SAGES masters program: the top 10 seminal articles for the laparoscopic left and sigmoid colectomy pathway for complex disease.

BACKGROUND: The SAGES University Colorectal Masters Program is a structured educational curriculum that is designed to aid practicing surgeons develop and maintain knowledge and technical skills for laparoscopic colorectal surgery. The Colorectal Pathway is based on three anchoring procedures (laparoscopic right colectomy, laparoscopic left and sigmoid colectomy for uncomplicated and complex disease, and intracorporeal anastomosis for minimally invasive right colectomy) corresponding to three levels of performance (competency, proficiency and mastery). This manuscript presents focused summaries of the top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease. METHODS: A systematic literature search of Web of Science for the most cited articles on the topic of laparoscopic complex left/sigmoid colectomy yielded 30 citations. These articles were reviewed and ranked by the SAGES Colorectal Task Force and invited subject experts according to their citation index. The top 10 ranked articles were then reviewed and summarized, with emphasis on relevance and impact in the field, study findings, strength and limitations and conclusions. RESULTS: The top 10 seminal articles selected for the laparoscopic left/sigmoid colectomy for complex disease anchoring procedure include advanced procedures such as minimally invasive splenic flexure mobilization techniques, laparoscopic surgery for complicated and/or diverticulitis, splenic flexure tumors, complete mesocolic excision, and other techniques (e.g., Deloyers or colonic transposition in cases with limited colonic reach after extended left-sided resection). CONCLUSIONS: The SAGES Colorectal Masters Program top 10 seminal articles selected for laparoscopic left and sigmoid colectomy for complex benign and malignant disease anchoring procedure are presented. These procedures were the most essential in the armamentarium of practicing surgeons that perform minimally invasive surgery for complex left and sigmoid colon pathology.

Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery.

BACKGROUND: Despite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions. METHODS: An ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ). RESULTS: We included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ±â€¯24.1 vs 46.1 ±â€¯37.0 MMEQ, P <0.001) and in per-day postoperative opioid consumption (10.9 ±â€¯8.7 vs 15.1 ±â€¯10.3 MMEQ, P <0.001), lower peak pain scores (7 [5-9] vs 8 [7-9], P=0.007) and a shorter hospital length of stay (2.5 ±â€¯0.5 vs 2.9 ±â€¯1.2 days, P <0.001) were found after the introduction of the ERAS protocol. CONCLUSIONS: Implementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.

Lift vs. drag based mechanisms for vertical force production in the smallest flying insects.

We used computational fluid dynamics to determine whether lift- or drag-based mechanisms generate the most vertical force in the flight of the smallest insects. These insects fly at Re on the order of 4-60 where viscous effects are significant. Detailed quantitative data on the wing kinematics of the smallest insects is not available, and as a result both drag- and lift-based strategies have been suggested as the mechanisms by which these insects stay aloft. We used the immersed boundary method to solve the fully-coupled fluid-structure interaction problem of a flexible wing immersed in a two-dimensional viscous fluid to compare three idealized hovering kinematics: a drag-based stroke in the vertical plane, a lift-based stroke in the horizontal plane, and a hybrid stroke on a tilted plane. Our results suggest that at higher Re, a lift-based strategy produces more vertical force than a drag-based strategy. At the Re pertinent to small insect hovering, however, there is little difference in performance between the two strategies. A drag-based mechanism of flight could produce more vertical force than a lift-based mechanism for insects at Re<5; however, we are unaware of active fliers at this scale.

A comparative study of the hovering efficiency of flapping and revolving wings.

Direct numerical simulations are used to explore the hovering performance and efficiency for hawkmoth-inspired flapping and revolving wings at Reynolds (Re) numbers varying from 50 to 4800. This range covers the gamut from small (fruit fly size) to large (hawkmoth size) flying insects and is also relevant to the design of micro- and nano-aerial vehicles. The flapping wing configuration chosen here corresponds to a hovering hawkmoth and the model is derived from high-speed videogrammetry of this insect. The revolving wing configuration also employs the wings of the hawkmoth but these are arranged in a dual-blade configuration typical of helicopters. Flow for both of these configurations is simulated over the range of Reynolds numbers of interest and the aerodynamic performance of the two compared. The comparison of these two seemingly different configurations raises issues regarding the appropriateness of various performance metrics and even characteristic scales; these are also addressed in the current study. Finally, the difference in the performance between the two is correlated with the flow physics of the two configurations. The study indicates that viscous forces dominate the aerodynamic power expenditure of the revolving wing to a degree not observed for the flapping wing. Consequently, the lift-to-power metric of the revolving wing declines rapidly with decreasing Reynolds numbers resulting in a hovering performance that is at least a factor of 2 lower than the flapping wing at Reynolds numbers less than about 100.

The significance of moment-of-inertia variation in flight manoeuvres of butterflies.

The objective of this study is to understand the role that changes in body moment of inertia might play during flight manoeuvres of insects. High-speed, high-resolution videogrammetry is used to quantify the trajectory and body conformation of Painted Lady butterflies during flight manoeuvres; the 3D kinematics of the centre of masses of the various body parts of the insect is determined experimentally. Measurements of the mass properties of the insect are used to parameterize a simple flight dynamics model of the butterfly. Even though the mass of the flapping wings is small compared to the total mass of the insect, these experiments and subsequent analysis indicate that changes in moment of inertia during flight are large enough to influence the manoeuvres of these insects.

Morning report: combining education with patient handover.

INTRODUCTION: The advent of resident work hour restrictions has challenged us to train residents within a shorter working week, while ensuring continuity of patient care. We instituted morning report (MR) at the University of Virginia primarily as a means to accomplish these objectives. Serendipitously MR has become an integral educational tool for the surgical residents. The rationale for the format and instructional design are discussed in the context of learning theory. METHODS: The chief residents as primary stakeholders were strongly encouraged to play a leadership role in designing MR. A faculty- led didactic format was rejected because of the importance of focusing on resident team building, and leadership, but poor faculty participation was also an issue. RESULTS: The initial obstacles included timing, and designing the format. CONCLUSIONS: MR is an opportunity for residents to exercise and improve their knowledge, leadership, presentation and problem-solving skills. We would hypothesise that the advantages for teaching are many and include that residents are prepared for actual clinical problems in a supportive environment with opportunities for immediate feedback and assessment. Reports of educational effectiveness of MR are mostly anecdotal and further studies are needed to characterise the types of learning and teaching that occur during MR and to document educational effectiveness.

Low speed maneuvering flight of the rose-breasted cockatoo (Eolophus roseicapillus). I. Kinematic and neuromuscular control of turning.

Maneuvering flight has long been recognized as an important component of the natural behavior of many bird species, but has been the subject of little experimental work. Here we examine the kinematics and neuromuscular control of turning flight in the rose-breasted cockatoo Eolophus roseicapillus (N=6), testing predictions of maneuvering flight and control based on aerodynamic theory and prior kinematic and neuromuscular studies. Six cockatoos were trained to navigate between two perches placed in an L-shaped flight corridor, making a 90 degrees turn midway through each flight. Flights were recorded with three synchronized high-speed video cameras placed outside the corridor, allowing a three-dimensional reconstruction of wing and body kinematics through the turn. We simultaneously collected electromyography recordings from bilateral implants in the pectoralis, supracoracoideus, biceps brachii and extensor metacarpi radialis muscles. The cockatoos maneuvered using flapping, banked turns with an average turn radius of 0.92 m. The mean rate of change in heading during a complete wingbeat varied through the turn and was significantly correlated to roll angle at mid-downstroke. Changes in roll angle were found to include both within-wingbeat and among-wingbeat components that bear no direct relationship to one another. Within-wingbeat changes in roll were dominated by the inertial effects while among-wingbeat changes in roll were likely the result of both inertial and aerodynamic effects.

Low speed maneuvering flight of the rose-breasted cockatoo (Eolophus roseicapillus). II. Inertial and aerodynamic reorientation.

The reconfigurable, flapping wings of birds allow for both inertial and aerodynamic modes of reorientation. We found evidence that both these modes play important roles in the low speed turning flight of the rose-breasted cockatoo Eolophus roseicapillus. Using three-dimensional kinematics recorded from six cockatoos making a 90 degrees turn in a flight corridor, we developed predictions of inertial and aerodynamic reorientation from estimates of wing moments of inertia and flapping arcs, and a blade-element aerodynamic model. The blade-element model successfully predicted weight support (predicted was 88+/-17% of observed, N=6) and centripetal force (predicted was 79+/-29% of observed, N=6) for the maneuvering cockatoos and provided a reasonable estimate of mechanical power. The estimated torque from the model was a significant predictor of roll acceleration (r(2)=0.55, P<0.00001), but greatly overestimated roll magnitude when applied with no roll damping. Non-dimensional roll damping coefficients of approximately -1.5, 2-6 times greater than those typical of airplane flight dynamics (approximately -0.45), were required to bring our estimates of reorientation due to aerodynamic torque back into conjunction with the measured changes in orientation. Our estimates of inertial reorientation were statistically significant predictors of the measured reorientation within wingbeats (r(2) from 0.2 to 0.37, P<0.0005). Components of both our inertial reorientation and aerodynamic torque estimates correlated, significantly, with asymmetries in the activation profile of four flight muscles: the pectoralis, supracoracoideus, biceps brachii and extensor metacarpi radialis (r(2) from 0.27 to 0.45, P<0.005). Thus, avian flight maneuvers rely on production of asymmetries throughout the flight apparatus rather than in a specific set of control or turning muscles.

Flight control in the hawkmoth Manduca sexta: the inverse problem of hovering.

The inverse problem of hovering flight, that is, the range of wing movements appropriate for sustained flight at a fixed position and orientation, was examined by developing a simulation of the hawkmoth Manduca sexta. Inverse problems arise when one is seeking the parameters that are required to achieve a specified model outcome. In contrast, forward problems explore the outcomes given a specified set of input parameters. The simulation was coupled to a microgenetic algorithm that found specific sequences of wing and body motions, encoded by ten independent kinematic parameters, capable of generating the fixed body position and orientation characteristic of hovering flight. Additionally, we explored the consequences of restricting the number of free kinematic parameters and used this information to assess the importance to flight control of individual parameters and various combinations of them. Output from the simulated moth was compared to kinematic recordings of hovering flight in real hawkmoths; the real and simulated moths performed similarly with respect to their range of variation in position and orientation. The simulated moth also used average wingbeat kinematics (amplitude, stroke plane orientation, etc) similar to those of the real moths. However, many different subsets of the available kinematic were sufficient for hovering flight and available kinematic data from real moths does not include sufficient detail to assess which, if any, of these was consistent with the real moth. This general result, the multiplicity of possible hovering kinematics, shows that the means by which Manduca sexta actually maintains position and orientation may have considerable freedom and therefore may be influenced by many other factors beyond the physical and aerodynamic requirements of hovering flight.

Implant-associated infections: an overview.

The discovery of a 5500-year-old dental implant near Gebel Ramlah, Egypt, marks the earliest discovery of a medical prosthesis. It would not be until the 20th century, however, that this ancient concept would resurface on a wide scale basis. With the introduction of physiologically inert biomaterials in the 1950s, the field of surgical implants has emerged as arguably one of the greatest medical advancements of our time. It is now estimated that millions of patients worldwide have received some type of prosthesis. This forces us to appreciate the impact of implant-associated infections on patients today and mandates that we as a medical community be prepared to manage these infections effectively. This article provides an in-depth review of the current most commonly used prosthetic devices and the infections that accompany them. We examine the epidemiology, diagnosis, prevention, and treatment of various implant-associated infections within the fields of general, plastic, orthopedic, dental, and neurosurgery. We will highlight the recent technological advancements and future prospects. We will also draw attention to the need for further research in this ever growing field.

Comparative power curves in bird flight.

The relationship between mechanical power output and forward velocity in bird flight is controversial, bearing on the comparative physiology and ecology of locomotion. Applied to flying birds, aerodynamic theory predicts that mechanical power should vary as a function of forward velocity in a U-shaped curve. The only empirical test of this theory, using the black-billed magpie (Pica pica), suggests that the mechanical power curve is relatively flat over intermediate velocities. Here, by integrating in vivo measurements of pectoralis force and length change with quasi-steady aerodynamic models developed using data on wing and body movement, we present mechanical power curves for cockatiels (Nymphicus hollandicus) and ringed turtle-doves (Streptopelia risoria). In contrast to the curve reported for magpies, the power curve for cockatiels is acutely concave, whereas that for doves is intermediate in shape and shows higher mass-specific power output at most speeds. We also find that wing-beat frequency and mechanical power output do not necessarily share minima in flying birds. Thus, aspects of morphology, wing kinematics and overall style of flight can greatly affect the magnitude and shape of a species' power curve.

Computed tomography assessment of sacroiliac screw placement relative to the first sacral neuroforamen.

The radiographic interpretation of sacroiliac screws relative to the S1 neuroforamen is difficult for orthopedic surgeons and radiologists. Computed tomography (CT) with axial images alone or combined with multiplanar reconstructions are often used to assess screw position. The reliability, reproducibility, and accuracy of orthopedist and radiologist interpretations of axial CT images with and without multiplanar reconstructions was determined using 24 cadaveric hemipelves with known sacroiliac screw position. Interobserver reliability of determining screw position was fair for orthopedists and slight for radiologists regardless of imaging modality or screw composition. Intraobserver reproducibility was moderate for orthopedists regardless of imaging modality or screw type. Reproducibility among radiologists was moderate using axial images of titanium screws and substantial with addition of multiplanar reconstructions. Overall accuracy was similar for orthopedists and radiologists. CT images with multiplanar reconstructions improve accuracy in determining sacroiliac screw position, but not significantly. Current imaging modalities are limited by large inaccuracies and by interobserver and intraobserver variation.

Muscle volume, MRI relaxation times (T2), and body composition after spaceflight.

Postflight changes in muscle volume, calf muscle transverse relaxation time, and total body composition were measured in 4 crewmembers after a 17-day mission and in 14-16 crewmembers in multiple shuttle/Mir missions of 16- to 28-wk duration. During the 17-day mission, all muscle regions except the hamstrings significantly decreased 3-10% compared with baseline. During the shuttle/Mir missions, there were significant decreases in muscle volume (5-17%) in all muscle groups except the neck. These changes, which reached a new steady state by 4 mo of flight or less, were reversed within 30-60 days after landing. Postflight swelling and elevation of calf muscle transverse relaxation time persisted for several weeks after flight, which suggests possible muscle damage. In contrast to the 17-day flight, in which loss in fat, but not lean body mass, was found (25), losses in bone mineral content and lean body mass, but not fat, were seen after the longer shuttle/Mir missions. The percent losses in total body lean body mass and bone mineral content were similar at approximately 3.4-3.5%, whereas the pelvis demonstrated the largest regional bone loss at 13%.

Severity of coronary artery calcification by electron beam computed tomography predicts silent myocardial ischemia.

BACKGROUND: Detection of subclinical coronary artery disease (CAD) before the development of life-threatening cardiac complications has great potential clinical relevance. Electron beam computed tomography (EBCT) is currently the only noninvasive test that can detect CAD in all stages of its development and thus has the potential to be an excellent screening technique for identifying asymptomatic subjects with underlying myocardial ischemia. METHODS AND RESULTS: Over 2.5 years, we prospectively studied 3895 generally asymptomatic subjects with EBCT, 411 of whom had stress myocardial perfusion tomography (SPECT) within a close (median, 17 days) time period. SPECT and exercise treadmill results were compared with the coronary artery calcium score (CACS) as assessed by EBCT. The total CACS identified a population at high risk for having myocardial ischemia by SPECT although only a minority of subjects (22%) with an abnormal EBCT had an abnormal SPECT. No subject with CACS <10 had an abnormal SPECT compared with 2.6% of those with scores from 11 to 100, 11.3% of those with scores from 101 to 399, and 46% of those with scores >/=400 (P<0.0001). CACS predicted an abnormal SPECT regardless of subject age or sex. CONCLUSIONS: CACS identifies a high-risk group of asymptomatic subjects who have clinically important silent myocardial ischemia. Our results support the role of EBCT as the initial screening tool for identifying individuals at various stages of CAD development for whom therapeutic decision making may differ considerably.

T2 vertebral bone marrow changes after space flight.

Bone biopsies indicate that during immobilization bone marrow adipose tissue increases while the functional cellular fraction decreases. One objective of our Spacelab flight experiment was to determine, using in vivo volume-localized magnetic resonance spectroscopy (VLMRS), whether bone marrow composition was altered by space flight. Four crew members of a 17 day Spacelab mission participated in the experiment. The apparent cellular fraction and transverse relaxation time (T2) were determined twice before launch and at several times after flight. Immediately after flight, no significant change in the cellular fraction was found. However, the T2 of the cellular, but not the fat component increased following flight, although to a variable extent, in all crew members with a time course for return to baseline lasting several months. The T2 of seven control subjects showed no significant change. Although these observations may have several explanations, it is speculated that the observed T2 changes might reflect increased marrow osteoblastic activity during recovery from space flight.

Imaging assessment of sacroiliac screw placement relative to the neuroforamen.

STUDY DESIGN: Twenty-four cannulated sacroiliac screws were placed bilaterally into 12 cadaveric pelvi (12 titanium screws and 12 stainless-steel screws) and were imaged using conventional and multiplanar reconstructed computed tomography. OBJECTIVES: To determine whether sacroiliac screw position assessment relative to the neuroforamen is enhanced by: 1) computed tomography using multiplanar reconstructions and 2) the use of titanium screws rather than stainless-steel screws. SUMMARY OF BACKGROUND DATA: To the authors' knowledge, there have been no prior studies demonstrating the accuracy of multiplanar computed tomography compared with that of conventional (axial) tomography in determining the position of sacroiliac screws relative to the neuroforamen. Although titanium screws have been shown to have less scatter than stainless-steel screws, the effect of alloy composition on the radiographic accuracy of interpreting the screw position relative to the sacral neuroforamen is unknown. METHODS: Screws were deliberately placed into: position A, in which the screw did not violate the neuroforamen; position B, in which the threads of the screw came within 3 mm of the neuroforamen; and position C, in which the screw clearly was nearly centered in the neuroforamen. The degrees of accuracy in assessing screw position relative to the neuroforamen using conventional (axial) images and using multiplanar reconstructed images were compared. RESULTS: The axial images were accurate in determining screw position relative to the neuroforamen in 50% of cases in which titanium screws were used and in 42% of cases in which stainless-steel screws were used. The corresponding values for multiplanar reconstructions were 92% for cases in which titanium screws were used and 67% for cases in which stainless-steel screws were used. The accuracy of multiplanar reconstructions was statistically better than that of axial images (P < 0.05). Metallic scatter was increased in stainless-steel screws. CONCLUSIONS: The results of this study suggest that the use of computed tomography with multiplanar reconstruction improves accuracy in determining sacroiliac screw position relative to the neuroforamen. The assessment of screw position may be facilitated using titanium screws.

CT reconstruction of an unusual chronic posttraumatic aneurysm of the thoracic aorta.

Chronic traumatic aneurysm of the thoracic aorta is an unusual occurrence. Previously, arteriography was performed on all patients seen in our institution with this entity to allow confirmation of the diagnosis and anatomic delineation for operation. A case of chronic traumatic aneurysm of the distal descending aorta discovered on a routine chest roentgenogram and evaluated with chest computed tomographic scanning with three-dimensional reconstruction is presented. It is our belief that not all thoracic aneurysms require arteriography, and improved methods of computed tomographic scanning allow adequate diagnosis and anatomic delineation with decreased morbidity and cost.

Regional muscle loss after short duration spaceflight.

BACKGROUND: Muscle strength and limb girth measurements during Skylab and Apollo missions suggested that loss of muscle mass may occur as a result of spaceflight. Extended duration spaceflight is important for the economical and practical use of space. The loss of muscle mass during spaceflight is a medical concern for long duration flights to the planets or extended stays aboard space stations. Understanding the extent and temporal relationships of muscle loss is important for the development of effective spaceflight countermeasures. HYPOTHESIS: We hypothesized that significant and measurable changes in muscle volume would occur in Shuttle crewmembers following 8 d of weightlessness. METHODS: MRI was used to obtain the muscle volumes of the calf, thigh and lower back before and after the STS-47 Shuttle mission. RESULTS: Statistical analyses demonstrated that the soleus-gastrocnemius (-6.3%), anterior calf (-3.9%), hamstrings (-8.3%), quadriceps (-6.0%) and intrinsic back (-10.3%) muscles were decreased, p < 0.05, compared to baseline, 24 h after landing. At 2 weeks post recovery, the hamstrings and intrinsic lower back muscles were still below baseline, p < 0.05. CONCLUSIONS: These results demonstrate that even short duration spaceflight can result in significant muscle atrophy.