers reported high satisfaction with BERT.CONCLUSION: This randomized, controlled trial demonstrates an evidence-based distraction tool that can be implemented across medical centers for pediatric patients undergoing office based orthopaedic procedures. BERT can be used to reduce fear and anxiety associated with these procedures, and increased patient and parent satisfaction.LEVEL OF EVIDENCE: Level I.

  View details for DOI 10.1097/BPO.0000000000002005

  View details for PubMedID 34739431

• Development and assessment of an efficient pediatric affect and cooperation scale. Journal of clinical anesthesia Kennedy, K., Wang, E., Rodriguez, S. T., Qian, J., Khoury, M., Kist, M. N., Jackson, C., Yun, R., Caruso, T. J. 2021; 76: 110569

  Abstract

  STUDY OBJECTIVE: HRAD± was developed to quickly evaluate pediatric preprocedural affect and cooperativity during mask induction of anesthesia and peripheral intravenous (PIV) placement. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to compare HRAD± to previously published scales.DESIGN: We conducted an observational study.SETTING: Videos of pediatric patients were collected in the perioperative environment.PATIENTS: Twenty-four children, twenty-one pediatric anesthesiologists and twenty pediatric perioperative providers were included.INTERVENTIONS: To assess the reliability of HRAD±, standard patient videos were created. Children underwent mask induction or PIV placement, and these interventions were video recorded. Mask induction and PIV placement videos were rated by pediatric anesthesiologists and perioperative non-physician providers respectively using HRAD±.MEASUREMENTS: Two trained researchers provided the modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC) scores, and we calculated correlations to HRAD±, inter-rater reliability, and intra-rater reliability.MAIN RESULTS: HRAD± scores strongly correlated with mYPAS (r=0.846, p<0.0001) and OSBD scores (r=0.723, p<0.0001). Cooperativity scores correlated strongly with ICC scores in the mask induction group (r=-0.715, p<0.0001) and in the PIV group (r=-0.869, p<0.0001). HRAD± inter-rater reliability for mask induction was 0.414 (p<0.0001) and for PIV assessment was 0.378 (p<0.0001). Inter-rater reliability for cooperativity on mask induction was 0.797 (p<0.0001) and PIV assessment was 0.683 (p<0.0001). Intra-rater reliability for mask induction was 0.675 and PIV assessments was 0.678. Intra-rater reliability for cooperativity for mask induction was 0.894 and for PIV assessments was 0.765.CONCLUSIONS: HRAD± is an efficient and reliable scale that serves as a practical alternative for measuring pediatric affect during mask induction and PIV placement. The results demonstrate strong correlation with commonly utilized yet more complex affect scales.

  View details for DOI 10.1016/j.jclinane.2021.110569

  View details for PubMedID 34739949

• Development of regional anesthesia curriculum and ultrasound-guided procedural simulation models for low- and middle-income countries Khoo, C., Chuter, B., Rodriguez, S. LIPPINCOTT WILLIAMS & WILKINS. 2021: 720

  View details for Web of Science ID 000713327100518

• Integrated eye tracking on Magic Leap One during augmented reality medical simulation: a technical report BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING Caruso, T. J., Hess, O., Roy, K., Wang, E., Rodriguez, S., Palivathukal, C., Haber, N. 2021; 7 (5): 431-434

  View details for DOI 10.1136/bmjstel-2020-000782

  View details for Web of Science ID 000672226300025

• Mindfulness-Based Virtual Reality Intervention for Children and Young Adults with Inflammatory Bowel Disease: A Pilot Feasibility and Acceptability Study CHILDREN-BASEL Wren, A. A., Neiman, N., Caruso, T. J., Rodriguez, S., Taylor, K., Madill, M., Rives, H., Nguyen, L. 2021; 8 (5)

  Abstract

  The aim of this pilot study was to assess: (1) the feasibility and acceptability of a Mindfulness-Based Virtual Reality (MBVR) intervention among children and young adults with Inflammatory Bowel Disease (IBD), and (2) the preliminary efficacy of MBVR on key psychological (anxiety) and physical (pain) outcomes. Participants were 62 children to young adults with IBD (M = 15.6 years; 69.4% Crohn's disease; 58% male) recruited from an outpatient pediatric IBD clinic. Participants completed a baseline assessment, underwent the 6-min MBVR intervention, completed a post-intervention assessment and study satisfaction survey, and provided qualitative feedback. Results suggest strong feasibility and acceptability. Participants reported high levels of satisfaction with MBVR including high levels of enjoyment (M = 4.38; range 1-5) and relaxation (M = 4.35; range 1-5). Qualitative data revealed several key themes including participants interest in using MBVR in IBD medical settings (e.g., hospitalizations, IBD procedures, IBD treatments), as well as in their daily lives to support stress and symptom management. Preliminary analyses demonstrated improvements in anxiety (t = 4.79, p = 0.001) and pain (t = 3.72, p < 0.001) following MBVR. These findings provide initial support for the feasibility and acceptability of MBVR among children and young adults with IBD. Results also suggest MBVR may improve key IBD outcomes (e.g., anxiety, pain) and highlight the importance of conducting a randomized controlled trial and more rigorous research to determine intervention efficacy.

  View details for DOI 10.3390/children8050368

  View details for Web of Science ID 000653585100001

  View details for PubMedID 34063034

• Unique considerations of virtual reality utilization for perioperative pediatric patients. Paediatric anaesthesia Yuan, J. C., Rodriguez, S., Caruso, T. J. 2021; 31 (3): 377–78

  View details for DOI 10.1111/pan.14108

  View details for PubMedID 33631038

• Integrated eye tracking on Magic Leap One during augmented reality medical simulation: a technical report. BMJ simulation & technology enhanced learning Caruso, T. J., Hess, O., Roy, K., Wang, E., Rodriguez, S., Palivathukal, C., Haber, N. 2021; 7 (5): 431-434

  Abstract

  Augmented reality (AR) has been studied as a clinical teaching tool, however eye-tracking capabilities integrated within an AR medical simulator have limited research. The recently developed Chariot Augmented Reality Medical (CHARM) simulator integrates real-time communication into a portable medical simulator. The purpose of this project was to refine the gaze-tracking capabilities of the CHARM simulator on the Magic Leap One (ML1). Adults aged 18 years and older were recruited using convenience sampling. Participants were provided with an ML1 headset that projected a hologram of a patient, bed and monitor. They were instructed via audio recording to gaze at variables in this scenario. The participant gaze targets from the ML1 output were compared with the specified gaze points from the audio recording. A priori investigators planned to iterative modifications of the eye-tracking software until a capture rate of 80% was achieved. Two consecutive participants with a capture rate less than 80% triggered software modifications and the project concluded after three consecutive participants' capture rates were greater than 80%. Thirteen participants were included in the study. Eye-tracking concordance was less than 80% reliable in the first 10 participants. The investigators hypothesised that the eye movement detection threshold was too sensitive, thus the algorithm was adjusted to reduce noise. The project concluded after the final three participants' gaze capture rates were 80%, 80% and 80.1%, respectively. This report suggests that eye-tracking technology can be reliably used with the ML1 enabled with CHARM simulator software.

  View details for DOI 10.1136/bmjstel-2020-000782

  View details for PubMedID 35515734

  View details for PubMedCentralID PMC8936533

• Leveraging VR/AR to combat chronic pain in youth: Position paper from the Interdisciplinary Network on Virtual and Augmented (AR/VR) Technologies for Pain (INOVATE-Pain) Management. Journal of medical Internet research Logan, D. E., Simons, L. E., Caruso, T. n., Gold, J. I., Greenleaf, W. n., Griffin, A. n., King, C. n., Menendez, M. n., Olbrecht, V. n., Rodriguez, S. n., Silvia, M. n., Stinson, J. n., Wang, E. n., Williams, S. n., Wilson, L. n. 2021

  Abstract

  Virtual reality (VR) and augmented reality (AR) interventions are emerging as promising tools in the treatment of pediatric chronic pain conditions, but in this young field there is little consensus to guide the process of engaging in the development and evaluation of targeted VR-based interventions.The INOVATE-Pain consortium aims to advance the field of VR for pediatric chronic pain rehabilitation by providing guidance for best practices in the design, evaluation, and dissemination of VR-based interventions targeting this population.An interdisciplinary meeting of 16 academics, clinicians, industry and philanthropy partners was held in January 2020.Reviewing the state of the field, the consortium identified important directions for research-driven innovation in VR/AR clinical care, highlighted key opportunities and challenges facing the field, and established a consensus on best methodological practices to adopt in future efforts to advance the research and practice of VR/AR in pediatric pain. The consortium also identified important next steps to undertake to continue to advance the work in this promising new area of digital health pain interventions.To realize the promise of this realm of innovation, key ingredients for the success include productive partnerships among industry, academic, and clinical stakeholders, a uniform set of outcome domains and measures for standardized evaluation, and widespread access to the latest opportunities, tools and resources. The INOVATE-Pain collaborative hopes to promote the creation, rigorous yet efficient evaluation, and dissemination of innovative VR-based interventions to reduce pain and improve quality of life for children.

  View details for DOI 10.2196/25916

  View details for PubMedID 33667177

• Virtual reality for pediatric periprocedural care. Current opinion in anaesthesiology Wang, E. n., Thomas, J. J., Rodriguez, S. T., Kennedy, K. M., Caruso, T. J. 2021; 34 (3): 284–91

  Abstract

  Commercial availability of virtual reality headsets and software has exponentially grown over the last decade as it has become more sophisticated, less expensive, and portable. Although primarily used by the general public for entertainment, virtual reality has been adopted by periprocedural clinicians to improve patient experiences and treatments. The purpose of this review is to explore recently reported evidence for virtual reality effectiveness for pediatric periprocedural care and discuss considerations for clinical implementation.In the preprocedure setting, practitioners use virtual reality to introduce children to periprocedural environments, distract attention from preprocedural vascular access, and increase cooperation with anesthesia induction. Intraprocedure, virtual reality decreases sedation requirements, and in some instances, eliminates anesthesia for minor procedures. Virtual reality also augments pain reduction therapies in the acute and extended rehabilitation periods, resulting in faster recovery and improved outcomes. Virtual reality seems to be well treated for pediatric use, given close clinical care and carefully curated content.Given the multiple clinical applications of virtual reality to supplement pediatric periprocedural care, practitioners should consider developing clinical programs that reliably provide access to virtual reality. Future research should focus on identification of patient characteristics and types of software that yield optimal patient outcomes.

  View details for DOI 10.1097/ACO.0000000000000983

  View details for PubMedID 33935176

• Virtual Reality Augments Movement during Physical Therapy: A Pragmatic Randomized Trial. American journal of physical medicine & rehabilitation Hemphill, S. n., Rodriguez, S. n., Wang, E. n., Koeppen, K. n., Aitken-Young, B. n., Jackson, C. n., Simons, L. n., Caruso, T. J. 2021

  Abstract

  Virtual reality (VR) facilitates physical therapy (PT) via improved engagement. While shown to benefit specific patient populations, such as stroke patients, it is less established in otherwise healthy adults and children receiving outpatient PT. The primary objective was to compare total PT-guided Movement supplemented with VR (PTMVR) to PT guided Movement alone, without VR (PTM).This pragmatic, randomized, crossover study compared PTMVR to PTM in outpatients (ages 6-80). This community sample had variable PT indications (injury, postoperative, chronic pain) and in preexisting conditions, therefore participants served as their own controls. Participants received 10 minutes of both PTMVR and PTM, separated by five minutes. The primary outcome was differences in aggregate movement of PT guided exercises. Secondary outcomes explored OMNI rating of perceived exertion (RPE) and participant and physical therapist satisfaction. Paired t-tests, chi-squared tests, and regression models were used to analyze differences.The 41 participants (17 pediatric and 24 adult) moved significantly more during PTMVR compared to PTM (1120.88 meters vs 672.65 meters p < 0.001), regardless of which intervention was completed first. PTMVR treatment was associated with more movement of the target limbs, lower-body (p < 0.001), upper-body (p <0.05). OMNI RPE scores did not differ between those who started with PTMVR or PTM, and physical therapist and patient surveys endorsed PTMVR.Patients completed more PT guided movement during PTMVR than PTM and therapists and patients supported its use. Future studies will examine finer tracking of movements.

  View details for DOI 10.1097/PHM.0000000000001779

  View details for PubMedID 33935153

• Virtual Reality Facilitates Engagement in Physical Therapy in the Pediatric CVICU. Pediatric physical therapy : the official publication of the Section on Pediatrics of the American Physical Therapy Association Hemphill, S. n., Nguyen, A. n., Kwong, J. n., Rodriguez, S. T., Wang, E. n., Caruso, T. J. 2021; 33 (1): E7–E9

  Abstract

  The purpose of this report is to demonstrate the successful application of virtual reality to improve physical therapy in the pediatric cardiovascular intensive care unit. Early mobilization and cognitive stimulation improve morbidity of critically ill children. However, maintaining child engagement with these therapies can be challenging, especially during extended intensive care stays.While virtual reality has been successfully used as an analgesic and anxiolytic in the cardiovascular intensive care unit, this report demonstrates its novel use as a tool to augment physical therapy for a child who had been debilitated after heart transplantation. Virtual reality encouraged the child to engage in physical therapy sessions, participate for greater durations, and directly address barriers to discharge.While further studies are needed to define best practice, this report demonstrates that virtual reality can be safely used for carefully selected and monitored children in critical care.

  View details for DOI 10.1097/PEP.0000000000000769

  View details for PubMedID 33337780

• Virtual Reality in Pain Rehabilitation for Youth With Chronic Pain: Pilot Feasibility Study. JMIR rehabilitation and assistive technologies Griffin, A., Wilson, L., Feinstein, A. B., Bortz, A., Heirich, M. S., Gilkerson, R., Wagner, J. F., Menendez, M., Caruso, T. J., Rodriguez, S., Naidu, S., Golianu, B., Simons, L. E. 2020; 7 (2): e22620

  Abstract

  BACKGROUND: In the field of pain, virtual reality (VR) technology has been increasingly common in the context of procedural pain management. As an interactive technology tool, VR has the potential to be extended beyond acute pain management to chronic pain rehabilitation with a focus on increasing engagement with painful or avoided movements.OBJECTIVE: We outline the development and initial implementation of a VR program in pain rehabilitation intervention to enhance function in youth with chronic pain.METHODS: We present the development, acceptability, feasibility, and utility of an innovative VR program (Fruity Feet) for pediatric pain rehabilitation to facilitate increased upper and lower extremity engagement. The development team was an interdisciplinary group of pediatric experts, including physical therapists, occupational therapists, pain psychologists, anesthesiologists, pain researchers, and a VR software developer. We used a 4-phase iterative development process that engaged clinicians, parents, and patients via interviews and standardized questionnaires.RESULTS: This study included 17 pediatric patients (13 female, 4 male) enrolled in an intensive interdisciplinary pain treatment (IIPT) program, with mean age of 13.24 (range 7-17) years, completing a total of 63 VR sessions. Overall reports of presence were high (mean 28.98; max 40; SD 4.02), suggestive of a high level of immersion. Among those with multisession data (n=8), reports of pain (P<.001), fear (P=.003), avoidance (P=.004), and functional limitations (P=.01) significantly decreased. Qualitative analysis revealed (1) a positive experience with VR (eg, enjoyed VR, would like to utilize the VR program again, felt VR was a helpful tool); (2) feeling distracted from pain while engaged in VR; (3) greater perceived mobility; and (4) fewer clinician-observed pain behaviors during VR. Movement data support the targeted impact of the Fruity Feet compared to other available VR programs.CONCLUSIONS: The iterative development process yielded a highly engaging and feasible VR program based on qualitative feedback, questionnaires, and movement data. We discuss next steps for the refinement, implementation, and assessment of impact of VR on chronic pain rehabilitation. VR holds great promise as a tool to facilitate therapeutic gains in chronic pain rehabilitation in a manner that is highly reinforcing and fun.

  View details for DOI 10.2196/22620

  View details for PubMedID 33226346

• A Retrospective Cohort Study of Predictors and Interventionsthat Influence Cooperation with Mask Induction in Children. Paediatric anaesthesia Marquez, J. L., Wang, E., Rodriguez, S. T., O'Connell, C., Munshey, F., Darling, C., Tsui, B., Caruso, J., Caruso, T. J. 2020

  Abstract

  BACKGROUND: Uncooperative pediatric mask induction is linked to perioperative anxiety. Although some risk factors for uncooperative inductions have been reported, there are no large cohort studies that identify intrinsic patient characteristics associated with cooperation.AIM: The primary aim was to identify patient characteristics associated with cooperative mask inductions. The secondary aim was to determine whether preoperative interventions were associated with increased cooperation.METHODS: This retrospective cohort study included patients 2 -11 years old and ASA class I-IV who underwent mask induction. Our primary outcome of interest was cooperation with mask induction, which was correlated against the Induction Compliance Checklist. The variables analyzed for association with cooperation were age, sex, ASA class, class of surgery, preferred language, and race. Interventions examined for association with induction cooperation included premedication with midazolam, exposure to distraction technology, parental presence, and the presence of a Child Life Specialist. Multivariate mixed effects logistic regression was used to assess the relationship between patient characteristics and cooperation. A separate multivariate mixed effects logistic regression was used to examine the association between preoperative interventions and cooperation.RESULTS: 9,692 patients underwent 23,474 procedures during the study period. 3,372 patients undergoing 5,980 procedures met inclusion criteria. The only patient characteristic associated with increased cooperation was age (OR 1.20, p-value 0.03). Involvement of Child Life Specialists was associated with increased cooperation (OR 4.44, p-value = 0.048) while parental/guardian presence was associated with decreased cooperation (OR 0.38, p-value = 0.002).CONCLUSION: In this cohort, increasing age was the only patient characteristic found to be associated with increased cooperation with mask induction. Preoperative intervention by a Child Life Specialists was the sole intervention associated with improved cooperation.

  View details for DOI 10.1111/pan.13930

  View details for PubMedID 32452092

• Retrospective Review of the Safety and Efficacy of Virtual Reality in a Pediatric Hospital. Pediatric quality & safety Caruso, T. J., O'Connell, C., Qian, J. J., Kung, T., Wang, E., Kinnebrew, S., Pearson, M., Kist, M., Menendez, M., Rodriguez, S. T. 2020; 5 (2): e293

  Abstract

  Introduction: Virtual reality (VR) is an emerging tool for anxiety and fear reduction in pediatric patients. VR use is facilitated by Certified Child Life Specialists (CCLS) at pediatric hospitals. The primary aim of this study was to retrospectively review the safety of VR by analyzing adverse events after the utilization of VR under CCLS supervision. Secondary objectives were to characterize the efficacy of VR in enhancing patient cooperation, describe the integration of VR into Child Life services, and identify interventions that accompanied VR.Methods: The Stanford Chariot Program developed VR applications, customized VR interfaces, and patient head straps, and distributed these to CCLS. Chart review analyzed VR utilization through CCLS patient notes. Inclusion criteria were all patients ages 6 to 18-years-old who received a Child Life intervention.Results: From June 2017 to July 2018, 31 CCLS saw 8,098 patients, 3,696 of which met age criteria with pre- and post-intervention cooperation data. Two hundred thirteen patients received VR with an accompanying intervention, while 34 patients received only VR. Adverse events were rare, and included increased anxiety (3.8%, n=8), dizziness (0.5%, n=1), and nausea (0.5%, n=1). Patients were more likely to be cooperative after receiving VR (99.5%, n=212) compared to pre-intervention (96.7%, n=206, p=0.041). VR use was most common in the perioperative setting (60%, n=128), followed by outpatient clinics (15%, n=32).Conclusion: VR is safe in pediatric patients with appropriate hardware, software, and patient selection. Side effects were rare and self-limited. VR appears to be associated with improvements in cooperation.

  View details for DOI 10.1097/pq9.0000000000000293

  View details for PubMedID 32426648

• Impact of Audio-Visual Assisted Therapeutic Ambience in Radiotherapy (AVATAR) on Anesthesia Use, Payer Charges, and Treatment Time in Pediatric Patients. Practical radiation oncology Balazy, K. E., Gutkin, P. M., Skinner, L., von Eyben, R., Fowler, T., Pinkham, D. W., Rodriguez, S., Maxim, P. G., Donaldson, S. S., Loo, B. W., Bush, K., Hiniker, S. M. 2020

  Abstract

  PURPOSE: Pediatric radiotherapy requires optimal immobilization that often necessitates daily anesthesia. To decrease anesthesia use, we implemented a novel XXX system which projects video onto a radiolucent screen within the child's line of vision to provide attentional diversion. We investigated its reduction on anesthesia use, payer charges, and treatment time, as well as its impact on radiation delivery.METHODS AND MATERIALS: A 6-year retrospective analysis was performed among children undergoing radiotherapy (n=224), 3 years before and 3 after introduction of XXX. The frequency of anesthesia use before and after XXX implementation, as well as radiotherapy treatment times were compared. The number of spared anesthesia treatments allowed for a charge to payer analysis. To document lack of surface dose perturbation by XXX, a phantom craniospinal treatment course was delivered both with and without XXX. Additionally, an ion chamber course was delivered to document changes to dose at depth.RESULTS: More children were able to avoid anesthesia use entirely in the post-XXX cohort, compared to the pre-XXX cohort (73.2% vs 63.4%, p=0.03) and fewer required anesthesia for each treatment (18.8% vs 33%; p = 0.03). XXX introduction reduced anesthesia use for all ages studied. Treatment time per session was reduced by 38% using XXX compared to anesthesia. There were 326 fewer anesthesia sessions delivered over three years after XXX was introduced, with an estimated savings of > $500,000. OSLDs revealed a small increase in dose of 0.8%-9.5% with XXX, while the use of a thermomolded face mask increased skin dose as much as 58%.CONCLUSIONS: XXX introduction decreased anesthesia use in children undergoing radiotherapy; more avoided anesthesia entirely, and fewer needed it for every treatment. This resulted in a reduction in treatment time, and savings of nearly $550,000 in approximately 3 years, with minimal perturbation of radiotherapy dose delivery.

  View details for DOI 10.1016/j.prro.2019.12.009

  View details for PubMedID 31935524

• Mobilization and calibration of the HTC VIVE for virtual reality physical therapy. Digital health Hemphill, S., Nguyen, A., Rodriguez, S. T., Menendez, M., Wang, E., Lawrence, K., Caruso, T. J. 2020; 6: 2055207620950929

  Abstract

  Aims: The HTC VIVE virtual reality (VR) system is a potential tool for collecting kinematic data during inpatient and outpatient physical therapy (PT). When validated against research-grade systems, the VIVE has a reported translational error between 1.7mm-2.0cm. Our purpose was to portabilize the VIVE for room to room PT and validate the motion tracking software.Methods: The VIVE was configured on a mobile cart. To validate the motion tracking software, the VIVE sensors (motion tracker, controller, headset) were mounted on a rigid linear track and driven through 10, one-meter translations in the X, Y, and Z axes.Results: The mean translational error for all three sensors was below 4.9cm. While error is greater than that reported for research-grade systems, motion tracking software on the portable VIVE unit appears to be a valid means of tracking aggregate movement.Conclusion: Some therapy may require more precise measurements, however, the advantages of portability and accessibility to patients may outweigh the limitation of reduced precision.

  View details for DOI 10.1177/2055207620950929

  View details for PubMedID 32963801

• Using Augmented Reality to Reduce Fear and Promote Cooperation During Pediatric Otolaryngologic Procedures. The Laryngoscope Caruso, T. J., Madill, M. n., Sidell, D. n., Meister, K. n., Wang, E. n., Menendez, M. n., Kist, M. N., Rodriguez, S. n. 2020

  Abstract

  This case series examines interactive AR during minor otolaryngologic procedures. Although VR has been successfully used for pediatric vascular access, removing children from comforting people in the real world has resulted in patient anxiety. AR offers a potential advantage, utilizing distracting holographic images when patients maintain eye contact with parents. The primary objective was to determine the effect of AR on fear during pediatric otolaryngologic procedures. Secondary objectives included evaluating pain; procedure compliance; and patient, parent and physician attitudes toward AR, as well as assessing the feasibility of adding AR to a busy outpatient otolaryngologic clinic. Laryngoscope, 2020.

  View details for DOI 10.1002/lary.29098

  View details for PubMedID 32886794

• Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) augments oxygenation in children with cyanotic heart disease during microdirect laryngoscopy and bronchoscopy JOURNAL OF CLINICAL ANESTHESIA Caruso, T. J., Sidell, D. R., Lennig, M., Menendez, M., Fonseca, A., Rodriguez, S. T., Tsui, B. 2019; 56: 53–54

  View details for DOI 10.1016/j.jclinane.2019.01.029

  View details for Web of Science ID 000468713500021

• Virtual reality use in adult ICU to mitigate anxiety for a patient on V-V ECMO JOURNAL OF CLINICAL ANESTHESIA Blair, G. J., Kapil, S., Cole, S., Rodriguez, S. 2019; 55: 26-27

  View details for DOI 10.1016/j.jclinane.2018.12.033

  View details for Web of Science ID 000462694300012

• Varying Screen Size for Passive Video Distraction During Induction of Anesthesia in Low Risk Children: A Pilot Randomized Controlled Trial. Paediatric anaesthesia Rodriguez, S., Jang, O., Hernandez, J. M., George, A. J., Caruso, T. J., Simons, L. 2019

  Abstract

  BACKGROUND: Preoperative anxiety affects up to 65% of children who undergo anesthesia induction and often results in uncooperative behaviour. Electronic devices have been used to distract children to reduce anxiety and create a more enjoyable preoperative experience. Few studies have compared the effects of different video delivery systems on preoperative anxiety.AIM: The primary aim was to determine if a large projection based video screen mounted to a patient's bed decreased anxiety when compared to a tablet during mask induction of anesthesia in children from 4-10 years of age.METHODS: We performed a prospective, randomized trial to determine differences in our primary outcome, preoperative anxiety, between the large Bedside Entertainment and Relaxation Theater (BERT) and a smaller tablet screen. Secondary outcomes included 1) induction compliance, 2) child fear, 3) frequency of emergence delirium, and 4) satisfaction.RESULTS: In examining the primary outcome for 52 patients, there was a main effect for time on mYPAS scores, f(2, 51)=13.18, p<0.01. mYPAS scores significantly increased across time for both groups. The interaction for time (T0, T1 or T2) x group (BERT vs. Tablet) was not significant, f(2, 51)=1.96, p=0.15; thus changes in mYPAS scores across time did not differ by group status. There was no significant difference in induction compliance, child fear, emergence delirium, or satisfaction between the two groups.CONCLUSION: In a low risk population, preoperative anxiety was low and induction compliance was high when pairing screen based distraction interventions, regardless of size, with parental presence at induction of anesthesia. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30916447

• Speeding the Detection of Vessel Cannulation: An In-Vitro Stimulation Study. Anesthesia and analgesia Muffly, M. K., Ku, A., Drover, D. R., Rodriguez, S., Caruso, T. J., Ku, A., Tsui, B. C. 2019

  Abstract

  BACKGROUND: Some practitioners "prime" small IV angiocatheter needles with 0.9% sodium chloride-claiming this modification speeds visual detection of blood in the angiocatheter flash chamber on vessel cannulation.METHODS: We compared the time required for human blood to travel the length of saline-primed and saline-unprimed 24- and 22-gauge angiocatheter needles (Introcan Safety IV Catheter; B. Braun, Bethlehem, PA). A syringe pump (Medfusion 4000, Cary, NC) advanced each angiocatheter needle through the silicone membrane of an IV tubing "t-piece" (Microbore Extension Set, 5 Inch; Hospira, Lake Forest, IL) filled with freshly donated human blood. When the angiocatheter needle contacted the blood, an electrical circuit was completed, illuminating a light-emitting diode. We determined the time from light-emitting diode illumination to visual detection of blood in the flash chamber by video review. We tested 105 saline-primed angiocatheters and 105 unprimed angiocatheters in the 24- and 22-gauge angiocatheter sizes (420 catheters total). We analyzed the median time to visualize the flash using the nonparametric Wilcoxon rank sum test in R (http://www.R-project.org/). The Stanford University Administrative Panel on Human Subjects in Medical Research determined that this project did not meet the definition of human subjects research and did not require institutional review board oversight.RESULTS: In the 24-gauge angiocatheter group, the median (and interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.14 (0.61-1.47) seconds compared with 0.76 (0.41-1.20) seconds in the saline-primed group (P = 0.006). In the 22-gauge catheter group, the median (interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.80 (1.23-2.95) seconds compared with 1.46 (1.03-2.54) seconds in the saline-primed group (P = .046).CONCLUSIONS: These results support the notion that priming small angiocatheter needles, in particular 24-gauge catheters, with 0.9% sodium chloride may provide earlier detection of vessel cannulation than with the unprimed angiocatheter.

  View details for PubMedID 30633054

• Virtual Reality during Pediatric Vascular Access: A Pragmatic, Prospective Randomized, Controlled Trial. Paediatric anaesthesia Caruso, T. J., George, A. n., Menendez, M. n., De Souza, E. n., Khoury, M. n., Kist, M. N., Rodriguez, S. T. 2019

  Abstract

  Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics.The primary aim was to determine if pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events.A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7-18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified induction compliance checklist, and satisfaction surveys, respectively. Chi-squared, t-tests, and regression models were used to analyze the results.The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in post-procedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, p=0.59), post-procedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater) or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96 to 5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events.This study demonstrates no reduction in pain while using VR across a heterogeneous pediatric inpatient population undergoing vascular access.

  View details for DOI 10.1111/pan.13778

  View details for PubMedID 31785015

• Virtual reality use in adult ICU to mitigate anxiety for a patient on V-V ECMO. Journal of clinical anesthesia Blair, G. J., Kapil, S., Cole, S. P., Rodriguez, S. 2018; 55: 26–27

  View details for PubMedID 30590187

• Saphenous nerve block for medial foot surgery: Saphenous nerve beyond cutaneous sensory distribution. Journal of clinical anesthesia Darling, C. E., Hoffinger, S. A., Rodriguez, S., Tsui, B. C. 2018; 54: 160–61

  View details for DOI 10.1016/j.jclinane.2018.12.012

  View details for PubMedID 30553226

• The Precision Portrait. AMA journal of ethics Rodriguez, S., Love, N. 2018; 20 (9): E891–893

  Abstract

  The Precision Portrait is a mixed-media portrait illustrating the future of precision medicine and its ethical challenges.

  View details for PubMedID 30242821

• Active Virtual Reality Improves Vascular Access Compliance in Anxious Children Yuan, J. C., Joseph, A., Rodriguez, S., Caruso, T. J. LIPPINCOTT WILLIAMS & WILKINS. 2018: 114–15

  View details for Web of Science ID 000453838000050

• A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety. Pediatric quality & safety Caruso, T. J., Tsui, J. H., Wang, E., Scheinker, D., Sharek, P. J., Cunningham, C., Rodriguez, S. T. 2018; 3 (4): e087

  Abstract

  Introduction: Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.Methods: We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children's Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients' emotion at induction. Ordinary least squares regression compared preoperative time.Results: Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be "playful" compared with "sedated" (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).Conclusions: Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling "playful."

  View details for PubMedID 30229198

• A Body of Work: Painting a Decade of Gross Dissection. Academic medicine : journal of the Association of American Medical Colleges Rodriguez, S. 2018; 93 (3): 428

  View details for DOI 10.1097/ACM.0000000000002089

  View details for PubMedID 29485505

• Continuous erector spinae plane block for an open pyeloplasty in an infant. Journal of clinical anesthesia Munshey, F. n., Rodriguez, S. n., Diaz, E. n., Tsui, B. n. 2018; 47: 47–49

  View details for DOI 10.1016/j.jclinane.2018.03.015

  View details for PubMedID 29573732

• Augmented reality for intravenous access in an autistic child with difficult access. Paediatric anaesthesia Rodriguez, S. n., Munshey, F. n., Caruso, T. J. 2018; 28 (6): 569–70

  View details for DOI 10.1111/pan.13395

  View details for PubMedID 29878540

• A Novel Bed-Mounted Projection System is as Effective as Pharmacologic Modalities to Treat Pediatric Preoperative Anxiety Caruso, T. J., Rodriguez, S., Wang, E., Terajewicz, A., Brockington, D., Cunningham, C., Sharek, P. J., Marquez, J. LIPPINCOTT WILLIAMS & WILKINS. 2017: 23–25

  View details for Web of Science ID 000404667000007

• Contralateral osteotomy of the pedicle and posterolateral elements for en bloc resection: a technique for oncological resection of posterolateral spinal tumors JOURNAL OF NEUROSURGERY-SPINE Vasudeva, V. S., Ropper, A. E., Rodriguez, S., Wu, K. C., Chi, J. H. 2017; 26 (3): 275-281

  Abstract

  En bloc resection of tumors involving the spinal column is technically challenging and is associated with high morbidity to the patient due to the proximity of critical neurological and vascular structures and the destabilizing nature of this surgery. Nevertheless, evidence has shown improved progression-free survival with en bloc resection for certain low-grade malignant and aggressive benign musculoskeletal tumors. To avoid the morbidity of en bloc spondylectomy in patients with tumors localized to the lateral and posterolateral spinal column, the authors have found that the goals of surgery can be accomplished through a contralateral osteotomy of the pedicle and posterolateral elements for en bloc resection (COPPER). They reviewed their series of 5 patients who underwent successful tumor removal through a COPPER approach. These patients were all found to harbor spinal column tumors involving the posterolateral elements that, based on pathology, would benefit from en bloc resection. Tumor pathology included chondrosarcoma, leiomyosarcoma, osteoblastoma, and liposarcoma. Resections were performed by completing ipsilateral facetectomies above and below the lesion and ipsilateral pedicle osteotomies from a contralateral approach following hemilaminectomy. By disarticulating the posterolateral elements while carefully protecting the thecal sac, the tumors were removed en bloc along with the affected lamina, pedicles, pars interarticularis, and spinous processes, allowing tumor-free margins. This technical report suggests that the COPPER approach is safe and effective for en bloc resection of tumors involving the posterolateral aspect of the spinal column with tumor-free margins and that it eliminates the need for anterior column reconstruction.

  View details for DOI 10.3171/2016.8.SPINE16398

  View details for Web of Science ID 000394925900001

• Initial clinical outcomes of audiovisual-assisted therapeutic ambience in radiation therapy (AVATAR). Practical radiation oncology Hiniker, S. M., Bush, K., Fowler, T., White, E. C., Rodriguez, S., Maxim, P. G., Donaldson, S. S., Loo, B. W. 2017

  Abstract

  Radiation therapy is an important component of treatment for many childhood cancers. Depending upon the age and maturity of the child, pediatric radiation therapy often requires general anesthesia for immobilization, position reproducibility, and daily treatment delivery. We designed and clinically implemented a radiation therapy-compatible audiovisual system that allows children to watch streaming video during treatment, with the goal of reducing the need for daily anesthesia through immersion in video.We designed an audiovisual-assisted therapeutic ambience in radiation therapy (AVATAR) system using a digital media player with wireless streaming and pico projector, and a radiolucent display screen positioned within the child's field of view to him or her with sufficient entertainment and distraction for the duration of serial treatments without the need for daily anesthesia. We piloted this system in 25 pediatric patients between the ages of 3 and 12 years. We calculated the number of fractions of radiation for which this system was used successfully and anesthesia avoided and compared it with the anesthesia rates reported in the literature for children of this age.Twenty-three of 25 patients (92%) were able to complete the prescribed course of radiation therapy without anesthesia using the AVATAR system, with a total of 441 fractions of treatment administered when using AVATAR. The median age of patients successfully treated with this approach was 6 years. Seven of the 23 patients were initially treated with daily anesthesia and were successfully transitioned to use of the AVATAR system. Patients and families reported an improved treatment experience with the use of the AVATAR system compared with anesthesia.The AVATAR system enables a high proportion of children to undergo radiation therapy without anesthesia compared with reported anesthesia rates, justifying continued development and clinical investigation of this technique.

  View details for DOI 10.1016/j.prro.2017.01.007

  View details for PubMedID 28242188

• Induction. Anesthesia and analgesia Wu, M., Rodriguez, S. T. 2017

  View details for DOI 10.1213/ANE.0000000000001772

  View details for PubMedID 28079583

• Provider-controlled virtual reality experience may adjust for cognitive load during vascular access in pediatric patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Yuan, J. C., Rodriguez, S. n., Caruso, T. J., Tsui, J. H. 2017

  View details for PubMedID 28861855

• Epidural Steroid Injections for Radiculopathy and/or Back Pain in Children and Adolescents: A Retrospective Cohort Study With a Prospective Follow-Up. Regional anesthesia and pain medicine Kurgansky, K. E., Rodriguez, S. T., Kralj, M. S., Mooney, J. J., Dinakar, P., d'Hemecourt, P. A., Hedequist, D. J., Proctor, M. R., Berde, C. B. 2016; 41 (1): 86-92

  Abstract

  Epidural steroid injections (ESIs) are commonly performed for adults with spinal pain and/or radiculopathy. Previous pediatric ESI case series were not identified by literature review. The primary aim of this study was to examine the safety and provisional outcomes of pediatric ESIs.With institutional review board approval, medical records were reviewed for patients aged 9 to 20 years receiving a first ESI at Boston Children's Hospital from 2003 through 2013. A subset of patients completed a Web-based follow-up questionnaire. Descriptive statistics included frequencies, medians, interquartile ranges, and Kaplan-Meier methods. Statistical comparisons were made using Wilcoxon rank sum, χ2, Fisher exact, and Cox proportional hazards regression analyses.A total of 224 patients aged 9 to 20 years underwent 428 ESIs. One hundred seventy-four (76.0%) patients had a lumbar disc herniation with radiculopathy; the others had a spectrum of other spinal disorders. There were no serious adverse events, hospitalizations, dural punctures, or nerve injuries. During follow-up, 69 (41.6%) of 166 previously nonoperated lumbar disc plus radiculopathy patients underwent discectomy at a median time of 128 days (interquartile range, 76-235 days) after first injection. Degrees of straight-leg raising at presentation was significantly associated with subsequent discectomy. On follow-up, patients who did and did not undergo discectomy had low pain scores and high function scores.Children and adolescents can receive ESIs under conscious sedation with good safety. Further prospective studies may better define the role for these injections in the comprehensive management of pediatric spinal pain disorders.

  View details for DOI 10.1097/AAP.0000000000000338

  View details for PubMedID 26655219

• Artist's statement: the mighty fellow. Academic medicine Rodriguez, S. 2015; 90 (11): 1527-?

  View details for DOI 10.1097/ACM.0000000000000940

  View details for PubMedID 26506607

• The development of pediatric anesthesiology and critical care medicine at the Cincinnati Children's Hospital: an interview with Dr. Theodore Striker PEDIATRIC ANESTHESIA Ahmed, Z., Samuels, P. J., Mai, C. L., Rodriguez, S., Iftikhar, A. R., Yaster, M. 2015; 25 (8): 764-769

  Abstract

  Dr. Theodore W. 'Ted' Striker (1936-), Professor of Anesthesiology and Pediatrics at the University of Cincinnati, has played a pioneering role in the development of pediatric anesthesiology in the United States. As a model educator, clinician, and administrator, he shaped the careers of hundreds of physicians-in-training and imbued them with his core values of honesty, integrity, and responsibility.

  View details for DOI 10.1111/pan.12677

  View details for Web of Science ID 000357730600002

  View details for PubMedID 25989362

• Extensive spinal epidural abscess treated with "apical laminectomies" and irrigation of the epidural space: report of 2 cases JOURNAL OF NEUROSURGERY-SPINE Abd-El-Barr, M. M., Bi, W. L., Bahluyen, B., Rodriguez, S. T., Groff, M. W., Chi, J. H. 2015; 22 (3): 318-323

  Abstract

  Spinal epidural abscess (SEA) is a rare but often devastating infection of the epidural space around the spinal cord. When an SEA is widespread, extensive decompression with laminectomy is often impossible, as it may subject the patient to very long operative times, extensive blood loss, and mechanical instability. A technique called "skip laminectomy" has been described in the literature, in which laminectomies are performed at the rostral and caudal ends of an abscess that spans 3-5 levels and a Fogarty catheter is used to mechanically drain the abscess, much like in an embolectomy. In this report of 2 patients, the authors present a modification of this technique, which they call "apical laminectomies" to allow for irrigation and drainage of an extensive SEA spanning the entire length of the vertebral column (C1-2 to L5-S1). Two patients presented with cervico-thoraco-lumbar SEA. Laminectomies were performed at the natural apices of the spine, namely, at the midcervical, midthoracic, and midlumbar spine levels. Next, a pediatric feeding tube was inserted in the epidural space from the thoracic laminectomies up toward the cervical laminectomy site and down toward the lumbar laminectomy site, and saline antibiotics were used to irrigate the SEA. Both patients underwent this procedure with no adverse effects. Their SEAs resolved both clinically and radiologically. Neither patient suffered from mechanical instability at 1 year after treatment. For patients who present with extensive SEAs, apical laminectomies seem to allow for surgical cure of the infectious burden and do not subject the patient to extended operating room time, an increased risk of blood loss, and the risk of mechanical instability.

  View details for DOI 10.3171/2014.11.SPINE131166

  View details for Web of Science ID 000350266300015

  View details for PubMedID 25555055

• Assessment of the length of myotomy in peroral endoscopic pyloromyotomy (G-POEM) using a submucosal tunnel technique (video). Surgical endoscopy Jung, Y., Lee, J., Gromski, M. A., Kato, M., Rodriguez, S., Chuttani, R., Matthes, K. 2014

  Abstract

  Peroral endoscopic pyloromyotomy is a novel technique that has recently been described in the literature. There is little data to guide the length of myotomy created. The aim of study was to evaluate the proper incision length of the muscular layer during peroral endoscopic pyloromyotomy using a submucosal tunnel technique.The study was designed as a prospective ex vivo study. Fresh ex vivo porcine stomachs from animals weighing 80-100 kg and porcine stomachs from animals weighing 15-25 kg were used for pyloromyotomy. Four different myotomy lengths (1, 2, 3, and 4) were compared in the large animal series and three different myotomy lengths (1, 2, and 3) were compared in the small series. A total of 23 cases of the submucosal tunnel technique were performed by two endoscopists using 12 large stomachs and 11 small stomachs.The mean overall procedure time (±SD) of pyloromyotomy was 65.7 (±14.3) min. In the large stomach series, the mean pyloric diameter (±SD) and change from baseline (as percentage) following a 1, 2, 3, and 4 pyloromyotomy were 13.3 ± 9.5 mm (7.1 %), 20.7 ± 11.7 mm (10.6 %), 31.1 ± 15.0 mm (15.2 %), and 33.0 ± 15.0 mm (16.0 %), respectively. In the small stomach series, the changes of mean pyloric diameter following a 1, 2, and 3 cm pyloromyotomy were 12.2 ± 5.6 mm (7.5 %), 23.1 ± 7.6 mm (13.1 %), and 28.0 ± 10.4 mm (15.5 %), respectively.A 3 cm pyloromyotomy for a large animal series and 2 cm for the small animal series appeared to be most appropriate for enlargement of the pylorus.

  View details for DOI 10.1007/s00464-014-3948-1

  View details for PubMedID 25424365

• A patient with surgically unrepaired single ventricle and uncontrolled amiodarone-induced thyrotoxicosis for emergent thyroidectomy. A & A case reports Downey, L., Rodriguez, S., Clendenin, D. 2014; 3 (5): 61-64

  Abstract

  We present the case of a 20-year-old woman with a history of hypoplastic left heart syndrome, D-transposition of the great arteries, and mitral/pulmonary valve atresia without surgical palliation, who was admitted with persistent atrial flutter/fibrillation and worsening cardiac function from amiodarone-induced thyrotoxicosis. Despite maximal medical therapy, she continued to have uncontrolled thyrotoxicosis and underwent successful emergent thyroidectomy under general anesthesia. With advances in the treatment of congenital heart disease, more patients are surviving to adulthood and require emergent noncardiac surgery. Therefore, anesthesiologists must understand the principles for managing patients with congenital heart disease and how the patient's physiology may affect the anesthetic plan.

  View details for DOI 10.1213/XAA.0000000000000080

  View details for PubMedID 25611355

• The development of a specialty: an interview with Dr. Mark C. Rogers, a pioneering pediatric intensivist. Paediatric anaesthesia Mai, C. L., Firth, P. G., Ahmed, Z., Rodriguez, S., Yaster, M. 2014

  Abstract

  Dr. Mark C. Rogers (1942-), Professor of Anesthesiology, Critical Care Medicine, and Pediatrics at the Johns Hopkins University, was recruited by the Department of Pediatrics at Johns Hopkins Hospital in 1977 to become the first director of its pediatric intensive care unit. After the dean of the medical school appointed him to chair the Department of Anesthesia in 1979, Rogers changed the course and culture of the department. He renamed it the Department of Anesthesiology and Critical Care Medicine, and developed a long-term strategy of excellence in clinical care, research, and education. However, throughout this period, he never lost his connection to pediatric intensive care. He has made numerous contributions to pediatric critical care medicine through research and his authoritative textbook, Rogers' Textbook of Pediatric Intensive Care. He established a training programme that has produced a plethora of leaders, helped develop the pediatric critical care board examination, and initiated the first World Congress of Pediatric Intensive Care. Based on a series of interviews with Dr. Rogers, this article reviews his influential career and the impact he made on developing pediatric critical care as a specialty.

  View details for DOI 10.1111/pan.12497

  View details for PubMedID 25065470

• Minimally invasive spine surgery for adult degenerative lumbar scoliosis NEUROSURGICAL FOCUS Dangelmajer, S., Zadnik, P. L., Rodriguez, S. T., Gokaslan, Z. L., Sciubba, D. M. 2014; 36 (5)

  Abstract

  Historically, adult degenerative lumbar scoliosis (DLS) has been treated with multilevel decompression and instrumented fusion to reduce neural compression and stabilize the spinal column. However, due to the profound morbidity associated with complex multilevel surgery, particularly in elderly patients and those with multiple medical comorbidities, minimally invasive surgical approaches have been proposed. The goal of this meta-analysis was to review the differences in patient selection for minimally invasive surgical versus open surgical procedures for adult DLS, and to compare the postoperative outcomes following minimally invasive surgery (MIS) and open surgery.In this meta-analysis the authors analyzed the complication rates and the clinical outcomes for patients with adult DLS undergoing complex decompressive procedures with fusion versus minimally invasive surgical approaches. Minimally invasive surgical approaches included decompressive laminectomy, microscopic decompression, lateral and extreme lateral interbody fusion (XLIF), and percutaneous pedicle screw placement for fusion. Mean patient age, complication rates, reoperation rates, Cobb angle, and measures of sagittal balance were investigated and compared between groups.Twelve studies were identified for comparison in the MIS group, with 8 studies describing the lateral interbody fusion or XLIF and 4 studies describing decompression without fusion. In the decompression MIS group, the mean preoperative Cobb angle was 16.7° and mean postoperative Cobb angle was 18°. In the XLIF group, mean pre- and postoperative Cobb angles were 22.3° and 9.2°, respectively. The difference in postoperative Cobb angle was statistically significant between groups on 1-way ANOVA (p = 0.014). Mean preoperative Cobb angle, mean patient age, and complication rate did not differ between the XLIF and decompression groups. Thirty-five studies were identified for inclusion in the open surgery group, with 18 studies describing patients with open fusion without osteotomy and 17 papers detailing outcomes after open fusion with osteotomy. Mean preoperative curve in the open fusion without osteotomy and with osteotomy groups was 41.3° and 32°, respectively. Mean reoperation rate was significantly higher in the osteotomy group (p = 0.008). On 1-way ANOVA comparing all groups, there was a statistically significant difference in mean age (p = 0.004) and mean preoperative curve (p = 0.002). There was no statistically significant difference in complication rates between groups (p = 0.28).The results of this study suggest that surgeons are offering patients open surgery or MIS depending on their age and the severity of their deformity. Greater sagittal and coronal correction was noted in the XLIF versus decompression only MIS groups. Larger Cobb angles, greater sagittal imbalance, and higher reoperation rates were found in studies reporting the use of open fusion with osteotomy. Although complication rates did not significantly differ between groups, these data are difficult to interpret given the heterogeneity in reporting complications between studies.

  View details for DOI 10.3171/2014.3.FOCUS144

  View details for Web of Science ID 000335969300008

  View details for PubMedID 24785489

• Breaking the glass ceiling: an interview with Dr. Shirley Graves, a pioneering woman in medicine PEDIATRIC ANESTHESIA Ahmed, Z., Mai, C. L., Elder, B., Rodriguez, S., Yaster, M. 2014; 24 (4): 440-445

  Abstract

  Shirley Graves M.D., D.Sc. (honorary) (1936), Professor Emeritus of Anesthesiology and Pediatrics at the University of Florida, was one of the most influential women in medicine in the 1960 and 1970s, a time when the medical profession was overwhelmingly male-dominated. In today's society, it is hard to believe that only 50 years ago, women were scarce in the field of medicine. Yet Dr. Graves was a pioneer in the fields of pediatric anesthesia and pediatric critical care medicine. She identifies her development of the pediatric intensive care unit and her leadership in the Division of Pediatric Anesthesia at the University of Florida as her defining contributions. Through her journal articles, book chapters, national and international lectures, and leadership in the American Society of Anesthesiology and the Florida Society of Anesthesiology, she inspired a generation of men and women physicians to conquer the unthinkable and break through the glass ceiling.

  View details for DOI 10.1111/pan.12363

  View details for Web of Science ID 000332773500012

  View details for PubMedID 24571660