Vaginoplasty: modified McIndoe using xenograft and a tailored 3D-printer mold.

INTRODUCTION AND HYPOTHESIS: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is the congenital absence of the vagina with variable uterine development. Different methods have been reported for vaginoplasty treatment. The preferred vaginal approach to treating this condition is usually McIndoe vaginoplasty supported by regular dilatation of the neovagina. We present a case video of a McIndoe modified vaginoplasty technique with a heterologous graft using a covering customized 3D-printed mold, its postoperative follow-up and postoperative complications. METHODS: Video presentation of a McIndoe modified vaginoplasty technique using porcine intestinal submucosa performed in a 18-year-old woman diagnosed with MRKH syndrome. Different sizes of a polylactic acid mold were manufactured with 3D printers. After dissection of the recto-vesical space, a mold tailored in terms of length and width was chosen for this patient. RESULTS: After 13 days of follow-up, the patient presented graft infection and subsequent total graft detachment. However, the patient continued to use the vaginal dilator permanently. After 7 months, 8 cm vaginal length with 90% epithelialization and satisfactory sexual intercourse were achieved. CONCLUSION: Functional, histological and anatomical results were reached despite the graft detachment. New technologies such as 3D printing facilitate the development of techniques using tailored molds.

Transvesical laparoscopy for bladder leiomyoma excision: a novel surgical technique.

INTRODUCTION AND HYPOTHESIS: Leiomyomas of the urinary bladder are rare tumors. Submucosal leiomyomas, when small and easily accessible, can be treated with transurethral resection, while unfavorably positioned or larger leiomyomas may be treated through an abdominal approach. In these cases, a laparoscopic approach for intravesical surgery is an alternative that may be considered. We aim to demonstrate a novel transvesical laparoscopic approach to bladder leiomyoma excision with a video. METHODS: A 45-year-old woman with urinary symptoms and a 40-mm submucosal bladder leiomyoma located at the interureteric ridge was referred to our hospital (tertiary referral hospital). Due to the location and size of the leiomyoma, and to increase the probability of complete resection, a transvesical laparoscopic approach was decided. A step-by-step video is presented to describe the surgical technique. RESULTS: There were no intra- or postoperative complications. The patient was discharged 48 h after the surgery. At 60 months' follow-up, the patient remains asymptomatic. CONCLUSIONS: Transvesical laparoscopy may be considered for excision of bladder leiomyomas. This approach is feasible for trained surgeons as it requires a small working space.

TeleBCI: remote user training, monitoring, and communication with an evoked-potential brain-computer interface.

Brain-computer interfaces (BCIs) are a movement-independent form of augmentative and alternative communication (AAC) for individuals with amyotrophic lateral sclerosis (ALS). The rare utilization of such devices in the homes of patients stems from a number of factors, one of which is the complexity of providing training and support for users. This paper describes the teleBCI interface used to train the patient and facilitator in the operation of a virtual keyboard using an evoked potential BCI. Fifteen patients with motor neuron disease and their communication partners were included in the study, participating from their homes while receiving remote support from the research team. Patient/caregiver teams completed 8 sessions each of P300 BCI training virtually with the researcher. As they participated in subsequent training sessions, participant teams required less help to complete physical, computer, and BCI-specific tasks associated with device use. A subset of users experienced improved performance over sessions, progressing to utilize the full functionality of the speller and communicate with a nurse partner over a telemedicine interface. Perceptions of device utility varied with accuracy of the BCI system. In the management of ALS, the integration of telemedicine provides new opportunities for care delivery, including how BCI-AAC are deployed and used.

Performance predictors of brain-computer interfaces in patients with amyotrophic lateral sclerosis.

OBJECTIVE: Patients with amyotrophic lateral sclerosis (ALS) may benefit from brain-computer interfaces (BCI), but the utility of such devices likely will have to account for the functional, cognitive, and behavioral heterogeneity of this neurodegenerative disorder. APPROACH: In this study, a heterogeneous group of patients with ALS participated in a study on BCI based on the P300 event related potential and motor-imagery. RESULTS: The presence of cognitive impairment in these patients significantly reduced the quality of the control signals required to use these communication systems, subsequently impairing performance, regardless of progression of physical symptoms. Loss in performance among the cognitively impaired was accompanied by a decrease in the signal-to-noise ratio of task-relevant EEG band power. There was also evidence that behavioral dysfunction negatively affects P300 speller performance. Finally, older participants achieved better performance on the P300 system than the motor-imagery system, indicating a preference of BCI paradigm with age. SIGNIFICANCE: These findings highlight the importance of considering the heterogeneity of disease when designing BCI augmentative and alternative communication devices for clinical applications.

Residual alterations of brain electrical activity in clinically asymptomatic concussed individuals: an EEG study.

OBJECTIVE: To examine the neural substrates underlying performance on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and HeadRehab Virtual Reality (VR) balance and spatial modules in a concussed and control group. METHODS: Thirteen controls and seven concussed participants were fitted with a Geodesic 128-channel EEG cap and completed three assessments: EEG baseline, ImPACT testing, and VR balance and spatial modules. Concussed participants completed were tested within 8 (5 ± 1) days after injury. RESULTS: EEG power was significantly (p < .05) decreased in the concussed group over all testing modalities. EEG coherence was significantly (p < .05) increased in the concussed group during EEG baseline and ImPACT. For VR testing, two conditions showed significant (p < .05) increases in EEG coherence between ROIs, while two different conditions showed significant (p < .05) decreases in coherence levels. CONCLUSIONS: Concussed participants passed all clinical concussion testing tools, but showed pathophysiological dysfunction when evaluating EEG variables. SIGNIFICANCE: Concussed participants are able to compensate and achieve normal functioning due to recruiting additional brain networks. This allows concussed participants to pass clinical tests while still displaying electrophysiological deficits and clinicians must consider this information when making return-to-play decisions.

Motor imagery task discrimination using wide-band frequency spectra with Slepian tapers.

We here studied the efficacy of wide-band frequency spectra (WBFS) features using multi-taper (MT) spectral analysis in application to motor imagery based Brain Computer Interfaces. We acquired motor imagery task related human scalp electroencephalography (EEG) signals for left vs. right hand movements using 3 different pairs of visual arrow cues. Left vs. right movement imagery discrimination was conducted using a Naïve Bayesian classifier using WBFS features and commonly used Mu-Beta spectral features for EEG signals from central+parietal and central only electrode positions. Task discrimination accuracy results showed that WBFS features using MT spectral analysis provided significantly better performance (with a 95% confidence level) than that of using Mu-Beta spectral features commonly used. The use of central+parietal electrode signals improved discrimination accuracy significantly when compared to the accuracy using the central only signals, implying that sensory information enhanced task discrimination significantly.

La disminución de las radiografías de tórax innecesarias en la Unidad de Cuidados Intensivos: aplicación de un ciclo conjunto de mejora de la calidad / Decrease of unnecessary chest x-rays in Intensive Care Unit: application of a combined cycle of quality improvement

Objetivo. Demostrar que el consenso interdisciplinar mejora la calidad del trabajo en la Unidad de Cuidados Intensivos (UCI), evitando exploraciones radiológicas rutinarias innecesarias, planteándose una monitorización de los resultados para mantener este bajo porcentaje de peticiones. Diseño. Ciclo de mejora de calidad asistencial. Ámbito. UCI de 18 camas de carácter polivalente. Pacientes. Pacientes ingresados en la UCI en el periodo de un mes, durante el cual se hizo un muestreo aleatorio sistemático. Intervenciones. Establecimiento de un protocolo consensuado de petición de radiografías de tórax portátiles (RTP) rutinarias. Tras comprobar el exceso de RTP siguiendo estos criterios, se acordó con todos los intensivistas su aplicación. Cinco años después se volvió a valorar el grado de incumplimiento y se incluyó un calendario de monitorizaciones para evitar la vuelta al exceso de solicitudes no justificadas. Además se introdujo un sistema de petición consensuado entre dos intensivistas, de manera que todas las RTP programadas para cada día se solicitaban por parte de dos intensivistas, atendiendo a los mencionados criterios. Variable. Peticiones que incumplen el protocolo de RTP programada. Resultados. En 1997, el grado global de incumplimiento era del 16,9%. Tras reducirlo al 6,1%, la falta de control posterior llevó a que en 2003 fuese del 27,6%. Los pacientes estables con cardiopatía isquémica (44,4% y 53,8% de todos los incumplimientos en esos dos años) constituyen el grueso de las indicaciones inadecuadas. El uso de un modelo de solicitud que requiere del consenso de dos intensivistas consiguió una reducción del incumplimiento al 2,5% en 2003. El calendario de monitorización ha permitido seguir en el tiempo el grado de cumplimiento y detectar la relajación en la prescripción. Conclusiones. Las RTP innecesarias pueden reducirse fácilmente incidiendo sobre los pacientes clínicamente estables. La obligación de justificar una petición rutinaria (consenso entre intensivistas) permite disminuir el número de peticiones de RTP. La monitorización periódica es la herramienta final para el éxito del ciclo de mejora

Purpose. To demonstrate that interdisciplinary consensus improves the quality of work in the daily Intensive Care Unit (ICU), thus avoiding unnecessary routine x-ray examinations. We propose to monitor the results to maintain this low percentage of requests for x-rays. Design. Cycle of improvement in care quality. Setting. An 18-bed polyvalent ICU. Patients. A random sample of patients admitted in ICU during one month. Interventions. Establishment of basic agreed on protocol for routine chest portable x-ray (CPR) indications. After assessing the excessive amount of CPR according to those criteria, all intensivists accepted their application. Five years later, a second assessment of the degree of non-compliance was carried out and a monitoring schedule was established in order to avoid making unnecessary CPR again. Furthermore, a consensus between two intensivists was considered obligatory before a CPR request. Accordingly, all non-urgent CPR forms were signed by two intensivists, following the mentioned clinical criteria. Variable. Unsuitable portable chest x-ray indications. Results. In 1997, the overall non-compliance rate (ONCR) was 16.9%. After reducing it to 6.1%, lack of follow-up led to a non-compliance rate of 27.6% in 2003. Stable patients with uncomplicated ischemic heart disease (44.4% in 1997 and 53.8% in 2003) accounted for most of the inadequate ONCR indications. By using the consensus system for requesting routine portable x-rays that required the agreement of two intensivists achieved a reduction of non-compliance to 2.5% in 2003. The monitoring schedule designed has made it possible to follow the time of compliance degree and detect relaxation in the prescriptions. Conclusions. Unnecessary CPR can be easily reduced stressing our control in clinically stable patients. The requirement to justify a routine request (agreement between intensivists) makes it possible to decrease the number of CPRs. Periodic monitoring is the definitive tool for a successful improvement cycle

[Decrease of unnecessary chest x-rays in Intensive Care Unit: application of a combined cycle of quality improvement]. / La disminución de las radiografías de tórax innecesarias en la Unidad de Cuidados Intensivos: aplicación de un ciclo conjunto de mejora de la calidad.

PURPOSE: To demonstrate that interdisciplinary consensus improves the quality of work in the daily Intensive Care Unit (ICU), thus avoiding unnecessary routine x-ray examinations. We propose to monitor the results to maintain this low percentage of requests for x-rays. DESIGN: Cycle of improvement in care quality. SETTING: An 18-bed polyvalent ICU. PATIENTS: A random sample of patients admitted in ICU during one month. INTERVENTIONS: Establishment of basic agreed on protocol for routine chest portable x-ray (CPR) indications. After assessing the excessive amount of CPR according to those criteria, all intensivists accepted their application. Five years later, a second assessment of the degree of non-compliance was carried out and a monitoring schedule was established in order to avoid making unnecessary CPR again. Furthermore, a consensus between two intensivists was considered obligatory before a CPR request. Accordingly, all non-urgent CPR forms were signed by two intensivists, following the mentioned clinical criteria. VARIABLE: Unsuitable portable chest x-ray indications. RESULTS: In 1997, the overall non-compliance rate (ONCR) was 16.9%. After reducing it to 6.1%, lack of follow-up led to a non-compliance rate of 27.6% in 2003. Stable patients with uncomplicated ischemic heart disease (44.4% in 1997 and 53.8% in 2003) accounted for most of the inadequate ONCR indications. By using the consensus system for requesting routine portable x-rays that required the agreement of two intensivists achieved a reduction of non-compliance to 2.5% in 2003. The monitoring schedule designed has made it possible to follow the time of compliance degree and detect relaxation in the prescriptions. CONCLUSIONS: Unnecessary CPR can be easily reduced stressing our control in clinically stable patients. The requirement to justify a routine request (agreement between intensivists) makes it possible to decrease the number of CPRs. Periodic monitoring is the definitive tool for a successful improvement cycle.

Choleriform enteritis

1. A brief review of the historical background of the El Tor Vibrio and possible mechanism of action is presented2. 200 cases of Choleriform Enteritis admitted into the San Lazaro Hospital from September 22, 1961 to October 16, 1961 are studied and incidences according to sex, age, immunization and symptomatology are shown3. Pathology and management are also discussed. (Summary)