Neural changes following equine-assisted therapy for posttraumatic stress disorder: A longitudinal multimodal imaging study.

BACKGROUND: While effective treatments for posttraumatic stress disorder (PTSD) exist, many individuals, including military personnel and veterans fail to respond to them. Equine-assisted therapy (EAT), a novel PTSD treatment, may complement existing PTSD interventions. This study employs longitudinal neuro-imaging, including structural magnetic resonance imaging (sMRI), resting state-fMRI (rs-fMRI), and diffusion tensor imaging (DTI), to determine mechanisms and predictors of EAT outcomes for PTSD. METHOD: Nineteen veterans with PTSD completed eight weekly group sessions of EAT undergoing multimodal MRI assessments before and after treatment. Clinical assessments were conducted at baseline, post-treatment and at 3-month follow-up. RESULTS: At post-treatment patients showed a significant increase in caudate functional connectivity (FC) and reduction in the gray matter density of the thalamus and the caudate. The increase of caudate FC was positively associated with clinical improvement seen immediately at post-treatment and at 3-month follow-up. In addition, higher baseline caudate FC was associated with greater PTSD symptom reduction post-treatment. CONCLUSIONS: This exploratory study is the first to demonstrate that EAT can affect functional and structural changes in the brains of patients with PTSD. The findings suggest that EAT may target reward circuitry responsiveness and produce a caudate pruning effect from pre- to post-treatment.

Further Comparison of 4 Display Modes for a Multi-Resolution Foveated Laparoscope.

Background. To overcome field of view and ergonomic limitations of standard laparoscopes, we are developing a multi-resolution foveated laparoscope (MRFL), which can simultaneously obtain both wide- and zoomed-in-view images. To facilitate the effectiveness of our MRFL, we have been investigating various ways of organizing and visualizing dual-view multi-resolution images acquired by the MRFL. In our prior study, we implemented and compared 6 display modes for the MRFL, assuming a typical clinical environment where a standard (but limited) resolution monitor is available. To take full advantage of our MRFL, displays having sufficient screen resolutions might be advantageous. The present study aims to further understand the effects of view configurations through displays with a standard high-definition (HD) resolution and a 4K resolution. In this study, we compare 3 display modes for limited-resolution displays against a new mode for sufficient-resolution displays. Methods. Twenty subjects performed 3 evaluation trials of a touching task with each display mode in an emulated MRFL environment. Various objective measurements including task completion time and the number of collisions, and subjective preference were recorded. Results. The new mode showed a better task completion time than the other modes, while it maintained a low number of collisions similar to the others. Moreover, the majority of participants selected the new mode as their most preferred one. Conclusions. With a sufficient display resolution, the co-registration between the unblocked and unwarped wide context view and the high-resolution zoomed-in view offered by the new mode was highly effective on both task performance and user preference.

Comparison of six display modes for a multi-resolution foveated laparoscope.

BACKGROUND: To overcome the field of view and ergonomic limitations of standard laparoscopes, we are developing a multi-resolution foveated laparoscope that can simultaneously obtain both wide- and zoomed-in-view images through a single scope. To facilitate the effective access to the dual views of images with different resolution and field coverage acquired by our laparoscope, six different display modes have been developed. Each of the six display modes has inherent advantages and disadvantages. This study compares the six display modes through a human-subject experiment, which was conducted with an emulated laparoscope using a 4K camera. METHODS: Twenty-four subjects without medicine background performed three evaluation trials of a touching task with each of the display modes. Various objective measurements including task completion time, the number of collisions, gaze position, and tooltip position, and subjective preference for the display modes were recorded. RESULTS: For all the measurements except for task completion time and moving speed of tooltip, there were statistically significant differences among the display modes. Although the focus plus warped context view mode was selected as one of the least preferred modes, it showed the best task performance. CONCLUSIONS: The unblocked wide context view was useful to provide a situational awareness even when it was severely distorted in some of the display modes, and information continuity played an important role in improving task performance. Moreover, the position change of viewing window coupled to the location of region of interest helped improve task performance, by providing an additional cue for spatial awareness.

Feasibility of Air Transport Simulation Training: A Case Series.

Limited clinical site availability and an increased need for clinical training experiences often make it difficult for prehospital health care providers to complete new and annual training requirements. Medical simulation provides an alternative learning environment that provides trainees the opportunity to acquire and perfect new clinical skills without compromising patient care. The following is a detailed description of an air medical transport simulation of a neonate with hypoxic ischemic encephalopathy requiring transport to a higher level of care. Patient parameters were altered during flight to simulate potential complications unique to air medical transport. Use of this training strategy is particularly beneficial for low-volume, high-risk patients, and these lessons can be applied across all age patient groups, making the experience broadly applicable.

Simulation trainer for practicing emergent open thoracotomy procedures.

BACKGROUND: An emergent open thoracotomy (OT) is a high-risk, low-frequency procedure uniquely suited for simulation training. We developed a cost-effective Cardiothoracic (CT) Surgery trainer and assessed its potential for improving technical and interprofessional skills during an emergent simulated OT. MATERIALS AND METHODS: We modified a commercially available mannequin torso with artificial tissue models to create a custom CT Surgery trainer. The trainer's feasibility for simulating emergent OT was tested using a multidisciplinary CT team in three consecutive in situ simulations. Five discretely observable milestones were identified as requisite steps in carrying out an emergent OT; namely (1) diagnosis and declaration of a code situation, (2) arrival of the code cart, (3) arrival of the thoracotomy tray, (4) initiation of the thoracotomy incision, and (5) defibrillation of a simulated heart. The time required for a team to achieve each discrete step was measured by an independent observer over the course of each OT simulation trial and compared. RESULTS: Over the course of the three OT simulation trials conducted in the coronary care unit, there was an average reduction of 29.5% (P < 0.05) in the times required to achieve the five critical milestones. The time required to complete the whole OT procedure improved by 7 min and 31 s from the initial to the final trial-an overall improvement of 40%. CONCLUSIONS: In our preliminary evaluation, the CT Surgery trainer appears to be useful for improving team performance during a simulated emergent bedside OT in the coronary care unit.

Telepresent intubation supervision is as effective as in-person supervision of procedurally naive operators.

BACKGROUND: Telepresence is emerging in clinical and educational settings as a potential modality to provide expert guidance during remote airway management. This study aimed to compare the effectiveness of telepresent versus in-person supervision of tracheal intubation. MATERIALS AND METHODS: A randomized, crossover study was performed in a university medical simulation center with 48 first- and second-year medical students with no formal procedural training in tracheal intubation. Each participant was assigned to receive each of four study arms in random sequence: (1) direct laryngoscopy (DL) with in-person supervision, (2) DL with telepresent supervision, (3) videolaryngoscopy (VL) with in-person supervision, and (4) VL with telepresent supervision. Telepresence was established with a smartphone (Apple [Cupertino, CA] iPhone(®)) via FaceTime(®) connection. The primary outcome measure was the time to successful intubation. Secondary outcome measures included first pass success rate and the number of blade and tube attempts. RESULTS: There was no significant difference between in-person and telepresent supervision for any of the outcomes. The median difference (in-person versus telepresent) for time to intubation was -3 s (95% confidence interval [CI], -20 to 14 s). The odds ratio for first attempt success was 0.7 (95% CI, 0.3-1.3), and the rate ratio for extra number of blade attempts (i.e., attempts in addition to first) was 1.1 (95% CI, 0.7-1.7) and 1.4 (95% CI, 0.9-2.2) for extra number of tube attempts. CONCLUSIONS: In this study population of procedurally naive medical students, telepresent supervision was as effective as in-person supervision for tracheal intubation.

Construction of a reusable, high-fidelity model to enhance extracorporeal membrane oxygenation training through simulation.

Initiation of extracorporeal membrane oxygenation (ECMO) is stressful, especially for inexperienced extracorporeal life support providers. The main objective of this study was to create a novel, reusable mannequin for high-fidelity simulation of ECMO initiation. We modified a Laerdal neonatal mannequin (SimNewB; Stavanger, Norway) so that it could be used to simulate an ECMO initiation. A simulation of a neonatal patient suffering from meconium aspiration was performed in the pediatric intensive care unit, and participants included new extracorporeal life support specialists in addition to the composition of the clinical ECMO team. A total of 17 individuals participated in the neonatal ECMO initiation simulation. Questionnaire results showed that 88% of participants felt better prepared to assist in an ECMO initiation after the simulation. All participants (100%) agreed that the modified mannequin and the environment were realistic and that this simulation helps teamwork and communication in future initiations of ECMO. Simulation can be used for the prevention, identification, and reduction of anxiety-related crisis situations that novice providers may infrequently encounter during routine clinical use of mechanical circulatory support. Use of a reusable, high-fidelity mannequin may be beneficial for effective team training of complex pediatric ECMO-related procedures.

A computerized assessment to compare the impact of standard, stereoscopic, and high-definition laparoscopic monitor displays on surgical technique.

BACKGROUND: Surgeons performing laparoscopic surgery have strong biases regarding the quality and nature of the laparoscopic video monitor display. In a comparative study, we used a unique computerized sensing and analysis system to evaluate the various types of monitors employed in laparoscopic surgery. METHODS: We compared the impact of different types of monitor displays on an individual's performance of a laparoscopic training task which required the subject to move the instrument to a set of targets. Participants (varying from no laparoscopic experience to board-certified surgeons) were asked to perform the assigned task while using all three display systems, which were randomly assigned: a conventional laparoscopic monitor system (2D), a high-definition monitor system (HD), and a stereoscopic display (3D). The effects of monitor system on various performance parameters (total time consumed to finish the task, average speed, and movement economy) were analyzed by computer. Each of the subjects filled out a subjective questionnaire at the end of their training session. RESULTS: A total of 27 participants completed our study. Performance with the HD monitor was significantly slower than with either the 3D or 2D monitor (p < 0.0001). Movement economy with the HD monitor was significantly reduced compared with the 3D (p < 0.0004) or 2D (p < 0.0001) monitor. In terms of average time required to complete the task, performance with the 3D monitor was significantly faster than with the HD (p < 0.0001) or 2D (p < 0.0086) monitor. However, the HD system was the overwhelming favorite according to subjective evaluation. CONCLUSION: Computerized sensing and analysis is capable of quantitatively assessing the seemingly minor effect of monitor display on surgical training performance. The study demonstrates that, while users expressed a decided preference for HD systems, actual quantitative analysis indicates that HD monitors offer no statistically significant advantage and may even worsen performance compared with standard 2D or 3D laparoscopic monitors.

The impact of implementation of a hysterectomy enhanced recovery pathway on anesthetic medication costs.

Aim: To evaluate the effect of implementation of a hysterectomy Enhanced Recovery After Surgery (ERAS) protocol on perioperative anesthetic medication costs. Patients & methods: Historical cohort study of 84 adult patients who underwent a hysterectomy. Forty-two patients who underwent surgery before protocol implementation comprised the pre-ERAS group. Forty-two patients who underwent surgery after protocol implementation comprised the post-ERAS group. Data on anesthetic medication costs and outcomes were analyzed. Results: Compared with the pre-ERAS group, the post-ERAS group's total medication cost was significantly lower (median: 325.20 USD; interquartile range [IQR]: 256.12-430.65 USD vs median: 273.10 USD; IQR: 220.63-370.59 USD, median difference: -40.76, 95% CI: -130.39, 16.99, p = 0.047). Length of stay was significantly longer in pre-ERAS when compared with post-ERAS groups (median: 5.0 days; IQR: 4.0-7.0 days vs median: 3.0 days; IQR: 3.0-4.0 days, median difference: -2.0 days, 95% CI: -2.5581, -1.4419, p < 0.0001). Conclusion: ERAS protocols may reduce perioperative medication costs.

Assessing radiology resident preparedness to manage IV contrast media reactions using simulation technology.

Investigate whether radiology residents make correct diagnosis of contrast media reactions and evaluate their treatment of reaction using simulation technology. Residents were presented with a test scenario of patient given IV contrast having anaphylactic reaction. A computer-run mechanical mannequin that simulates, with mathematical, pharmacokinetic, pharmacodynamic and cardiovascular algorithms, was used. Sessions were evaluated with respect to whether residents performed key actions to treat anaphylaxis. Times were recorded. All residents recognized the contrast reaction and initiated basic actions. As the scenario progressed and patient deteriorated, all recognized need to intubate, but intubation performance varied significantly. Radiology residents generally not prepared to deal with IV contrast reactions. Simulation technology to practice key actions would improve their preparedness.

Case Report of Wernicke's Encephalopathy After Sleeve Gastrectomy.

BACKGROUND: We report a case of a patient who was 3 months post-sleeve gastrectomy and presented with acute stroke symptoms ultimately due to Wernicke's encephalopathy (WE) after bariatric surgery. A 20-year-old white female presented to an outside hospital 3 months after sleeve gastrectomy complaining of nausea and vomiting. She initially underwent a cholecystectomy and later became less responsive and required intubation. Magnetic resonance imaging changes, presumed to be an acute stroke, prompted her transfer to our facility. Intravenous (IV) thiamin was administered, and the patient's symptoms improved over the course of her hospital stay. RESULTS: Thiamin levels were markedly low, and the patient rapidly improved with the administration of IV thiamin. The patient was discharged to inpatient rehabilitation. CONCLUSION: Bariatric surgery is a less common cause of WE but can lead to acute WE due to malabsorption of thiamin. In patients undergoing bariatric surgery, clinicians should be vigilant about the potential for WE to occur. In addition, based on history, WE should be considered in the differential diagnosis for symptoms of acute ischemic stroke.

A novel and inexpensive ballistic gel phantom for ultrasound training.

BACKGROUND: Ultrasonography use is increasing in emergency departments, and ultrasound education is now recommended in resident training. Ultrasound phantoms are used in many institutions for training purposes. The purpose of this study is to describe an inexpensive and simple method to create ultrasound-imaging models for the purpose of education and practice using clear ballistic gel. METHODS: Clear ballistic gel is used to simulate tissue for firing practice and other military evaluations. RESULTS: The transparent and durable ultrasound phantom we produced was clear and contained four vessel lumens. The images obtained using the phantom were of high quality and compared well to normal sonographic anatomy. CONCLUSIONS: The clear ballistic brand gel is unique because it is inexpensive, does not dry out, does not decay, is odorless, and is reusable. The ultrasound images obtained using the phantom are realistic and useful for ultrasound education.

Efficacy of antimicrobial-impregnated external ventricular drain catheters: a prospective, randomized, controlled trial.

OBJECT: Catheter-related infection of the cerebrospinal fluid (CSF) pathways is a potentially life-threatening complication of external ventricular drainage. A major source of infection is bacterial contamination along the external ventricular drain (EVD) catheter track. The authors examined the efficacy of EVD catheters impregnated with minocycline and rifampin in preventing these catheter-related infections. METHODS: The authors conducted a prospective, randomized clinical trial at six academic medical centers. All hospitalized patients 18 years or older who required placement of an EVD catheter were eligible for inclusion in the study. Patients were randomly assigned to undergo placement of an EVD with a catheter impregnated with minocycline and rifampin or a standard untreated catheter (control group). To assess primary outcome, CSF samples were collected using a sterile technique at the time of catheter insertion, at least every 72 hours while the catheter remained in place, and at the time of catheter removal. At the time of removal, CSF cultures were obtained from the tip and tunneled segments of each catheter by performing semiquantitative roll-plate and quantitative sonication techniques. Of the 306 patients enrolled in the study, data from 288 were included in the final analysis. Eighteen patients were excluded from analysis: 14 because the ventricular catheter was in place less than 24 hours, and four because CSF cultures obtained at the time of catheter insertion were positive for infection. Of these 288 patients, 139 were assigned to the control group and 149 to the treatment group. The two groups were well matched with respect to all clinical characteristics, including patient sex and mean age, indication for catheter placement, and length of time the catheter remained in place. The antibiotic-impregnated catheters were one half as likely to become colonized as the control catheters (17.9 compared with 36.7%, respectively, p < 0.0012). Positive CSF cultures were seven times less frequent in patients with antibiotic-impregnated catheters compared with those in the control group (1.3 compared with 9.4%, respectively, p = 0.002). CONCLUSIONS: The use of EVD catheters impregnated with minocycline and rifampin can significantly reduce the risk of catheter-related infections.

Evaluation of a navigation grid to increase the efficacy of instrument movement during laparoscopic surgery.

INTRODUCTION: The objective of this study was to determine whether or not a navigation grid (NG) with a coordinate system overlaid on a laparoscopic display might allow attending surgeons to more easily and precisely direct their assistants' instruments to specific sites in a simulated laparoscopic field. MATERIALS AND METHODS: In this randomized, crossover study, we evaluated the impact of the NG on an individual's performance in a target identification task. One hundred thirty pins served as targets in a standard laparoscopic box trainer. An instructor guided 30 naive subjects to locate five randomly selected targets each, either with verbal instructions alone or with verbal instructions supplemented by a localizing NG. The NG appeared on both the instructor's and the participants' monitors, but the randomly selected targets were visible only to the instructor. Each participant performed 10 trials alternating between with and without the NG. The outcome measure was the interval (in seconds) from when the laparoscopic instrument was first visible in the field to when the subject grasped the correct target with forceps. RESULTS: The mean time to identify each selected target was significantly shorter with the NG (9.150±3.43 seconds) than without (12.53±4.89 seconds) (P<.0001). This effect was sustained throughout the learning curve. CONCLUSIONS: The use of the NG appears to improve efficiency in guiding an instrument to randomly identified targets within a laparoscopic field. The use of an NG may reduce the time required to move instruments to specific sites during surgery.

The effect of age on acquiring laparoscopic skills.

BACKGROUND AND PURPOSE: Laparoscopic surgery is well known as having a long and variable learning curve. In fact, successive generations of surgeons were able to reduce their operative time and plateau their learning curves. This raises the question as to how early in medical education we can integrate laparoscopic skills. In this study, we are trying to demonstrate the effect of age on acquiring new laparoscopic skills. METHODS: Thirty-two trainees at various educational levels and ages were recruited to our study. Trainees were divided into four age groups with eight persons in each group. Senior high school students, undergraduate college students, medical students, and junior surgery residents comprised the first, second, third, and the fourth groups, respectively. The trainees performed nine inanimate laparoscopic tasks in the laparoscopic training box and repeated each task five times. The time needed for each trial was recorded, and the results were statistically analyzed. RESULTS: The youngest group of trainees showed the largest improvement in performance time, followed by the second and third groups. The most senior group showed the least improvement. CONCLUSION: These preliminary data suggest that younger trainees are faster to acquire new laparoscopic skills than the older persons. This finding suggests a potential benefit from earlier integration of laparoscopic skills in medical education.