Using apprenticeship communication flow as an ergonomic design input for future OR systems

Removing the gallbladder is a relatively simple laparoscopic operation. Tissue trauma, caused by laparoscopic cholecystectomy, is usually minimal. Misidentifying the cystic duct and artery and the common hepatic duct represents the most severe complication. However, the Critical View of Safety (CVS) technique reduces the risk of trauma, by accomplishing a safe 360° identification of the cystic duct origin at the gallbladder neck [5]. This technique is employed and trained at the Erasmus Medical Centre (EMC), Rotterdam, The Netherlands.

?This study presents the potential value of a training device which residents can use during practice. This training device must cover both user friendliness and information supply. The current information supply was studied subjectively; the CVS protocol and the users' experience were studied both objectively and subjectively. The results of these studies show that the present information supply is not satisfactory, that there is a CVS protocol which can be easily used in a training device, and that most actions defining the cystic duct during operation revert on users' experience. Therefore, it is desirable to design a new training device according to the experience of the target group and the protocols, and taking into account an optimal human‐product interaction.     

The effect of cooling on muscle co-ordination in spasticity: assessment with the repetitive movement test

Purpose: Cooling muscles might produce a temporary reduction of spasticity. This study investigated muscle coordination in spasticity under the influence of cooling. Methods: A repetitive movement (RM-) test of the ankle was used, while measuring the angle and surface-electromyography (EMG) of the m. tibialis anterior and m. triceps surae. Ensemble averaging provided quantified measures of muscle activation. Sixteen patients with spasticity in their lower extremity due to stroke or spinal cord injury participated in the study. Physical examination and the RM-test was done before and after cooling the m. triceps surae for 20 minutes by coldpacks. Results: The results show that Achilles hyperreflexia and clonus were abolished in all, and all but one patient, respectively. The EMG of the m. triceps surae, acting as a prime mover, was increased (p 0.028). However, this improved muscle coordination resulted in just a slightly increased active range of motion (less than 2 degrees at p 0.049). Conclusion: Apparently, the increase in excitability of the alpha motoneuron pool in voluntary movements of patients with spasticity is not followed by an improvement in the ability to move.     

High-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation for severe multiple sclerosis

There were 26 patients enrolled in a pilot study of high-dose immunosuppressive therapy (HDIT) for severe multiple sclerosis (MS). Median baseline expanded disability status scale (EDSS) was 7.0 (range, 5.0-8.0). HDIT consisted of total body irradiation, cyclophosphamide, and antithymocyte globulin (ATG) and was followed by transplantation of autologous, granulocyte colony-stimulating factor (G-CSF)-mobilized CD34-selected stem cells. Regimen-related toxicities were mild. Because of bladder dysfunction, there were 8 infectious events of the lower urinary tract. One patient died from Epstein-Barr virus (EBV)-related posttransplantation lymphoproliferative disorder (PTLD) associated with a change from horse-derived to rabbit-derived ATG in the HDIT regimen. An engraftment syndrome characterized by noninfectious fever with or without rash developed in 13 of the first 18 patients and was associated in some cases with transient worsening of neurologic symptoms. There were 2 significant adverse neurologic events that occurred, including a flare of MS during mobilization and an episode of irreversible neurologic deterioration after HDIT associated with fever. With a median follow-up of 24 (range, 3-36) months, the Kaplan-Meier estimate of progression (>/= 1.0 point EDSS) at 3 years was 27%. Of 12 patients who had oligoclonal bands in the cerebrospinal fluid at baseline, 9 had persistence after HDIT. After HDIT, 4 patients developed new enhancing lesions on magnetic resonance imaging of the brain. The estimate of survival at 3 years was 91%. Important clinical issues in the use of HDIT and stem cell transplantation for MS were identified; however, modifications of the initial approaches appear to reduce treatment risks. This was a heterogeneous high-risk group, and a phase 3 study is planned to fully assess efficacy.