Remote ischemic conditioning: from experimental observation to clinical application: report from the 8th Biennial Hatter Cardiovascular Institute Workshop

In 1993, Przyklenk and colleagues made the intriguing experimental observation that 'brief ischemia in one vascular bed also protects remote, virgin myocardium from subsequent sustained coronary artery occlusion' and that this effect '.... may be mediated by factor(s) activated, produced, or transported throughout the heart during brief ischemia/reperfusion'. This seminal study laid the foundation for the discovery of 'remote ischemic conditioning' (RIC), a phenomenon in which the heart is protected from the detrimental effects of acute ischemia/reperfusion injury (IRI), by applying cycles of brief ischemia and reperfusion to an organ or tissue remote from the heart. The concept of RIC quickly evolved to extend beyond the heart, encompassing inter-organ protection against acute IRI. The crucial discovery that the protective RIC stimulus could be applied non-invasively, by simply inflating and deflating a blood pressure cuff placed on the upper arm to induce cycles of brief ischemia and reperfusion, has facilitated the translation of RIC into the clinical setting. Despite intensive investigation over the last 20 years, the underlying mechanisms continue to elude researchers. In the 8th Biennial Hatter Cardiovascular Institute Workshop, recent developments in the field of RIC were discussed with a focus on new insights into the underlying mechanisms, the diversity of non-cardiac protection, new clinical applications, and large outcome studies. The scientific advances made in this field of research highlight the journey that RIC has made from being an intriguing experimental observation to a clinical application with patient benefit

Single-stage Total Cranial Vault Remodeling for Correction of Turricephaly: Description of a New Technique.

Background: Turricephaly is considered one of the most difficult cranial deformities to correct as addressing cranial height can result in increased intracranial pressure. We describe a new technique of total calvarial remodeling with bony transposition to simultaneously correct turricephaly and brachycephaly while preserving intracranial volume. Methods: A retrospective review of patients undergoing single-stage cranial vault remodeling by a single surgeon (J.G.M.) at a single center between 2007 and 2015 was performed. The procedure consists of a frontal bandeau followed by a 1 cm 360o axial strip craniectomy. The strip is then rotated 90 degrees into a coronal orientation and interposed between fronto-parietal and parito-occipital segments. Modification for occipital widening can also be performed. Results: Six patients with turribrachycephaly underwent the procedure over the 8-year period. Four patients were operated at less than 1 year of age, one patient underwent surgery at 2 years, and one at 9 years. Mean operative time was 4 hours, and mean transfusion was 300cc. There were no major complications. Mean cranial height reduction achieved was 1.6 cm (range, 1.0-2.0 cm), and mean anterior-posterior expansion was 3.4 cm (range, 2.3-4.5 cm). Patients also showed improvement in supraorbital retrusion. Conclusion: Single-stage cranial vault remodeling with axial strip craniectomy and coronal interposition is safe and allows for simultaneous correction of turricephaly and brachycephaly while preserving intracranial volume

Modification of the Melbourne Method for Total Calvarial Vault Remodeling.

Background: Sagittal synostosis is the most common form of single suture synostosis. It often results in characteristic calvarial deformities, including a long, narrow head, frontal bossing, a bullet-shaped occiput, and an anteriorly placed vertex. Several methods for correcting the phenotypic deformities have been described, each with their own advantages and challenges. In this study, we describe a modification of the Melbourne method of total calvarial remodeling for correcting scaphocephaly. Methods: We conducted a retrospective review of all consecutive patients who underwent total calvarial remodeling using a modified version of the Melbourne technique from 2011 to 2015. We evaluated clinical photographs, computed tomographic imaging, and cephalic indices both pre- and postoperatively to determine morphologic changes after operation. Results: A total of 9 patients underwent the modified Melbourne technique for calvarial vault remodeling during the study period. Intraoperative blood loss was 260 mL (range, 80-400 mL), and mean intraoperative transfusion was 232 mL (range, 0-360 mL). The average length of stay in the hospital was 3.9 days. The mean cephalic indices increased from 0.66 to 0.74 postoperatively (P < 0.01). Conclusions: A modified Melbourne method for calvarial vault reconstruction addresses the phenotypic aspects of severe scaphocephaly associated with isolated sagittal synostosis and maintains a homeotopic relationship across the calvaria. It is associated with shorter operative times, lower blood loss, and lower transfusion requirements

Collection of Bilateral Cleft Lip and Palate Standard Set Variables: Establishing a Baseline

Background: The International Consortium for Healthcare Outcomes Measurement recently published a consensus Standard Set of clinical and patient-centered metrics to measure outcomes for patients with cleft lip and/or palate (CLP). This study aims to evaluate how the Standard Set compares to existing data collected to anticipate the impact that the Standard Set may have on quality and quantity of outcome data. Methods: Extraction of the Standard Set data points was attempted retrospectively for all nonsyndromic patients with bilateral cleft lip and/or palate who underwent primary lip and/or palate repair by a single surgeon (JGM) between June 2007 and June 2014. Results: Bilateral cleft lip repair was performed on 32 patients of which 29 also underwent palate repair. All but one of the baseline demographic and phenotypic variables were available. All perioperative variables were collected, but data quality was heterogeneous. There were no early complications. At 5 years, 29.6% of patients were lost to follow-up; however, a degree of data was available on 11 of the 12 clinical metrics for those remaining. Of patients with Veau IV cleft palate and follow-up at age 5, 1 patient (6.7%) had an oronasal fistula and 1 had velopharyngeal incompetence requiring Furlow palatoplasty (6.7%). No patient-reported data were collected for any time point. Conclusion: Prospective collection of the International Consortium for Healthcare Outcomes Measurement Standard Set will improve consistency of clinical data and add the patient perspective currently lacking in outcome measures collected for patients with bilateral cleft

Multi-modal 3D Simulation Makes the Impossible Possible

B.Y. was born full term after a large vertex encephalocele was diagnosed prenatally. The unique challenge to repairing B.Y.'s encephalocele was a microcephalic skull and large proportion of likely functional extracranial brain tissue, which would need to be preserved. At Boston Children's Hospital, a simulation-based collaborative presurgical planning and rehearsal process, using both digital and 3D printed models, enabled successful technical completion and outcome of an otherwise inoperable case

Design of an Online Histology and Pathology Atlas for Medical Students: an Instructional Aid to Self-Directed Learning

© 2017, International Association of Medical Science Educators. Background: Several institutions have integrated histology with other disciplines in team-based laboratory designs, but the integration of histology and pathology instructional tools for medical student learning has been less commonly reported in the literature compared to other basic sciences. Objective: The primary aim of this study was to develop and pilot an on-line and accessible atlas of histology and histopathology, the Microanatomy and Pathology Atlas (MAPA), for use by medical students as an adjunct to learning histology and pathology in a medical school curriculum. The design of MAPA is based on the theoretical framework of adult learning theory and Gagne’s theory of learning as applied to instructional design. Student evaluations of MAPA as an instructional resource tested the hypothesis that the Atlas would be self-selected by students and that students would find it a satisfactory and valuable asset to their learning. Method: MAPA was developed by a multidisciplinary team at The George Washington University School of Medicine and Health Sciences (GWU-SMHS). The Atlas includes a library of histology and histopathology images. Images in the Atlas illustrate key features of histology and pathology that are present in the associated digital slides assigned for student learning. Traditional laboratory manual instructions and study objectives are linked to specific interactive online-labeled images that allow for self-testing, and all of the pathology slides are embedded in clinical case studies that give the pathology real-world context. A mixed method design was used to evaluate data collected in 2015 on the frequency and usage of MAPA by medical students in the preclinical years, using a modified four-point Likert-style survey and open-ended questions to capture student satisfaction and perceived learning. Results: Survey results demonstrated that in students’ opinions, MAPA is a useful too, complemented their other teaching courses, and it was set at a difficulty level that they felt was appropriate. About 92% of students indicated they would use the tool again in the future. Conclusion: MAPA has been successfully implemented as an instructional tool for medical student learning of histology and histopathology and has been perceived by medical students as a helpful, web-based, and self-selected adjunct for learning. The results suggest that MAPA and similar web-based learning tools can be used to encourage and support self-directed medical student learning in histology and pathology and suggests that similar instructional tools may be useful in other disciplines to promote more active student learning