Training Performance Assessment for Intracranial Aneurysm Clipping Surgery Using a Patient-Specific Mixed-Reality Simulator: A Learning Curve Study.

BACKGROUND AND OBJECTIVES: The value of simulation-based training in medicine and surgery has been widely demonstrated. This study investigates the introduction and use of a new mixed-reality neurosurgical simulator in aneurysm clipping surgery, focusing on the learning curve and performance improvement. METHODS: Five true-scale craniotomy head models replicating patient-specific neuroanatomy, along with a mixed-reality simulator, a neurosurgical microscope, and a set of microsurgical instruments and clips, were used in the operation theater to simulate aneurysm microsurgery. Six neurosurgical residents participated in five video-recorded simulation sessions over 4 months. Complementary learning modalities were implemented between sessions. Thereafter, three blinded analysts reported on residents' use of the microscope, quality of manipulation, aneurysm occlusion, clipping techniques, and aneurysm rupture. Data were also captured regarding training time and clipping attempts. RESULTS: Over the course of training, clipping time and number of clipping attempts decreased significantly (P = .018, P = .032) and the microscopic skills improved (P = .027). Quality of manipulation and aneurysm occlusion scoring improved initially although the trend was interrupted because the spacing between sessions increased. Significant differences in clipping time and attempts were observed between the most and least challenging patient models (P = .005, P = .0125). The least challenging models presented higher rates of occlusion based on indocyanine green angiography evaluation from the simulator. CONCLUSION: The intracranial aneurysm clipping learning curve can be improved by implementing a new mixed-reality simulator in dedicated training programs. The simulator and the models enable comprehensive training under the guidance of a mentor.

Dynamic Mixed-Reality Patient-Specific Aneurysm Clipping Simulation for Two Cases-A Feasibility Study.

BACKGROUND AND OBJECTIVE: Intracranial aneurysm (IA) clipping is a complex neurosurgical procedure which demands advanced technology to minimize risks and maximize patient outcomes. This study aims to evaluate the feasibility of training patient-specific microsurgical clipping procedures using a mixed-reality physical neurosurgical simulator for unruptured IA. METHODS: Two board-certified neurosurgeons were asked to simulate surgery in 2 patient-specific left-side unruptured middle cerebral artery-bifurcation IA models. The study was conducted in the operation theater under realistic conditions using a mixed-reality physical neurosurgical simulator. Time, procedural, and outcome-related information was collected. The participating neurosurgeons were encouraged to attempt all possible clipping strategies, even those deemed suboptimal, reporting the outcome of each strategy. Finally, to evaluate the feasibility and added value of integrating indocyanine green fluorescence angiography (ICG-FA) with the simulator, the ICG-FA videos for each clipping strategy were analyzed and compared with the reported clipping outcomes. RESULTS: Between 4 and 8, different clipping strategies were applied per aneurysm model; the number of strategies was higher in Patient Model 1 (6.5 ± 1.5) (more complex aneurysm) than in Patient Model 2 (5.0 ± 1.0). The clipping strategies differed between surgeons. At most, 53.5 minutes were necessary to complete each training session, but more than double the time was spent on the more complex aneurysm. Up to 53.8% (Patient Model 1) and 50% (Patient Model 2) of the attempted strategies were discarded by the neurosurgeons during the simulation. Evaluation of aneurysm occlusion through ICG-FA was specific, although sensitivity was poor. CONCLUSION: The present mixed-reality patient-specific simulator allows testing, anticipating, and discarding different aneurysm microsurgical clipping strategies regardless of the pathology complexity. Specific limitations should be considered regarding ICG-FA aneurysm inspection after clipping.

A Proposal of a Motion Measurement System to Support Visually Impaired People in Rehabilitation Using Low-Cost Inertial Sensors.

The rehabilitation of a visually impaired person (VIP) is a systematic process where the person is provided with tools that allow them to deal with the impairment to achieve personal autonomy and independence, such as training for the use of the long cane as a tool for orientation and mobility (O&M). This process must be trained personally by specialists, leading to a limitation of human, technological and structural resources in some regions, especially those with economical narrow circumstances. A system to obtain information about the motion of the long cane and the leg using low-cost inertial sensors was developed to provide an overview of quantitative parameters such as sweeping coverage and gait analysis, that are currently visually analyzed during rehabilitation. The system was tested with 10 blindfolded volunteers in laboratory conditions following constant contact, two points touch, and three points touch travel techniques. The results indicate that the quantification system is reliable for measuring grip rotation, safety zone, sweeping amplitude and hand position using orientation angles with an accuracy of around 97.62%. However, a new method or an improvement of hardware must be developed to improve gait parameters' measurements, since the step length measurement presented a mean accuracy of 94.62%. The system requires further development to be used as an aid in the rehabilitation process of the VIP. Now, it is a simple and low-cost technological aid that has the potential to improve the current practice of O&M.

Auto- medicación y auto-prescripción en el personal de salud del primer nivel de atención de México, Bolivia y Ecuador / Selfmedication and selfprescription in health care workers in primary care in Mexico, Bolivia and Ecuador

Introducción. La prevalencia general de la automedicación en la población general fluctúa de 27.3% a 61.3%. En trabajadores de la salud está menos documentado (Definido como auto prescripción), así como su frecuencia y las características del personal médico. Material y métodos. Se trata de un estudio comparativo transversal de 3 países, México (178), Bolivia (250) y Ecuador (130) en población de Médicos Familiares y Médicos Generales de Primer nivel de atención en salud; sexo y edad indistintos, activos en consulta pública o institucional. El muestreo fue por conveniencia calculado por fórmula. Se usó una encuesta con datos demográficos, Frecuencia de automedicación y auto prescripción, patologías donde se usaron, y razones de uso y fuentes de información. Se capturaron y analizaron en SPSS versión 20. Se utilizaron estadísticas descriptivas e inferenciales como ji-cuadrada y Kruskal Wallis. Aprobado por el comité de ética de dos países. Resultados. De los participantes 58.0% son médicos familiares, la mayoría femeninas (p<.05), con pareja, y con promedio de edad de 39.3. Laboran en el sistema público 42.2%. Se automedicaron y auto prescribieron más medicamentos los médicos en México y menos en Ecuador (p<.0001). En general, en el último mes, 61.5% de los profesionales estudiados se auto medicó (media 2.99 veces), y menor porcentaje se auto prescribió 35.8%, (media 1.28 veces) principalmente analgésicos y antibióticos (p<.0001) y por patologías respiratorias (p<.05). Las variables numéricas no cumplieron los supuestos de normalidad. Conclusión. Más de la mitad de los profesionales estudiados se auto medicó y más de un tercio se auto prescribió (antibióticos y analgésicos), esto más en México (AU)

Introduction. The general prevalence of selfmedication in the general population fluctuates from 27.3% to 61.3%. It is less documented in health workers (denominated as selfprescription), as well as its frequency and the characteristics of medical personnel. Material and methods. This is a cross- sectional, comparative study of 3 countries, Mexico (178), Bolivia (250) and, Ecuador (130) in the population of Family Physicians and General Practitioners of the first level of care; indistinct sex and age, active practice in public or institutional consultation. Sampling was for convenience calculated by a formula. A survey with demographic data, II Frequency of self-medication and self-prescription, pathologies where they were used, reasons for use and, sources of information were used. They were captured and analyzed in SPSS version 20. Descriptive and inferential statistics such as chi-square and Kruskal Wallis were used. It was approved by the ethic committee from two countries. Results. Of the participants, 58.0% are family doctors, the majority female (p <.05), with a partner, and with an average age of 39.3 years; 42.2% work in the public system. More physicians in Mexico and fewer in Ecuador used self-medicated and self- prescribed medications (p <.0001). In general in the last month, 61.5% of the professionals self-medicated (average 2.99 times), and a lower percentage (35.8%,)self-prescribed (average 1.28 times) mainly pain relievers and antibiotics (p <.0001) and for respiratory pathologies (p <.05). The numerical variables did not meet the assumptions of normality. Conclusion. More than half of the professionals studied practice self-medication and more than third antibiotics and analgesics as self-prescription this more in Mexico (AU)

MIRADAS: PASADO, PRESENTE Y FUTURO DE LA MEDICINA FAMILIAR / LOOKS: PAST, PRESENT AND FUTURE OF THE MEDICINE FAMILY

En el mundo la Medicina Familiar se encuentra en unpunto de inflexión importante para introducir la especialidad como efectora de la Atención Primaria, consideramos que como país no podemos conformarnos y dejar las cosas como están. Nuestras autoridades deben de pensar con seriedad y madurez, y hacer suyas las recomendaciones emanadas de las siete Cumbres Iberoamericanas de Medicina Familiar donde además dela participación de Ministros de Salud, participan representantes de la OMS-OPS, autoridades universitarias y decisores de salud.

Miradas: pasado, presente y futuro de la medicina familiar / Looks: past, present and future of family medicine

En el mundo la Medicina Familiar se encuentra en unpunto de inflexión importante para introducir la especialidad como efectora de la Atención Primaria, consideramos que como país no podemos conformarnos y dejar las cosas como están. Nuestras autoridades deben de pensar con seriedad y madurez, y hacer suyas las recomendaciones emanadas de las siete Cumbres Iberoamericanas de Medicina Familiar donde además dela participación de Ministros de Salud, participan representantes de la OMS-OPS, autoridades universitarias y decisores de salud.

Percepción de la visita médica domiciliaria a adultos mayores / Perception of home health care visits in elderly patients

OBJETIVO: describir la percepción de la visita médica domiciliaria realizada a pacientes adultos mayores por la Unidad de Medicina Familiar de la Policlínica Central de la CNS, La Paz Bolivia. METODOLOGÍA: investigación de tipo cualitativa. Médicos familiares (4), trabajadoras sociales (2), bioquímicas farmacéuticas (2), médico residente de medicina familiar de tercer año (1) y auxiliares de enfermería (4) participaron de la visita domiciliaria a pacientes adultos mayores con diferentes problemas de salud crónicos. Se procedió al análisis de narrativas como producto de la observación. RESULTADOS: los participantes manifestaron la importancia de la visita domiciliaria tanto para pacientes como para profesionales. Afirmaron que, el seguimiento del control de salud del paciente fue más cercano y adecuado a la realidad dado que se produce un conjunto de emociones positivas y negativas entre médicos, pacientes y sus familias; y que esta debe ser realizada por un equipo multidisciplinario donde cada profesional tiene un rol. También se resaltó la necesidad de fortalecer esta actividad. CONCLUSIÓN: las visitas médicas domiciliarias generan sentimientos de empatía que son útiles para el seguimiento médico.

OBJECTIVE: to describe the perception ofhome health care visits to elderly patients by family medicine unit in CNS at La Paz, Bolivia. METHODOLOGY: It was conducted a qualitative research. Medical professionals such us family physicians (4), social workers (2), pharmaceutical biochemists (2), third-year medical resident (1) and nursing assistants (4) participated in the home health care visits to elderly patients with chronic health problems. Narratives were elaborated as a product of observation. RESULTS: Physicians expressed the importance of home health care visits for both patients and professionals. They argued that patients follow up were closer and more appropriate to reality, considering the positive and negative feelings produced among doctors, patients and their families. They held visits must be done by a multidisciplinary team where each professional has a role. The need to strengthen this activity was also highlighted. CONCLUSION: home health care visits generate empathy feelings that are useful for medical follow-up.

La investigación en la atención primaria de salud / Research in primary health care

El objetivo fundamental, pero no el único, de la investigación en APS es aprovechar el contacto con la gente para contribuir a aumentar los conocimientos sobre los factores relacionados con la salud, promover estilos de vida saludables y, en consecuencia, alcanzar una mayor independencia (autonomía) respecto a los servicios de salud.

La importancia el análisis de los acontecimientos vitales estresantes en la práctica clínica / The importance of analyzing stressful life events in clinical practice

Por todas las consideraciones precedentemente descritas, el propósito de este artículo es recordar la existencia de múltiples e importantes formas de encuesta y/o cuestionarios sistematizados, destinados a la investigación y análisis de los Acontecimientos Vitales Estresantes (AVE) que pueden afectar al paciente, entre los que destaca la Escala de Holmes - Rahe.