Twofold improved tumor-to-brain contrast using a novel T1 relaxation-enhanced steady-state (T1RESS) MRI technique.

A technique that provides more accurate cancer detection would be of great value. Toward this end, we developed T1 relaxation-enhanced steady-state (T1RESS), a novel magnetic resonance imaging (MRI) pulse sequence that enables the flexible modulation of T1 weighting and provides the unique feature that intravascular signals can be toggled on and off in contrast-enhanced scans. T1RESS makes it possible to effectively use an MRI technique with improved signal-to-noise ratio efficiency for cancer imaging. In a proof-of-concept study, "dark blood" unbalanced T1RESS provided a twofold improvement in tumor-to-brain contrast compared with standard techniques, whereas balanced T1RESS greatly enhanced vascular detail. In conclusion, T1RESS represents a new MRI technique with substantial potential value for cancer imaging, along with a broad range of other clinical applications.

A phase II study of bevacizumab and erlotinib after radiation and temozolomide in MGMT unmethylated GBM patients.

Survival for glioblastoma (GBM) patients with an unmethyated MGMT promoter in their tumor is generally worse than methylated MGMT tumors, as temozolomide (TMZ) response is limited. How to better treat patients with unmethylated MGMT is unknown. We performed a trial combining erlotinib and bevacizumab in unmethylated GBM patients after completion of radiation (RT) and TMZ. GBM patients with an unmethylated MGMT promoter were trial eligible. Patient received standard RT (60 Gy) and TMZ (75 mg/m2 × 6 weeks) after surgical resection of their tumor. After completion of RT they started erlotinib 150 mg daily and bevacizumab 10 mg/kg every 2 weeks until progression. Imaging evaluations occurred every 8 weeks. The primary endpoint was overall survival. Of the 48 unmethylated patients enrolled, 46 were evaluable (29 men and 17 women); median age was 55.5 years (29-75) and median KPS was 90 (70-100). All patients completed RT with TMZ. The median number of cycles (1 cycle was 4 weeks) was 8 (2-47). Forty-one patients either progressed or died with a median progression free survival of 9.2 months. At a follow up of 33 months the median overall survival was 13.2 months. There were no unexpected toxicities and most observed toxicities were categorized as CTC grade 1 or 2. The combination of erlotinib and bevacizumab is tolerable but did not meet our primary endpoint of increasing survival. Importantly, more trials are needed to find better therapies for GBM patients with an unmethylated MGMT promoter.

Skill performance in open videoscopic surgery.

INTRODUCTION: Application of minimally invasive surgery represents the future of modern surgical care. Previous studies by our group provided a novel way for viewing open surgery using a rigid endoscope attached to charged coupled device (CCD) camera in proximity to the surgical field using a robotic arm (AESOP) and a stabilizing fulcrum (Alpha port). MATERIALS AND METHODS: This study is a follow-up to investigate the technical feasibility, advantages, and disadvantages of relying only on video images displayed on standard monitors in performing open surgical procedures instead of direct binocular eye vision. This study used two surgeons as participants with training in basic surgical skill and previous experience in performing an intestinal anastomosis in an ordinary fashion. The standard task consisted of anastomosing porcine intestine in two layers with digital viewing of the operative field. A total of 40 anastomoses (20 by each surgeon) were compared with 10 control performances using direct vision of the field. RESULTS: All the resulting anastomoses were accurate, well coapted, and fully patent with no leakage. Time for task performance was approximately twice as long (p < 0.05) with videoscopic vision as with direct vision. DISCUSSION: These findings suggest it is technically feasible to conduct open surgeries with visualization of the open surgical field limited to video display on standard monitors.

Telementoring versus on-site mentoring in virtual reality-based surgical training.

BACKGROUND: Telementoring can be an adjunct to surgical training using virtual reality surgical simulation. Telementoring is hypothesized to be as effective as a local mentor for surgical skills training. METHODS: In this study, 20 Romanian medical students trained using a virtual reality surgical simulator (LapSim) with a telementor or local mentor. All the students watched an instructional module at the beginning of the exercise. The telementor, in the United States, interacted by videoconferencing. Before and after training sessions, tool path length and time for task completion were measured. RESULTS: Instructional media and training with mentoring resulted in similar levels of performance between locally mentored and telementored groups. Right- and left-hand path length and time decreased significantly within each group from the initial to the final evaluation (p < 0.05) for most tasks (grasping, cutting, suturing). No significant difference was achieved for clip-applying. CONCLUSIONS: Integration of instructional media with telementoring can be as effective for the development of surgical skills as local mentoring.

Ergonomics and human factors in endoscopic surgery: a comparison of manual vs telerobotic simulation systems.

BACKGROUND: Minimally invasive surgical techniques expose surgeons to a variety of occupational hazards that may promote musculoskeletal disorders. Telerobotic systems for minimally invasive surgery may help to reduce these stressors. The objective of this study was to compare manual and telerobotic endoscopic surgery in terms of postural and mental stress. METHODS: Thirteen participants with no experience as primary surgeons in endoscopic surgery performed a set of simulated surgical tasks using two different techniques--a telerobotic master--slave system and a manual endoscopic surgery system. The tasks consisted of passing a soft spherical object through a series of parallel rings, suturing along a line 5-cm long, running a 32-in ribbon, and cannulation. The Job Strain Index (JSI) and Rapid Upper Limb Assessment (RULA) were used to quantify upper extremity exposure to postural and force risk factors. Task duration was quantified in seconds. A questionnaire provided measures of the participants' intuitiveness and mental stress. RESULTS: The JSI and RULA scores for all four tasks were significantly lower for the telerobotic technique than for the manual one. Task duration was significantly longer for telerobotic than for manual tasks. Participants reported that the telerobotic technique was as intuitive as, and no more stressful than, the manual technique. CONCLUSIONS: Given identical tasks, the time to completion is longer using the telerobotic technique than its manual counterpart. For the given simulated tasks in the laboratory setting, the better scores for the upper extremity postural analysis indicate that telerobotic surgery provides a more comfortable environment for the surgeon without any additional mental stress.

A pilot telemedicine project in the Privolzhsky District, Russia.

The geography of Russia and the complex structure of the Russian health-care system make telemedicine systems especially appropriate. The telemedicine project described here deploys a telemedicine system in Nizhny Novgorod with further integration into the Privolzhsky District telemedicine network. It started with the creation of a telemedicine center with high-speed dedicated communication links to various medical institutions in Moscow, interregional telemedicine centers, and several district hospitals in rural areas of the Privolzhsky district. In addition to this specialized network, training by telemedicine specialists from the Space Biomedical Center at Moscow State University was provided along with teleconsultations with specialists from the most advanced medical institutions in Moscow. Consultations were carried out via the interregional telemedicine center on a contractual basis. The regional telemedicine network linked nearly 78 medical sites. This system provided approximately 500 teleconsultations and 100 educational sessions within the past 3 years.

Tele-affiliation in medical education: experience from the international program at Yale Office of Telemedicine.

OBJECTIVES: Telemedicine is developed in response to the needs of users that results in a more viable model. Yale has developed a process called tele-affiliation to combine services that are customized to the international client's needs. METHODS: Several defined steps compose the tele-affiliation process. The Yale-Greece telemedicine program is used as an illustration of this process. Some of the programs developed in response to Greek needs include breast cancer clinics, women's health clinics and tele-homecare monitoring for post-operative and chronically ill patients. RESULTS: Tele-affiliation creates on infrastructure that has the potential to change the method of health care delivery. By using the infrastructure created by the tele-affiliation process, templates for disease management, as well as health promotion and education can be delivered to a global audience. CONCLUSIONS: A tele-affiliation education environment has been developed and tested between Yale University School of Medicine and Greece resulting in an improved infrastructure for health education and management.

Applications of robotics in surgery.

The end of the 20th century brought an increased use of computerized technology in medicine and surgery. The development of robotic surgical systems opened new approaches in general and cardiac surgery. Two leading robotic companies, Computer Motion, Inc. and Intuitive Surgical, Inc. have developed the Zeus and Da Vinci respectively, as very effective tools for surgeons to use. Both of them consist of a surgeon console, located far from the operating table, and three robotic arms, which reproduce inside the patient's body the movements performed by the surgeon at the console. The advantages of robotic surgery over laparoscopy and open surgery include: better eye-hand coordination, tremor filtration, steadiness of camera, 3-D vision, motion scale, more degrees of freedom for instruments etc. Of course, there are also some disadvantages, like the lack of tactile feedback, long time of set up, long learning curve, high cost etc. However, the advantages seem to overcome the disadvantages and more and more operations are conducted using robots. The impact of robotics in surgery is therefore very promising and in the future it will probably open even more new ways in the surgical practice and education both in Romania and across the globe.

Association of p53, p16, and vascular endothelial growth factor protein expressions with the prognosis and metastasis of gallbladder cancer.

BACKGROUND: Tumor suppressor genes were studied in gallbladder disease including cancer for correlation. VEGF (vascular endothelial growth factor) expression was assessed against Nevin staging and metastasis of gallbladder carcinoma. The importance of p53, p16, and VEGF in gallbladder cancer was estimated. STUDY DESIGN: Twenty-four gallbladder carcinomas, 20 gallbladder adenomas, and 18 chronic cholecystitis specimens were immunohistochemically and histopathologically investigated for the relation of p53, p16, and VEGF to Nevin staging and pathologic grading. RESULTS: The expression rate of abnormal p53 in gallbladder carcinomas was significantly higher than that in gallbladder adenoma and chronic cholecystitis (p = 0.003, p = 0.014). The expression rate of abnormal p53 in Nevin staging S1, S2, S3 gallbladder carcinoma was significantly higher than that in S4, S5 (p = 0.01). Abnormal p16 was highest in carcinoma, next in adenoma, and lowest in chronic cholecystitis (p = 0.031, p = 0.017). Gallbladder carcinoma expressed VEGF far more often than adenoma or cholecystitis (p = 0.001); VEGF-positive rates were lower in S1, S2, S3 than S4, S5 by Nevin staging of gallbladder cancer (p = 0.044). CONCLUSION: Mutation of p53 and p16 genes might correlate with progression of of gallbladder carcinoma. Analysis of p53 and p16 can estimate the prognosis of gallbladder cancer. VEGF expression correlates with Nevin staging in gallbladder cancer.

Laparoscopic telescope with alpha port and aesop to view open surgical procedures.

Laparoscopy has advanced surgery by allowing the surgeon to operate within a patient's abdominal and pelvic cavity with minimal trauma and scarring. The coupling of a video camera to the laparoscopic telescope has had the secondary effect of allowing others to view the surgical field either on color video monitors or by watching the video feed over the Internet at a remote location. These advancements have allowed better teaching and mentoring of operations. Open procedures can benefit from this technology as well but have suffered in the past from inadequate methods to depict the open surgical field. We used the Alpha Port and Aesop robot to position a sterile laparoscopic telescope near the surgical field to view open cholecystectomies performed on five pigs and to send the video feed over the Internet to remote physicians. Viewing the video on the monitor, the surgeons performed the operation in a comfortable ergonomic upright position. Both the surgeons and the remote physicians found the quality of the video to be excellent, and the remote physicians felt comfortable learning and mentoring surgical procedures using this technique.

Real-time Internet connections: implications for surgical decision making in laparoscopy.

OBJECTIVE: To determine whether a low-bandwidth Internet connection can provide adequate image quality to support remote real-time surgical consultation. SUMMARY BACKGROUND DATA: Telemedicine has been used to support care at a distance through the use of expensive equipment and broadband communication links. In the past, the operating room has been an isolated environment that has been relatively inaccessible for real-time consultation. Recent technological advances have permitted videoconferencing over low-bandwidth, inexpensive Internet connections. If these connections are shown to provide adequate video quality for surgical applications, low-bandwidth telemedicine will open the operating room environment to remote real-time surgical consultation. METHODS: Surgeons performing a laparoscopic cholecystectomy in Ecuador or the Dominican Republic shared real-time laparoscopic images with a panel of surgeons at the parent university through a dial-up Internet account. The connection permitted video and audio teleconferencing to support real-time consultation as well as the transmission of real-time images and store-and-forward images for observation by the consultant panel. A total of six live consultations were analyzed. In addition, paired local and remote images were "grabbed" from the video feed during these laparoscopic cholecystectomies. Nine of these paired images were then placed into a Web-based tool designed to evaluate the effect of transmission on image quality. RESULTS: The authors showed for the first time the ability to identify critical anatomic structures in laparoscopy over a low-bandwidth connection via the Internet. The consultant panel of surgeons correctly remotely identified biliary and arterial anatomy during six laparoscopic cholecystectomies. Within the Web-based questionnaire, 15 surgeons could not blindly distinguish the quality of local and remote laparoscopic images. CONCLUSIONS: Low-bandwidth, Internet-based telemedicine is inexpensive, effective, and almost ubiquitous. Use of these inexpensive, portable technologies will allow sharing of surgical procedures and decisions regardless of location. Internet telemedicine consistently supported real-time intraoperative consultation in laparoscopic surgery. The implications are broad with respect to quality improvement and diffusion of knowledge as well as for basic consultation.

Wireless ECG monitoring by telephone.

The objective of this work was to study a wireless one channel limited (3-lead) home electrocardiogram (ECG) transmission system and ambulatory devices data transmission using telephone lines. ECG screenings were conducted in two groups. The first group consisted of construction workers examined at first aid stations at construction sites in Moscow, Russia. The second group was a selected set of patients admitted to a hospital in Tblisi, Republic of Georgia. All patients were on constant monitoring and follow-up after hospitalization. Patients themselves connected the ECG leads at home or with the help of paramedics at ambulatory stations. The ECG signals were transmitted to receiving stations where doctors interpreted them. Frequency modulation was used for ECG transmission over regular telephone lines. Of 231 readings in 74 patients--70 male and 4 female (age 21-56)--in the first group, 33 patients were abnormal. In the second group, 15 out of 165 readings in 8 patients--5 male and 3 female (age 31-70)--were abnormal. ECG screening can be significantly simplified and made widely acceptable at home and distant sites using wireless monitoring tools and telephone line transfer of the signal. This project has been implemented under the auspices of the International Telecommunication Union and the Russian Telemedicine Foundation.

Impact of varying transmission bandwidth on image quality.

The objective of this paper is to determine the effect of varying transmission bandwidth on image quality in laparoscopic surgery. Surgeons located in remote operating rooms connected through a telemedicine link must be able to transmit medical images for interaction. Image clarity and color fidelity are of critical importance in telementoring laparoscopic procedures. The clarity of laparoscopic images was measured by assessing visual acuity using a video image of a Snellen eye chart obtained with standard diameter laparoscopes (2, 5, and 10 mm). The clarity of the local image was then compared to that of remote images transmitted using various bandwidths and connection protocols [33.6 Kbps POTS (IP), 128 Kbps ISDN, 384 Kbps ISDN, 10 Mbps LAN (IP)]. The laparoscopes were subsequently used to view standard color placards. These color images were sent via similar transmission bandwidths and connection protocols. The local and remote images of the color placards were compared to determine the effect of the transmission protocols on color fidelity. Use of laparoscopes of different diameter does not significantly affect image clarity or color fidelity as long as the laparoscopes are positioned at their optimal working distance. Decreasing transmission bandwidth does not significantly affect image clarity or color fidelity when sufficient time is allowed for the algorithms to redraw the remote image. Remote telementoring of laparoscopic procedures is feasible. However, low bandwidth connections require slow and/or temporarily stopped camera movements for the quality of the remote video image to approximate that of the local video image.