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ABSTRACTThis paper examines the accommodation in houses in Trinidad in the context of older persons with disabilities. An exploratory sequential mixed-methods research design was used. In the qualitative phase, a list of accommodation items was identified via interviews. This information was used to develop a questionnaire to measure accommodation items of a large nationally representative sample of houses in Trinidad. Only physical accessibility items were identified, and data from 768 houses indicated that no house had all identified items. There is a need for urgent adoption and implementation of accessibility standards. Findings also indicate modification cost is a challenge and that responses targeted to low-income and rural households are needed. Lastly, the social care context, specifically the family care potential, is an important consideration in housing policy debates, and community homes for the aged and programs involving multiple experts to identify and support housing modification are recommended.

To compare to three nonlinear imaging techniques to conventional, grayscale ultrasound imaging of renal lesions. Twenty adults with a known renal lesion and a body mass index >25 kg/m2were enrolled in this prospective, institutional review board approved study. Each subject was imaged with an Aplio 500 scanner (Canon Medical Systems, Tokyo, Japan) using grayscale ultrasound, tissue harmonic imaging (THI) and two dual‐frequency, differential tissue harmonic imaging modes (DTHI and DTHI‐II, respectively). In total 184 images were scored by three independent and blinded observers for detail resolution, image quality, margin delineation, and depth penetration. Quantitative contrast‐to‐noise ratios (CNRs) were also calculated. Readers and CNR values showed that nonlinear imaging was superior to grayscale ultrasound (P< .0014). DTHI‐II outperformed DTHI, THI, and grayscale ultrasound with respect to detail resolution, image quality, and margin delineation (P< .012). The depth penetration of DTHI and DTHI‐II was similar (P= .16), but superior to grayscale ultrasound and THI (P< .001). Two observers saw improvements in detail resolution with DTHI‐II over DTHI (P< .05), while image quality and margin delineation were considered similar by two readers (P> .07) and improved with DTHI‐II by one (P< .017). DTHI‐II improves the imaging of renal lesions compared to DTHI, THI, and grayscale ultrasound, albeit based on a limited sample size.

Abstract:This piece examines the narrativization of the scars on Prince's back to read a narrative of an alternative humanism, that teaches us out of dispossession as ethics. Sylvia Wynter has argued that under the Western bourgeois order gender and race are a "function of genre." In showing the scars on her back to the culture that produced them, Prince disrupts these genres and no longer remains (only) subject to the white power around her but a maker of alternative and extrinsic narratives about blackness and being that we might read if we wish to do so.

Abstract:This essay reads displaced Black voices and figures in abolitionist art and poetry as African Indigenes. It discusses the beads around the necks of two figures in Romantic visual culture. The first is a painting of a real Senegalese man, Prince Peter Panah, with Carl Bernhard Wädstrom by Carl Frederik Von Breda. The second is a reinterpretation of this painting in a mezzotint, The Benevolent Effects of Abolishing Slavery, or the Planter Instructing His N--- by W. Pyott, 1792. The beads in both images articulate Black diasporic resistance and Indigeneity that puncture the totality of Romantic abolitionism’s framing.

Laser-exposed plasmonic substrates permeabilize the plasma membrane of cells when in close contact to deliver cell-impermeable cargo. While studies have determined the cargo delivery efficiency and viability of laser-exposed plasmonic substrates, morphological changes in a cell have not been quantified. We porated myoblast C2C12 cells on a plasmonic pyramid array using a 532-nm laser with 850-ps pulse length and time-lapse fluorescence imaging to quantify cellular changes. We obtain a poration efficiency of 80%, viability of 90%, and a pore radius of 20 nm. We quantified area changes in the plasma membrane attached to the substrate (10% decrease), nucleus (5 – 10% decrease), and cytoplasm (5 – 10% decrease) over 1 h after laser treatment. Cytoskeleton fibers show a change of 50% in the alignment, or coherency, of fibers, which stabilizes after 10 mins. We investigate structural and morphological changes due to the poration process to enable the safe development of this technique for therapeutic applications.

In this article we focus on the relationship between vision and the hand to develop an understanding of the experience of mobile media use which in turn informs a methodology for researching it; a tactile digital ethnography. Theories of knowing through the hand, and uses of the hand in documentary practice already highlight its significance. We bring these together with our video ethnographies of mobile media use, to show how a focus on the hand offers both new insights into other people’s digital worlds, and an approach to learning about these.

BACKGROUND The feasibility of video-assisted retroperitoneal debridement (VARD) for infected pancreatic walled-off necrosis is established. We provide prospective data on the safety and efficacy of VARD. DESIGN Multicenter, prospective, single-arm phase 2 study. SETTING Six academic medical centers. PATIENTS We evaluated 40 patients with pancreatic necrosis who had infection determined using Gram stain or culture. INTERVENTIONS Percutaneous drains were placed at enrollment, and computed tomographic scans were repeated at 10 days. Patients who had more than a 75% reduction in collection size were treated with drains. Other patients were treated with VARD. Crossover to open surgery was performed for technical reasons and/or according to surgeon judgment. MAIN OUTCOME MEASURES Efficacy (ie, successful VARD treatment without crossover to open surgery or death) and safety (based on mortality and complication rates). Patients received follow-up care for 6 months. RESULTS We enrolled 40 patients (24 men and 16 women) during a 51-month period. Median age was 53 years (range, 32-82 years). Mean (SD) Acute Physiology and Chronic Health Evaluation II score at enrollment was 8.0 (5.1), and median computed tomography severity index score was 8. Of the 40 patients, 24 (60%) were treated with minimally invasive intervention (drains with or without VARD). Nine patients (23%) did not require surgery (drains only). For 31 surgical patients, VARD was possible in 60% of patients. Most patients (81%) required 1 operation. In-hospital 30-day mortality was 2.5% (intent-to-treat). Bleeding complications occurred in 7.5% of patients; enteric fistulas occurred in 17.5%. CONCLUSIONS This prospective cohort study supports the safety and efficacy of VARD for infected pancreatic walled-off necrosis. Of the patients, 85% were eligible for a minimally invasive approach. We were able to use VARD in 60% of surgical patients. The low mortality and complication rates compare favorably with open debridement. An unexpected finding was that a reduction in collection size of 75% according to the results of computed tomographic scans at 10 to 14 days predicted the success of percutaneous drainage alone.Arch Surg. 2010;145(9):817-825--

Simulation-based training is becoming integral to the training of surgical residents. The authors describe the use of simulation-based training to address a specific clinical problem. Cognitive and procedural training in central venous catheter (CVC) placement are used to achieve the goal of decreasing CVC-related complications. Training goals and outcome measures—both educational and clinical—are described. This model of using simulation-based training as a tool to address a specific clinically applicable training need should be extended to additional procedures where a specific educational goal can be targeted.

We hypothesized that the use of muscle flaps, known as tissue transfer (TT), at the time of abdominoperineal resection (APR) reduces perineal wound complications. A restrospective review of patients undergoing an APR at the University of Washington (1984–2003) was conducted. Perineal wound complications and eventual wound healing were compared in patients with and without TT. Ninety-two patients (mean age, 56.6 years) underwent APR; 23.9 per cent (n = 22) had concurrent TT. Patients undergoing TT were more likely to have cancer (91% vs.77%, P= 0.05) and radiation therapy (86% vs. 52%, P< 0.01). Operative times were nearly 2 hours longer in patients having TT (7.4 hours ± 2.5 hours vs.5.6 hours ± 1.8 hours, P= 0.03), but lengths of stay were similar (13 ± 5.9 days vs.12 ± 7.6 days, P= 0.5). Patients undergoing TT had a higher rate of all wound-healing complications (59% vs.40%, P= 0.1) and major wound-healing complications (32% vs.26%, P= 0.6). However, these differences were not statistically significant. No differences in major complications were identified in patients with and without preoperative radiation therapy (26% vs.28%, P= 0.8). Fifteen per cent (n = 14) of all patients failed to heal wounds at 6 months, but only 9 per cent (n = 2) of patients undergoing TT failed to heal their wounds at 6 months compared with 17 per cent (n = 12) in the non-TT group (P= 0.3). After controlling for important covariates, patients undergoing TT during an APR did not have a significantly lower rate of wound complications. The impact of TT on wound healing in patients with recurrent cancer and preoperative radiation therapy is suggestive of a benefit but requires prospective investigation.

Background: The incorporation of new devices into surgical practice often requires that surgeons acquire and master new skills. We studied the learning curve for intracorporeal knot tying in robotic surgery. Methods: We developed an objective scoring system to evaluate knot tying and tested eight attending surgeons during 3 weeks of training on a surgical robot. Each performed intracorporeal knot tying tasks both before and after robotic skills training. These performances were compared to their laparoscopic knots and analyzed to determine and define skill improvement. Results: Baseline laparoscopic knot completion took 140 sec (range, 47–432), with a mean composite score of 77 (100 possible), whereas robotic knot tying took 390 sec, with a mean composite score of 40. After initial robotic training, times decreased by 65% to 139 sec and scores increased to 71. With more training, completion times and composite scores were improved and errors were reduced. Conclusion: Like any new technology, surgical robotics requires dedicated training to achieve mastery. Initially, even experienced laparoscopists may register an inferior performance. However, after adequate training, surgeons can exceed their laparoscopic performance, completing intracorporeal knots better and faster using robotics.

Objective: Evaluation of the laparoscopic surgical skills of surgical residents is usually a subjective process carried out in the operating room by senior surgeons. The two hypotheses of the current study were: (1) haptic information and tool/tissue interactions (types and transitions) performed in laparoscopic surgery are skill-dependent, and (2) statistical models (Hidden Markov Models - HMMs) incorporating these data are capable of objectively evaluating laparoscopic surgical skills.Materials and Methods: Eight subjects (six residents - two first-year (R1), two third-year (R3), and two fifth-year (R5) - and two expert laparoscopic surgeons) performed laparoscopic cholecystectomy on pigs using an instrumented grasper equipped with force/torque (F/T) sensors at the hand/tool interface, and F/T data was synchronized with video of the operative maneuvers. Fourteen types of tool/tissue (T/T) interactions, each associated with unique F/T signatures, were defined from frame-by-frame video analysis. HMMs for each subject and step of the operation were compared to evaluate the statistical distance between expert surgeons and residents with different skill levels.Results: The statistical distances between HMMs representing expert surgeons and residents were significantly different (α < 0.05). Major differences occurred in: (1) F/T magnitudes; (2) type of T/T interactions and transitions between them; and (3) time intervals for each T/T interaction and overall completion time. The greatest difference in performance was between Rl (junior trainee) and R3 (midlevel trainee). Smaller changes were seen as expertise increased beyond the R3 level.Conclusion: HMMs incorporating haptic and visual information provide an objective tool for evaluating surgical skills. Objective evidence for a "learning curve" suggests that surgical residents acquire a major portion of their laparoscopic skill between year 1 and year 3 of training.

Evaluation of the laparoscopic surgical skills of surgical residents is usually a subjective process carried out in the operating room by senior surgeons. The two hypotheses of the current study were: (1) haptic information and tool/tissue interactions (types and transitions) performed in laparoscopic surgery are skill-dependent, and (2) statistical models (Hidden Markov Models—HMMs) incorporating these data are capable of objectively evaluating laparoscopic surgical skills. Eight subjects (six residents—two first-year (R1), two third-year (R3), and two fifth-year (R5)—and two expert laparoscopic surgeons) performed laparoscopic cholecystectomy on pigs using an instrumented grasper equipped with force/torque (F/T) sensors at the hand/tool interface, and F/T data was synchronized with video of the operative maneuvers. Fourteen types of tool/tissue (T/T) interactions, each associated with unique F/T signatures, were defined from frame-by-frame video analysis. HMMs for each subject and step of the operation were compared to evaluate the statistical distance between expert surgeons and residents with different skill levels. The statistical distances between HMMs representing expert surgeons and residents were significantly different (α &lt; 0.05). Major differences occurred in: (1) F/T magnitudes; (2) type of T/T interactions and transitions between them; and (3) time intervals for each T/T interaction and overall completion time. The greatest difference in performance was between R1 (junior trainee) and R3 (midlevel trainee). Smaller changes were seen as expertise increased beyond the R3 level. HMMs incorporating haptic and visual information provide an objective tool for evaluating surgical skills. Objective evidence for a “learning curve” suggests that surgical residents acquire a major portion of their laparoscopic skill between year 1 and year 3 of training. Comp Aid Surg 7:49–61 (2002). © 2002 Wiley-Liss, Inc.

The remodelling of connective tissue components is a fundamental requirement for a number of pivotal processes in cell biology. These may include myoblast migration and fusion during development and regeneration. In other systems, similar biological processes are facilitated by secretion of the matrix metalloproteinases (MMPs), especially the gelatinases. This study investigated the activity of the gelatinases MMP-2 and 9 by zymography on cell conditioned media in cultures of cells derived from explants of the human masseter muscle and in the murine myoblast cell-line C2C12. Expression of MMP-9 by western blotting and TIMP-1, the major inhibitor of MMPs, by northern blotting, during all phases of myoblast proliferation, migration, alignment and fusion, was also measured. Irrespective of the origin of the cultures, MMP-9 activity was secreted only by single cell and pre-fusion cultures whilst MMP-2 activity was secreted at all stages as well as by myotubes. The loss of MMP-9 activity was due to the loss of MMP-9 protein expression. TIMP-1 mRNA was not detectable at the single cell stage but its expression increased as cells progressed through the pre-fusion and post-fusion stages to reach a maximal in myotube containing cultures. Migration of cells derived from human masseter muscle was inhibited, using a specific anti-MMP-9 blocking monoclonal antibody (6-6B). These data are consistent with the concept that regulation of matrix turnover via MMP-9 may be involved in the events leading to myotube formation, including migration. Loss of expression of this enzyme and expression of TIMP-1 mRNA is associated with myotube containing cultures. Consequently, the ratio between MMPs and TIMPs maybe important in determining myoblast migration and differentiation.

Abstract: The age of minimally invasive surgery has brought forth astounding changes in the health care field. Less pain and quicker patient recovery have been demonstrated with several types of operations that were once performed by an open technique. With these changes have come reports of complications. The decreased sense of touch is just one of several limitations inherent to current techniques of minimally invasive surgery that limit detection of subtle or unapparent lesions on palpation, such as common duct stones and liver lesions. The purpose of this study is to demonstrate the ability of a force-feedback-equipped grasper to restore some of the sense of touch that is lost in minimally invasive surgery. To demonstrate this ability, we created six silicone phantoms of identical dimensions but graded compliance, and asked 10 subjects to place them in increasing/decreasing order of compliance. They used three tools (their dominant gloved hand, a standard laparoscopic Babcock grasper, and our force-feedback device fitted with the identical Babcock grasper) to rate the compliance of the samples in a blinded fashion. These conditions thus approximated the conditions of open surgery, minimally invasive surgery, and minimally invasive surgery fitted with a force-sensing device, in terms of palpating tissues. Five surgeons skilled in minimally invasive surgery and five nonsurgeons participated in the study. The results indicate that the force-feedback device is significantly (P <0.05) better than a standard Babcock grasper at rating tissue compliance, but was not as successful as a gloved hand (mean of squared errors = 1.06, 3.15, and 0.25, respectively). There was no significant difference between surgeons and nonsurgeons in rating compliance. We conclude that this force-feedback instrument is able to partially restore the sense of touch in minimally invasive surgery. This restored ability may thus potentially result in more efficient operations with improved diagnostic capabilities and fewer complications during minimally invasive surgery.

This paper is a sequel to reference [1]. In that paper, the dynamics of the steelpan notes were developed as systems of non-linear mode-localized oscillators. The present paper examines the coupled note-note and note-skirt systems on the steelpan modelled as a plexus of non-linear oscillators interconnected by linear mechanical filters. The tonal qualities of a note depend on the degree of coupling and the closeness in frequency of the excited modes on the interacting subsystems. Modes above the fundamental (the partials) are produced by internal and combination resonances.

We examined the relationship between severity of alcohol dependence, subtle neurological impairment, neuropsychological deficits and genetic vulnerability among 36 day hospital attenders who satisfied the DSM‐III‐R criteria for alcohol dependence. Severity of alcohol dependence was unrelated to the presence of a family history, but was correlated with neurological soft signs and neuropsychological impairment. Neurological soft signs were correlated with neuropsychological impairment on both Trail A and Trail B. Patients with an affected first‐degree relative exhibited more neurological soft signs. These data indicate that severity of alcohol dependence is related not only to neuropsychological impairment, but also to subtle neurological deficits which may not be apparent on conventional neurological examination. Patients with a positive family history of alcohol dependence may be particularly susceptible to the neurological sequelae of alcohol dependence, or may have neurological deficits which antedate their alcohol dependence.

Although the procedures of endoscopic surgery are in many ways, simply a new way of approaching old, familiar problems, certain technical aspects are sufficiently different enough from the common experience of the general surgeon so as to require special training and certification for competency. The introduction of laparoscopic cholecystectomy worldwide showed that many aspects of endoscopic surgery deserved emphasis in training. These include the unique instruments, equipment, and techniques associated with videoendoscopic procedures and, perhaps of even greater importance, the differences in anatomic exposure and perspective afforded by the laparoscope [1-4]. Surgeons used to working in a three-dimensional environment with extensive tactile sensation were forced to learn to operate at a distance from the target tissue using instruments that provided much less feel for the tissues. Direct visualization of the operative field was replaced by a narrow field of view and a magnified, two-dimensional video image, with the video monitor often at an angle to the operative field. Despite these hurdles, the new endoscopic technology was rapidly introduced to clinical practice, stimulated both by the pace of development in the industry and by patient demand for less invasive surgery. But the endoscopic revolution was not accomplished without cost. In the years between 1989 and 1994, many practicing surgeons took brief, 1 or 2 day courses and proceeded to initiate laparoscopic cholecystectomy into their clinical practice with a minimum of experience or expert assistance. Concomitantly, anecdotal experience from oversight institutions and referral centres documented a sharp increase in major, primarily bile duct-related, complications from these procedures, complications that occurred significantly more often than would be expected from open cholecystectomy. Although equipment failure and the early state of the technology accounted for some of these complications, professional organizations and government groups in the United States [5,6] and Europe [7] concluded that many occurred because of inadequate training, minimal supervision and poor endoscopic surgical technique despite the fact that many of the surgeons were otherwise quite experienced open biliary surgeons. More recently, a similar learning curve has been observed for other, more advanced laparoscopic procedures such as antireflux procedures and colectomy [8]. In response, numerous organizations and individuals have proposed or ratified a structured approach to training and credentialing [9-12].

• Patients in an intensive care unit who have intra-abdominal (IA) infections producing clinical deterioration in their conditions require urgent intervention. However, detection is often difficult. To define preoperative criteria for, and improve the specificity of, laparotomy, we reviewed 100 explorations in 71 patients with suspected IA sepsis. Eighty-one explorations demonstrated an infected or ischemic process; 19 were negative. Preoperative features associated with a positive laparotomy were as follows: (1) objective evidence by physical examination, ultrasonography, or computed tomography suggesting an IA focus (89%); (2) septic shock (80%); and (3) positive blood cultures (95%). Absence of these features significantly lowered the accuracy of exploration. Septic shock or bacteremia had a 90% mortality regardless of findings at exploration. The best accuracy (89%) and survival (51%) rates were achieved with "directed" exploration before septic shock or bacteremia. Early use of sensitive detection techniques that permit directed laparotomy before septic deterioration should improve survival.(Arch Surg 1984;119:652-658)

Acute cholangitis is a clinical syndrome marked by fever, jaundice, and abdominal pain that develops because of stasis and infection in the biliary tract. Patients with cholangitis may present with symptoms ranging from a mild, recurrent illness to overwhelming sepsis. Increased age, malignant obstruction, and a rapidly progressive, systemic illness define a group of patients at increased risk. Patients who are delayed in diagnosis, present with septicemia, or fail to respond to conservative treatment still have substantial morbidity and death from cholangitis. Antibiotic therapy that includes coverage for anaerobes and gram-negative, enteric organisms together with other supportive measures often resolves the acute episode, permitting elective diagnostic procedures prior to definitive treatment of biliary tract obstruction. Advances in endoscopic and transhepatic procedures have reduced the necessity for and risks associated with emergent operative biliary drainage.

The article focuses on the result of a study conducted by the University of Washington (UW) School of Medicine on the use of natural language processing (NLP) to assign Evaluation & Management (E&M) codes for billing professional services. The authors state that NLP increased coding accuracy, provided rapid feedback to physicians, and identified difficult problems. They believe that the tool will increase billing compliance, and assist in practitioner education and reduce billing cost.

Rectosigmoid endometriosis is a relatively rare condition and may commonly mimic carcinoma. We report a case presenting with frozen pelvis that was unresectable during an emergency laparotomy. Clinically and radiologically it was suspected to be carcinoma and the patient was subjected to radio- and chemotherapy. The lesion was resected during a second laparotomy and was found to be endometriotic mass. A high index of suspicion is necessary to diagnose this condition.

A 44-year-old woman with a large benign cartilaginous tumor (chondroma) of the liver is presented. After being followed up by computed tomography for 6 years and with imagining evidence for a recent increase in its size, this asymptomatic tumor was successfully removed at surgery. The resected tumor proved to be chondroma, a benign cartilaginous tumor. A review of the literature showed no previous reports of this type of hepatic neoplasm.