Search Results (5,511)

Background: The integration of neoadjuvant and perioperative chemo-immunotherapy (CT-IO) has significantly reshaped the treatment of resectable non-small-cell lung cancer (NSCLC), improving pathological response and survival outcomes. However, its impact on surgical management—particularly robotic-assisted thoracic surgery (RATS)—remains incompletely defined. This review provides a practical overview of current evidence and technical considerations for robotic lung resection following neoadjuvant chemo-immunotherapy. Methods: A narrative review of the literature was performed, focusing on phase III trials, meta-analyses, and surgical series reporting perioperative, oncological, and technical outcomes of minimally invasive—especially robotic—approaches after neoadjuvant or perioperative chemo-immunotherapy. Results: Randomized trials have established CT-IO as a standard treatment option for selected patients with resectable stage II–III NSCLC—although the specific standard varies according to stage, molecular and PD-L1 status, and regulatory approval—significantly improving pathological complete response and event-free survival. However, immune-related fibrosis, nodal scarring, and altered tissue planes increase surgical complexity and intra-postoperative complications. Available evidence, largely retrospective and derived from selected patient populations treated at experienced centers, suggest that RATS is feasible and safe, offering enhanced visualization and dexterity that may facilitate dissection in challenging post-induction settings. Vascular management and lymph node dissection remain critical technical aspects, and early conversion to open surgery, when required, should be regarded as an appropriate safety strategy rather than a complication. Conclusions: RATS after neoadjuvant chemo-immunotherapy appears feasible and promising in selected patients treated at experienced centers, but current evidence does not yet establish it as the preferred approach for all patients. Careful patient selection, adherence to oncological principles, and surgeon experience are essential. Prospective data are needed to define optimal surgical timing and standardize techniques. Full article

Introduction: Uterine leiomyosarcoma (uLMS) is a rare, highly aggressive malignancy arising from the smooth muscle tissue of the uterine wall. It typically presents with abnormal vaginal bleeding, pelvic pain, or a pelvic mass. In rare instances, symptoms may result from local invasion or metastasis. We report a case of uLMS initially diagnosed following colonic perforation due to direct tumor invasion, accompanied by a comprehensive narrative review of the literature on the incidental identification of uterine sarcomas during emergency general surgery to further emphasize the diagnostic challenges, treatment approaches, and need for individualized care in these complex cases. Case Presentation: A 45-year-old woman presented to the Emergency Department with acute abdominal pain of several hours’ duration, in the absence of other associated symptoms. An emergency exploratory laparotomy was performed, revealing feculent peritonitis secondary to sigmoid colon rupture, resulting from local invasion by a large uterine mass. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was undertaken, followed by en bloc resection of the sigmoid colon, appendectomy and construction of a terminal colostomy. Her postoperative course was uneventful, and she was discharged on postoperative day eight. Histopathological examination of the specimen revealed a high-grade uterine leiomyosarcoma. Following evaluation by a multidisciplinary oncology board, the patient received adjuvant chemotherapy. Methods and Results: A narrative review of the literature was performed to identify cases of uterine sarcomas incidentally diagnosed during emergency surgery performed by general surgeons. Including the present case, six cases were identified. Most patients presented with acute abdomen mimicking gastrointestinal pathology, with diagnosis established intraoperatively or postoperatively. Definitive surgical management was achieved during the initial emergency procedure in all cases. Conclusion: Although exceptionally rare, uterine sarcoma should be considered in the differential diagnosis of acute abdomen in female patients undergoing emergency surgery. Awareness of this atypical presentation, the appropriate diagnostic approach, real-time intraoperative adaptability, and individualized multidisciplinary management are essential for ensuring appropriate surgical management and optimizing patient care. Full article

Objective: The aim of this study is to identify clinical and obstetric factors associated with acute postoperative pain in pregnant women undergoing primary elective cesarean section and, in particular, to investigate the relationship between intraoperative subcutaneous tissue thickness and the severity of postoperative pain. Materials and Methods: This prospective cohort study included 82 pregnant women who underwent primary elective cesarean section between August 2025 and April 2026. All patients underwent cesarean delivery under spinal anesthesia by the same surgeon using a Pfannenstiel incision and received the clinic’s standard postoperative analgesia protocol. Subcutaneous tissue thickness was measured along the Pfannenstiel incision line during cesarean section using a sterile millimeter ruler. Postoperative pain intensity was assessed using the Visual Analog Scale (VAS) at 0, 2, 6, 12, and 24 h. Relationships between variables were examined using Spearman’s correlation analysis. Multivariate linear regression analyses were performed for the 12th- and 24th-hour VAS scores to evaluate the independent predictors of postoperative pain. Results: The participants’ mean age was 26.1 ± 4.6 years, and their mean BMI was 30.4 ± 5.1 kg/m². The median subcutaneous tissue thickness was 20 mm (interquartile range (IQR): 15–25). No significant association was found between subcutaneous tissue thickness and postoperative pain scores or changes in hemoglobin levels (all p > 0.05). A moderate positive correlation was observed between subcutaneous tissue thickness and BMI (r = 0.501, p < 0.001) and fetal weight (r = 0.428, p < 0.001). In multivariate regression analyses, subcutaneous tissue thickness, age, BMI, fetal weight, gestational age, hemoglobin change, and parity were found not to be independent predictors of VAS scores at 12 or 24 h (all p > 0.05). Conclusions: Subcutaneous tissue thickness was not found to be associated with the severity of postoperative pain in patients undergoing primary elective cesarean section. Furthermore, none of the clinical and obstetric variables evaluated were shown to be independent predictors of acute postoperative pain. These findings suggest that local anatomical measurements alone may not be sufficient to explain postoperative pain following cesarean delivery and that postoperative pain is likely influenced by multiple non-anatomical factors. Full article

Background/Objectives: In modern medicine, humanization of care is a central theme that highlights the complementarity of clinical care with empathy, communication, and patient-centered values. The increasing use of robotic surgery is rapidly modifying surgical practice, introducing new challenges and opportunities in preserving the human dimension of care. This review aimed to synthesize the available evidence and propose a conceptual model of humanized robotic surgical care. Methods: A structured narrative review of the PubMed/MEDLINE database (from inception to January 2026) was conducted using predefined keywords related to humanization of care, robotic surgery, patient perception, surgeon experience, human factors, communication, ethics, and technological mediation. Relevant English-language publications were critically synthesized to develop a conceptual framework. Results: The literature indicates that robotic surgery influences humanized care through three interconnected domains. First, patients frequently perceive robotic surgery as more precise and technologically advanced, which may generate unrealistic expectations and misconceptions regarding robotic autonomy. Second, robotic platforms reshape the surgeon’s experience by improving ergonomics while simultaneously modifying cognitive workload, sensory feedback, and professional identity. Third, technology itself acts as an active mediator influencing communication, trust, decision-making, and relational dynamics. Building upon these findings, we propose an original triangular conceptual framework integrating the patient, the surgeon, and the technology as three interdependent determinants of humanized robotic surgical care. The framework also provides a conceptual basis for understanding the future integration of artificial intelligence into surgical practice. Conclusions: Humanization of care in the era of robotic surgery requires an integrated approach that recognizes the interdependence of patient perception, surgeon experience, and technological mediation. Ensuring effective communication, supporting surgeon well-being, and preserving ethical principles will be essential to aligning innovation with patient-centered care. Full article

Objectives: Hypospadias is one of the most common congenital malformations of the male genitourinary system, and postoperative complications remain a major concern affecting surgical outcomes and patients‘ quality of life. Whether machine learning models can effectively predict complication risk using routinely available clinical variables remains unclear. Methods: A retrospective analysis was performed on 671 hypospadias patients who underwent urethroplasty at the Department of Urology, Capital Children’s Medical Center, between December 2015 and September 2024. The final dataset included 671 patients (training set: 536; validation set: 135). The median follow-up duration was 48 months (range: 19 to 72 months). Least absolute shrinkage and selection operator (LASSO) regression with nested cross-validation within the training set was used for feature selection, followed by the development of five machine learning models (Random Forest, XGBoost, LightGBM, Logistic Regression, and Support Vector Machine). Model performance was evaluated using AUC, calibration curves, Brier score, and decision curve analysis. Feature importance was assessed using SHapley Additive exPlanations (SHAP). Results: LASSO retained four features for model development: hypospadias type, surgical technique, surgeon experience, and patient age. The overall complication rate was 22.9% (154/671). Among the models evaluated, the Support Vector Machine (SVM) showed the most balanced performance in the validation set, achieving an AUC of 0.810 and a Brier score of 0.157. LightGBM demonstrated comparable performance (AUC: 0.802). SHAP analysis identified surgical technique as the most influential predictor, followed by surgeon volume and hypospadias type, though these findings should be interpreted with caution given the confounding between surgical complexity and disease severity. Conclusions: An interpretable SVM-based prediction model was developed and internally validated to stratify risk for postoperative complications after hypospadias repair using routinely available clinical variables. SHAP provided clinicians with visual insights into key risk-associated factors. However, given the single-center retrospective design and lack of external validation, further multicenter prospective studies are warranted to confirm the generalizability of these findings before clinical implementation. Full article

Background/Objectives: Lead acrylic shields (LASs) enhance radiation protection, with variation of their usage among different specialties. This prospective multicentric observational study aimed to explore patterns of ocular radiation exposure and LAS usage among interventionalists from different disciplines and to assess behavioral dose changes in a longitudinally monitored subgroup. Methods: From July 2019 to July 2020, ocular doses (protected and unprotected) were measured in 15 interventionalists from four specialties (radiology, neuroradiology, cardiology and vascular surgery) across 2286 procedures using thermoluminescent dosimeters. Procedure type, operator position, total body dose, fluoroscopy time, dose area product, LAS usage and dose exceedances were documented. Ocular doses of five interventionalists, who participated in our previous study, allowed a longitudinal comparison of radiation doses and protective behavior. Results: Cumulative annual unprotected ocular doses ranged from 0 to 59 mSv, with five participants exceeding the annual limit of 20 mSv, whereas protected doses (0 to 18 mSv) remained within the limits. Procedural LAS usage was seen in 89% of radiologists and 82% of vascular surgeons. Participants with 100% LAS usage recorded minimal measurable ocular doses, whereas lower LAS compliance resulted in higher ocular doses. Longitudinal subgroup data analyses showed a decrease in ocular dose per procedure in all five participants, suggesting a potential learning effect, without statistical significance. Conclusions: Unprotected ocular doses exceeded the annual occupational eye lens dose limit in several participants, whereas protected doses remained within recommended limits in all participants. No specialty demonstrated universally lower ocular doses, while consistent LAS use proved highly effective in reducing the dose in all groups. Longitudinal findings suggest that structured dose monitoring and repeated training may support behavioral improvements in radiation protection over time. Full article

Background: Transcatheter Edge-to-Edge Repair (TEER) is a therapeutic option established for older patients with heart failure and concomitant mitral regurgitation. Frailty is associated with prognosis after transcatheter valve interventions. However, despite clinical potential, evidence for gait speed as a simplified prognostic marker in patients undergoing TEER remains insufficient. Objectives: This study aimed to investigate the association between preoperative gait speed and mid- to long-term mortality after TEER. Methods: We conducted a single-center retrospective cohort study of 97 patients (mean age: 78.9 ± 8.7 years; 56.7% male) who survived the first 7 days after TEER and had available preoperative gait speed data. Preoperative gait speed was assessed, and clinical data were obtained from medical records. Cox regression analysis was performed to elucidate the association between preoperative gait speed and mortality. Results: In Cox proportional hazards models, higher gait speed (per 0.1 m/s increase) was associated with lower mortality after adjustment for the Society of Thoracic Surgeons risk score and handgrip strength (hazard ratio: 0.81; 95% confidence interval: 0.68–0.97; p = 0.02). In time-dependent receiver operating characteristic curve analysis, gait speed showed moderate discriminative ability for mortality, with area under the curve values of 0.749 at 1 year and 0.710 at 2 years. A gait speed of 0.8 m/s was used as an exploratory threshold for survival stratification, and patients with gait speed < 0.8 m/s had lower survival than those with gait speed ≥ 0.8 m/s (log-rank p < 0.01). Conclusions: Lower preoperative gait speed was associated with higher mid- to long-term mortality after TEER. Preoperative gait speed may provide clinically useful information for exploratory risk stratification, although the cutoff-based findings require external validation. Full article

Background: Robotic platforms expand minimally invasive options in colorectal surgery but raise concerns about training and patient safety. Dual-console systems may enable real-time coaching while preserving outcomes. Methods: We implemented a structured framework for safe implementation of robotic colorectal surgery that balances trainee autonomy with patient safety using a dual-console model. Early cases emphasized low-complexity pathology with escalation by predefined benchmarks. We prospectively gathered data and evaluated early program outcomes with primary endpoints including intraoperative adverse events, conversion to open surgery, 30-day morbidity, anastomotic integrity, and oncologic quality metrics. Secondary endpoints included operative time. Results: We included the analysis of 17 patients operated by one surgeon under supervision and compared the results to other senior colorectal surgeons. Out of the 17 patients, there were no conversions or anastomotic leaks. Overall complications were comparable to baseline robotic cases. Resection margins and lymph node yields met oncologic standards. Operative times were longer during early adoption but approached baseline with progression. Operative times were significantly reduced after eight cases and approached the times of senior surgeons after 13 cases. Conclusions: A dual-console strategy enables safe, scalable training in robotic colorectal surgery without compromising short-term patient outcomes or oncologic quality. Key elements include rigorous case selection, proficiency-based progression, real-time coaching, standardized protocols, and continuous data surveillance. This framework can guide institutions seeking to expand robotic colorectal programs while safeguarding patients and accelerating the learning curve. Full article

Background: Acute diverticulitis (AD) is a prevalent gastrointestinal disorder with a significant recurrence rate. Faecal calprotectin (FC) is a non-invasive biomarker of intestinal inflammation, but its role in diagnosing and monitoring diverticulitis remains to be fully established. Objective: This narrative review aims to evaluate the current evidence on the utility of FC in the diagnosis, severity assessment, prediction of recurrence, and monitoring of therapeutic response in patients with diverticular disease (DD) and AD. Methods: A structured literature search was conducted using PubMed, Scopus, and ScienceDirect for peer-reviewed original studies published in English between 2004 and April 2025. The search strategy combined terms related to diverticular disease and faecal calprotectin. Studies reporting original data on FC in DD were synthesised narratively. Results: FC demonstrates significant utility across multiple clinical applications in DD. For diagnosis, FC is markedly elevated in AD (mean 556–695 μg/g) and symptomatic uncomplicated diverticular disease (SUDD) (median 181 μg/g), while remaining normal in irritable bowel syndrome (mean 50 μg/g), enabling differentiation between organic and functional disorders. FC correlates strongly with endoscopic disease severity, with positivity rates increasing from 48.6% in DICA 1 to 93.2% in DICA 3 (p < 0.0001). For predicting recurrence, elevated FC identifies patients at high risk, with one study reporting 87.5% of recurrent cases showing prior FC elevation and a negative predictive value of 96.8%. FC also exhibits excellent short-term prognostic capacity (AUC 0.976 at 3 months) and responds to therapeutic intervention, with significant reductions following successful treatment with probiotics, nutraceuticals, budesonide, and other agents. Conclusions: FC is a promising non-invasive biomarker for diagnosing diverticulitis, assessing disease severity, predicting recurrence, and monitoring treatment response. Its ability to detect subclinical inflammation makes it particularly useful for risk stratification. However, the current evidence base consists predominantly of retrospective and observational studies, and standardised thresholds require further validation through prospective trials before routine clinical implementation can be recommended. Full article

Background/objectives: Evidence on gait and postural recovery after robotically assisted total knee arthroplasty (raTKA), particularly with the ROSA system, remains limited. This study compared early gait, postural, functional, and patient-reported outcomes (PROMs) between ROSA raTKA and manual TKA (mTKA), with PROMs also assessed at final follow-up. Methods: This comparative cohort study included primary TKA patients treated by a single senior surgeon using the same implant and alignment strategy. Patients underwent either ROSA raTKA or mTKA. At three months, a senior physiotherapist assessed quadricep and tibialis anterior maximum voluntary isometric strength (MVIS), centre-of-mass (CoM) kinematics, lower-limb weight distribution, timed-up-and-go (TUG), range of motion (ROM), KOOS Pain, activities of daily living (ADL), and quality of life (QoL). The same KOOS domains were compared at final follow-up. Results: Seventy primary TKAs were included: 46 raTKAs and 24 mTKAs. No intraoperative complications occurred. Groups were comparable for age, BMI, sex, grip strength, and preoperative KOOS. At three months, no significant differences were found in quadricep MVIS (p = 0.257), tibialis anterior MVIS (p = 0.327), CoM kinematics (p = 0.066), weight distribution (p = 0.189), TUG (p = 0.599), ROM (p = 0.165), or KOOS domains. At final follow-up, KOOS-ADL (p = 0.041) and QoL (p = 0.032) were better in the raTKA group, but after Holm–Bonferroni correction, they were no longer significant (QoL, p = 0.384; ADL, p = 0.451). Conclusions: ROSA raTKA showed comparable early gait and postural recovery to mTKA. The marginal differences in KOOS domains are exploratory, as they were no longer significant after multiple-comparisons correction. Full article

Background: Proximal ligation of the internal iliac artery (IIA) is a life-saving procedure for uncontrollable pelvic bleeding, often underutilized because of concerns about secondary buttock or pelvic organ ischemia, especially when ligation is performed proximal to the posterior IIA division. Methods: The primary aim was to evaluate clinically detected postoperative ischemic complications after IIA ligation, with secondary aims including technical success, primary hemostatic success, and overall hemorrhage control. In this single-center retrospective study, we evaluated 61 patients undergoing IIA ligation at a tertiary center in Bulgaria between January 2014 and March 2025. Demographics, indication, surgical approach, ligation level and laterality, comorbidities, and postoperative outcomes were analyzed. Ischemic complications were assessed by clinical examination and structured symptom inquiry at each follow-up visit (two visits in the first postoperative month, then at months 2, 3, 5, and 6). Imaging was reserved for patients with symptoms suggesting ischemia; none required further imaging. Results: IIA ligation was performed for obstetric (n = 18), benign gynecologic (n = 13), or gynecologic oncologic (n = 30) indications. The median age was 31.5 years (range 21–42), 50 years (range 35–76), and 64 years (range 31–81) in the obstetric, benign gynecologic, and gynecologic oncology groups, respectively. Bilateral ligation was achieved in 54/61 (88.5%) cases and unilateral ligation in 7/61 (11.5%). Bilateral proximal ligation was performed in 49/61 (80.3%); in 59/61 (96.7%) patients, at least one side was ligated proximally. Technical success was achieved in all patients (61/61, 100%). Primary hemostatic success was achieved in 59/61 (96.7%) patients. Hemostatic failure requiring escalation occurred in 2/61 (3.3%) patients: one with placenta accreta spectrum and one with placental abruption complicated by disseminated intravascular coagulation. Both required packing/laparostomy with delayed abdominal closure. Overall hemorrhage control was achieved in all patients (61/61, 100%). No clinical signs of ischemic complications (buttock, pelvic organ, spinal cord, or neuropathic) were recorded during the six-month follow-up period. Conclusions: In this cohort, proximal (including bilateral) IIA ligation was not associated with clinically detected ischemic complications and supported rapid hemorrhage control when performed by experienced surgeons. Larger prospective and comparative studies with standardized ischemia assessment are needed. Full article

Background: Perforation associated with intrauterine devices (IUDs) occurs in approximately 1 in 1000 insertions and may be either partial or complete. Perforation may be primary, occurring during device insertion, or secondary, developing after the device has remained in situ for more than eight weeks. Typical symptoms of IUD perforation include chronic pain and intestinal obstruction. Rarely, the device is found either completely within the rectal lumen or partially embedded in the rectal wall with partial intraluminal extension. Removal of the device may require colonoscopy, laparoscopy, or a combination of both. Case: A 45-year-old woman was referred for evaluation of intermittent rectal bleeding. Initial outpatient evaluation included contrast-enhanced computed tomography (CT), which demonstrated two intrauterine devices: one appropriately positioned within the uterine cavity and another located within the rectouterine pouch. A multidisciplinary discussion involving gastroenterologists, gynecologists, and colorectal surgeons was subsequently conducted. Under general anesthesia, laparoscopy was initiated. Upon entering the abdominal cavity, a free IUD string was visualized embedded within the pelvic peritoneum. Using simultaneous colonoscopic guidance with transillumination, a targeted peritoneal incision was made overlying the IUD. The arms were removed laparoscopically. Subsequent colonoscopy removed the remaining segment of the IUD traversing the rectal wall. Conclusions: Although uterine perforation and migration of intrauterine devices are uncommon, they may result in severe and potentially life-threatening complications. Early diagnosis, careful documentation, routine follow-up, and timely removal of misplaced devices remain essential to minimizing morbidity and preventing adverse outcomes. Full article

Reduction malarplasty (RMP) is performed frequently in East Asia. Although various complications of RMP have been reported, intracranial hemorrhage has been described only rarely. Although intracranial hemorrhage is an extremely rare complication, it is a catastrophic event that should not occur in esthetic plastic surgery. In this review, I describe the occurrence and prevention of this serious complication through a detailed analysis of intracranial hemorrhage following RMP. Evaluation of RMP surgical techniques was performed. A search of PubMed and Google Scholar was conducted to identify studies reporting cerebral hemorrhage following RMP. The search strategy combined the terms “cosmetic surgery” OR “plastic surgery”, AND “cerebral hemorrhage”. The two major surgical approaches to RMP are the coronal and intraoral incisions. In the coronal approach, osteotomy is performed under direct visualization, which allows precise bone cutting. There is no risk of penetrating the intracranial cavity during RMP performed via the coronal approach. Two reported cases of intracranial hemorrhage occurred during RMP performed via the intraoral approach due to inappropriate instrument handling. There is a potential risk of injury to the middle cranial fossa by a reciprocating saw or chisel during osteotomy of the zygomatic body. When performing an osteotomy on a zygomatic body using a reciprocating saw in RMP via the intraoral approach, surgeons should avoid inserting the saw too deeply to prevent injury to the middle cranial fossa. Full article

Objectives: Incomplete partition type III is a rare malformation of the inner ear characterized by the absence of the modiolus, fixation of the stapes, and significant communication between the cochlea and the internal auditory canal (IAC). During cochlear implant (CI) surgery, there is a risk that the electrode array may enter the IAC, resulting in non-specific stimulation of auditory neurons or other nerve fibers inside the IAC. In this study, we present our experience with CI surgery in patients with incomplete partition type III and report the types of devices utilized. Methods: A retrospective analysis was conducted on all our patients with cochlear incomplete partition type III who underwent surgical cochlear implantation in a tertiary referral unit over the past 16 years. Results: Of the perimodiolar electrodes used initially, four were correctly positioned within the cochlea from initial insertion, and no reinsertion was necessary. A lateral wall electrode array CI was selected to replace the last failed perimodiolar insertion, but it also required two insertion attempts due to its initial misplacement into the internal auditory canal. Conclusions: In this study, electrode array selection was influenced by surgeon preference and by intraoperative factors such as the severity of the gusher. Our observations suggest that perimodiolar CIs can be used in selected cases of incomplete partition type III and did not appear to increase the risk of IAC misplacement compared with the lateral wall array used in one patient. However, these findings should be interpreted cautiously as observations from the authors’ experience rather than as generalized conclusions regarding the relative safety of perimodiolar versus lateral wall electrode arrays. Lateral wall arrays may also be misplaced into the IAC, and their use may be considered in cases with severe and difficult-to-control gusher. Full article

Background: Supplemental oxygen and aerosol therapy may be used simultaneously to treat neonates suffering from hypoxemia caused by respiratory diseases. Due to the cost and lack of availability of oxygen cylinders in some countries, oxygen concentrators are a reported substitute. We assessed whether an oxygen concentrator compared to low-flow oxygen therapy impacts neonatal aerosol drug delivery. Methods: A vibrating mesh nebulizer (A-VMN; Aerogen Solo) was used to aerosolize a 500 µg dose of salbutamol. The aerosol was delivered via a nasal cannula to a neonate head model in combination with oxygen concentrator at gas flow rates of 0.2, 1.0, and 5.0 L per minute (LPM), and low-flow oxygen therapy at gas flow rates of 1.0, 4.0, and 5.0 LPM. Emitted and tracheal doses were recorded. The impact of A-VMN operation and refill on circuit pressure in both systems was also measured. Results: The oxygen concentrator delivered a higher emitted dose than the low-flow system, the largest emitted dose (%) being 20.58 ± 0.50% and 14.69 ± 0.89%, respectively, at 1.0 LPM, p = 0.018. At 5.0 LPM, the tracheal dose was 11.01 ± 0.29% for the oxygen concentrator compared to 9.66 ± 1.53% for low-flow oxygen therapy, p = 0.073. Refill and operation of the A-VMN did not impact the circuit pressure in either system. Conclusions: This study shows that the system used to provide concurrent aerosol and supplemental oxygen therapy has a significant impact on the quantity of nebulized drug delivered to patients. Full article