See (n)One, Do (n)One, Teach (n)One: Reality of Surgical Resident Training in Germany.

INTRODUCTION: Due to technological changes, working time restrictions and the creation of specialized centers, surgical training has changed. A competence-based learning technique of surgical skills is the sub-step practice approach, which has been proven important in nationwide opinion surveys. The aim of this prospective multi-center trial was to determine the status quo of the sub-step concept in Germany. METHODS: Over 6 months, the voluntarily participating centers evaluated the following index procedures: laparoscopic cholecystectomy (LCHE), laparoscopic and open sigmoid resection, minimally invasive inguinal hernia repair, thyroid resection and pylorus-preserving pancreaticoduodenectomy (PPPD). Patients with private insurance were excluded. The detailed sub-steps were documented as well as the reason why these were not performed. In addition, an online survey regarding the sub-step concept was performed before and after the study. RESULTS: In total, 21 centers included 2969 surgical procedures in 2018 for final analyses. While 24.4% of the procedures were performed by residents, sub-steps were performed in 22.2%. LCHE was most often performed completely by residents (43.3%), and PPPD revealed the highest rate of performed sub-steps (43.3%). Reasons for not assisting sub-steps to residents were often organizational and other reasons. After an initial increase, the number of performed sub-steps decreased significantly during the second half of the survey. The opinion survey revealed a high importance of the sub-step concept. The number of resident procedures was overestimated, and the number of performed sub-steps was underestimated. After the study, these estimations were more realistic. CONCLUSION: Even though the sub-step practice concept is considered highly important for surgical education, it needs to be put into practice more consequently. The current data suggest a low participation of surgical residents in the operating room, although the participating hospitals are most likely highly interested in surgical education, hence their voluntary participation. Conceptual changes and a control of surgical education are needed.

Recommendations for Improving Consistency in the Radiation Fields Used During Testing of Radiation Detection Instruments for Homeland Security Applications.

Several measurements and calculations were performed to illustrate the differences that can be observed in the determination of exposure rate or ambient dose equivalent rate used for testing radiation detection systems against consensus standards. The large variations observed support our recommendation that better consistency in the test radiation fields can be achieved by specifying the source activity and testing distance instead of the field strength.

Calibration of Traceable Solid Mock (131)I Phantoms Used in an International SPECT Image Quantification Comparison.

The International Atomic Energy Agency (IAEA) has organized an international comparison to assess Single Photon Emission Computed Tomography (SPECT) image quantification capabilities in 12 countries. Iodine-131 was chosen as the radionuclide for the comparison because of its wide use around the world, but for logistical reasons solid (133)Ba sources were used as a long-lived surrogate for (131)I. For this study, we designed a set of solid cylindrical sources so that each site could have a set of phantoms (having nominal volumes of 2 mL, 4 mL, 6 mL, and 23 mL) with traceable activity calibrations so that the results could be properly compared. We also developed a technique using two different detection methods for individually calibrating the sources for (133)Ba activity based on a National standard. This methodology allows for the activity calibration of each (133)Ba source with a standard uncertainty on the activity of 1.4 % for the high-level 2-, 4-, and 6-mL sources and 1.7 % for the lower-level 23 mL cylinders. This level of uncertainty allows for these sources to be used for the intended comparison exercise, as well as in other SPECT image quantification studies.

Sodium current properties of primary skeletal myocytes and cardiomyocytes derived from different mouse strains.

The mouse has become the preferred animal for genetic manipulations. Because of the diverse genetic backgrounds of various mouse strains, these can manifest strikingly different characteristics. Here, we studied the functional properties of currents through voltage-gated sodium channels in primary cultures of skeletal myocytes and cardiomyocytes derived from the three commonly used mouse strains BL6, 129/Sv, and FVB, by using the whole-cell patch-clamp technique. We found strain-specific sodium current function in skeletal myocytes, which could partly be explained by differences in sodium channel isoform expression. In addition, we found significant effects of cell source (neonatal or adult animal-derived) and variation of the differentiation time period. In contrast to skeletal myocytes, sodium current function in cardiomyocytes was similar in all strains. Our findings are relevant for the design and proper interpretation of electrophysiological studies, which use excitable cells in primary culture as a model system.

An intercomparison of Monte Carlo codes used in gamma-ray spectrometry.

In an intercomparison exercise, the Monte Carlo codes most commonly used in gamma-ray spectrometry today were compared with each other in order to gauge the differences between them in terms of typical applications. No reference was made to experimental data; instead, the aim was to confront the codes with each other, as they were applied to the calculation of full-energy-peak and total efficiencies. Surprising differences between the results of different codes were revealed.

PIECEWISE POLYNOMIAL APPROXIMATIONS TO THE ICRP 116 EFFECTIVE DOSE COEFFICIENTS: PHOTONS AND NEUTRONS.

We present fitting equations for estimating effective dose per unit fluence at any photon energy between 10 keV and 10 GeV and any neutron energy between 0.001 eV and 10 GeV. These new equations are based on the latest radiation protection quantities for external radiation exposure found in International Commission on Radiological Protection (ICRP) Publication 116 and incorporate the latest definition of effective dose as described in ICRP Publication 103. The ICRP 116 dose coefficients were fit to piecewise polynomial functions. A total of 8 irradiation geometries were considered: the six in ICRP 116 and two additional geometries presented elsewhere in the literature. The fitting functions generally reproduce the ICRP 116 data to within 3% or better. The functions were used to modify the Monte Carlo N-Particle radiation transport code version 6 (MCNP6) and were applied to a sample problem. The results are intended to be used as a basis for revising the American National Standards Institute/American Nuclear Society 6.1.1-1991 standard.

Stepping boundary of external force-controlled perturbations of varying durations: Comparison of experimental data and model simulations.

This study investigated the stepping boundary - the force that can be resisted without stepping - for force-controlled perturbations of different durations. Twenty-two healthy young adults (19-37 years old) were instructed to try not to step in response to 86 different force/time combinations of forward waist-pulls. The forces at which 50% of subjects stepped (F50) were identified for each tested perturbation durations. Results showed that F50 decreased hyperbolically when the perturbation's duration increased and converged toward a constant value (about 10%BW) for longer perturbations (over 1500 ms). The effect of perturbation duration was critical for the shortest perturbations (less than 1 s). In parallel, a simple function was proposed to estimate this stepping boundary. Considering the dynamics of a linear inverted pendulum + foot model and simple balance recovery reactions, we could express the maximum pulling force that can be withstood without stepping as a simple function of the perturbation duration. When used with values of the main model parameters determined experimentally, this function replicated adequately the experimental results. This study demonstrates for the first time that perturbation duration has a major influence on the outcomes of compliant perturbations such as force-controlled pulls. The stepping boundary corresponds to a constant perturbation force-duration product and is largely explained by only two parameters: the reaction time and the displacement of the center of pressure within the functional base of support. Future work should investigate pathological populations and additional parameters characterizing the perturbation time-profile such as the time derivative of the perturbation.

Behavioral outcomes following below-knee amputation in the coordination between balance and leg movement.

Lateral leg movement is accompanied by opposite movements of the supporting leg and trunk segments. This kinematic synergy shifts the center of mass (CM) towards the supporting foot and stabilizes its final position, while the leg movement is being performed. The aim of the present study was to provide insight in the behavioral substitution process responsible for the performance of this kinematic synergy. The kinematic synergy was assessed by the principal component analysis (PCA) applied to both hip joints and supporting ankle joint. Patients after unilateral below-knee amputation and control subjects were asked to perform a lateral leg raising. The first principal component (PC(1)) accounted for more than 99% of the total angular variance for all subjects (amputees and controls). PC(1) thus well represents the possibility to describe this complex multi-joint movement as a one degree of freedom movement with fixed ratios between joint angular time course. In control subjects, the time covariation between joints changes holds during all phases of the leg movement (postural phase, ascending and braking phases). In amputees, PC(1) score decreased during the ascending phase of the movement (i.e. when the body weight transfer is completed, while the movement is initiated). We conclude that a feedback mechanism is involved and discuss the hypothesis that this inter-joint coordination in amputees results from a failure in the pre-setting of the inter-joint coupling.

Kinematic features of whole-body reaching movements underwater: Neutral buoyancy effects.

Astronauts' training is conventionally performed in a pool to reproduce weightlessness by exploiting buoyancy which is supposed to reduce the impact of gravity on the body. However, this training method has not been scientifically validated yet, and requires first to study the effects of underwater exposure on motor behavior. We examined the influence of neutral buoyancy on kinematic features of whole-body reaching underwater and compared them with those produced on land. Eight professional divers were asked to perform arm reaching movements toward visual targets while standing. Targets were presented either close or far from the subjects (requiring in the latter case an additional whole-body displacement). Reaching movements were performed on land or underwater in two different contexts of buoyancy. The divers either wore a diving suit only with neutral buoyancy applied to their center of mass or were additionally equipped with a submersible simulated space suit with neutral buoyancy applied to their body limbs. Results showed that underwater exposure impacted basic movement features, especially movement speed which was reduced. However, movement kinematics also differed according to the way buoyancy was exerted on the whole-body. When neutral buoyancy was applied to the center of mass only, some focal and postural components of whole-body reaching remained close to land observations, notably when considering the relative deceleration duration of arm elevation and concomitant forward trunk bending when reaching the far target. On the contrary, when neutral buoyancy was exerted on body segments, movement kinematics were close to those reported in weightlessness, as reflected by the arm deceleration phase and the whole-body forward displacement when reaching the far target. These results suggest that astronauts could benefit from the application of neutral buoyancy across the whole-body segments to optimize underwater training and acquire specific motor skills which will be used in space.

Are human anticipatory postural adjustments affected by a modification of the initial position of the center of gravity?

During a lateral leg raising task, the position of the center of gravity (CG) in the horizontal plane shifts towards the supporting leg prior to the movement onset. The aim of this study was to explore whether the anticipatory postural adjustments were calibrated as a function of the initial horizontal location of the CG. Experiments were performed on 8 healthy subjects, with three initial positions of the CG (close to the supporting leg, between the two legs, close to the moving leg). Simultaneous kinematic, kinetic and electromyographic (EMG) data were recorded with the ELITE. system. The results show that the duration of the kinetic variables and EMG pattern are scaled as a function of the distance covered by the CG and constitute the means of modulating the CG shift. They suggest that the evaluation of the support conditions is necessary to calibrate the CG shift, this is done during the early phase of the postural adjustments.

Arthroscopic treatment of anterior ankle impingement.

Ankle arthroscopy has recently allowed the elaboration of less invasive techniques for the treatment of anterior impingement. Its indications, advantages, and drawbacks in this application are discussed. Between 1987 and 1994, 133 patients were treated for ankle impingement. Among them, 58 patients, 37 men and 21 women (mean age, 28.5 years), who had failed a trial of conservative treatment were treated by means of tibiotalar arthroscopy. Twenty-seven were athletes engaged in sports with abnormal stressing of the ankle. According to McDermott's radiological classification, there were 15 stage I cases, 23 stage II, 13 stage III, and 7 stage IV. Preoperative evaluation with a modified version of McGuire's scoring system gave 50 cases rated as "poor" (< 60 points) and 8 cases rated as "fair" (60-67 points). Treatment consisted of removal of adhesions, cartilage shaving, and removal of the bone impingement with powered instruments, curettes, or small osteotomes. Follow-up was from 8 to 62 months (mean, 21.5 months). The postoperative McGuire ratings were 37 good, 13 fair, and 8 poor. There were no major complications. Recurrence of impingement was observed in four cases of stage III and IV. The conclusion is drawn that ankle arthroscopy is a sound method for the treatment of anterior impingement. Even in cases with severe joint cartilage impairment, it plays a therapeutic role as a means of postponing a possible arthrodesis.

Extra-articular localized nodular synovitis (giant cell tumor of tendon sheath origin) attached to the subtalar joint.

A large soft tissue mass of the left ankle was documented by ultrasonography in a 24-year-old man. Histologic examination of biopsy samples was consistent with pigmented villonodular synovitis. Magnetic resonance, performed to establish the extension of the mass, revealed an extra-articular lesion involving the posteromedial extra-articular soft tissues, which, by means of a thin peduncle, extended into the subtalar joint space. The mass was excised; gross and microscopic examinations were characteristic of localized nodular synovitis. Bone and cartilage abnormalities were not revealed by either preoperative imaging or surgery. At 15-month follow-up, the patient was free of recurrences. This case is an uncommon example of localized nodular synovitis of the subtalar joint, characterized by the absence of bone and articular cartilage abnormalities. In addition, this case reveals that the pattern of growth (i.e., the shape of the lesion) is an important factor in determining secondary lesions of bone and cartilage.

Equilibrium and movement control strategies in trans-tibial amputees.

This study was aimed at identifying changes in equilibrium and movement control strategies in trans-tibial amputees (TTA) related to both the biomechanical changes and the loss of afferent inflow. The coordinations between equilibrium and movement were studied in traumatical TTA and in controls during transition from bipedal to monopodal stance. TTA failed to perform the task in a high percentage of trials both when the sound and the prosthetic limb were supporting. Significant differences were also found between TTA and controls in the duration of the weight transfer phase, in the length of the initial centre of pressure (CP) displacement and in the electromyographic (EMG) patterns. Despite adaptive posturomotor control strategies, transition from bipedal to monopodal stance remains a difficult task to perform for TTA, both when the supporting limb is the affected one and when the sound one is. The results of this study are discussed with respect to the rehabilitation programme and the prosthesis design for transtibial amputees.

[Discharge and transfer management]. / Entlassungs- und Überleitungsmanagement.

The demographic changes together with the increasingly shorter duration of hospital stays are leading to changes in the current health care systems. Not least due to statutory requirement for an assured access to post-hospital health care, the discharge or, respectively, medical transfer management accordingly represent an increasingly important component of hospital routine and should thus help to avoid health-care gaps in the post-hospital periods.A successful discharge management is characterised by the interdisciplinary cooperation of several professions. It is thus necessary to understand as such the issues at stake and the differing concepts. A successful discharge management ensures the success of surgical treatment and in the meantime has also emerged as a showcase for the respective department of hospital. In future it will only be possible to combine high quality medicine with economic interests and competitiveness with the help of a qualitatively high class discharge or, respectively, medical transfer management. The present article is intended to provide an overview of the possible concepts in the files of discharge/medical transfer management and also to illustrate the steps and structures necessary for the successful discharge of the patient.

Development of a calibration methodology for large-volume, solid 68Ge phantoms for traceable measurements in positron emission tomography.

We have developed a methodology to calibrate the (68)Ge activity concentration in large (9L) cylindrical epoxy phantoms in a way that is traceable to national standards. The method was tested on two prototype cylindrical phantoms that are being used in a clinical trial and gave (68)Ge activity concentration values with combined standard uncertainties of about 1.1%. Imaging data from the phantoms using a calibrated PET-CT scanner gave values consistent with the calibrated activity concentrations within experimental uncertainties.

Circulatory effects of apnoea in elite breath-hold divers.

AIM: Voluntary apnoea induces several physiological adaptations, including bradycardia, arterial hypertension and redistribution of regional blood flows. Elite breath-hold divers (BHDs) are able to maintain very long apnoea, inducing severe hypoxaemia without brain injury or black-out. It has thus been hypothesized that they develop protection mechanisms against hypoxia, as well as a decrease in overall oxygen uptake. METHODS: To test this hypothesis, the apnoea response was studied in BHDs and non-divers (NDs) during static and dynamic apnoeas (SA, DA). Heart rate, arterial oxygen saturation (SaO(2)), and popliteal artery blood flow were recorded to investigate the oxygen-conserving effect of apnoea response, and the internal carotid artery blood flow was used to examine the mechanisms of cerebral protection. RESULTS: The bradycardia and peripheral vasoconstriction were accentuated in BHDs compared with NDs (P < 0.01), in association with a smaller SaO(2) decrease (-2.7% vs. -4.9% during SA, P < 0.01 and -6% vs. -11.3% during DA, P < 0.01). Greater increase in carotid artery blood flow was also measured during apnoea in BHDs than in controls. CONCLUSION: These results confirm that elite divers present a potentiation of the well-known apnoea response in both SA and DA conditions. This response is associated with higher brain perfusion which may partly explain the high levels of world apnoea records.

CT arthrography and arthroscopy in chronic glenohumeral joint instability.

The authors evaluate the value of CT arthrography in glenohumeral joint instability. A study was conducted on a group of 16 patients with recurrent dislocation of the shoulder. All patients underwent CT arthrography and arthroscopy. The diagnostic accuracy of CT arthrography was rated for different types of lesions on the basis of arthroscopic confirmation of its findings. Our results, which include a statistical analysis, showed a diagnostic accuracy of 97.3% in Bankart lesions and 100% in Hill-Sachs lesions and loose bodies. Dilation of the subscapular bursa and injury of the glenoid labrum-IGHL complex were often identified, while chondritis and synovitis were less frequently diagnosed. The authors therefore conclude that CT arthrography may be considered an extremely reliable diagnostic test for obtaining an overall picture of injuries due to instability. Arthroscopy, on the other hand, should be reserved for cases in which surgery may be performed in the same stage as diagnosis.

Postural reorganization of weight-shifting in below-knee amputees during leg raising.

The position of the center of gravity (CG) is a reference value that is controlled by the nervous system during the performance of movements. In order to maintain equilibrium, leg movement is preceded by a shift of the CG towards the supporting side. This CG shift is initiated by an early displacement of the center of pressure (CP) towards the moving leg. This characteristic CP thrust partly results from the activity of a distal muscle in the leg to be moved: the gastrocnemius medialis (GM). The aim of this study was to determine how this weight-shifting is initiated when the distal muscles are missing, as in amputees, and to identify any change in the central command. Experiments were performed on ten subjects: five below-knee amputees with no pathology and five control subjects. While standing, the subjects were instructed to raise one leg laterally as fast as possible to an angle of 45 degrees and to maintain the final position. The same weight-shifting strategy was used by both groups, whereas local adaptations associated with the behavior occurred. When the GM is lacking, an early tensor-fasciae-latae (TFL) burst is observed just prior to and associated with the onset of the lateral CP change. This moving-leg abductor may be responsible for initiating the thrust at a proximal level when that leg is still on the ground. In addition, upon analyzing the lateral displacement of the CP, two modes of CP shift were detected. The first CP-shift mode has been previously described and the second mode (which we term here the pre-pushing mode) was used by both amputees and controls. The prepushing mode consisted of two thrusts: an early thrust onto the ground was exerted by the leg about to become the supporting leg followed by the previously described thrust exerted by the leg about to be raised. The early thrust, which could be exerted by either the sound or prosthetic leg, may have increased the efficiency of the second, classical thrust by initiating a swing.