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PubMed2005

Performance of diadochokinetic movements in schizophrenic patients.

Motor deficits are common and disabling symptoms in schizophrenic patients, which have enormous impact on the long-term outcome of the disease by affecting work performance and daily functioning. They are attributed to the disorder itself, as well as to treatment with dopamine-blocking antipsychotics. This study assessed the kinematic parameters of motor performance of a diadochokinetic hand movement in 20 drug-naïve, 20 conventionally treated (haloperidol or fluphenazine), and 20 atypically treated (olanzapine) patients, as well as in 20 healthy controls using a three-dimensional ultrasonic movement analysis system. It also tested differences in motor enhancement as induced by an attentional strategy and in dexterity advantages of motor performance for the dominant hand between the four study groups. Amplitude and peak velocity of diadochokinetic hand movements were significantly reduced in all patient groups compared to the controls, while frequency of the repetitive movement remained unaffected. The reduction was most pronounced in the conventionally treated patients. In addition, movement automation was impaired, primarily under conventional antipsychotic treatment. The study also revealed weaker effects of an attentional enhancing strategy on the movement amplitude in atypically and conventionally treated patients compared to both controls and drug-naïve patients. Alterations of dexterity could not be detected either in the drug-naïve or in the treated patients. The results indicate that patients with schizophrenia suffer from a specific primary motor deficit in diadochokinesia with reduction of amplitude and peak velocity. This deficit is significantly worsened by conventional antipsychotic treatment. Antipsychotic treatment additionally reduces the enhancing effect of an attentional strategy on motor performance.

Analysis of Variance↗

PubMed2006

Training junior operative residents in laparoscopic suturing skills is feasible and efficacious.

BACKGROUND: Laparoscopic suturing has been regarded as an advanced operative task, and courses to develop this skill are aimed at senior trainees and consultants. This study evaluates the role of laparoscopic suturing courses in the modern operative training curriculum. METHODS: The performance of 9 senior operative trainees (course A) was compared to that of 14 junior operative trainees (course B) at identical, 2-day laparoscopic suturing courses. Pre- and post-course assessments measured time taken, dexterity, and quality for the placement of 1 intracorporeal suture on synthetic bowel. Post-course data was compared to the performance of a group of 6 experts. RESULTS: The median number of laparoscopic procedures carried out unassisted was 130 for surgeons on course A, and 0 for those on course B. At the pre-course assessment, senior trainees (course A) were significantly faster, more dexterous, and had higher checklist scores then those on course B. Both groups had improved significantly by the end of each the course. Post-course comparison between the 2 groups showed equivalent path length and checklist scores, although group A remained faster (P = .003) and made fewer movements (P = .033). Senior trainees had similar performance data to the group of expert surgeons, although this was not the case for junior trainees. CONCLUSIONS: Endoscopic suturing is a task that can be learned by operative trainees during short skills courses, regardless of baseline laparoscopic experience. Skills training in laparoscopic suturing should thus not be reserved only for those contemplating advanced laparoscopic operation.

General Surgery↗

PubMed2006

Effectiveness of suturing training with 10-0 nylon under fixed and maximum magnification (x 20) using desk type microscope.

BACKGROUND: Microvascular anastomosis using 10-0 nylon needs a higher level of technical dexterity compared with routine neurosurgical maneuvers. Although this technique remains an important part of treating complex intracranial aneurysms or cerebrovascular disease, the surgeon's clinical experience in using this technique is not so common. METHODS: To improve dexterity and maneuverability in the limited clinical case volume, we developed an easily accessible training system, using commercially available desk type microscope and simply suturing neighboring fibers of the gauze with 10-0 nylon under fixed and highest (x 20) magnification. RESULT: This training system is somewhat of a drawback compared to the simulation of a real clinical setting. However, because of the extremely easy availability and accessibility of the dark type microscope repeated training and the accumulation of more than 10000 stitches, on average, was accomplished. This resulted in a steep learning curve of the technique. CONCLUSION: For residency and post-residency year young neurosurgeons, who need to brush up their skills due to lower surgical case volume compared with what senior neurosurgeons have experienced this easily available training would contribute to establishing daily and long-lasting microsurgical practice.

Humans↗

PubMed2006

Training of A3-A3 side-to-side anastomosis in a deep corridor using a box with 6.5-cm depth: technical note.

BACKGROUND: Cerebral revascularization in the deep surgical field is technically challenging. Especially, side-to-side anastomosis like A3-A3 could be technically more difficult compared with end-to-side anastomosis. To improve surgeon's dexterity and maneuverability in the deep surgical field, the authors developed an easily accessible and well-simulating training system using prosthetic tubes and a box. METHODS: Two prosthetic tubes (silicon tube, 1.2 mm in diameter) are mounted in parallel on the bottom of 6.5-cm-deep emptied 'tissue paper box.' The orifice of the box is restricted to 2 x 2 cm to simulate a deep and narrow surgical corridor. Using bayonet-shaped micro needle holder and forceps, the side-to-side anastomosis of the tubes is performed with 10-0 nylon under operative microscope. RESULTS: Prosthetic tubes well simulated real A3-A3 anastomosis. From the standpoint of technical difficulty, this training system needed slightly higher level of dexterity compared with real A3-A3 anastomosis because of narrower and deeper surgical corridor, and the wall of prosthetic tube was slightly thicker and more inflexible. After this training, the surgical technique in real A3-A3 anastomosis was improved. CONCLUSIONS: This training system worked well to ease the transition from anastomosis in shallow surgical field to deep and narrow surgical field. The prosthetic tube we used approximates real A3 relatively well, and the ease in setting up this system enabled repeated practice, which resulted in steep learning curve of the technique.

Aged↗

PubMed2004

Robotic renal surgery.

Robotic technology is an expansion of laparoscopic surgery. Robots can be conceived of as specialized laparoscopic tools; their aim is to improve dexterity of the operating surgeon, and therefore they correspond to computer-enhanced telemanipulator devices. For the patient, the advantage of robotic surgery is essentially the advantage of the laparoscopic approach. It gives surgeons tremendous benefits, however, with its intuitive Endowrist and dexterity. From the patient perspective, the biggest difference is between an open operation and one that uses minimally invasive techniques. The contribution of robotics to the evolution of surgery will be obvious if these new systems increase the number of conventionally trained surgeons performing more complex operations using minimally invasive surgical techniques, or if the outcome data from different centers worldwide suggest that the use of advanced technology permits surgeons to have augmented technical performance.

Forecasting↗

PubMed1999

The development and evaluation of an ergonomic glove.

The primary intent of this study was to determine if a hand glove could be designed on a criterion of selective protection. Force distribution patterns on the palmar side of hand were obtained from various studies to develop zones of hand that needed protection. A new design for gloves was developed based on the principle of selective protection, where protective material is introduced in varying levels over different parts of the glove, in order to provide protection where it is most needed, and at the same time preserve the desirable dexterity and strength capabilities of the barehand, optimizing the trade-off between protection and performance. Two pairs of prototype gloves incorporating different levels of protection were fabricated and tested using a battery of performance tests and an algometer test for pressure sensitivity. The test battery comprising four dexterity tasks and a maximal voluntary grip strength task was used to assess a number of glove conditions, including the two prototype gloves developed. The results indicate that the performance of the prototype gloves are comparable, and that the performance times for the double glove and the two prototype gloves tested were not significantly different. For the grip strength, the two prototype gloves were better than the double glove. The assembly task performance for the prototype II (laminar glove) was significantly lower than that of the other glove types tested. It appears that gloves of variable thickness can be developed to afford adequate protection at zones of most need. Glove manufacturers are recommended to use an ergonomic approach in the design of gloves. Such an approach, besides protecting the safety objective of gloves, could enhance productivity considerably.

Accidents, Occupational↗

PubMed2003

Motor training effects on recovery of function after striatal lesions and striatal grafts.

Environment, training, and experience can influence plasticity and recovery of function after brain damage. However, it is less well known whether, and how, such factors influence the growth, integration, and functional recovery provided by neural grafts placed within the brain. To explore this process, rats were pretrained on the skilled staircase test, then lesioned unilaterally in the lateral dorsal striatum with quinolinic acid. Half of the animals were given suspension grafts prepared from E15 whole ganglionic eminence implanted into the lesioned striatum. For the following 5 months, half of the animals in each group were trained daily in a bilateral manual dexterity task. Then, 23 weeks after surgery, all animals were retested on the staircase test. The grafts promoted recovery in the reaching task, irrespective of the additional dexterity training, and within the trained group recovery was proportional to the volume of the striatal-like tissue in the graft, suggesting that training influenced the pattern of graft-induced functional recovery. The additional training also benefited the rats with lesions alone, raising their performance close to level of the grafted groups. In separate tests of rotation, the grafts reduced drug-induced ipsilateral turning in response to both amphetamine and apomorphine, an effect that was greater in the grafted rats given extra training. The results suggest that both nonspecific motor training and cell transplantation can contribute to recovery of lost function in tests of spontaneous and skilled lateralized motor function after striatal damage, and that these two factors interact in a task-specific manner.

Animals↗

PubMed2000

Self-retaining abdominal retractor for minilaparotomy.

BACKGROUND: We describe our experience using a new self-retaining atraumatic abdominal retractor for minilaparotomy performed either alone or in conjunction with laparoscopy. TECHNIQUE: Minilaparotomy was performed by a conventional technique and the self-retaining abdominal wall retractor (Dexterity Protractor) was placed for the duration of the open surgery. EXPERIENCE: The device was employed in 72 consecutive cases in which minilaparotomy was performed either alone or in conjunction with laparoscopy. Indications for minilaparotomy included extensive myomectomies and tubal ligation reversals in fertility patients, hysterectomies, adnexal surgery, appendicitis, and either planned or incidental concomitant bowel surgery. No allergic reactions to the plastic device were noted. Postoperative evaluation demonstrated no evidence of wound infections, nerve injuries, seromas or dehiscence in the short term, nor hernia formation or other complications in the long term. CONCLUSION: The Dexterity Protractor permitted effective retraction of the abdominal wall. The device provided gentle retraction around the entire incision, excellent surgical exposure, and a barrier to specimens containing bacterial or potentially malignant cells. The method of application was uncomplicated and well-suited to abdominal walls of varying thickness. The utilization of this device was not associated with wound-related complications in this study of patients.

Abdomen↗

PubMed2003

Robotic mitral valve surgery.

A renaissance in cardiac surgery has begun. The early clinical experience with computer-enhanced telemanipulation systems outlines the limitations of this approach despite some procedural success. Technologic advancements, such as the use of nitinol U-clips (Coalescent Surgical Inc., Sunnyvale, CA) instead of sutures requiring manual knot tying, have been shown to decrease operative times significantly. It is expected that with further refinements and development of adjunct technologies, the technique of computer-enhanced endoscopic cardiac surgery will evolve and may prove to be beneficial for many patients. Robotic technology has provided benefits to cardiac surgery. With improved optics and instrumentation, incisions are smaller. The ergometric movements and simulated three-dimensional optics project hand-eye coordination for the surgeon. The placement of the wristlike articulations at the end of the instruments moves the pivoting action to the plane of the mitral annulus. This improves dexterity in tight spaces and allows for ambidextrous suture placement. Sutures can be placed more accurately because of tremor filtration and high-resolution video magnification. Furthermore, the robotic system may have potential as an educational tool. In the near future, surgical vision and training systems might be able to model most surgical procedures through immersive technology. Thus, a "flight simulator" concept emerges where surgeons may be able to practice and perform the operation without a patient. Already, effective curricula for training teams in robotic surgery exist. Nevertheless, certain constraints continue to limit the advancement to a totally endoscopic computer-enhanced mitral valve operation. The current size of the instruments, intrathoracic instrument collisions, and extrathoracic "elbow" conflicts still can limit dexterity. When smaller instruments are developed, these restraints may be resolved. Furthermore, a working port incision is still required for placement of an atrial retractor, as well as needle, tissue, and suture retrieval. With the development of specialized retractors and a delivery/retrieval port, a truly endoscopic approach will be consistently reproducible. New navigation systems and image guided surgery portend an improving future for robotic cardiac surgery. Recently, we have combined robotically guided microwave catheters for ablation of atrial fibrillation with robotic mitral valve repairs (Fig. 8). Thus, we are beginning to achieve the ideal operation, with a native valve repair and a return to normal sinus rhythm. Robotic cardiac surgery is an evolutionary process, and even the greatest skeptics must concede that progress has been made toward endoscopic cardiac valve operations. Surgical scientists must continue to critically evaluate this technology in this new era of cardiac surgery. Despite enthusiasm, caution cannot be overemphasized. Surgeons must be careful because indices of operative safety, speed of recovery, level of discomfort, procedural cost, and long-term operative quality have yet to be defined. Traditional valve operations still enjoy long-term success with ever-decreasing morbidity and mortality, and remain our measure for comparison. Surgeons must remember that we are seeking the most durable operation with the least human trauma and quickest return to normalcy, all done at the lowest cost with the least risks. Although we have moved more asymptotically to these goals, surgeons alone must map the path for the final ascent.

Cardiac Surgical Procedures↗

PubMed2000

Suturing and knotting techniques for thoracoscopic cardiac surgery.

The preceding description of E-CABG may seem excessively detailed, even redundant, for trained cardiac surgeons; however, the authors' extensive experience with training surgeons on endoscopic techniques suggests that, despite a high level of proficiency and dexterity that a surgeon may possess in open surgery, becoming equally proficient and dexterous in the endoscopic environment is not simple. Participating in an in-depth, systematic endoscopic microvascular surgery training program in a laboratory setting is essential before applying the previously described E-CABG techniques in humans. The E-CABG procedure is one of the most challenging endoscopic techniques. Successful completion of this procedure requires that the surgeon be motivated to succeed and willing to invest the time and effort necessary to develop the new skills. Also critical is the avoidance of the temptation to use devices and systems that promise to obviate the need to bother with learning these difficult endoscopic skills. Long term results of the minimally invasive approach remain to be defined. However, some early studies of port-access procedures are encouraging. To date, a prospective randomized clinical trial comparing conventional LAD bypass to E-CABG has not been conducted. Although most investigators believe that long term patency of the IMA to the LAD using either technique should be the same, this is as yet unproven. Nonetheless, the adaption of endoscopic skills by the cardiac surgeon will further advance the evolution of this specialty.

Coronary Artery Bypass↗

PubMed1997

Neurocognitive impairments associated with ambiguous handedness in the chronically mentally ill.

One form of atypical handedness, ambiguous handedness, is found in roughly one-quarter of chronic schizophrenic patients. Despite its prevalence, relatively little is known about the neurocognitive underpinnings of ambiguous handedness. In the present study we examined the performance of ambiguous (n = 19) and non-ambiguous (n = 39) handed chronically mentally ill inpatients on selected measures of verbal learning, motor learning and manual dexterity. The results revealed that ambiguous handers were more impaired than non-ambiguous handers in verbal learning, but not motor learning. Group differences in manual dexterity were significant for the entire sample, but not when analyses were limited to males. These findings suggest that impairments in verbal learning may be linked to the pathogenesis of ambiguous handedness in chronic psychiatric patients.

Adult↗

PubMed1986

Surgical management of the rheumatoid wrist--fusion or arthroplasty.

Forty-eight patients with 33 wrist fusions and 37 silicone wrist arthroplasties were reviewed and compared. Of those who had arthrodesis 97% showed a good or excellent result. Follow-up time averaged 82 months. All patients had a decrease in pain. Most patients had stronger wrists but complained of decreased dexterity. There were no pseudarthroses. The complication rate was 18%. Of patients in the arthroplasty group, 78% had a good or excellent result. Follow-up time averaged 51 months. Most patients in the arthroplasty group had improved dexterity and adequate wrist strength. Average flexion/extension was 32 degrees/29 degrees. The complication rate was 25%, which included four revisions. Of patients who had arthroplasties, 14% had bone resorption about the stem, and 11% of the patients with arthroplasties had x-ray evidence of settling. Factors that did not influence the result of the arthroplasty were patient age, duration of disease before surgery, finger extensor tendon rupture, preoperative motion, and hand dominance. Factors that were associated with failure and/or a fair result in arthroplasty patients were the use of ambulatory aids, the older and narrower prosthetic design, dislocated wrist preoperatively, and the chronic use of steroids.

Adult↗

PubMed1996

Outcome after Colles fracture: the relative responsiveness of three questionnaires and physical examination measures.

Clinical evaluation of outcome after Colles fracture has not been standardized. To assess the relative responsiveness of various clinical and questionnaire measures for the assessment of outcome after Colles fracture, 21 patients were surveyed on the day fracture immobilization was discontinued and again 3 months after that date with the following measures: a short form general health survey (SF-36), the Arthritis Impact Measurement Scale (AIMS2), the Brigham and Women's Hospital carpal tunnel questionnaire; pinch strength, grip strength, pressure sensibility, range of motion, and dexterity. Significant changes, all in the direction of improved health status, occurred in the following scales or measures: AIMS2 mobility, hand and finger function, arm function, household tasks, "arthritis" (fracture) pain, self-care, satisfaction, physical health, affect, and tension; Brigham function; SF-36 physical role and mental health; and grip, pinch, dexterity, and range of motion. The impairments that occur after Colles fracture are multidimensional and are only partially captured by traditional physical measures. Questionnaires such as the SF-36, AIMS2, and Brigham and Women's instruments provide a mechanism to capture the function and symptom dimensions objectively.

Colles' Fracture↗

PubMed1996

Outcome assessment for carpal tunnel surgery: the relative responsiveness of generic, arthritis-specific, disease-specific, and physical examination measures.

Clinical evaluation of outcome after treatment of carpal tunnel syndrome has not been standardized. To assess the value of various clinical and questionnaire measures for the assessment of outcome after carpal tunnel surgery, we surveyed 22 patients 1 day before and 3 months after carpal tunnel release with the following measures: the Medical Outcomes Study 36-item short form health survey, the Arthritis Impact Measurement Scale, the Brigham and Women's Hospital carpal tunnel questionnaire, wrist range of motion, power pinch grip strength, pressure sensibility, and dexterity. Significant changes, all in the direction of improved health status postoperatively, were noted in the following scales or measures: the Arthritis Impact Measurement Scale pain, satisfaction, health perception, arthritis impact, and symptom scales; the Brigham and Women's Hospital symptom and function scales; the short form health survey's physical role, emotional role, and bodily pain scales; and the measurement of dexterity. In this study, standardized questionnaires were more sensitive to the clinical change produced by carpal tunnel surgery than many commonly performed physical measures of outcome. The condition-specific questionnaire was more sensitive to change than were more generic questionnaires.

Activities of Daily Living↗

PubMed2002

Neuropsychologic and motor function in small-for-gestation preschoolers.

The aim of this study was to evaluate neuropsychologic and motor performance in term small-for-gestation preschool children. A patient-based sample of 311 5-year-old children with birth weights less than the fifteenth percentile for gestation was compared with a random sample of 321 appropriate-for-gestation control subjects. The main assessment tools were subscales from the Wechsler Preschool and Primary Scale of Intelligence Revised, subscales from the Illinois Test of Psycholinguistic Abilities, tests of manual dexterity and figure copying, and the Peabody Developmental Motor Scales. The small-for-gestation children had mean scores on tests of visuospatial and visuomotor abilities that were one fourth standard deviation lower than appropriate-for-gestation control subjects and slightly lower scores on manual dexterity. The small-for-gestation children were comparable to appropriate-for-gestation children regarding motor performance. We therefore conclude that the neuropsychologic and neuromotor performance in preschool years of term small-for-gestation children is reassuring.

Child Development↗

PubMed1996

The crystal structure of the light-harvesting complex II (B800-850) from Rhodospirillum molischianum.

BACKGROUND: The light-harvesting complexes II (LH-2s) are integral membrane proteins that form ring-like structures, oligomers of alpha beta-heterodimers, in the photosynthetic membranes of purple bacteria. They contain a large number of chromophores organized optimally for light absorption and rapid light energy migration. Recently, the structure of the nonameric LH-2 of Rhodopseudomonas acidophila has been determined; we report here the crystal structure of the octameric LH-2 from Rhodospirillum molischianum. The unveiling of similarities and differences in the architecture of these proteins may provide valuable insight into the efficient energy transfer mechanisms of bacterial photosynthesis. RESULTS: The crystal structure of LH-2 from Rs. molischianum has been determined by molecular replacement at 2.4 A resolution using X-ray diffraction. The crystal structure displays two concentric cylinders of sixteen membrane-spanning helical subunits, containing two rings of bacteriochlorophyll-a (BChl-a) molecules. One ring comprises sixteen B850 BChl-as perpendicular to the membrane plane and the other eight B800 BChl-as that are nearly parallel to the membrane plane; eight membrane-spanning lycopenes (the major carotenoid in this complex) stretch out between the B800 and B850 BChl-as. The B800 BChl-as exhibit a different ligation from that of Rps. acidophila (aspartate is the Mg ligand as opposed to formyl-methionine in Rps. acidophila). CONCLUSIONS: The light-harvesting complexes from different bacteria assume various ring sizes. In LH-2 of Rs. molischianum, the Qy transition dipole moments of neighbouring B850 and B800 BChl-as are nearly parallel to each other, that is, they are optimally aligned for Föster exciton transfer. Dexter energy transfer between these chlorophylls is also possible through interactions mediated by lycopenes and B850 BChl-a phytyl tails; the B800 BChl-a and one of the two B850 BChl-as associated with each heterodimeric unit are in van der Waals distance to a lycopene, such that singlet and triplet energy transfer between lycopene and the BChl-as can occur by the Dexter mechanism. The ring structure of the B850 BChl-as is optimal for light energy transfer in that it samples all spatial absorption and emission characteristics and places all oscillator strength into energetically low lying, thermally accessible exciton states.

Amino Acid Sequence↗

PubMed2001

The use of electromagnetic motion tracking analysis to objectively measure open surgical skill in the laboratory-based model.

BACKGROUND: Technical performance has traditionally been assessed subjectively within the operating theater, with few successful attempts at objective analysis. The Imperial College Surgical Assessment Device (ICSAD) has already been shown to be a valid quantitative measure of dexterity in laparoscopic surgical simulation. We describe its application to the assessment of open surgical procedures. STUDY DESIGN: Fifty-one participants were recruited from four different levels of general surgical experience: basic surgical trainees (n = 12), junior specialist registrars (n = 13), senior specialist registrars (n = 13), and consultants (n = 13). They completed two tasks: a small bowel anastomosis and a vein patch insertion into an artery. Surgical performance was measured with the Imperial College Surgical Assessment Device, a motion analysis system that measures the number of hand movements made and time taken to complete a task. The four groups were compared statistically using the Kruskal-Wallis test (K-W). Pairwise group comparisons used the Mann-Whitney U test and p values were adjusted for multiple comparisons to determine the statistical significance of these comparisons. RESULTS: Mean values for number of movements and time (secs) for small bowel anastomosis were 2,080/1,236 (basic surgical trainees), 1,673/1,016 (junior specialist registrars), 1,375/862 (senior specialist registrars), and 1,337/782 (consultants), respectively. Comparison of the medians by K-W revealed a p < 0.001 for each variable (No. of movements, time), respectively. Mean vein patch insertion results were 1,653/1,258, 1,297/1,006, 1,090/912, and 925/736 for each of the four groups. Again, comparison of the medians by K-W revealed a p < 0.001 for each variable. CONCLUSIONS: These findings suggest that hand motion analysis may be an effective objective measure of dexterity in open surgical simulation.

Anastomosis, Surgical↗

PubMed2003

Long-latency motor evoked potentials in congenital hemiplegia.

OBJECTIVE: To investigate long-latency motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation in congenital hemiplegia (CH) and to seek for correlation with paretic hand movement deficits. METHODS: MEPs were recorded from the first dorsal interosseous of both hands in 12 CH patients and 12 age-matched controls; dexterity and upper limb function were quantitatively assessed in both groups. RESULTS: In CH patients, long-latency MEPs, occurring much later than the commonly reported MEPs, were frequently observed in the paretic and non-paretic hands. Four distinct groups of long-latency MEPs were found, each cluster being identified by its mean latency, namely 35, 85, 160 and 225 ms. The residual dexterity of the paretic hand was correlated with the presence of contralateral MEPs with a 20 and 225 ms latency and was negatively correlated with ipsilateral MEPs, irrespective of their latency. In controls, only few MEPs with a latency of 225 ms were found in 4 out of 12 subjects. CONCLUSIONS: The pattern of MEPs found in CH patients differs dramatically from that reported in adult stroke patients, suggesting that long-latency MEPs are a rather distinctive consequence of early corticospinal lesions. The hypothesis that a given cluster of long-latency MEPs is mediated by a particular pathway appears very unlikely. Rather, we suggest that an exacerbation of cortical and/or spinal excitability is at the origin of these long-latency MEPs.

Adolescent↗