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North Bethesda, MD, United States

Pulse!! The Virtual Clinical Learning Lab at Texas A&M University-Corpus Christi, in collaboration with the United States Navy, has developed a model for research and technological development that they believe is an essential element in the future of military and civilian medical education. The Pulse!! project models a strategy for providing cross-disciplinary expertise and resources to educational, governmental, and business entities challenged with meeting looming health care crises. It includes a three-dimensional virtual learning platform that provides unlimited, repeatable, immersive clinical experiences without risk to patients, and is available anywhere there is a computer. Pulse!! utilizes expertise in the fields of medicine, medical education, computer science, software engineering, physics, computer animation, art, and architecture. Lab scientists collaborate with the commercial virtual-reality simulation industry to produce research-based learning platforms based on cutting-edge computer technology.

OBJECT: Minimal-access transforaminal lumbar interbody fusion (TLIF) has gained popularity as a method of achieving interbody fusion via a posterior-only approach with the aim of minimizing injury to adjacent tissue. While many studies have reported successful outcomes, questions remain regarding the potential learning curve for successfully completing this procedure. The goal of this study, based on a single resident's experience at the only Accreditation Council for Graduate Medical Education-approved neurosurgical training center in the US military, was to determine if there is in fact a significant learning curve in performing a minimal-access TLIF. METHODS: The authors retrospectively reviewed all minimal-access TLIFs performed by a single neurosurgical resident between July 2006 and January 2008. Minimal-access TLIFs were performed using a tubular retractor inserted via a muscle-dilating exposure to limit approach-related morbidity. The accuracy of screw placement and operative times were assessed. RESULTS: A single resident/attending team performed 28 minimal-access TLIF procedures. In total, 65 screws were placed at L-2 (1 screw), L-3 (2 screws), L-4 (18 screws), L-5 (27 screws), and S-1 (17 screws) from the resident's perspective. Postoperative CTs were reviewed to determine the accuracy of screw placement. An accuracy of 95.4% (62 of 65) properly placed screws was noted on postoperative imaging. Two screws (at L-5 in the patient in Case 17 and at S-1 in the patient in Case 9) were lateral, and no revision was needed. One screw (at L-4 in Case 24) was 1 mm medial without symptoms or the need for revision. In evaluating the operative times, 2 deformity cases (Grade III spondylolisthesis) were excluded. The average operating time per level in the remaining 26 cases was 113.25 minutes. The average time per level for the first 13 cases was 121.2 minutes; the amount of time decreased to 105.3 minutes for the second group of 13 cases (p = 0.25). CONCLUSIONS: In summary, minimal-access TLIF can be safely performed in a training environment without a significant complication rate due to the expected learning curve.

Etienne M.,National Naval Medical Center
American journal of disaster medicine | Year: 2010

On January 12, 2010, a 7.0 Richter earthquake devastated Haiti and its public health infrastructure leading to a worldwide humanitarian effort. The United States sent forces to Haiti's assistance including the USNS Comfort, a tertiary care medical center on board a ship. Besides setting a transparent triage and medical regulating system, the leadership on the Comfort instituted a multidisciplinary Healthcare Ethics Committee to assist in delivering the highest level efficient care to the largest number of victims. Allocation of resources was based on time-honored ethics principles, the concept of mass casualty triage in the setting of resource constraints, and constructs developed by the host nation's Ministry of Health. In offering aid in austere circumstances, healthcare practitioners must not only adhere to the basic healthcare ethics principles but also practice respect for communities, cultures, and traditions, as well as demonstrate respect for the sovereignty of the host nation. The principles outlined herein should serve as guidance for future disaster relief missions. This work is in accordance with BUMEDINST 6010.25, Establishment of Healthcare Ethics Committees.

Bell R.S.,National Naval Medical Center
Neurosurgical focus | Year: 2010

The approach to traumatic craniocervical vascular injury has evolved significantly in recent years. Conflicts prior to Operations Iraqi and Enduring Freedom were characterized by minimal intervention in the setting of severe penetrating head injury, in large part due to limited far-forward resource availability. Consequently, sequelae of penetrating head injury like traumatic aneurysm formation remained poorly characterized with a paucity of pathophysiological descriptions. The current conflicts have seen dramatic improvements with respect to the management of severe penetrating and closed head injuries. As a result of the rapid field resuscitation and early cranial decompression, patients are surviving longer, which has led to diagnosis and treatment of entities that had previously gone undiagnosed. Therefore, in this paper the authors' purpose is to review their experience with severe traumatic brain injury complicated by injury to the craniocervical vasculature. Historical approaches will be reviewed, and the importance of modern endovascular techniques will be emphasized.

Wang K.P.,Johns Hopkins Hospital | Browning R.,National Naval Medical Center
Thoracic Cancer | Year: 2010

Transbronchial needle aspiration (TBNA) has been used for over three decades in the diagnosis and staging of mediastinal adenopathy and masses. Although first described in Argentina in 1949 by Dr. Eduardo Schieppati, this rigid bronchoscope technique received very little attention until 1978 at Johns Hopkins Hospital where Wang and colleagues described in detail the diagnosis of a paratracheal mass by TBNA biopsy through a rigid bronchoscope using a 25-gauge esophageal variceal needle. In 1983, a novel flexible needle that could be used with the flexible bronchoscope to perform TBNA was developed and introduced for diagnosis and staging of bronchogenic carcinoma. Immediately to follow was the expansion of its use in the diagnosis of peripheral pulmonary nodules and benign mediastinum and hilar disorders by obtaining histological core specimens. Recent development of the endobronchial ultrasound-guided TBNA is most exciting and promising. Whether this will enhance the result of TBNA and spread the TBNA technique as a standard lung cancer staging procedure is yet to be seen. TBNA is simpler and easier. Endobronchial ultrasound-guided TBNA currently is more complicated and more difficult. Its future relies on a hybrid instrument and methodology to be widely applied to the diagnosis and staging of bronchogenic carcinoma. © Tianjin Lung Cancer Institute and Blackwell Publishing Asia Pty. Ltd.

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