Surgical robotics and laparoscopic training drills

PURPOSE: We investigated the impact of robotics on surgical skills by comparing traditional laparoscopy with the da Vinci Surgical System in the performance of various laparoscopic training drills. SUBJECTS AND METHODS: Twenty-one surgeons performed eight timed drills of increasing difficulty with a laparoscopic trainer and the da Vinci Surgical System (Intuitive Surgical Sunnyvale, CA). The mean time to drill completion, drill time variance, and statistical analysis were performed. Surgeons were also questioned about their perception of the robotic technology following completion of the drill series. RESULTS: The mean time required to complete the first drill was 69 seconds with laparoscopy and 57 seconds with the robotic system. The mean times for drill two were 67 seconds with laparoscopy and 44 seconds with robotics; for drill three, the times were 88 seconds for laparoscopy and 61 seconds for robotics, and for drill four, 186 seconds with laparoscopy and 71 seconds with robotics. Only the first drill failed to show a statistically significant difference between the laparoscopic and robotic groups. CONCLUSIONS: The robotic system allowed surgeons to complete drills faster than traditional laparoscopy. Novice laparoscopic surgeons performed three of the four drills faster robotically than did expert laparoscopic surgeons. These findings may indicate that the attributes of the robotic system level the playing field between surgeons of different skill levels. The next generation of surgeons must focus on this evolving technology and its application in the operating room of the future.     

Hypertension: pathophysiology and treatment

Arterial hypertension is a major cause of morbidity and mortalitybecause of its association with coronary heart disease, cerebrovasculardisease and renal disease. The extent of target organ involvement(i.e. heart, brain and kidneys) determines outcome. North Americanstudies have shown that hypertension is a major contributorto 500 000 strokes (250 000 deaths) and 1 000 000 myocardialinfarctions (500 000 deaths) per annum.     

The surgical hypertensive patient

We reviewed the pathophysiology and treatment of hypertensionin a recent edition of this journal (see key references). Inthis article, we discuss the management of the hypertensivepatient presenting for surgery and anaesthesia.     

Oncologic outcomes of primary lymphoma of bone in adults

A retrospective analysis of adult patients who had lymphomatous involvement of bone was done to evaluate the prognostic factors and the oncologic outcome. Between 1984 and 1994, 28 patients (nine women and 19 men) were diagnosed with lymphoma of bone. The median age was 45 years (range, 23-76 years). The median followup was 40.3 months (range, 0.5 months-15.8 years). Eighteen patients (64%) were classified as having Stage IE disease, two patients (36%) were classified as having stage II disease, and eight patients were classified as having Stage IV disease. Twenty-one of the lesions were classified as diffuse large B cell with multilobulated nuclei. Two patients had local recurrence. Three patients had osteonecrosis develop at the site of their radiation therapy. The 5-year Kaplan-Meier survival estimate was 57.8% (95% confidence interval range, 40-33 82.8). Statistically improved survival was seen in patients younger than 40 years and those patients with diffuse large B cell with multilobulated nuclei. Patients with primary lymphoma of bone did not have a statistically improved survival compared with patients with systemic disease. The results of the current study suggest that age at diagnosis and histologic subtypes are important prognostic factors; however, the diagnosis of primary lymphoma of bone does not confer improved prognosis.     

Rosai-Dorfman disease manifesting as a solitary lesion of the radius in a 41-year-old woman

Rosai-Dorfman disease is a rare entity predominantly affecting children and young adults, characterized in 83-95% of cases by painless bilateral cervical lymphadenopathy. We report the unusual case of a 41-year-old woman with Rosai-Dorfman disease that presented as a solitary lesion of the radius without other clinical manifestations.     

Home apnea monitor use in preterm infants discharged from newborn intensive care units

PURPOSE: To identify current factors associated with home apnea monitor use in preterm infants and to determine whether home monitor use was associated with a shorter length of hospital stay. SETTING: We evaluated neonates who were < or =34 weeks' estimated gestational age and admitted for neonatal intensive care. We excluded neonates with congenital anomalies, neonates transferred out before discharge, and neonates who died. METHODS: Using a database created with a computer-assisted tool that generates hospital notes, we reviewed the epidemiology of monitor use. Differences between neonates sent home with an apnea monitor and those who were not were evaluated by using stepwise logistic regression analysis to identify which factors were independently associated with a neonate being discharged with a monitor. RESULTS: We studied 14,532 neonates; 1588 (11%) were sent home with monitors and 12,944 (89%) were not. The most important variables associated with being discharged with a monitor were site of care and a diagnosis of apnea. Site variation remained significant when adjusted for gestational age, diagnosis of apnea, and a history of use of methylxanthines. When corrected for gestational age, monitor use was not associated with shorter hospital stays. CONCLUSION: The data suggest that monitor use is more dependent on physician preference than medical indication and is not associated with earlier hospital discharge.     

Survey on the usefulness of trazodone in patients with PTSD with insomnia or nightmares

BACKGROUND: Trazodone is commonly used in the treatment of insonmia and nightmares in patients with PTSD. There is little evidence in the literature for this practice. METHOD: Seventy-four patients from the Palo Alto Veterans Affairs Health Care System in California who were admitted to a specialized 8 week inpatient treatment program for PTSD were surveyed regarding their use of trazodone in the treatment of insomnia or nightmares. Patients were asked to complete a questionnaire regarding trazodone's effectiveness, side effects, and optimal doses. RESULTS: Of 74 patients surveyed, 60 patients were able to maintain an effective dose of trazodone. The other 14 patients were unable to tolerate the medication. Seventy-two percent of the 60 patients assessed found trazodone helpful in decreasing nightmares, from an average of 3.3 to 1.3 nights per week (p<.005). Ninety-two percent found it helped with sleep onset, and 78% reported improvement with sleep maintenance. There was a significant correlation between the effectiveness in decreasing nightmares and improving sleep (r= .57, p < .005). The effective dose range of trazodone for 70% of patients was 50 to 200 mg nightly. Of the 74 patients surveyed, 9 (12%) reported priapism. CONCLUSION: Trazodone appears effective for the treatment of insomnia and nightmares associated with chronic PTSD. However, controlled trials are needed before any definite conclusions can be drawn. The higher than expected occurrence of priapism warrants clinicians asking directly about this side effect.     

Influence of caloric restriction on the development of atherosclerosis in nonhuman primates: progress to date

Caloric restriction (CR) has been observed to retard aging processes and extend the maximum life span in rodents. In an effort to evaluate the effect of this nutritional intervention on physiologic variables in higher species, several nonhuman primate trials are ongoing. In particular, a study evaluating the independent effect of CR on the extent of atherosclerosis was initiated in 1993 in 32 adult cynomolgus monkeys. Therefore, the trial was designed to achieve identical cholesterol intake after animals were randomized to a control group or a calorie-restricted group (30% reduction from baseline caloric intake). The animals were routinely evaluated for glycated proteins, plasma insulin and glucose levels, insulin sensitivity, and specific measures for abdominal fat distribution by CT scans over a 4-year interval. The results from 4 years of intervention demonstrate that CR improves cardiovascular risk factors (such as visceral fat accumulation) and improves insulin sensitivity. In contrast to other primate studies with normolipidemic animals, CR had no independent effects on plasma lipid levels and composition in the presence of equivalent amounts of dietary cholesterol intake. Preliminary analysis of atherosclerotic lesion extent in the abdominal aorta has failed to demonstrate differences between control animals and CR animals. Follow- up studies are being conducted to determine the effect of CR on atherosclerosis extent in coronary and carotid arteries.      

Inherited disorders of 3-methylcrotonyl CoA carboxylation

The clinical course of 4 patients who had reduced activities of 3-methylcrotonyl CoA carboxylase (also called 3-methylcrotonylglycinuria) is described. Two children presented with a metabolic acidosis, one in the neonatal period and the other with episodes of acidosis that started in the second year of life. In the other 2 children neurological symptoms were prominent, one having infantile spasms and the other developmental regression with a skin rash and alopecia. Three of the children responded well to oral biotin and dietary protein restriction but the fourth, despite a biochemical response to biotin, has a severe neurological handicap. The clinical presentation of inborn errors of 3-methylcrotonyl CoA carboxylase is variable. Metabolic acidosis may not be conspicuous and instead neurological features may predominate.