Diminished differentiation of rewards in individuals at clinical high-risk for psychosis.

Reward processing is impaired in people with schizophrenia, which may begin in the clinical high-risk (CHR) for psychosis period. The Monetary Incentive Delay (MID) task has been important in understanding the neural correlates of reward processing deficits in various psychiatric disorders. Previous research has found that CHR individuals have an imprecise mental representation of rewards, which leads to a diminished differentiation between rewards, though this has not been observed behaviorally. A total of 19 CHR individuals and 20 controls were given a novel variant of the MID task, designed to examine how modulating reward context may impact responses to reward cues, a process often referred to as "adaptive coding." Both groups appeared to update their behavior in response to the rewards available in this adaptive task. However, when compared to controls who showed a more graded decrease in response time to increasing reward contexts, CHR individuals appeared to have a sharp decrease in response time in the low reward context that is nearly stable across higher reward contexts. This is largely driven by the exponential component of the response time distribution, which is often interpreted to be more cognitively or effortfully influenced. Response times are related to negative symptoms, but not positive symptoms, disorganized symptoms, or estimated intelligence. Although an adaptive coding effect was not observed, these results provide novel insight into the reward processing mechanisms and volitional processes in the CHR population, as this was the first study to observe the diminished differentiation of rewards behaviorally.

Rapamycin-based graft-versus-host disease prophylaxis increases the immunosuppressivity of myeloid-derived suppressor cells without affecting T cells and anti-tumor cytotoxicity.

The immunosuppressant rapamycin (RAPA) inhibits mammalian target of rapamycin (mTOR) functions and is applied after allogeneic bone marrow transplantation (BMT) to attenuate the development of graft-versus-host disease (GVHD), although the cellular targets of RAPA treatment are not well defined. Allogeneic T cells are the main drivers of GVHD, while immunoregulatory myeloid-derived suppressor cells (MDSCs) were recently identified as potent disease inhibitors. In this study, we analyzed whether RAPA prevents the deleterious effects of allogeneic T cells or supports the immunosuppressive functions of MDSCs in a BMT model with major histocompatibility complex (MHC) classes I and II disparities. RAPA treatment efficiently attenuated clinical and histological GVHD and strongly decreased disease-induced mortality. Although splenocyte numbers increased during RAPA treatment, the ratio of effector T cells to MDSCs was unaltered. However, RAPA treatment induced massive changes in the genomic landscape of MDSCs preferentially up-regulating genes responsible for uptake or signal transduction of lipopeptides and lipoproteins. Most importantly, MDSCs from RAPA-treated mice exhibited increased immunosuppressive potential, which was primarily inducible nitric oxide synthase (iNOS)-dependent. Surprisingly, RAPA treatment had no impact on the genomic landscape of T cells, which was reflected by unchanged expression of activation and exhaustion markers and cytokine profiles in T cells from RAPA-treated and untreated mice. Similarly, T cell cytotoxicity and the graft-versus-tumor effect were maintained as co-transplanted tumor cells were efficiently eradicated, indicating that the immunosuppressant RAPA might be an attractive approach to strengthen the immunosuppressive function of MDSCs without affecting T cell immunity.

Abnormal cognitive effort allocation and its association with amotivation in first-episode psychosis.

BACKGROUND: Abnormal effort-based decision-making represents a potential mechanism underlying motivational deficits (amotivation) in psychotic disorders. Previous research identified effort allocation impairment in chronic schizophrenia and focused mostly on physical effort modality. No study has investigated cognitive effort allocation in first-episode psychosis (FEP). METHOD: Cognitive effort allocation was examined in 40 FEP patients and 44 demographically-matched healthy controls, using Cognitive Effort-Discounting (COGED) paradigm which quantified participants' willingness to expend cognitive effort in terms of explicit, continuous discounting of monetary rewards based on parametrically-varied cognitive demands (levels N of N-back task). Relationship between reward-discounting and amotivation was investigated. Group differences in reward-magnitude and effort-cost sensitivity, and differential associations of these sensitivity indices with amotivation were explored. RESULTS: Patients displayed significantly greater reward-discounting than controls. In particular, such discounting was most pronounced in patients with high levels of amotivation even when N-back performance and reward base amount were taken into consideration. Moreover, patients exhibited reduced reward-benefit sensitivity and effort-cost sensitivity relative to controls, and that decreased sensitivity to reward-benefit but not effort-cost was correlated with diminished motivation. Reward-discounting and sensitivity indices were generally unrelated to other symptom dimensions, antipsychotic dose and cognitive deficits. CONCLUSION: This study provides the first evidence of cognitive effort-based decision-making impairment in FEP, and indicates that decreased effort expenditure is associated with amotivation. Our findings further suggest that abnormal effort allocation and amotivation might primarily be related to blunted reward valuation. Prospective research is required to clarify the utility of effort-based measures in predicting amotivation and functional outcome in FEP.

[Evaluation of a Micro-Manipulator for Middle Ear Surgery: A Preclinical Trial]. / Evaluation eines Mikromanipulators für die Mittelohrchirurgie: Eine präklinische Studie.

BACKGROUND: Microsurgical preparation is limited by geometric and mechanical constraints. In preparation for clinical use, this study investigates performance, ease of handling and precision of a novel manipulator concept for microsurgery. MATERIAL AND METHODS: A group of 15 ENT experienced doctors, as well as a group of 17 medical students with low/non surgical experience participated in the study. Each of the subjects carried out 4 trials of simulated surgeries on a phantom with built-in force sensors. The task was to apply a defined force between 1.5 and 2 N using a Fisch micro perforator, 16 cm length, 0.4 mm (Storz) targeting holes with a diameter of 0.5 mm. For comparison, the Fisch micro perforator was moved manually or with the manipulator. RESULTS: Assessing the total number of errors proved a significantly lower error number (p<0.0001) and an improvement of the accuracy of 76% with the manipulator. The time requirement for the procedure with the micro manipulator is on average 2-3 times higher than with manual control (p<0.0001). But it is notable that this time requirement significantly decreases with training (p<0.0001). CONCLUSION: The study shows a significant reduction in the number of errors by using a new manipulator concept compared to the non-augmented human hand in an experimental setup. We observed a significant learning effect when subjects applied the micro manipulator, resulting in reduction of the time requirement while maintaining a constant number of errors.

Adjuvant chemotherapy for elderly patients with stage I non-small-cell lung cancer ≥4 cm in size: an SEER-Medicare analysis.

BACKGROUND: The role of adjuvant chemotherapy for non-small-cell lung cancer (NSCLC) stage I patients with tumors size ≥4 cm is not well established in the elderly. PATIENTS AND METHODS: We identified 3289 patients with stage I NSCLC (T2N0M0 and tumor size ≥4 cm) who underwent lobectomy from the Surveillance, Epidemiology and End Results (SEER)-Medicare linked database diagnosed from 1992 to 2009. Overall survival and rates of serious adverse events (defined as those requiring admission to hospital) were compared between patients treated with resection alone, platinum-based adjuvant chemotherapy, or postoperative radiation (PORT) with or without adjuvant chemotherapy. Propensity scores for receiving each treatment were calculated and survival analyses were conducted using inverse probability weights based on the propensity score. RESULTS: Overall, 84% patients were treated with resection alone, 9% received platinum-based adjuvant chemotherapy, and 7% underwent PORT with or without adjuvant chemotherapy. Adjusted analysis showed that adjuvant chemotherapy [hazard ratio (HR), 0.82; 95% confidence interval (CI) 0.68-0.98] was associated with improved survival compared with resection alone. Conversely, the use of PORT with or without adjuvant chemotherapy (HR 1.91; 95% CI 1.64-2.23) was associated with worse outcomes. Patients receiving adjuvant chemotherapy had more serious adverse events compared with those treated with resection alone, with neutropenia (odds ratio, 21.2; 95% CI 5.8-76.6) being most significant. No significant difference was observed in rates of fever, cytopenias, nausea, and renal dysfunction. CONCLUSIONS: Platinum-based adjuvant chemotherapy is associated with reduced mortality and increased serious adverse events in elderly patients with stage I NSCLC and tumor size ≥4 cm.

Outcomes of mismatched and unrelated donor hematopoietic stem cell transplantation in Fanconi anemia conditioned with chemotherapy only.

Fanconi anemia (FA) is a genomic instability syndrome associated with bone marrow failure, myelodysplastic syndrome (MDS), and/or acute myeloid leukemia (AML) requiring hematopoietic stem cell transplantation (HSCT) to restore normal hematopoiesis. Although low-intensity fludarabine-based preparative regimens without radiation confer excellent outcomes in FA HSCTs with HLA-matched sibling donors, outcomes for FA patients with alternative donors are less encouraging, albeit improving. We present our experience with 17 FA patients who completed mismatched related or unrelated donor HSCT using a non-radiation fludarabine-based preparative regimen at Charité University Medicine Berlin. All patients engrafted; however, one patient had unstable chimerism in the setting of multi-viral infections that necessitated a stem cell boost to revert to full donor chimerism. Forty-seven percent of patients developed grade I acute graft-verus-host disease (aGVHD). No grade II-IV aGVHD or chronic graft-versus-host disease of any severity occurred. At a median follow-up of 30 months, 88 % of patients are alive with normal hematopoiesis. Two patients died of infections 4 months post-transplantation. These results demonstrate that short-term outcomes for FA patients with mismatched and unrelated donor HSCTs can be excellent using chemotherapy only conditioning. Viral reactivation, however, was a major treatment-related complication.

[Effect of a multifunctional instrument (HF scissors) in parotis surgery]. / Effekte eines multifunktionalen Instruments (HF-Schere) in der Parotischirurgie.

PROBLEM: Lateral parotidectomy is a demanding surgical procedure and requires a large number of instruments with a high frequency (HF) of alternating. Many functions, such as preparing, spreading, coagulating and cutting could be combined by using scissors with an integrated function of bipolar coagulation. This study has targeted an investigation of technical application, influence on surgery time, frequency of HF application and change of instruments. MATERIAL AND METHODS: In the period between 01 April 2011 and 30 September 2012 (18 months) 35 procedures of lateral parotidectomy in 35 patients were investigated. In all cases lateral parotidectomy was carried out with a similar technique (modified extracapsular preparation). Workflow data were used from a control group in the period between 01 January 2009 and 31 December 2010 (24 months). The following parameters from both groups were documented and evaluated: incision-suture times (subdivided into nine sections of the procedure), change of instruments, period of application for HF function and early facial nerve function (6 h and 6 days after surgery according to House-Brackmann). Additionally, in the HF+ group a questionnaire that facilitated subjective evaluation of instruments was analyzed. RESULTS: It was possible to perform the surgery in both groups with neither technical nor surgical intraoperative complications. Incision-suture times showed an average reduction of 31.6 min (34.8 %) in the HF+ group. There was a reduction in the change of instruments compared to a conventional group (CONV) by up to 62.7 %. With the deployment of HF scissors there was a clear increase in the use of HF surgery by more than 100 % when comparing incision-suture times. Evaluation of both groups according to House-Brackmann showed a similar postoperative facial nerve function. The surgeons involved were of the opinion that in all 35 surgeries with HF scissors the intervention was easier and more comfortable. DISCUSSION: The use of HF scissors is appropriate for parotid gland surgery and can be used in all steps of the procedure. Incision-suture time can be reduced and the ergonomics of the intervention can be improved. Up to now no negative effects have been found in the quality of the results.

[Interdisciplinary teleconsultation: first practical experiences with 100 patients]. / Interdisziplinäre Telekonsultation: Erste praktische Erfahrungen mit 100 Patienten.

UNLABELLED: PROBLEM DEFINITION: Increasing specialization can be observed in the various medical fields and as a consequence there is little professional exchange between ear nose and throat (ENT) specialists and general practitioners. At the same time there has been significant technological development in telemedicine over the last 5 years; however, this potential is not being sufficiently exploited. The objective of this project is to implement a practicable solution for teleconsulation between ENT specialists and general practitioners. MATERIALS AND METHODS: The connection is based on a secure broadband internet connection, the corresponding server structure and a video endoscopic system. In the period from 01 January 2011 to 30 June 2012 (18 months) a total of 102 patients were included in the study in which 4 general practitioners and 5 ENT specialists participated. The protocol comprised the following parameters: indications and typical questions, number of patients presenting to the ENT specialist due to the available teleconsultation service (CBO), number of patients referred to the ENT specialist after teleconsultation (CIO), assessment of the quality of the additional expert opinion (LOQ GP), assessment of the accuracy of the specialist physician tele-diagnosis (TDS-FA) and assessment of the impact of the expert physician diagnosis on the general medical treatment (COS). RESULTS: Teleconsultation was most frequently used for diagnostics on tonsils (37% of the presented cases), the external auditory canal (32%) and the inner nose (15%). Of the patients analyzed were 53.9% presented to the ENT specialist only because the teleconsultation service provided an effortless opportunity and after teleconsultation 40.1% of the patients were referred to the ENT specialist. General practitioners assessed the benefit from the specialist opinion with 64 points. Diagnostic certainty of the specialist opinion, i.e. the validity scale of the diagnosis made, was on average 2.0. In approximately 35.3% of the cases (36 out of 102 patients) participating general practitioners documented a considerable impact of teleconsultation on the diagnosis and/or therapy. CONCLUSIONS: Teleconsultation between general practitioners and ENT specialists can provide an advantage in treatment quality and patient comfort. According to the experience gained there is a very low risk of diminishing the professional competency of ENT medicine and the involvement of the expert group in the early project stage allows a greater leeway in project implementation. This could also have an impact on future medical performance specifications. According to the ENT experts involved in the project further applications of teleconsultation are very conceivable.

[Instrument navigation in ensonasal sinus surgery]. / Instrumentennavigation in der endonasalen Stirnhöhlenchirurgie: Gibt es eine Operation unter "reiner Navigationsführung"?

BACKGROUND: It is to be expected that, microsurgical operations in ENT must be partially performed without direct vision, e. g. without the possibility of controlling the preparation progress. This study provides a clinical example of how instrument navigation may be used in a safe and reasonable manner to the benefit of treatment quality. It is assumed that a median frontal sinus drainage procedure may be performed by means of a tracked sinus drill using solely instrument navigation. MATERIAL AND METHODS: The sinus drill was registered using an optoelectric navigation system. An optical registration device was attached to the drill. In the period from 1 December 2011 to 30 April 2012 (5 months) 24 patients underwent a median frontal sinus drainage. 12 of the surgeries were performed under the condition operation navigation. The other 12 surgeries were performed using solely instrument navigation. RESULTS: When applying mode Instrument Navigation (IN), a significantly reduced incision-to-suture time was registered within both groups. Within the group Draf IIB, it was reduced to 68.5% (from 67.1 min to 46.0 min). Resection efficiency, i. e., the ratio between the width of the frontal sinus ostium and the required total surgery time, widely differed to the benefit of group IN. Within both groups, the questionnaire revealed a high level of confidence in Surgical Management and Guidance Systems (SMGS) functionalities (100%). CONCLUSION: The present study was designed to show for the first time a median frontal sinus drainage under the condition solely instrument navigation.

[QR-Code based patient tracking: a cost-effective option to improve patient safety]. / QR-Code Patienten-Tracking: eine kostengünstige Möglichkeit zur Verbesserung der Patientensicherheit.

BACKGROUND: Hospitals are implementing a risk management system to avoid patient or surgery mix-ups. The trend is to use preoperative checklists. This work deals specifically with a type of patient identification, which is realized by storing patient data on a patient-fixed medium. MATERIAL AND METHODS: In 127 ENT surgeries data relevant for patient identification were encrypted in a 2D-QR-Code. The code, as a separate document coming with the patient chart or as a patient wristband, has been decrypted in the OR and the patient data were presented visible for all persons. The decoding time, the compliance of the patient data, as well as the duration of the patient identification was compared with the traditional patient identification by inspection of the patient chart. RESULTS: A total of 125 QR codes were read. The time for the decrypting of QR-Code was 5.6 s, the time for the screen view for patient identification was 7.9 s, and for a comparison group of 75 operations traditional patient identification was 27.3 s. Overall, there were 6 relevant information errors in the two parts of the experiment. This represents a ratio of 0.6% for 8 relevant classes per each encrypted QR code. CONCLUSION: This work allows a cost effective way to technically support patient identification based on electronic patient data. It was shown that the use in the clinical routine is possible. The disadvantage is a potential misinformation from incorrect or missing information in the HIS, or due to changes of the data after the code was created. The QR-code-based patient tracking is seen as a useful complement to the already widely used identification wristband.

[The 'Surgical Deck': a new generation of integrated operational rooms for ENT]. / Das "Surgical Deck": Eine neue OP-Generation für die HNO-Chirurgie.

BACKGROUND: Existing operating room concepts do not meet modern technological opportunities anymore. The "Surgical Deck" is supposed to represent a prototype for a new operating room generation. The objective of the project is to achieve a better integration of functions and to develop an innovative concept for a highly developed surgical workstation. MATERIAL AND METHODS: 3 working areas are defined: Surgical, Airway and Technical Cockpit. The evaluation was conducted on 284 surgeries carried out from 01.08. 2011 to 31.01. 2012. The evaluation team consisted of 6 surgeons, 3 surgery nurses, 3 anesthesiologists and 4 anesthesia nurses. Within a detailed analysis, the data of 50 FESS surgeries were compared to those of a control group. RESULTS: Within the FESS group, the average slot time was reduced by 13%. 88.2% of those questioned assessed ergonomics as being better than in the conventional OR. 71.5% stated that the Surgical Deck provided an added value with regard to the surgical procedure. 91.3% confirmed that the system control required additional training. 79.3% described the cost-benefit-ratio as appropriate. For 96% of the surgeries, respondents said that they were feeling adequately supported by the technology. CONCLUSION: The results show a clear advantage of the system architecture. The Surgical Deck may present a solid foundation with regard to the transfer of the system into the clinical practice. This is relevant for new assistance functions such as process control software or navigation-based collision warning systems. It is to be expected that the project will significantly contribute to further develop the future surgical workstation and its standardization.

[Implementation of biosecurity measures by hoof trimmers in Switzerland]. / Umsetzung von Biosicherheitsmassnahmen durch Klauenpfleger in der Schweiz.

INTRODUCTION: Biosecurity in livestock farming includes all measures preventing pathogen introduction onto a farm (external biosecurity) and pathogen transmission on the farm itself (internal biosecurity). An important risk factor for the dissemination of infectious diseases are specialised external persons working on numerous farms, such as professional hoof trimmers in Switzerland. In the present study, 49 hoof trimmers, participating in the Swiss claw health programme and working as professionals, were questioned regarding their biosecurity measures and observed by two veterinarians during hoof trimming in order to assess the implementation of biosecurity measures by hoof trimmers. Data were processed using a scoring system, in which points were allocated to the different working methods taking into account their assumed transmission potential for infectious diseases such as digital dermatitis (DD) and Salmonellosis. The working method, which complied with the ideal biosecurity measure, was always given a whole point, whereas less optimal working methods were only given an intermediate value or no point. The scoring system helped identify precisely the strengths and weaknesses of the hoof trimmers in terms of biosecurity. The level of implementation of biosecurity measures by hoof trimmers was overall quite low (53 %=average of the overall biosecurity scores of the 49 hoof trimmers). Hoof trimmers which attended specialised training courses tended to have a higher level of implementation of biosecurity measures. The answers given by the hoof trimmers and the observations made by the veterinarians were compared, whereby it was found that hoof trimmers generally evaluated themselves better in regard to biosecurity than veterinarians assessed them. In summary and based on the results of this study, the dissemination of pathogens, such as DD associated treponemes and salmonella is possible during hoof trimming performed by external persons working on numerous farms. Thus, future training and continuing education courses should place emphasis on biosecurity.

INTRODUCTION: Le concept de biosécurité englobe, en lien avec la production animale, toutes les mesures empêchant l'introduction de germes dans une exploitation (biosécurité externe) et la propagation de germes à l'intérieur de l'exploitation (biosécurité interne). Un facteur de risque important pour la propagation de maladies infectieuses est le personnel spécialisé externe travaillant sur plusieurs exploitations, dont font partie les pareurs d'onglons professionnels intervenant sur les exploitations bovines suisses. Dans la présente étude, afin de donner un aperçu de la situation actuelle concernant la mise en oeuvre de mesures de biosécurité par les pareurs d'onglons, 49 pareurs d'onglons participant au programme suisse de santé des onglons, ont été questionnés à ce sujet et observés lors du parage des onglons par des vétérinaires. Le traitement des données a été effectué à l'aide d'un système de notation, attribuant des points aux différentes pratiques de travail selon leur potentiel supposé de transmission des maladies infectieuses que sont la Dermatite digitale (DD) et la Salmonellose. La pratique de travail, qui correspondait à la mesure de biosécurité idéale, obtenait toujours un point entier, alors que les pratiques de travail moins optimales ne recevaient qu'une valeur intermédiaire ou aucun point. Le système de notation a permis de désigner précisément les forces et les faiblesses des pareurs d'onglons en terme de biosécurité. Le niveau de mise en œuvre de mesures de biosécurité par les pareurs d'onglons est de manière générale relativement faible (53 % = moyenne du score de biosécurité générale des 49 pareurs). Les pareurs d'onglons ayant suivi plus fréquemment des formations spécifiques présentaient tendanciellement un niveau de mise en oeuvre de mesures de biosécurité plus élevé. De plus, les réponses des pareurs d'onglons et les observations des vétérinaires ont été comparées. Il a été constaté, que les pareurs d'onglons s'évaluaient généralement meilleurs en matière de biosécurité que les vétérinaires ne les jugeaient. En résumé et en tenant compte des résultats de cette étude, la propagation de germes pathogènes par les pareurs d'onglons dans le cadre de leur activité professionnelle, tels que les tréponèmes associés à la DD et les salmonelles, est possible. Par conséquent, la biosécurité devrait être thématisée en priorité lors des formations et formations continues futures.

Endoscopic sinus surgery training courses: benefit and problems - a multicentre evaluation to systematically improve surgical training.

BACKGROUND: The aim of this multicentre study was to systematically analyse the strengths and weaknesses in the surgical training for endoscopic sinus surgery (ESS) and identify measures that may improve training. METHODOLOGY: Using a structured questionnaire, 133 participants of ESS courses in seven centres in Germany, Switzerland and Australia were asked about their experiences during their dissection courses and how they perceived their course could be improved. RESULTS: Gaining confidence in handling of instruments and endoscopes was only a problem for participants with little experience in ESS. The majority of the participants, independent from their level of training, considered infundibulotomy and anterior ethmoidectomy as the easiest dissection steps, whilst surgery of the frontal sinus posed a considerable challenge for many surgeons even those with a higher level of training. Participants with and without ESS experience thought that emphasis on anatomy was the most important improvement that could be made during their surgical training. Virtually all participants stated that the course improved their anatomical knowledge, their surgical skills and their confidence when performing ESS. CONCLUSIONS: ESS dissection courses are considered beneficial by surgical trainees. Participants felt that more emphasis on sinus anatomy in conjunction with private study is essential to maximize their skills in surgical dissection. For beginners with ESS, an infundibulotomy and anterior ethmoidectomy were thought to be the best initial procedures to help develop endoscopic surgical skills.

[A surgical micromanipulator in ear surgery: potential and comparison to freehand preparation]. / Ein chirurgischer Mikromanipulator in der Ohrchirurgie: Potenzial und Vergleich mit der freien Präparation.

INTRODUCTION: Surgical accuracy in microscopic ear surgery is reduced by limited access and tremor. At this point a micromanipulator could have a positive influence. The goal of the study was: 1. To develop a system that would enable measurements of accuracy, time and precision during a manual approach to the middle ear 2. To apply a manipulator that can easily be a compact part of the regular setup in ear surgery 3. To compare the manual results critically considering accuracy and tremor reduction and to compare these results with those of a manipulator A manipulator in ear surgery does not need to be a highly complex structure with force feedback and multiple degrees of freedom. The surgeon's preparation in middle ear surgery is most of the time straight without potentially applying the 15 degrees of freedom the human hand can offer. The micromanipulator in this study was developed in order to serve as a compact, teleoperated instrument without limiting the surgeon's dexterity. The use of standard instruments facilitates the integration of the system in existing surgical procedures and sterilisation concepts. MATERIAL AND METHODS: Ten head and neck surgeons simulated an approach to the stapedial footplate on a modified 3D cast of a realistic human skull in an experimental OR. A perforator was moved to a reference point on the stapedial footplate. The movements were detected by means of an image acquisition system. Each trial was repeated more than 200 times, aiming both manually and with the aid of a micromanipulator (> 4,000 measurements). RESULTS: Accuracy for the manual and micromanipulator approach revealed no considerable differences. In absolute terms, the manual approach was more accurate. However, the learning curves indicated a stronger decrease in deviation when the micromanipulator was used and also less deviation in scatter plots. At the beginning, the time required for pointing increased when using the micromanipulator, but decreased to a greater extent in the course of the trial when compared to the manual approach. The work strain was distinctively lower when the micromanipulator was applied. CONCLUSION: The micromanipulator gave evidence of a stronger effect as regards individual improvement in accuracy and time span. The micromanipulator shows potential for improvements in accuracy as well as compensation for poor ergonomics.

[Clinical experience with navigation functions for temporal bone surgery : interim result after 40 patients]. / Klinischer Einsatz von Navigationsfunktionen in der Felsenbeinchirurgie : Zwischenbilanz nach 40 Patienten.

PROBLEM: Although robust algorithms for registration and segmentation are available, the majority of surgical approaches to the temporal bone are nowadays made without navigation assistance. Beside instrument navigation (IN), functions such as distance control (DC) and navigated control (NC) can be used. This study analyzes the application of these navigation functionalities in lateral skull base and middle ear surgery. PATIENTS AND METHODS: A total of 41 patients with an indication of temporal bone approaches were included. The navigation was realized with an optoelectric navigation system with both non-invasive and invasive markers. Parameters such as surgical time, Level of Quality (LoQ) index, and Change of Surgical Strategy (COS) index were evaluated. RESULTS: In 14.6% of patients, the conventional mode of IN was used. In 70.7% of cases, the function DC was also used. In another 14.6% of cases, the function NC was used to control the speed of the drill. The facial nerve was the dominant segmented risk structure for active navigation. The time for setup was on average 7.78 min. The LoQ index score was on average 66 points. In 17% of the patients, surgeons evaluated the assistance mode as "necessary for the surgery". No technical-related complications were recorded. CONCLUSION: This study proves the usability of navigation technology for temporal bone surgery in clinical routine. DC and NC are two additional features for higher acceptance of navigation in microscopic surgery.

[Clinical use of a micromanipulator system: preliminary clinical experience in middle ear surgery]. / Klinischer Einsatz eines Mikromanipulators : Erste Erfahrungen in der Mittelohr- und Felsenbeinchirurgie.

PROBLEM DESCRIPTION: Nowadays all procedures in tympanoplasty are performed using conventional instrumentation without any mechatronic based manipulators. A micromanipulator system (MMS) holds microinstruments and transmits the surgeon's hand movements to a monitor, thus, improving precision and ergonomics. MATERIALS AND METHODS: Using the Cartesian principle, a telemanipulator with three linear degrees of freedom controlled with a joystick was designed. The three axes are powered by a servomotor. The manipulator is equipped with a sterilizable instrument holder, which is placed on a sterile covered system. On this instrument holder, sterile surgical instruments can be clipped and can be easily changed during surgery. In the scope of this study, the MMS was used to perform a tympanoplasty III in 20 patients. A workflow expert protocol, a video of the surgery, and a questionnaire completed by all surgeons were evaluated. RESULTS: Clinical use of the MMS 2.0 was performed in all 20 patients as planned. A partial/total ossicular replacement prosthesis (PORP/TORP) was used in all cases with the MMS as planned. Significantly more time was necessary not only to prepare for surgery but also to prepare the equipment intraoperatively, and the incision to suture time was longer. The number of intraoperative changes of instruments decreased by 24%. The frequency of contact between the instrument and the prosthesis was significantly decreased. All questionnaires indicated that further improvement of the MMS is needed. CONCLUSION: The manipulator MMS 2.0 was successfully used in the clinical setting for the first time. The tool offers great potential for middle ear surgery (e.g., tympanoplasty III, stapes surgery and cochlear implant insertion). The principal of telemanipulation (master-slave) could be transferred to middle ear surgery. However, numerous technical improvements are still required.

[Evaluation of a context sensitive system for intra-operative usage of the electronic patient record]. / Bewertung eines kontextsensitiven Systems zur intraoperativen Nutzung der E-Patientenakte.

This article analyzes the usage of an electronic patient record (EPR), which may be accessed intra-operatively by the surgeon. The focus lies on the automatic prioritization of documents to dramatically reduce the surgeon's interaction with the EPR system. An EPR system has been developed, which displays documents in accordance to the current procedure. The system is controlled by a foot switch and the documents are displayed on a large-scale screen in the operating room. The usage of the system by 2 surgeons has been recorded in clinical routine. 55 surgical procedures have been recorded. The EPR system has been used 2 times per procedure in average for surgeries at the middle ear, for surgeries of the paranasal sinuses, it has been used 1.3 times per procedure. The EPR-system has been used pre-operatively in 58% of cases. The surgeons did not have to interact with the EPR system for more than the half of the procedures to view the desired document. The existence of digitized documents in a clinic does not automatically lead to improved workflows. The evaluated EPR system presented the patient data in a simple and comfortable way. The extensive pre-operative usage had not been expected. Because of the low barrier to view patient data, higher patient safety may be assumed. On the other hand, the surgeon could be encouraged to skip the important preparation before the procedure. Due to the low pervasiveness of medical communication standards at this time, the integrated connection between clinic IT and an EPR system would nowadays only be possible by great efforts.

[Impact of transtympanic miniature endoscopy of the middle ear--a conceptual cadaver study]. / Wertigkeit der transmyringealen Mini-Endoskopie des Mittelohres--Eine konzeptionelle Kadaver-Studie.

OBJECTIVE: Endoscopic inspections of the middle ear have already been described. So far, the low optical quality due to the small diameter is limiting this type of procedure. In this study the use of a miniature endoscope for visualization of the middle ear structures has been evaluated. MATERIAL AND METHODS: 8 human cadaveric head specimens have been inspected. Following myringotomy, 2 miniature endoscopes were placed into the middle ear and the promontory, the incudostapedial joint, the round und oval window niche with stapes footplate were visualized and fotodocumentated. After endaural approach all middle ear structures were visualized microscopically and the quality of pictures was compared. Technical picture quality and anatomical visualization were evaluated by 5 ear surgeons. In addition, 2 interventional procedures were performed (control of ossicular chain mobility and intratympanic substance application). RESULTS: Still, the technical picture quality was significantly better for the microscope. The anatomical visualization of the middle ear structures with the miniature endoscope was not inferior compared to the microscope. The feasibility of additional interventions, e.g. control of ossicular chain mobility or intratympanic substance application could be shown. An inspection of the correct prosthesis position after tympanoplasty could be evaluated, too. CONCLUSION: This study showed that middle ear structures can be visualized by trans-tympanic miniature endoscopy equal or even better compared to conventional microscopy in spite of reduced technical quality.

[First clinical experiences with an endoscope manipulator system in endo- and transnasal surgery]. / Klinischer Einsatz eines Endoskop-Manipulator-Systems in der endo- und transnasalen Chirurgie.

BACKGROUND: Endo- and transnasal surgery needs optical support. The use of a microscope allows bimanual manipulation. More often the endoscopic technique is used which needs one hand for endoscope guidance "loosing" it for manipulation or demanding an assistant for endoscope guidance. In this work the use of a miniature endoscope manipulator system for endonasal and transnasal surgery was evaluated. MATERIAL AND METHODS: 31 FESS with manipulator-assisted endoscope guidance were performed. The used endoscope positions, the number of position changes and conditional interruptions were documented. In addition, a transsphenoidal approach to the pituitary gland was performed in a cadaver trial. RESULTS: Non-inferiority was shown for the use of the endoscope manipulator with reference to time and accuracy of manipulator-assisted endoscope guidance. There were 6.4 position changes for each side. Bimanual manipulation was possible in all cases. In the region of high-risk structures (lamina papyracea, frontal recess) we conceptual switched to manual endoscope guidance. CONCLUSION: The evaluated endoscope manipulator fulfills the minimum requirements to be integrated into the surgical workflow of endo- and transnasal surgery. The number of required endoscope position changes is small allowing bimanual instrumentation. Still a disadvantage is the need for interrupting the workflow to remote the endoscope manipulator with the joystick console. Further development potential would be a forced-feedback function and hands-free navigated-controlled guidance.

[A concept to improve wet-lab training in ENT surgery]. / Ein Konzept zur Verbesserung von Präparationskursen in der HNO-Heilkunde.

BACKGROUND: In literature and scientific societies no binding methodical-didactic recommendations or guidelines exist in order to design surgical training courses. The educating institutions plan, organise and evaluate the educational program on their own initiative. MATERIAL AND METHODS: Through a research project surgical training courses were investigated through structured surveys, expert discussions with course responsibles and trainers and analysis of participant's questionnaires. The investigation was performed by an pedagogical-psychological research institution. First implementations were installed and immediately included in the running process of evaluation. RESULTS: From the evaluation, specific alterations in the organisational and micro didactic process were implemented. In addition, changes in a long term process had to be implemented such as: (a) conception of the trainer role, (b) giving feedback and judge performance and (c) provide contents in a sophisticated manner. CONCLUSION: For advanced medical training providers a long term cooperation with a pedagogical institution seems to be highly advisable.