Search

Aim: Facebook is an increasingly popular online social networking site. The purpose of this study was to describe the Facebook activity of residents and fellows and their opinions regarding the impact of Facebook on the doctor-patient relationship., Methods: An anonymous questionnaire was emailed to 405 residents and fellows at the Rouen University Hospital, France, in October 2009., Results: Of the 202 participants who returned the questionnaire (50%), 147 (73%) had a Facebook profile. Among responders, 138 (99%) displayed their real name on their profile, 136 (97%) their birthdates, 128 (91%) a personal photograph, 83 (59%) their current university and 76 (55%) their current position. Default privacy settings were changed by 61% of users, more frequently if they were registered for >1 year (p=0.02). If a patient requested them as a 'friend', 152 (85%) participants would automatically decline the request, 26 (15%) would decide on an individual basis and none would automatically accept the request. Eighty-eight participants (48%) believed that the doctor-patient relationship would be altered if patients discovered that their doctor had a Facebook account, but 139 (76%) considered that it would change only if the patient had open access to their doctor's profile, independent of its content., Conclusions: Residents and fellows frequently use Facebook and display personal information on their profiles. Insufficient privacy protection might have an impact the doctor-patient relationship.

In this review, we describe plans to monitor the impact of human papillomavirus (HPV) vaccine on biologic outcomes in selected international areas (Australia, Canada, Mexico, the Nordic countries, Scotland, and the United States) that have adopted this vaccine. This summary of monitoring plans provides a background for discussing the challenges of vaccine monitoring in settings where resources and capacity may vary. A variety of approaches that depend on existing infrastructure and resources are planned or underway for monitoring HPV vaccine impact. Monitoring HPV vaccine impact on biologic outcomes is a complex and challenging task, but also plays an important role in documenting the benefit of vaccination, monitoring the progress of vaccination programs, and providing data to inform vaccination and disease prevention policies., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

The ulnar collateral ligament (UCL), particularly the anterior portion of the anterior oblique ligament, is the primary static contributor to elbow valgus stability. UCL injuries are most common in athletes participating in overhead sports. Acute and chronic injuries to the UCL result in valgus instability, which may predispose the athlete to the development of disabling secondary elbow conditions. Provocative physical examination maneuvers include the valgus abduction test, the modified milking maneuver, and the moving valgus stress test. Plain radiographs and magnetic resonance imaging are the most common imaging modalities, although ultrasonography and computed tomography arthrograms can alternatively be used. UCL injuries can be treated initially with rest, anti-inflammatory medications, bracing, and/or physical therapy. Acute avulsion injuries can be repaired, especially in those under 20 years of age, but most UCL tears are now treated with reconstruction. Modifications of the Jobe figure-of-8 technique, and now the Altchek docking technique, are the most common reconstruction techniques. Many new and hybrid techniques have been described with limited clinical experience in the literature. Current techniques offer the athlete a greater than 90% chance of return to play at their preinjury level., (Copyright © 2010 Elsevier Inc. All rights reserved.)

The ulnar, radial, median, medial antebrachial cutaneous, and lateral antebrachial cutaneous nerves are subject to traction and compression in athletes who place forceful, repetitive stresses across their elbow joint. Throwing athletes are at greatest risk, and cubital tunnel syndrome (involving the ulnar nerve) is clearly the most common neuropathy about the elbow. The anatomy and innervation pattern of the nerve involved determines the characteristic of the neuropathy syndrome. The most important parts of the work-up are the history and physical examination as electrodiagnostic testing and imaging are often not reliable. In general, active rest is the first line of treatment. Tailoring the surgery and rehabilitation protocol according to the functional requirements of that athlete's sport(s) can help optimize the operative outcomes for recalcitrant cases., (Copyright © 2010. Published by Elsevier Inc.)

Purpose: To evaluate the change in thickness of the anterior, stromal, and posterior corneal laminae in response to hypoxia-induced corneal swelling, by means of ultrahigh-resolution optical coherence tomography (UHR-OCT)., Methods: A UHR-OCT system, operating in the 1060-nm range, was used to acquire in vivo cross-sectional images of human cornea with a 3.2x10-microm (axial x lateral) resolution in corneal tissue. Corneal edema was induced by inserting a thick, positive-powered, soft contact lens, over which the eye was closed and patched for 3 hours. Tomograms were acquired from eight non-contact-lens wearers. Baseline images were obtained before inducing corneal edema, immediately after removal of the patch and the lens, and then every 15 minutes for approximately 2 hours. All images were postprocessed with a segmentation algorithm to identify the laminae visible in the image. The apical thickness of the laminae (epithelium [EPI], epithelial-Bowman's membrane [Ep-BM] complex, stroma, and endothelial-Descemet's membrane [En-DM] complex) were determined at each time interval., Results: There was an interaction between time after removal of the hypoxic stimulus and deswelling of the layers (RM-ANOVA; P<0.001). The epithelial and stromal thickness reduced significantly with time (P=0.001; P<0.001, respectively), whereas the Ep-BM and En-DM complexes did not (P>0.50). All layers except the En-DM complex exhibited a biphasic pattern of recovery., Conclusions: UHR-OCT showed regional differences in swelling due to hypoxic provocation. On removal of the hypoxic stimulus, the rate of recovery varied between layers, and all layers except the En-DM complex exhibited a biphasic recovery.

Post-licensure evaluation of vaccines plays an important role in monitoring the progress of immunization programs, demonstrating population impact of vaccines, and providing data for ongoing policy decisions. Two human papillomovirus (HPV) vaccines are licensed and recommended for use in females in the United States, a quadrivalent human HPV vaccine, licensed in 2006 and a bivalent vaccine HPV vaccine licensed in 2009. HPV vaccination is recommended for females 11 or 12 years of age with catch-up vaccination through age 26 years. Post-licensure monitoring of the HPV vaccine program has included some of the same systems established for other vaccines, such as those for vaccine safety and coverage monitoring. However, monitoring HPV vaccine impact on infection and disease outcomes has required new efforts. While there are well established cancer registries in the United States, it will take decades before the impact of vaccine on cervical cancer is observed. More proximal measures of vaccine impact include outcomes such as prevalence of HPV vaccine types, incidence of cervical precancers and genital warts. We review systems in place or being established for post-licensure monitoring of HPV vaccine in the United States., (Published by Elsevier Ltd.)

Due to intensive use of multileaf collimators (MLCs) in clinics, finding an optimum design for the leaves becomes essential. There are several studies which deal with comparison of MLC systems, but there is no article with a focus on offering an optimum design using accurate methods like Monte Carlo. In this study, we describe some characteristics of MLC systems including the leaf tip transmission, beam hardening, leakage radiation and penumbra width for Varian and Elekta 80-leaf MLCs using MCNP4C code. The complex geometry of leaves in these two common MLC systems was simulated. It was assumed that all of the MLC systems were mounted on a Varian accelerator and with a similar thickness as Varian's and the same distance from the source. Considering the obtained results from Varian and Elekta leaf designs, an optimum design was suggested combining the advantages of three common MLC systems and the simulation results of this proposed one were compared with the Varian and the Elekta. The leakage from suggested design is 29.7% and 31.5% of the Varian and Elekta MLCs. In addition, other calculated parameters of the proposed MLC leaf design were better than those two commercial ones. Although it shows a wider penumbra in comparison with Varian and Elekta MLCs, taking into account the curved motion path of the leaves, providing a double focusing design will solve the problem. The suggested leaf design is a combination of advantages from three common vendors (Varian, Elekta and Siemens) which can show better results than each one. Using the results of this theoretical study may bring about superior practical outcomes.

A computational model was developed to evaluate the limitations to the highest axial resolution, achievable with ultrahigh resolution optical coherence tomography (UHROCT) in the 1060 nm wavelength region for in-vivo imaging of the human and rodent retina. The model considers parameters such as the wavelength dependent water absorption, the average length of the human and rodent eyes, and the power limitations for the imaging beam as defined in the ANSI standard. A custom-built light source with re-shaped spectrum was used to verify experimentally the results from the computational model. Axial OCT resolution of 4.2 microm and 7.7 microm was measured from a mirror reflection with the custom light source by propagating the imaging beam through water cells with 5 mm and 25 mm thickness, corresponding to the average axial length of the rodent and human eye respectively. Assuming an average refractive index of 1.38 for retinal tissue, the expected axial OCT resolution in the rodent and human retina is 3 microm and 5.7 microm respectively. Retinal tomograms acquired in-vivo from the rat eye with the modified light source show clear visualization of all intraretinal layers, as well as a network of capillaries (approximately 10 microm in diameter) in the inner- and outer plexiform layers of the retina.

Background: Screw and suture fixations are the most commonly used methods of fixation in treatment of anterior cruciate ligament tibial avulsion fractures. Even though a few biomechanical studies have compared the stability of the 2 fixation techniques, a clinical comparison has not yet been reported., Hypothesis: The authors hypothesized that both fixations would be identical in all studied clinical outcome measures at a minimum 2-year follow-up., Study Design: Cohort study; Level of evidence, 3., Materials and Methods: Thirty-three patients treated with either screw fixation (16 patients) or suture fixation (17 patients) within 1 month of the anterior cruciate ligament tibial avulsion fracture (type II or III) without associated ligamentous injury were included. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm knee scores and return to preinjury activities. Knee stability was compared based on the Lachman test and stress radiography., Results: No significant differences were found between the 2 groups in terms of average Lysholm knee scores (91.7 in the screw group and 92.7 in the suture group, P = .413) at follow-up. All patients except 2 (1 in each group) returned to preinjury activity levels. However, flexion contractures (5 degrees to 10 degrees) were found in 3 patients in the screw group and 2 patients in the suture group without significant intergroup difference. Stabilities based on the Lachman test and instrumented stress radiography were also similar between the 2 groups at follow-up. However, 2 patients in the screw group and 1 in the suture group showed more than 5 mm laxity compared with the contralateral knee on stress radiographs., Conclusion: Both the screw and suture fixation techniques for the anterior cruciate ligament tibial avulsion fracture produced relatively good results in terms of functional outcomes and stability without any significant differences. However, some patients in both groups showed residual laxity or flexion contractures.

Objectives: Decision-making bringing to an admission or not in intensive care is complex. The aim of this study is to analyze with an ethical point of view the making decision process leading to the refusal and its consequences. It is proposed a setting in prospect through the principles of beneficence, non-maleficience, respect for autonomy, justice, and the Leonetti law., Patients and Methods: Prospective study in surgical reanimation at the University Hospital of Rouen over 9 months (November 2007-September 2008). Systematic collection for each non-admitted patient of the general characters, the methods of decision making, immediate becoming and within 48 h Constitution of two groups: patients for whom an admission in intensive care could be an unreasonable situation of obstinacy, and patients for whom an admission in reanimation would not be about unreasonable if it occurred., Results: One hundred and fifty situations were analyzed. The potentially unreasonable character of an admission does not involve necessarily a refusal of care in intensive care. The question of the lack of place and equity in the access to the care is real but relative according to the typology of the patients. The research of the respect of the autonomy of the patient is difficult but could be facilitated. The Leonetti law does not appear to be able to be a framework with the situation of refusal of care in intensive care., Conclusion: It is not a question of going towards a systematic admission in intensive care of any patient proposed, but to make sure that so if there is a refusal, it is carried out according to a step ethically acceptable.

Background: Iliotibial band friction syndrome (ITBFS) is an overuse injury causing lateral knee pain. There is evidence that the pathological lesion is in fact an inflamed bursa underlying the iliotibial band (ITB) rather than an inflamed ITB itself., Hypothesis: Resection of the bursa underlying the ITB in ITBFS patients will relieve their pain and allow them to return to their preinjury activity level., Study Design: Case series; Level of evidence, 4., Methods: We describe the technique of ITB bursectomy and report a minimal 20-month follow-up of patients who had ITB bursectomies performed by a single surgeon. The patients completed a survey detailing their preoperative and postoperative symptoms and activities., Results: The senior author performed 12 consecutive cases of ITB bursectomies (12 patients). One was excluded from the study (previous microfracture). The average age at surgery was 32 years (standard deviation, 5; range, 24-41). There were 7 men and 4 women. Postoperatively, patients were able to return to their preinjury Tegner activity levels, and the visual analog pain scores decreased by an average of 6 points (P < .001). Six patients were completely satisfied with the surgical outcome, 3 were mostly satisfied, 2 were somewhat satisfied, and none were dissatisfied. Nine of 11 patients said that knowing what they know now, they would have the surgery performed again for the same problem., Conclusion: Iliotibial band bursectomy successfully reduces knee pain in patients with ITBFS and allows them to return to their preinjury level of activity. The great majority of patients were satisfied with the results of the procedure.

It is unclear whether hypertension (HTN) is a predisposing factor for the development of trigeminal neuralgia (TN). The purpose of this study was to determine the prevalence of HTN in TN patients and controls at the USC Orofacial Pain and Oral Medicine Center. A retrospective chart review was conducted from a database of over 3,000 patient records from 2003 to 2007. We identified patients diagnosed with TN with or without HTN. A total of 84 patients (54 females; 30 males) between the ages of 33 and 93 years were diagnosed with TN; 37% had TN with HTN and 32% of controls had HTN. The increased prevalence of HTN in the TN patients was not statistically significant (P = 0.50). Since, both TN and HTN are seen in the elderly, it is likely that HTN is simply a co-existing condition in patients with TN and not a risk factor for its development.

Background: the long-term outcomes of wartime transtibial amputations have not been well documented. The purpose of this case series is to present the long-term functional, social, and psychological outcomes of modern-day military unilateral transtibial amputees., Patients and Methods: the Iranian Veterans Administration of the Khorasan province invited their Iranian military amputees from the Iran-Iraq War (1980-1988) to its medical center for evaluation. The patients filled out a detailed questionnaire and were interviewed and examined by each team member., Results: two hundred (77%) of the 260 invited amputees were willing and able to come back for follow-up. Ninety-six of these patients (48%) were unilateral transtibial amputation. The average follow-up was 17.4 years (range 15-22 years). Land mines were the leading cause of war injury necessitating a transtibial amputation (68%). The most common symptoms about their amputated limbs were phantom sensations (54%), phantom pain (17%), and stump pain (42%). Lower back pain, contralateral (nonamputated limb) knee pain, and ipsilateral (amputated limb) knee pain were reported by 44%, 38%, and 13% of subjects, respectively. Sixty-five percent of patients were employed or had been employed for multiple years after their war injury. All patients were married, and 97% had children. Fifty-four percent of amputees reported psychological problems; 26% were currently utilizing psychological support services., Conclusions: at long-term follow-up, most military transtibial amputees experienced phantom sensation or some type of stump pain. More than half had persistent psychiatric problems, but only about half of these patients were receiving psychological treatment. Although this case series reports the status of these amputees, the next step would be to prospectively follow modern wartime amputees using standardized, validated outcome measures. With the goal of optimizing long-term amputee outcomes, researchers should correlate outcomes with demographics, injury characteristics, and treatments to identify and modify factors affecting the amputees' prognosis.

Background: Functional loss is a common complication of the fractured distal part of the radius. The purpose of the present study was to determine if the moment arms of the first dorsal extensor compartment are altered by distal radial fracture malunion. We hypothesized that the moment arms of the abductor pollicis longus and extensor pollicis brevis are significantly affected by dorsal angulation, radial inclination, and radial shortening, the most common deformities accompanying distal radial malunion., Methods: Moment arms of the extensor pollicis brevis and abductor pollicis longus were estimated in twelve cadaver wrists with use of the tendon-displacement method, which involves calculating the moment arm as the derivative of tendon displacement with respect to joint angle. Tendon displacement was quantified in different wrist postures before and after a closing-wedge osteotomy simulating a complex malunion of an extra-articular radial fracture., Results: The simulated distal radial malunion resulted in a decrease in the wrist flexion moment arm for both the extensor pollicis brevis (p = 0.0003) and the abductor pollicis longus (p < 0.0001). The wrist flexion moment arms for the extensor pollicis brevis and abductor pollicis longus decreased by a mean (and standard deviation) of 114% +/- 75% and 77% +/- 50%, respectively, after the osteotomy. The wrist radial deviation moment arms for the extensor pollicis brevis and abductor pollicis longus increased by 16% +/- 26% (p = 0.071) and 28% +/- 44% (p = 0.043), respectively, after the osteotomy. Radiographs of the wrist that were made before and after the osteotomy indicated that radial tilt changed from 11.1 degrees of volar angulation to 14.8 degrees of dorsal angulation, radial inclination decreased from 21.8 degrees to 7.7 degrees, and radial height decreased from 11.6 to 4.4 mm., Conclusions: Distal radial malunion alters the mechanical advantage of the muscles in the first dorsal extensor compartment.

Objectives: The national seroprevalence of the nononcogenic human papillomavirus (HPV) type 11, one of the types targeted by the quadrivalent HPV vaccine, has not been evaluated in the United States. The objectives of this study were to estimate the national seroprevalence and evaluate predictors of HPV-11 seropositivity., Study Design: We tested serum samples for HPV-11 antibodies and analyzed questionnaire data from the second phase of the National Health and Nutrition Examination Survey III, 1991--1994. Seroprevalence estimates were weighted to represent the US population., Results: : Overall seroprevalence of HPV-11 infection was 4.7%. Seroprevalence was significantly higher among females (5.7%) than among males (3.6%). Independent predictors of HPV-11 seropositivity included sex, race/ethnicity, lifetime number of sex partners, education, and HPV-16 seropositivity., Conclusion: This study represents the most comprehensive picture of HPV-11 infection in the United States to date, and provides baseline data on the prevalence of HPV-11 before availability of the quadrivalent HPV vaccine.

Background: Pseudoxanthoma elasticum (PXE), an autosomal recessive disorder with considerable phenotypic variability, mainly affects the eyes, skin and cardiovascular system, characterised by dystrophic mineralization of connective tissues. It is caused by mutations in the ABCC6 (ATP binding cassette family C member 6) gene, which encodes MRP6 (multidrug resistance-associated protein 6)., Objective: To investigate the mutation spectrum of ABCC6 and possible genotype-phenotype correlations., Methods: Mutation data were collected on an international case series of 270 patients with PXE (239 probands, 31 affected family members). A denaturing high-performance liquid chromatography-based assay was developed to screen for mutations in all 31 exons, eliminating pseudogene coamplification. In 134 patients with a known phenotype and both mutations identified, genotype-phenotype correlations were assessed., Results: In total, 316 mutant alleles in ABCC6, including 39 novel mutations, were identified in 239 probands. Mutations were found to cluster in exons 24 and 28, corresponding to the second nucleotide-binding fold and the last intracellular domain of the protein. Together with the recurrent R1141X and del23-29 mutations, these mutations accounted for 71.5% of the total individual mutations identified. Genotype-phenotype analysis failed to reveal a significant correlation between the types of mutations identified or their predicted effect on the expression of the protein and the age of onset and severity of the disease., Conclusions: This study emphasises the principal role of ABCC6 mutations in the pathogenesis of PXE, but the reasons for phenotypic variability remain to be explored.

The human immunodeficiency virus (HIV) epidemic emerged in the early 1980s with HIV infection as a highly lethal disease among men who have sex with men and among frequent recipients of blood product transfusions. Advances in the treatment of HIV infection have resulted in a fundamental shift in its epidemiology, to a potentially chronic and manageable condition. However, challenges in the prevention of this infection remain. In particular, increasing evidence suggests that transmission of drug-resistant virus is becoming more common and that the epidemic is having a profound impact on morbidity and mortality in ethnic and racial minority subgroups in the United States. New population-based data collection systems designed to describe trends in behaviors associated with HIV transmission and better methods for measuring the true incidence of transmission will better elucidate the characteristics of HIV infection in the United States and inform future public health policies.

Direct-to-consumer advertising (DTCA) has become an influential factor in healthcare delivery in the United States. We evaluated the influence of DTCA on surgeon and patient opinions and behavior in orthopaedics by surveying orthopaedic surgeons who perform hip and knee arthroplasties and patients who were scheduled to have hip or knee arthro-plasty. Respondents were asked for their opinions of and experiences with DTCA, including the influence of DTCA on surgeon and patient decision making. Greater than 98% of surgeon respondents had experience with patients who were exposed to DTCA. The majority of surgeon respondents reported DTCA had an overall negative impact on their practice and their interaction with patients (74%), and their patients often were confused or misinformed about the appropriate treatment for their condition based on an advertisement (77%). Fifty-two percent of patient respondents recalled seeing or hearing advertisements related to hip or knee arthroplasty. These patients were more likely to request a specific type of surgery or brand of implant from their surgeon and to see more than one surgeon before deciding to have surgery. Direct-to-consumer advertising seems to play a substantial role in surgeon and patient decision making in orthopaedics. Future efforts should be aimed at improving the quality and accuracy of information contained in consumer-directed advertisements related to orthopaedic implants and procedures.

The traditional hospital-physician relationship in the United States was an implicit symbiotic collaboration sheltered by financial success. The health care economic challenges of the 1980s and 1990s unmasked the weaknesses of this relationship as hospitals and doctors often found themselves in direct competition in the struggle to maintain revenue. We recount and examine the history of the largely implicit American hospital-physician relationship and propose a means of establishing formal, explicit hospital-physician collaborations focused on delivering quality patient care and ensuring economic viability for both parties. We present the process of planning a joint hospital-physician ambulatory surgery center (ASC) at a not-for-profit academic institution as an example of a collaboration to negotiate a model embraced by both parties. However, the ultimate success of this new center, as measured in quality of patient care and economic viability, has yet to be determined.

Purpose: We examined the utility of a three-level familial risk stratification system as a screening tool for diabetes in a nationally representative sample of the U.S. adult population., Methods: National Health and Nutrition Examination Survey data were used to assess the prevalence and distribution of familial risk for diabetes, the association between three levels of familial risk and undiagnosed diabetes, and the use of familial risk as a screening tool for diabetes, alone and in combination with body mass index and age., Results: The prevalence of undiagnosed diabetes was 3% and increased with increasing familial risk (average = 2%, moderate = 4%, high = 10%). High familial risk was significantly associated with undiagnosed diabetes (adjusted odds ratio = 4.6; 95% confidence interval: 1.9-11.3). The use of a three-tiered familial risk stratification for diabetes screening yielded higher specificity (94%) and positive predictive value (9.9%) for high familial risk than body mass index > or = 25 (specificity = 38%, positive predictive value = 4.2%). High familial risk and body mass index > or = 25 combined had higher specificity (97%) and positive predictive value (13.4%); the addition of age > or = 45 years further improved positive predictive value (21.0%) without reducing specificity., Conclusions: There was a strong and proportional association between familial risk and undiagnosed diabetes, suggesting that a three-tiered assessment of familial diabetes risk may increase the effectiveness of diabetes screening.

Purpose: To evaluate the use of self-reported family medical history as a potential screening tool to identify people at-risk for diabetes., Methods: The HealthStyles 2004 mail survey comprises 4345 US adults who completed a questionnaire to ascertain personal and family history of diabetes, perceived risk of diabetes, and practice of risk-reducing behaviors. Using number and type of affected relatives, respondents were ranked into three familial risk levels. Adjusted odds ratios (AORs) were obtained to evaluate associations between familial risk and prevalent diabetes, perceived risk of disease, and risk-reducing behaviors. Validity of family history as a screening tool was examined by calculating sensitivity, specificity, and positive and negative predictive values., Results: Compared to those of average risk, people with moderate and high familial risk of diabetes were more likely to report a diagnosis of diabetes (AOR: 3.6, 95% CI: 2.8, 4.7; OR: 7.6, 95% CI: 5.9, 9.8, respectively), a higher perceived risk of diabetes (AOR: 4.6, 95% CI: 3.7, 5.7; OR: 8.5, 95% CI: 6.6, 17.7, respectively), and making lifestyle changes to prevent diabetes (AOR: 2.2, 95% CI: 1.8, 2.7; OR: 4.5, 95% CI: 3.6, 5.6, respectively). A positive familial risk of diabetes identified 73% of all respondents with diabetes and correctly predicted prevalent diabetes in 21.5% of respondents., Conclusion: Family history of diabetes is not only a risk factor for the disease but is also positively associated with risk awareness and risk-reducing behaviors. It may provide a useful screening tool for detection and prevention of diabetes.

Background: New techniques in imaging and surgery have made 3-dimensional anatomical knowledge an increasingly important goal of medical education. This study compared the efficacy of 2 supplemental, self-study methods for learning shoulder joint anatomy to determine which method provides for greater transfer of learning to the clinical setting., Methods: Two groups of medical students studied shoulder joint anatomy using either a second-generation virtual reality surgical simulator or images from a textbook. They were then asked to identify anatomical structures of the shoulder joint as they appeared in a videotape of a live arthroscopic procedure., Results: The mean identification scores, out of a possible score of 7, were 3.1 +/- 1.3 for the simulator group and 2.9 +/- 1.5 for the textbook group (P = 0.70). Student ratings of the 2 methods on a 5-point Likert scale were significantly different. The simulator group rated the simulator more highly as an effective learning tool than the textbook group rated the textbook (means of 3.2 +/- 0.7 and 2.6 +/- 0.5, respectively, P = 0.02). Furthermore, the simulator group indicated that they were more likely to use the simulator as a learning tool if it were available to them than the textbook group was willing to use the textbook (means of 4.0 +/- 1.2 and 3.0 +/- 0.9, respectively, P = 0.02)., Conclusion: Our results show that this surgical simulator is at least as effective as textbook images for learning anatomy and could enhance student learning through increased motivation. These findings provide insight into simulator development and strategies for learning anatomy. Possible explanations and future research directions are discussed.

Formal evaluation of surgical simulators is essential before their introduction into training programs. We report our assessment of the Mentice Corp Procedicus shoulder arthroscopy simulator. This study tests the hypothesis of construct validity that experienced surgeons will score better on the simulator than individuals with minimal to no experience with the technique. Thirty-five subjects were stratified into three groups (novice, intermediate, and expert) based on their past 5 years' experience with shoulder arthroscopies. Each subject had an identical session on the simulator and completed anatomic identification, hook manipulations, and scope navigation exercises. We found statistically significant differences among the three groups in hook manipulation and scope navigation exercises, with the expert group performing the exercises more quickly (P =.013) and more accurately (P =.002) than the other two groups. No statistically significant differences were found among the groups in the identification of anatomic landmarks. Experts rated the simulator as an effective teaching tool, giving it a mean score of 4.22 and 4.44 (maximum, 5) for teaching instrument control and triangulation, respectively.

The use of neuronavigation (NN) in neurosurgery has become ubiquitous. A growing number of neurosurgeons are utilizing NN for a wide variety of purposes, including optimizing the surgical approach (macrosurgery) and locating small areas of interest (microsurgery). The goal of our team is to apply rapid advances in hardware and software technology to the field of NN, challenging and ultimately updating current NN assumptions. To identify possible areas in which new technology may improve the surgical applications of NN, we have assessed the accuracy of neuronavigational measurements in the Radionics and BrainLab systems. Using a phantom skull, we measured how accurate the visualization of a navigational probe's tip was in these systems, taking a total of 2180 measurements. We found that, despite current NN tenets, error is maximal at the six marker count and minimal in the spreaded marker setting; that is, placing less markers around the area of interest maximizes accuracy and active tracking does not necessarily increase accuracy. Comparing the two systems, we also found that accuracy of NN machines differs both overall and in different axes. As researchers continue to apply technological advances to the NN field, an increasing number of currently held tenets will be revised, making NN an even more useful tool in neurosurgery.

In the quest to develop a viable, frameless spinal navigation system, many researchers are utilizing the C-arm fluoroscope. However, there is a significant problem with the C-arm that must be quantified: the gravity-dependent sag effect resulting from the geometry of the C-arm and aggravated by the inequity of weight at each end of the C-arm. This study quantified the C-arm sag effect, giving researchers the protocol and data needed to develop a program that accounts for this distortion. The development of spinal navigation algorithms that account for the C-arm sag effect should produce a more accurate spinal navigation system.

We present a system involving a computer-instrumented fluoroscope for the purpose of 3D navigation and guidance using pre-operative diagnostic scans as a reference. The goal of the project is to devise a computer-assisted tool that will improve the accuracy, reduce risk, minimize the invasiveness, and shorten the time it takes to perform a variety of neurosurgical and orthopedic procedures of the spine. For this purpose we propose an apparatus that will track surgical tools and localize them with respect to the patient's 3D anatomy and pre-operative 3D diagnostic scans using intraoperative fluoroscopy for in situ registration and embedded fiducials. Preliminary studies have found a fiducial registration error (FRE) of 1.41 mm and a Target Localization Error (TLE) of 0.48 mm. The resulting system leverages equipment already commonly available in the operating room (OR), providing an important new functionality that is free of many current limitations, while keeping costs contained.

The localization of a seizure focus for resective surgery often requires invasive monitoring for precise localization of the target as well as structures to avoid. We report on the use of intra-operative surgical navigation to precisely localize and co-register subdural electrodes to regions of know radiographic pathology. Additionally, the navigation system was used to develop intra-operative electrode maps. These maps were subsequently used in the sub-acute recording phase to assign electrographic pathology and function (e.g. speech) to a specific cortical surface anatomy. This permitted for more precise planning of surgery and better assessment of potential risk, based on functional as well as anatomical criterion.

In the last 7 years, 18 patients with large alopecia (approximately one-third of hair-bearing scalp) were treated with 31 tissue expansion procedures. In the previous 44 patients, with various degrees of alopecia treated with conventional tissue expansion technique, the major complication rates were as high as reported in the relevant literature. The clinical experience gained with these cases led us to make some modifications in the surgical technique. We applied some simple surgical maneuvers and Z-plasties to the last 18 cases with large alopecia. The major complication rate of 3.2% observed in this study is comparable to the lower complication rates of 6-12% reported in the literature for different degrees of alopecia. We believe that these simple modifications and meticulous approach improve the results of conventional treatment of alopecia with tissue expansion and flap. In this paper, details of the insertion technique and reconstructive procedures and their relevance to the success rate of the aesthetic treatment of the large alopecia are discussed.

Endoscopic surgical approaches for chronic frontal sinusitis require the reestablishment of adequate frontal sinus ventilation and drainage for relief of symptoms. After the resection of anterior ethmoid mucosal disease and cellular structure, the anterior to posterior depth of the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla (frontal sinus ostium) often represents a critical margin for functional success. However, little information concerning this dimension is available. Depending on intraoperative surgical judgment of this distance, extended endoscopic surgical procedures involving additional bone resection may be indicated. These approaches may be hazardous due to the proximity of the cranial cavity and orbit. In addition, secondary stenosis can result from the subsequent inflammatory response. Improved CT imaging, high resolution sagittal reformatting, and computer workstations provide the ability to obtain direct preoperative measurements of the frontal recess. We used a paramedian sagittal section and recorded the maximal anterior to posterior depth from the nasofrontal beak to the base of skull at the insertion of the ethmoidal bulla in 20 patients, 31 sides, undergoing primary endoscopic frontoethmoidectomy. In addition, we found a positive correlation between this distance and agger nasi air cell size measured in the same 31 sides.

Seventy-one patients have undergone percutaneous endoscopic gastrostomy (PEG) on our otolaryngology service. Most commonly, these were neurologically-impaired (63%) or head and neck cancer (31%) patients. The PEG procedures were done, in almost all instances, in the operating room in conjunction with other indicated ORL-HNS procedures such as tracheotomy (71%) or with endoscopy or resection for head and neck cancer. The success rate in placement of the gastrostomy was 98%. There was one major complication, namely, seeding of the gastrostomy site with squamous cell carcinoma from a hypopharyngeal tumor. We conclude that PEG is a useful addition to the armamentarium of the head and neck surgeon.