SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
Besides the technical aspects of bio-feed-back, pelvic floor training of voiding disorders in children requires a careful approach in order to understand the nature of the voiding disorders, and then to give clear explanations to the child and his/her parents. Success of pelvic floor training in large part depends upon the good concern and understanding of its voiding disorder by the child.
OBJECTIVE: Current guidelines of the Accreditation Council for Graduate Medical Education have restricted the amount of intensive care experience obtained during pediatric residency. The impact on performing procedures has not been evaluated. To determine the current level of competency in 1 common procedure, we investigated the proficiency of pediatric residents in performing neonatal endotracheal intubation during the academic years 1998-1999 and 2000-2001. METHODS: Indication for intubation, number of attempts, and achievement of success were recorded by the respiratory therapist present for the procedure. Each intubation was scored according to the attempt on which intubation was successful. Indications for intubation were categorized as respiratory failure, delivery room resuscitation, and meconium-stained amniotic fluid. Competency was defined as a successful intubation occurring on the first or second attempt >or=80% of the time. Intubation scores were compared between residents at various stages of training and analyzed by multivariate logistic regression analysis for significance. Comparisons were then performed to determine percentage success with confidence intervals. We also surveyed previous graduates of the training program not included in the observations for this study and asked them to indicate how frequently they perform intubation in current practice and to assess their own competence in the procedure. RESULTS: A total of 449 resident procedures were observed during the study periods: 192 by postgraduate year 1 (PGY-1) residents, 126 by PGY-2 residents, and 131 by PGY-3 residents. A total of 35% (160 of 449) of intubation procedures were never successful by pediatric house officers. Intubation was successful on the first or second attempt for 50% of PGY-1 residents (95% confidence interval [CI]: 42.6-56.8), 55% of PGY-2 residents (95% CI: 46-63.5), and 62% of PGY-3 residents (95% CI: 53.9-70.7). The third-year residents exhibited a significantly higher likelihood of performing a successful intubation compared with first-year residents. The first-year residents in 1998-1999 showed no improvement by their third year in 2000-2001. Surveys were sent to 56 graduates of our residency program (1998-2000). Completed surveys were received from 31 (66%) of 47. A total of 71% of the respondents are practicing general pediatrics, and 36% attend deliveries or perform intubations. A total of 87% reported that their level of confidence with endotracheal intubation was good or excellent after completion of residency training. CONCLUSIONS: We provide objective and subjective data concerning the proficiency of pediatric residents in performing neonatal endotracheal intubation. None of our resident groups met the specified definition of technical competence, although there was improvement with advancing training level in bivariate analyses. However, graduates of our training program felt confident with their intubation skills in contrast to our objective findings. As exposure to these important skills becomes limited, methods to ensure attainment of technical competency during training may need to be redefined.
PURPOSE: To test the image quality (ImQ) and interscan coverage of MRI for measuring carotid atherosclerosis across multiple centers. MATERIALS AND METHODS: Thirty-nine subjects from five clinical sites (site 1: n=11; site 2: n=16; site 3: n=2; site 4: n=3; site 5: n=7) were imaged on GE 1.5T scanners using a standardized carotid imaging protocol with five weightings (T1, proton density (PD), T2, time-of-flight (TOF), and contrast-enhanced (CE) T1). MR technologists from the five sites received comprehensive protocol training. A maximum coverage of 24 mm (12 slices) was designed for each of four scans (baseline and at four, eight, and 13 weeks). The adequacy of coverage was calculated as the percentage of arteries with at least six slices matched across all four scans. ImQ was evaluated using an established five-point scale for each image. ImQ>or= 3 was considered acceptable for image analysis. RESULTS: Across five sites, the mean ImQ was 3.4-4.2 for T1W, 3.6-4.4 for CE-T1W, 3.4-4.2 for PDW, 3.3-4.2 for T2W, and 3.4-4.0 for TOF. The mean ImQ per site was 3.5-4.2. All sites generated at least six-slice coverage (mean=8.0-9.1) for all index carotid arteries. CONCLUSION: The ImQ and coverage values were comparable among clinical sites using a standardized carotid imaging protocol. With comprehensive protocol training, carotid MRI is technically feasible for use in multicenter studies.
Transoral surgery for ventral craniocervical pathology is an integral part of modern neurosurgery. This approach should be considered in many more cases than in current practice. On the basis of our experiences with 15 operations in 13 patients we feel able to improve the surgical technique in some small details, as 1. the double, two flap incision of the posterior wall of the pharynx, 2. the method of "deep" resection of the odontoid in its high upward and backward position, and 3. insertion of bone grafts and chips in the cavity of tumorous vertebrae for fixation. Admittedly, these cases are not encountered every day in neurosurgical units. An exact knowledge of the anatomical, neurological, pathological, radiological and surgical details is of vital importance and constitutes the basis of this account. This method should not be confined to specialised regional neurosurgical centres, but is within the technical capacity of all trained neurosurgeons.
Endoscopic retrograde sphincterotomy was performed on four sedated pigs, ages 3-4 months, using a standard human duodenoscope and papillotome. Sphincterotomies, 1 cm in length, were well-tolerated, and all animals recovered promptly, spontaneously regained gastrointestinal function, and gained weight. The first three animals were sacrificed after one week, and autopsy revealed no complications. The fourth animal was sacrificed immediately following the procedure, and no evidence of perforation was found. These observations demonstrate that the pig is a valid experimental model for endoscopic sphincterotomy. Its use in training is limited by technical and anatomic differences from humans. Potential uses of this technique in research are discussed.
The presence of HIV antibodies was screened in 241 paired samples of serum and saliva from seronegative subjects with risk factors for human immune deficiency virus (HIV) infection (n = 99), asymptomatic and symptomatic HIV-seropositive patients (n = 104) and healthy blood donors (n = 38) as negative controls, in order to assess the reliability of two saliva tests for the detection of HIV antibodies. These results were confirmed by Western blot. The saliva samples were collected using an oral device (Salivette) maintained in the lateral gingival fold until the individual perceived that it was becoming less rigid due to hydration with saliva. The two tests were a rapid one (Test Pack) and a conventional one (GACELISA). The results for antibody detection in saliva show 99% specificity and 99% sensitivity for the rapid test versus 100% sensitivity and 81% specificity for the conventional test. All results for the saliva samples which were positive in the rapid test were confirmed by Western blot (WHO criteria), and there were no indeterminate Western blot results among the samples which were false-positive in the conventional enzyme immunoassay. No statistically significant differences were observed between the absorbance values of HIV-infected symptomatic and asymptomatic patients. The correlation for the results of the HIV-antibody analysis in the paired sera was 98%. This method of saliva sampling in combination with a rapid and sensitive test for HIV-antibody detection may be applicable in studies conducted with limited technical resources or insufficiently trained health personnel or where blood sample collection is difficult.
The second part of this series deals with the tasks of the ENT-specialist, who must not endorse the prescription before making sure that the hearing aid recommended by the acoustician will bring sufficient hearing improvement, and that the suggested hearing aid is suitable. The report and audiograms of the acoustician must be compared to his own results, and a check of whether at least three hearing aids from different companies have been compared must be made. The primary aim of patient satisfaction can be checked by means of the "Oldenburger Inventar" (Oldenburg questionnaire), which determines the improvement of hearing ability in quiet and noise, and of auditory localization. Since the otoplastic substantially effects the amplification of the hearing aid, the ENT specialist should make sure that it does not produce feedback, that it has a second boring, and, in case of need, a Libby horn. He should also consider whether an open fitting would be more appropriate. A free-field measurement--with and without noise--shows whether the dB(opt) has been reached. The in situ measurement and the loudness rating by the Würzburger Hörfeld (Wuerzburg auditory field) are of great help in detecting fitting errors. Additional procedures, such as auditory speech training, lip reading, or technical devices, for instance FM-communication or a light alarm clock, are often employed in elderly patients.
Between 01.01.88 and 30.07.94 we treated 81 traumatic and 19 pathologic humeral shaft fractures with the Seidel humeral locking nail (HLN). The majority of the 100 patients (60 women, 40 men) were older than 60 years of age. The dominant fracture type according to AO was type A. Operative stabilization was considered indicate because of fracture distraction during functional bracing in most cases. In general, patients choose surgical intervention in preference to conservative management. Radiological consolidation was observed within 10 weeks. In 48 cases sonography revealed motor disturbances between the gliding sheath of the rotator cuff, but there was no correlation between this and the shoulder mobility. In 7 cases an additional fracture was created during introduction of the nail. This complication can be avoided by using the right technique. There were no cases of non-union or radial nerve lesion. There were 2 patients who developed an infection, which disappeared after removal of the nail and introduction of antibiotic-loaded beads. Functional results were recorded in 63 patients: 53 patients (84%) had an excellent or satisfactory result (NEER score > 80). Among the others, problems at the site of nail insertion predominated. In our view, the Seidel humeral locking nail is an implant that provides exercise stability without intraoperative positioning problems or risk of injury to nerves or vessels. Nevertheless, this method needs a skilled surgeon with special training to handle typical technical nailing problems.
BACKGROUND: It has been suggested that virtual reality (VR) might be useful for the selection of surgical trainees and the measurement of technical performance during preoperative training and retraining. This study was designed to determine whether it is possible to define and measure the acquisition, loss, and reacquisition of psychomotor skills in novice surgical trainees. METHODS: Novice surgical trainees (NSTs n = 10, junior surgical registrars with little or no prior experience with laparoscopic surgery) were tested and retested after 1 month using the Minimally Invasive Surgical Trainer-Virtual Reality. Two tasks were used: the simple task [stretch diathermy (SD)] and the more complex task [manipulation diathermy (MD)]. The score was derived from the time taken to complete the task and the number of errors that occurred. Acquisition is the difference between the first and last score of the first training session, loss is the difference in score that occurs between the last score of the first training session and the first score of the second training session, and reacquisition is the difference in the first and last scores of the second training session. A performance criterion level was defined for each task by testing a group of experienced laparoscopic surgeons (n = 10). Groups were compared using the nonparametric Wilcoxon signed rank test, with p < 0.05 considered to be significant. RESULTS: Acquisition of skill was found for five of 10 NSTs with the SD task and 10/10 for the MD task. As a group the NSTs achieved the criterion level from the outset with the SD task and exceeded it by the eighth attempt for the MD task. The best score was achieved with fewer attempts during the second training session for the SD but not the MD task. The defined parameters are expressed as mean percentage score +/- SD for the 10 NSTs and for each task. There was a 36% (+/- 26) acquisition for the SD task compared with 50% (+/- 4) for the MD task (Wilcoxon p = 0.241). There was a 23% (+/- 19) loss for the SD task compared with 81% (+/- 16) for the MD task (p < 0.005). There was a 20% (+/- 10) reacquisition for the SD task compared with 54% (+/- 7) for the MD task (p < 0.005). The mean scores were greater for the more complex task (MD), which was more useful in discriminating between the individual trainees and the two training sessions. CONCLUSIONS: It is possible to use VR to define the acquisition, loss, and reacquisition of psychomotor skills in individual NSTs and to compare them with a predefined performance criterion level. This study defines parameters that will be useful in repeated training sessions of NSTs in the preoperative phase of training and during retraining.
BACKGROUND: The aim of this comparative study was to gain subjective and objective data to determine for which operative tasks three-dimensional (3-D) vision systems are superior to two-dimensional (2-D) systems and to demonstrate any advantages or disadvantages of 3-D systems. METHODS: A model with five standardized tasks including sewing and knotting was developed to objectively measure performance times and to count technical faults. In our training center for minimally invasive surgery, surgeons involved in basic and advanced laparoscopic courses trained using both 2-D and 3-D vision systems. They subsequently completed analog scale questionnaires to record a subjective impression of comparative ease of operation tasks under 2-D and 3-D vision and to identify perceived deficiencies in the 3-D system. RESULTS: Compared to 2-D vision, the objective performance time was significantly shorter and significantly less mistakes were made using 3-D vision. All operative tasks were subjectively judged significantly easier under 3-D vision. CONCLUSIONS: Users with a normal capability for spatial perception can perform standard tasks more quickly and safely using 3-D vision, and a greater benefit is apparent for more complicated surgical maneuvers.
Cognitive-behavioral treatments (CBTs) for adolescents with ADHD demonstrate promise of long-term effects on outcome. However, their implementation in routine care community clinics faces barriers that impact quantity, efficiency, and quality of delivery, as well as client outcomes. This study is a randomized controlled trial designed to evaluate the impact of an AI-assisted service delivery model on therapist implementation of Supporting Teens' Autonomy Daily (STAND), a CBT blended with Motivational Interviewing (MI) for adolescents with ADHD. Adolescents with ADHD (N = 51), who were clients at three community mental health agencies, received treatment from 23 therapists. There was randomization of adolescents and therapists to AI-assisted or standard implementation supports. In addition to standard supports (i.e., training, standard facilitation resources, technical assistance, case supervision), AI-assisted support package included digitized facilitation resources housed in a clinical dashboard (Care4), feedback on content fidelity, and AI-generated feedback on MI implementation quality. The AI-assisted group was associated with more efficient treatment delivery and lower number of appointments attended by the adolescent. There was also a significant decrement in MI quality over time in the AI-assisted group compared to the standard support group. Feedback in focus groups indicated that therapists perceived a task-oriented mindset to be associated with receipt of the AI-assisted support package, leading therapists to prioritize efficiency over relational aspects of therapy. Following the results of this trial, a future, larger RCT should examine the impact of the AI-assisted implementation model on mental health outcomes and cost savings to organizations, third party payers, and clients. Trial registration number: NCT05135065; https://www.clinicaltrials.gov ; Registered September 2021.
Development of a replantation program entails establishment of microsurgical skills in the laboratory, training in clinical microvascular technics, supervision, if possible, in the first microvascular free flaps, and close liaison with supporting personnel who transport patients, care for them acutely, and carry out their rehabilitation. Of twenty-six replantations or revascularizations (14 incomplete and 12 complete), twenty-three were successful. The three failures (1 complete and 2 incomplete procedures) were all digits, and each was part of a multiple digit injury.
Maintaining the highest possible level of talented researchers relies critically on the ability to recruit, train and retain the best young students to the neurosciences. This article addresses the need for trainers to look beyond technical skills, on which research training conventionally concentrates, to some para-scientific skills that may help assure survival during the apparently perennial periods of scarce resources.
OBJECTIVES: To correlate between surgeons' experience in urological laparoscopy and their performance of a set of laparoscopic tasks performed on a box trainer in the laparoscopic laboratory. METHODS: 44 urologists participated in this study. A self-administrated questionnaire enquired about their experience in laparoscopy and they were divided to 4 categories: no experience, minimal experience, basic and advanced laparoscopists. Tests consisted of 4 tasks: passage of a ligature, intracorporeal knotting, intracorporeal suturing, and cutting a carton circle out of a square. All tests were supervised and time was recorded for each of the tasks. Histograms were plotted showing the mean time for performance of each task in each experience group. The Kruskal-Wallis analysis of variance was used to assess statistical significance. RESULTS: Seven participants had no previous experience in laparoscopy and 14 had minimal experience. 15 had basic experience and 8 were advanced laparoscopists. No difference in performance was found between the no experience and minimal experience group and they were united and defined as beginners. A significant difference in performance was noted between the beginners, basic and advanced groups, especially when comparing beginners to advanced. Criterion level values of surgical performance drawn from this data were highly discriminative with sensitivity of 71-85% and specificity of 74.2%-88%. CONCLUSIONS: We were able to differentiate between various levels of laparoscopic skills among the participating urologists. Values drawn from such studies could be the basis of criterion level values for technical laparoscopic performance during training programs and before granting laparoscopic privileges to urologists.
BACKGROUND: Rapid improvements in computer technology allow us to consider the use of computer-assisted learning (CAL) for teaching technical skills in surgical training. The objective of this study was to compare in a prospective, randomized fashion, CAL with a lecture and feedback seminar (LFS) for the purpose of teaching a basic surgical skill. METHODS: Freshman medical students were randomly assigned to spend 1 hour in either a CAL or LFS session. Both sessions were designed to teach them to tie a two-handed square knot. Students in both groups were given knot tying boards and those in the CAL group were asked to interact with the CAL program. Students in the LFS group were given a slide presentation and were given individualized feedback as they practiced this skill. At the end of the session the students were videotaped tying two complete knots. The tapes were independently analyzed, in a blinded fashion, by three surgeons. The total time for the task was recorded, the knots were evaluated for squareness, and each subject was scored for the quality of performance. RESULTS: Data from 82 subjects were available for the final analysis. Comparison of the two groups demonstrated no significant difference between the proportion of subjects who were able to tie a square knot. There was no difference between the average time required to perform the task. The CAL group had significantly lower quality of performance (t = 5.37, P <0.0001). CONCLUSIONS: CAL and LFS were equally effective in conveying the cognitive information associated with this skill. However, the significantly lower performance score demonstrates that the students in the CAL group did not attain a proficiency in this skill equal to the students in the LFS group. Comments by the students suggest that the lack of feedback in this model of CAL was the significant difference between these two educational methods.
OBJECTIVES: To define those patients with upper urinary tract calculi who are more likely to have an unsuccessful outcome from extracorporeal shock-wave lithotripsy (ESWL). METHODS: A critical prospective analysis of 121 patients, referred to two university centers after ESWL had been exhausted as a treatment modality for upper urinary tract calculi, was performed. Patients were subdivided into the following groups: failure to clear fragments, failure to fragment, difficulty in calculus localization, and failure due to inherent upper urinary tract obstruction. Other important variables include the type of extracorporeal lithotriptor used, number of treatment sittings before referral, calculus location, calculus composition, patient body habitus, and the imaging leading to and associated with extracorporeal therapy. RESULTS: Large renal calculi (mean, 22.2 mm) and those within dependent or obstructed portions of the collecting system were frequently referred for endoscopic management after failed ESWL. Steinstrasse can be an extremely morbid complication from ESWL and in this series was associated with irreversible loss of renal function and ureteral stricture disease. Extracorporeal lithotripsy of infectious calculi can be associated with severe septic complication. Inadequate preoperative and intraoperative imaging and morbid obesity were also associated with failure. Second- and third-generation lithotriptors were represented in greater numbers than the Dornier HM-3 in this group of ESWL failures. CONCLUSIONS: ESWL remains the treatment of choice for moderately sized, uncomplicated renal calculi. Large calculi, those within obstructed or dependent portions of the collecting system, and those composed of calcium oxalate monohydrate, frequently fail ESWL. Training in the more technically challenging aspects of endoscopic lithotripsy must be encouraged.
STUDY OBJECTIVE: The study was designed to determine if open peritoneal lavage is superior to closed peritoneal lavage. DESIGN AND PARTICIPANTS: Patients who were admitted to a trauma center and needed peritoneal lavage were assigned to alternate trauma teams. Team 1 performed only open lavages one month and then switched to closed lavages; team 2 did only closed lavages and then switched to open lavages. MEASUREMENTS: The incidences of positive lavages and lavage complication were noted. Also measured were the length of time for catheter insertion, length of time of fluid retrieval, volume of effluent, technical difficulty of lavage, training level of the operator, effluent RBC count, and material cost. RESULTS: Two hundred twenty patients were randomized. No differences were noted in complication rate, volume of effluent, or length of time for fluid retrieval. Significant differences were noted for catheter insertion time (3.6 minutes for closed lavage and 6.9 minutes for open), ease of catheter insertion (closed technique is favored), and material cost ($96.26 for open lavage and $69.70 for closed lavage). CONCLUSION: Closed peritoneal lavage is superior to open peritoneal lavage in abdominal trauma; it is faster, easier to use, cheaper, and as safe as open lavage.
A test object for 3D-ultrasound (US) imaging equipment was constructed, that could be used for various purposes: For training of the correct technical setup procedures and practical handling of a 3D-US equipment, as well as for various quality assurance procedures. The size and volume of these structures were known precisely (+/- 0.1 mm resp. +/- 0.06 mL, respectively; smallest volume: 0.1 mL). The stability of the structures was in agreement with guideline IEC 854 and allowed to quantify exactly the imaging and measurement errors of size and volume measurements performed with commercial 3D-equipment. The test object is well suited to validate measured volume data, as well as to perform procedures of technical quality assurance in a reproducible manner.