Motion Analysis in the Assessment of Surgical Skill

Abstract

Manual skill is now widely recognised as an important aspect of training in surgery. However, measurement of the skill of a surgeon has in the past been rather subjective in nature, relying on the judgement of experts in the analysis of videotapes. Objective measurements can be made by analysing the velocities of a surgeon's hands during a procedure. In particular, we have found that the number of movements made during a typical procedure will decrease as the surgeon's skill increases. Velocity traces display purposeful movements corrupted by uncorrelated noise from sources such as hand tremor and measurement artefacts. However, we have found that it is possible to filter the noise effectively. Furthermore, we have shown that the skill measurement obtained by counting movements is highly robust to over or under filtering.     

What Role Should Government Regulation Play in Ecological Restoration? Ongoing Debate in São Paulo State,Brazil

Around the world, there is growing desire and momentum for ecological restoration to happen faster, with better quality, and in more extensive areas. The question we ask is how can laws and governmental regulations best contribute to effective, successful, and broad‐scale restoration? In the state of São Paulo, Brazil, there is a legal instrument (SMA 08‐2008) whose aim is to increase the effectiveness of tropical forest restoration projects in particular. It establishes, among other things, requirements regarding the minimum number of native tree species to be reached within a given period of time in restoration projects and the precise proportion of functional groups or threatened species to be included when reforestation with native species is used as a restoration technique. There are, however, two differing perspectives among Brazilian restoration ecologists on the appropriateness of such detailed legal rules. For some, the rules help increase the chances that mandatory projects of ecological restoration will succeed. For the other group, there is no single way to achieve effective ecosystem restoration, and the existing science and know‐how are far from sufficient to establish standardized technical and methodological norms or to justify that such norms be imposed. Both points of view are discussed here, aiming to help those developing new legislation and improving existing laws about ecological restoration. The precedents established in São Paulo, and at the federal level in Brazil, and the ongoing debate about those laws are worth considering and possibly applying elsewhere.     

Angiogenesis in the Ischemic Rat Lung

The adult lung is perfused by both the systemic bronchial artery and the entire venous return flowing through the pulmonary arteries. In most lung pathologies, it is the smaller systemic vasculature that responds to a need for enhanced lung perfusion and shows robust neovascularization. Pulmonary vascular ischemia induced by pulmonary artery obstruction has been shown to result in rapid systemic arterial angiogenesis in man as well as in several animal models. Although the histologic assessment of the time course of bronchial artery proliferation in rats was carefully described by Weibel ¹, mechanisms responsible for this organized growth of new vessels are not clear. We provide surgical details of inducing left pulmonary artery ischemia in the rat that leads to bronchial neovascularization. Quantification of the extent of angiogenesis presents an additional challenge due to the presence of the two vascular beds within the lung. Methods to determine functional angiogenesis based on labeled microsphere injections are provided.     

Beneficial effects of the n-3 long-chain polyunsaturated fatty acids in surgical patients: updating the evidence

The use of n-3 polyunsaturated fatty acids in surgical patients has risen by the fact that this may attenuate systemic and acute inflammatory responses secondary to surgical trauma through modulation of inflammatory mediators and cell membrane interactions. Moreover, the inclusion of n-3 fatty acids in clinical trials as part of the therapy in patients, who expect to undergo a surgical stress, suggests benefits on clinical progress. Therefore, the objective of this article is to review data from n-3 polyunsaturated fatty acid effects on biochemical parameters and on reduced length of hospitalization, number of infections, and mortality as main clinical outcomes in human surgical patients.     

Growth,survival, and tag retention of steelhead trout (<Emphasis Type="Italic">O. mykiss</Emphasis>) surgically implanted with dummy acoustic tags

Recent advances in micro-electronics make the study of the migration of even small marine animals (>12 cm) over many 1000s of kilometres a serious possibility. Important assumptions in long-term studies are that rates of tag loss caused by mortality or tag shedding are low, and that the tagging procedure does not have an unacceptable negative effect on the animal. This paper reports results from a study to examine the retention of relatively large (24 × 8 mm) surgically-implanted dummy acoustic tags over a 7-month period in steelhead pre-smolts (O. mykiss), and the effects of implantation on growth and survival. Although there was some influence on growth to week 12, survival was high for animals > 13 cm FL. In the following 16-week period, growth of surgically implanted pre-smolts was the same as the control population and there was little tag loss from mortality or shedding. Currently available acoustic tags can be implanted in salmonid fish ≥12 cm FL, although combined losses from mortality and tag shedding were 33–40% for animals in the 12 and 13 cm FL size classes. By 14 cm FL, combined rates of tag loss (mortality plus tag shedding) for surgically implanted tags dropped to <15% and growth following surgery was close to that of the controls. Our results suggest that studies of ocean migration and survival over periods of many months are now feasible even for animals as small as salmon smolts. Surgically implanted salmon smolts are therefore good candidates for freshwater and coastal ocean-tracking studies on relatively long time scales (months). On such time scales, even relatively small salmon smolts may move thousands of kilometers in the ocean.     

以经济手段促进生物多样性保护

当前各国协调经济与生态的关系呈加速态势, 主要表现在: (1)深化。从“发展优先, 兼顾保护”到二者并重, “在发展中保护, 在保护中发展”, 再到“保护优先”, 越来越强调统筹协同“以保护优化发展, 以发展促进保护”; (2)分化。发展中国家大多依赖财政与金融, 发达国家则将市场作为主要资金渠道, 逐步形成以系统化的法律体系、多元化的激励机制、契约化的公私合作模式和市场化交易为主体的生态产品价值实现体系; (3)多元化。自然价值的多元性决定政府需要综合运用多种举措, 以减少单一政策的局限性; (4)市场化。加强市场解决财政在环保投入不足的主体作用已成为主流。本文为探索我国向“自然受益型”经济转型, 梳理了30多个国家在不同行业实施经济手段的150个实例, 以多元化视角归纳为8种举措: 顶层设计、环经核算、生态转型、绿色金融、市场认证、激励改革、气候协同和实施配套; 并从10个方面分析以经济手段促进生物多样性保护的国际经验和趋势, 各国之间的共性及分化; 最后提出利用“2020后全球生物多样性框架”提供协调各国行动一致的平台机制, 以外促内, 内外结合, 通过创新政策工具和组合应用, 促进我国经济政策与生态环境政策融合的建议。     

肌电图检查评估腕管综合征手术效果的临床分析

目的:探讨采用肌电图检查评估腕管综合征的手术治疗效果。方法:选取35例(患侧手共39侧)临床确诊为腕管综合征并接受腕管切开减压术治疗的患者,于手术前后分别行肌电图检查,应用正中神经传导检查和拇短展肌针极肌电图检查,分析患者手术前和手术后腕部正中神经功能的变化情况。结果:手术后,患者正中神经感觉传导潜伏期异常率(33%)、正中神经运动传导潜伏期异常率(36%)较手术前(72%、74%)明显下降(P0.05),正中神经感觉传导波幅(7.40±5.05)较手术前(4.86±3.60)显著降低(P0.001),拇短展肌静息状态下失神经电位的异常率(69%)、重收缩时募集电位异常率(13%)均较手术前(85%、26%)明显下降(P0.05)。患者手术前后正中神经感觉传导速度和运动传导速度对比差异无统计学意义(P0.05)。结论:腕管切开减压术可解除正中神经卡压状态,明显恢复正中神经功能,增强拇短展肌肌力,临床治疗效果好。肌电图检查可为腕管综合征患者手术治疗效果的评估提供客观的依据。     

A Chitosan Based,Laser Activated Thin Film Surgical Adhesive, 'SurgiLux': Preparation and Demonstration

Sutures are a 4,000 year old technology that remain the ''gold-standard'' for wound closure by virtue of their repair strength (~100 KPa). However, sutures can act as a nidus for infection and in many procedures are unable to effect wound repair or interfere with functional tissue regeneration.¹ Surgical glues and adhesives, such as those based on fibrin and cyanoacrylates, have been developed as alternatives to sutures for the repair of such wounds. However, current commercial adhesives also have significant disadvantages, ranging from viral and prion transfer and a lack of repair strength as with the fibrin glues, to tissue toxicity and a lack of biocompatibility for the cyanoacrylate based adhesives. Furthermore, currently available surgical adhesives tend to be gel-based and can have extended curing times which limit their application.² Similarly, the use of UV lasers to facilitate cross-linking mechanisms in protein-based or albumin ''solders'' can lead to DNA damage while laser tissue welding (LTW) predisposes thermal damage to tissues.³ Despite their disadvantages, adhesives and LTW have captured approximately 30% of the wound closure market reported to be in excess of US $5 billion per annum, a significant testament to the need for sutureless technology.⁴In the pursuit of sutureless technology we have utilized chitosan as a biomaterial for the development of a flexible, thin film, laser-activated surgical adhesive termed ''SurgiLux''. This novel bioadhesive uses a unique combination of biomaterials and photonics that are FDA approved and successfully used in a variety of biomedical applications and products. SurgiLux overcomes all the disadvantages associated with sutures and current surgical adhesives (see Table 1).In this presentation we report the relatively simple protocol for the fabrication of SurgiLux and demonstrate its laser activation and tissue weld strength. SurgiLux films adhere to collagenous tissue without chemical modification such as cross-linking and through irradiation using a comparatively low-powered (120 mW) infrared laser instead of UV light. Chitosan films have a natural but weak adhesive attraction to collagen (~3 KPa), laser activation of the chitosan based SurgiLux films emphasizes the strength of this adhesion through polymer chain interactions as a consequence of transient thermal expansion.⁵ Without this ''activation'' process, SurgiLux films are readily removed.^6-9 SurgiLux has been tested both in vitro and in vivo on a variety of tissues including nerve, intestine, dura mater and cornea. In all cases it demonstrated good biocompatibility and negligible thermal damage as a consequence of irradiation.^6-10     

外科ICU 中心静脉导管相关血流感染的回顾性病例对照研究

目的:了解外科ICU中心静脉导管相关血流感染(CRBSI)的发病率、病原菌分布及相关危险因素,为临床预防和经验性治疗提供依据。方法:回顾性调查我院外科ICU 2010年1月～2011年8月的中心静脉导管置管病例,根据血培养和导管培养结果分为CRBSI组和非CRBSI组,统计CRBSI的发病率、致病菌;比较CRBSI组与非CRBSI的临床资料,应用多因素Logistic回归分析筛查相关危险因素。结果:共收集249例中心静脉置管病例,CRBSI发病率为8.41例次/千导管日,病原菌分布为G+菌4例,G-菌9例,真菌8例。Logistic回归分析显示导管留置时间(OR 3.298,95%CI 1.070~10.168,P=0.038)、APACHEII评分(OR 1.137,95%CI 1.067~1.213,P=0.000)、完全胃肠外营养(OR 1.117,95%CI 1.023~1.219,P=0.014)是CRBSI的独立危险因素。结论:导管留置时间、APACHEII评分、完全胃肠外营养是发生CRBSI的独立危险因素。     

颈静脉孔区肿瘤各手术入路的选择及对比分析

颈静脉孔区肿瘤位置深,结构复杂,周围有重要的神经血管走形,此区域肿瘤类型较多,常见的有颈静脉球瘤,其次为神经鞘瘤和脑膜瘤。由于此区域位置深,结构复杂,手术显露困难,切除此区域肿瘤难度较大,选择合适的手术入路以及术中正确的处理是该区域肿瘤手术成功的关键。此区域的手术入路可分为三种:后方入路、侧方入路、前方入路;各自又有新型的改良术式。手术入路的选择取决于病变性质、生长范围、受累结构、患者的功能状态及术者的个人经验。术中保护重要的神经血管是此手术的关键。尽管如此,术后出现的并发症在所难免,其主要的并发症有:脑神经损伤后功能障碍、脑脊液漏和脑膜炎等。