Objective: Operating rooms (OR) generate a large portion of hospital revenue and waste. Consequently, improving efficiency and reducing waste is a high priority. Our objective was to quantify waste associated with opened but unused instruments from trays and to compare this with the cost of individually wrapping instruments.Methods: Data was collected from June to November of 2013 in a 550-bed hospital in the United States. We recorded the instrument usage of two commonly-used trays for ten cases each. The time to decontaminate and reassemble instrument trays and peel packs was measured, and the cost to reprocess one instrument was calculated.Results: Average utilization was 14% for the Plastic Soft Tissue Tray and 29% for the Major Laparotomy Tray. Of 98 instruments in the Plastics tray (n = 10), 0% was used in all cases observed and 59% were used in no observed cases. Of 110 instruments in the Major Tray (n = 10), 0% was used in all cases observed and 25% were used in no observed cases. Average cost to reprocess one instrument was $0.34-$0.47 in a tray and $0.81-$0.84 in a peel pack, or individually-wrapped instrument.Conclusions: We estimate that the cost of peel packing an instrument is roughly two times the cost of tray packing. Therefore, it becomes more cost effective from a processing standpoint to package an instrument in a peel pack when there is less than a 42%-56% probability of use depending on instrument type. This study demonstrates an opportunity for reorganization of instrument delivery that could result in a significant cost-savings and waste reduction.

Vitiligo is characterized by progressive loss of skin pigmentation. The search for aetiologic factors has led to the biochemical, the neurologic and the autoimmune theory. The convergence theory was then proposed several years ago to incorporate existing theories of vitiligo development into a single overview of vitiligo aetiology. The viewpoint that vitiligo is not caused only by predisposing mutations, or only by melanocytes responding to chemical/radiation exposure, or only by hyperreactive T cells, but rather results from a combination of aetiologic factors that impact melanocyte viability, has certainly stood the test of time. New findings have since informed the description of progressive depigmentation. Understanding the relative importance of such aetiologic factors combined with a careful selection of the most targetable pathways will continue to drive the next phase in vitiligo research: the development of effective therapeutics. In that arena, it is likewise important to acknowledge that pathways affected in some patients may not be altered in others. Taken together, the convergence theory continues to provide a comprehensive viewpoint of vitiligo aetiology. The theory serves to intertwine aetiologic pathways and will help to define pathways amenable to disease intervention in individual patients.

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Therapeutic, IV.

Predictive airway volume calculation may be an effective adjunct to determine anatomic endpoint of mandibular distraction but small sample size, operator and software variability, and patient airway morphology may confound firm conclusions. Further studies are warranted.