To Improve Your Surgical Drilling Skills, Make Use of Your Index Fingers

BACKGROUND: Surgery has greatly benefited from various technologic advancements over the past decades. Surgery remains, however, mostly manual labor performed by well-trained surgeons. Little research has focused on improving osseous drilling techniques. The objective of this study was to compare the accuracy and precision of different orthopaedic drilling techniques involving the use of both index fingers. QUESTIONS/PURPOSES: (1) Does the shooting grip technique and aiming at the contralateral index finger improve accuracy and precision in drilling? (2) Is the effect of drilling technique on accuracy and precision affected by the experience level of the performer? METHODS: This study included 36 participants from two Dutch training hospitals who were subdivided into three groups (N = 12 per group) based on their surgical experience (that is, no experience, residents, and surgeons). The participants had no further experience with drilling outside the hospital nor were there other potential confounding variables that could influence the test outcomes. Participants were instructed to drill toward a target exit point on a synthetic bone model. There were four conditions: (1) clenched grip without aiming; (2) shooting grip without aiming; (3) clenched grip with aiming at the contralateral index finger; and (4) shooting grip aiming at the contralateral index finger. Participants were only used to a clenched grip without aiming in clinical practice. Each participant had to drill five times per technique per test, and the test was repeated after 4 weeks. Accuracy was defined as the systematic error of all measurements and was calculated as the mean of the five distances between the five exit points and the target exit point, whereas precision was defined as the random error of all measurements and calculated as the SD of those five distances. Accuracy and precision were analyzed using mixed-design analyses of variance. RESULTS: Accuracy was highest when using a clenched grip with aiming at the index finger (mean 4.0 mm, SD 1.1) compared with a clenched grip without aiming (mean 5.0 mm, SD 1.2, p = 0.004) and a shooting grip without aiming (mean 4.9 mm, SD 1.4, p = 0.015). The shooting grip with aiming at the index finger (mean 4.1 mm, SD 1.2) was also more accurate than a clenched grip without aiming (p = 0.006) and a shooting grip without aiming (p = 0.014). Shooting grip with aiming at the opposite index finger (median 2.0 mm, interquartile range [IQR] 1.2) showed the best precision and outperformed a clenched grip without aiming (median 2.9 mm, IQR 1.1, p = 0.016), but was not different than the shooting grip without aiming (median 2.2 mm, IQR 1.4) or the clenched grip with aiming (median 2.4 mm, IQR 1.3). The accuracy of surgeons (mean 4.1 mm, SD 1.1) was higher than the inexperienced group (mean 5.0 mm, SD 1.1, p = 0.012). The same applied for precision (median 2.2 mm, IQR 1.0 versus median 2.8 mm, IQR 1.4, p = 0.008). CONCLUSIONS: A shooting grip combined with aiming toward the index finger of the opposite hand had better accuracy and precision compared with a clenched grip alone. Based on this study, experience does matter, because the orthopaedic surgeons outperformed the less experienced participants. Based on our study, we advise surgeons to aim at the index finger of the opposite hand when possible and to align the ipsilateral index finger to the drill bit. LEVEL OF EVIDENCE: Level II, therapeutic study

Evaluation of a coupled hydrodynamic-closed ecological cycle approach for modelling dissolved oxygen in surface waters

The description of intertwined ecological processes in surface waters requires a holistic approach that accounts for spatially distributed hydrological/water quality processes. This study describes a new approach to model dissolved oxygen (DO) based on linked hydrodynamic and closed nutrient cycle ecological models. Long term datasets from the River Dommel (Netherlands) are used to determine: 1) if this methodology is suitable for modelling DO concentrations, 2) the model sensitivity to various levels of nutrients input, and 3) the DO production and consumption processes and their response to nutrient input changes. Results show that seasonal dynamics of DO are well quantified at long timescales; the sensitivity of DO to different pollutant sources exhibits significant seasonal variation and the largest influences on DO are aeration and mineralization of organic material. The approach demonstrates an ability to consider the impacts of nutrient input and long term vegetation maintenance on ecological quality

Multidisciplinary approach in medicine: successful pregnancy in a patient with hyperinsulinism/hyperammonaemia (HI/HA) syndrome

This case illustrates the importance of multidisciplinary counselling and management of pregnancies in women with complex medical conditions, especially concerning women with cognitive impairment. We present a woman with hyperinsulinism/hyperammonaemia (HI/HA) syndrome. This syndrome is characterised by recurrent episodes of hypoglycaemia and elevated ammonia levels, which are potentially harmful to both the patient and a developing fetus. We describe a successful multidisciplinary approach during the pregnancy of a mentally challenged patient with HI/HA syndrome. This case illustrates the importance of personalised counselling during the preconception period and emphasises to include all disciplines involved in the medical and daily care of such a patient. In our case, the extensive multidisciplinary care during the preconception period, pregnancy, delivery and postpartum period resulted in a good maternal and neonatal outcome

Food or medicine? A European regulatory perspective on nutritional therapy products to treat inborn errors of metabolism

Dietary or nutritional management strategies are the cornerstone of treatment for many inborn errors of metabolism (IEMs). Though a vital part of standard of care, the products prescribed for this are often not formally registered as medication. Instead, they are regulated as food or as food supplements, impacting the level of oversight as well as reimbursed policies. This scoping literature review explores the European regulatory framework relevant to these products and its implications for current clinical practice. Searches of electronic databases (PubMed, InfoCuria) were carried out, supplemented by articles identified by experts, from reference lists, relevant guidelines and case-law by the European Court of Justice. In the European Union (EU), nutritional therapy products are regulated as food supplements, food for special medical purposes (FSMPs) or medication. The requirements and level of oversight increase for each of these categories. Relying on lesser-regulated food products to treat IEMs raises concerns regarding product quality, safety, reimbursement and patient access. In order to ascertain whether a nutritional therapy product functions as medication and thus could be classified as such, we developed a flowchart to assess treatment characteristics (benefit, pharmacological attributes, and safety) with a case-based approach. Evaluating nutritional therapy products might reveal a justifiable need for a pharmaceutical product. A flowchart can facilitate systematically distinguishing products that function medication-like in the management of IEMs. Subsequently, finding and implementing appropriate solutions for these products might help improve the quality, safety and accessibility including reimbursement of treatment for IEMs.</p

Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation:A Systematic Review and Meta-Analysis

Background: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. Methods: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. Results: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ±.7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. Conclusions: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.</p

Giant deer (Megaloceros giganteus) diet from Mid-Weichselian deposits under the present North Sea inferred from molar-embedded botanical remains

The molar of a giant deer, Megaloceros giganteus (Blumenbach, 1799), was discovered in sandy deposits of the North Sea, about 10 km west of the present shoreline of the Netherlands. Compacted masticated plant remains were preserved in the molar's deep folds. A palaeoecological analysis of these plant remains shows the complete dominance of pollen from Artemisia (sage) and other Asteraceae Tubuliflorae (Compositae), indicating that the animal foraged in a steppe environment, and may have preferred to eat Artemisia, which contain a high level of nutrients such as calcium and phosphorous components, which are important for antler building. Radiocarbon dating indicates that the plant remains are of mid‐Weichselian age [38 570 (+300, −290) 14C a BP, Greenland Interstadial‐11]. This is the first study of the food choice of M. giganteus based on palaeoecological evidence. We hypothesize about links between the extirpation of M. giganteus at the onset of the Holocene in North‐West Europe and the transition from a landscape with highly dynamic geomorphological processes and consequently prevalence of immature and nutrient‐rich soils, to a less dynamic landscape with stable, leached and acidifying soils, and the decline of Artemisia and other calciphilous plants

Search for Millicharged Particles at SLAC

Particles with electric charge q < 10^(-3)e and masses in the range 1--100 MeV/c^2 are not excluded by present experiments. An experiment uniquely suited to the production and detection of such "millicharged" particles has been carried out at SLAC. This experiment is sensitive to the infrequent excitation and ionization of matter expected from the passage of such a particle. Analysis of the data rules out a region of mass and charge, establishing, for example, a 95%-confidence upper limit on electric charge of 4.1X10^(-5)e for millicharged particles of mass 1 MeV/c^2 and 5.8X10^(-4)e for mass 100 MeV/c^2.Comment: 4 pages, REVTeX, multicol, 3 figures. Minor typo corrected. Submitted to Physical Review Letter

Dopant-induced crossover from 1D to 3D charge transport in conjugated polymers

The interplay between inter- and intra-chain charge transport in bulk polythiophene in the hopping regime has been clarified by studying the conductivity as a function of frequency (up to 3 THz), temperature and doping level. We present a model which quantitatively explains the observed crossover from quasi-one-dimensional transport to three-dimensional hopping conduction with increasing doping level. At high frequencies the conductivity is dominated by charge transport on one-dimensional conducting chains.Comment: 4 pages, 2 figure

Considering rain gauge uncertainty using Kriging for Uncertain Data

In urban hydrological models, rainfall is the main input and one of the main sources of uncertainty. To reach sufficient spatial coverage and resolution, the integration of several rainfall data sources, including rain gauges and weather radars, is often necessary. The uncertainty associated with rain gauge measurements is dependent on rainfall intensity and on the characteristics of the devices. Common spatial interpolation methods do not account for rain gauge uncertainty variability. Kriging for Uncertain Data (KUD) allows the handling of the uncertainty of each rain gauge independently, modelling space- and time-variant errors. The applications of KUD to rain gauge interpolation and radar-gauge rainfall merging are studied and compared. First, the methodology is studied with synthetic experiments, to evaluate its performance varying rain gauge density, accuracy and rainfall field characteristics. Subsequently, the method is applied to a case study in the Dommel catchment, the Netherlands, where high-quality automatic gauges are complemented by lower-quality tipping-bucket gauges and radar composites. The case study and the synthetic experiments show that considering measurement uncertainty in rain gauge interpolation usually improves rainfall estimations, given a sufficient rain gauge density. Considering measurement uncertainty in radar-gauge merging consistently improved the estimates in the tested cases, thanks to the additional spatial information of radar rainfall data but should still be used cautiously for convective events and low-density rain gauge networks.</p

Nutrient management on vegetable farms; what will be the future?

Production of field vegetables is known for its high nitrogen input and consequently high nitrogen losses towards the environment. All over the world research tries to find opportunities to reduce these losses. In 2000 the Dutch government initiated and funded a research project (Telen met toekomst) to explore the possibilities to reduce the adverse effects of nitrogen and phosphate inputs on the quality of soil and surface water by farm management. A participatory research approach was chosen, so the farmer, the consultant and scientist work closely together in making annual plans to reach a number of set goals for fertilization on the farm level. By registration of all activities concerning fertilization on the farm, the nitrogen input and output could be monitored. The gap between the reference point at the start of the project and the environmental goals is big for nitrogen: the nitrogen balance surplus on the whole farm level should be reduced from 300 kg N/ha to 90 kg N/ha. First results show that this gap is unlikely to be bridged on all farms within the set period of time, without affecting the farmer's income. However, distinct differences could be observed in the farmers' attitude towards the challenge, the rate of progress varied significantly among farmers