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Introduction: Chronic pain is defined as pain lasting longer than 3 months. This often causes persistent emotional distress and functional disability that is refractory to conventional treatments. Emerging evidence suggests that oral Ketamine therapy may have a specific role in managing treatment-resistant chronic pain. This study aimed to assess the effectiveness of oral ketamine within a tertiary chronic pain management clinic., Methods: This study was a clinic-based retrospective descriptive study of 79 patients with a broad range of chronic pain diagnoses and treated with oral ketamine over a period up to 12 years. Changes in pain, mood and quality of life (QoL) were assessed using a numerical pain severity score, the Brief Pain Inventory (BPI), the Public Health Questionnaire (PHQ-9) and American Chronic Pain Association Quality of Life (QoL) scale., Results: 73 patients were accessible for follow-up (mean daily dose and treatment duration were 193.84 mg and 22.6 months respectively). Pain scores decreased ( p  < 0.0001) on both numerical scores (41.6% decrease) and BPI scoring (mean decrease 2.61). Mood improved ( p  < 0.0001) across both PHQ-9 and BPI measurements. Patients also reported less difficulty with daily activities and improved QoL. The most common adverse reaction was drowsiness (21.9%), with 30.1% reporting no adverse reactions from Ketamine., Discussion: This work adds to the growing body of evidence that under the supervision of a pain specialist, oral ketamine therapy may be a safe, tolerable and effective treatment for chronic pain conditions which have not responded to other management options. Further research is required to produce a more accurate understanding of its chronic use., Key Message: This real-world study shows that patients being treated with oral ketamine for chronic pain report decreased severity of pain, improved mood and increased quality of life across all conditions., Competing Interests: KL has received previous funding from Medtronic Ltd not related to this research. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Al Mukhaizeem, Nasa, Waldron, McDaid, Gorman, Featherstone, Barry, Murphy, Gallagher, Nair, O'Connor, Kelly, O'Hora, Dolan, Mac Colgain, McGrath, Blouin, Roman, Gaffney, Roddy and Levins.)

Background: The Endotine Forehead device (Coapt Systems, Inc., Palo Alto, Calif.) is an implantable bioabsorbable fixation device designed to provide intuitive, multipoint, distributed tension and repeatable and predictable brow fixation during endoscopic and open browplasty. The purpose of this study was to evaluate early results in a series of endoscopic brow lift cases using the Endotine Forehead device., Methods: Two versions of the Endotine device were used in this study. One was composed of polylactic acid, and the other was a smaller version consisting of 82/18 L-lactide/glycolide). In a consecutive series of endoscopic brow lift cases, preoperative and postoperative standardized photographs were taken in the Frankfort horizontal plane and three measurements were compared: midpupil to superior brow, midpupil to hairline, and lateral canthus to superior brow., Results: A total of 21 patients (19 women and two men) underwent endoscopic browplasty. Photographs were obtained preoperatively and 54 to 174 days postoperatively. Brow elevation measurements were obtained postoperatively. No significant adverse events were encountered in the follow-up period., Conclusion: The Endotine Forehead device provides significant and reproducible brow elevation, with no significant adverse events, as measured at three points in excess of 14 weeks postoperatively.

Traditional microsurgery involves the use of bulky and expensive stereo microscopes that have limited portability. Recent advances in video technology have enabled the exploration of alternative visualization methods. The purpose of this study was to evaluate standard laparoscopic equipment for microvascular anastomoses. Eight surgeons completed anastomoses on rat femoral and synthetic vessels using stereo microsurgery and video microsurgery visualization systems. All surgeons had previous experience with stereo microsurgery and none had ever used video microsurgery. Data were collected on overall anastomosis and individual suture times. A sample of completed anastomoses was placed in a video database and evaluated by use of a quality rating scale (8 to 10, excellent; 6 to 7, adequate; less than 6, poor). All surgeons subjectively evaluated the video microsurgery system. A total of 48 anastomoses were completed. The average total anastomosis time for the stereo microsurgery was 1018.9 +/- 463.2 seconds versus 1738.9 +/- 460.1 seconds for the video microsurgery. The average individual suture placement time was 114.6 +/- 60.6 seconds for the stereo microsurgery versus 211.7 +/- 128.4 seconds for the video microsurgery (p < 0.05). Twenty-five of the anastomoses underwent quality review. The overall score of the stereo microsurgery group was 8.1 +/- 1.7, and the video microsurgery group had an overall score of 7.3 +/- 1.6. Survey results revealed that 75 percent of the participants thought that the video microsurgery would be useful for human operations and would improve surgeon comfort, but 87.5 percent would not use the present video microsurgery system over stereo microsurgery in their practice. Although significant differences exist in overall anastomosis and individual suture completion times, no difference was found in the overall quality. Video microsurgery could become a useful tool on the basis of surgeon ergonomics; however, optical parameters require further refinement.

Background: Computerized human patient simulators (HPSs) have been used to improve diagnostic and therapeutic decision making. The goal of this study was to investigate the impact of HPSs and Advanced Trauma Life Support (ATLS) on the development of trauma management skills and self-confidence in surgical interns., Methods: Three teams of interns completed two ATLS-like trauma scenarios on the HPS (pre-ATLS). They then took the ATLS provider course. After ATLS, the interns were evaluated on two different HPS trauma scenarios (post-ATLS). Two teams of senior residents, experienced in trauma care, completed the same HPS scenarios and were used as controls. Trauma management skills were scored in three areas--critical treatment decisions, potential for adverse outcomes, and team behavior--by staff trauma surgeons. After participating in the HPS trauma scenarios, the interns completed self-confidence questionnaires and a course evaluation survey., Results: Trauma management skill scores increased 23% in critical treatment decisions, 25% in potential for adverse outcomes, and 47% in team behavior after ATLS/HPS (p < 0.002). Senior residents' performance on HPS trauma scenarios was better than the interns (p < 0.05) in all three areas evaluated. The interns' self-confidence scores rose significantly after the course. (p < 0.01) The HPS course evaluation survey averaged 8.3 out of a maximum 10., Conclusion: Use of HPSs in conjunction with ATLS appears to enhance the development of trauma management skills. The surgical interns participating in the study deemed the HPS to be a worthwhile experience and a confidence-building tool. In particular, trauma team behavior improved significantly after ATLS/HPS.

In the United States, medical care consumes approximately $1.2 trillion annually (14% of the gross domestic product) and involves 250,000 physicians, almost 1 million nurses, and countless other providers. While the Information Age has changed virtually every other facet of our life, the education of these healthcare professionals, both present and future, is largely mired in the 100-year-old apprenticeship model best exemplified by the phase "see one, do one, teach one." Continuing medical education is even less advanced. While the half-life of medical information is less than 5 years, the average physician practices 30 years and the average nurse 40 years. Moreover, as medical care has become increasingly complex, medical error has become a substantial problem. The current convulsive climate in academic health centers provides an opportunity to rethink the way medical education is delivered across a continuum of professional lifetimes. If this is well executed, it will truly make medical education better, safer, and cheaper, and provide real benefits to patient care, with instantaneous access to learning modules. At the Center for Advanced Technology in Surgery at Stanford we envision this future: within the next 10 years we will select, train, credential, remediate, and recredential physicians and surgeons using simulation, virtual reality, and Web-based electronic learning. Future physicians will be able to rehearse an operation on a projectable palpable hologram derived from patient-specific data, and deliver the data set of that operation with robotic assistance the next day.

Background: Surgical interns accept significant patient care responsibilities with minimal orientation. We have developed a multifaceted training program for incoming surgical interns in which learning in a simulated environment plays a key role. The purpose of this study was to evaluate resident perceptions of simulated clinical calls as an educational modality and to measure the effect on self-ratings of confidence., Methods: A multidisciplinary team compiled 15 clinical scenarios. Simulated nurse-to-resident clinical call sessions were held on 3 separate days. Daily course evaluation surveys and identical precourse and postcourse confidence surveys were completed., Results: The resident confidence measure increased significantly postcourse (6.73 versus 8.35, P <0.03). The evaluation survey score averaged 4.35 out of 5., Conclusions: Simulated clinical call sessions were well received and resulted in a significant increase in resident confidence levels. Based on this modality's apparent efficacy and ease of implementation, we offer it as a useful educational tool for incoming postgraduate year-1 surgical residents.

The teaching and learning of surgery is a time-honored tradition based upon the "see one, do one, teach one" apprenticeship model. Recent improvement of this model has centered upon incremental change in skills teaching and testing and curricular development. Economic pressures have strained the resources of academic health centers and faculty responsible for teaching surgery, even as information technology has opened new avenues for obtaining and benefitting from relevant information. Combining the tools of simulation theory, virtual reality, and the principles of adult education offers new opportunities to optimize surgical education as we enter a more highly connected and interdependent era, where the boundaries between teacher and student blur as the modern surgeon truly becomes a lifelong learner., (Copyright 2000 Wiley-Liss, Inc.)

Rapid change is under way on several fronts in medicine and surgery. Advances in computing power have enabled continued growth in virtual reality, visualization, and simulation technologies. The ideal learning opportunities afforded by simulated and virtual environments have prompted their exploration as learning modalities for surgical education and training. Ongoing improvements in this technology suggest an important future role for virtual reality and simulation in surgical education and training.

Background: The applications of minimally invasive surgery (MIS) and laparoscopy are rapidly expanding. Despite this expansion, our understanding of the importance of haptic feedback during laparoscopic surgery is incomplete. Although many surgeons believe that the use of minimally invasive techniques eliminates force feedback and tactile sensation (haptics), the importance of haptics in MIS has not been fully evaluated. There is considerable interest in the development of simulators for MIS even though the importance of force feedback remains poorly understood. This study was designed to determine the ability of experienced surgeons to interpret haptic feedback with respect to texture, shape, and consistency of an object., Study Design: A randomized, single-blinded study was designed. Twenty surgeons were presented objects in a random order, with participants blinded as to their identity. Inspection by direct palpation, conventional instruments, and laparoscopic instruments was performed on all objects. Statistic analysis of the data was performed using chi-square analysis and, when appropriate, a Fischer exact probability test., Results: Direct palpation was associated with the highest accuracy for shape identification and was superior to both conventional instruments (p < 0.001) and laparoscopic instruments (p<0.001). Fine texture analysis with either a conventional instrument or a laparoscopic instrument was superior to direct palpation (p < 0.05). Finally, the three methods of analysis were comparable for consistency analysis., Conclusions: These data indicate that laparoscopic instruments do, in fact, provide surgeons with haptic feedback. Interpretation of the texture, shape, and consistency of objects can be performed. In some situations, laparoscopic instruments appear to amplify the haptic information available. Our ongoing work is directed at further defining force interactions.

Burn injury is known to cause thrombosis and occlusion of dermal vessels that come in direct contact with thermal energy. Progressive ischemia secondary to diminished blood flow may compromise dermal tissues immediately surrounding the primary burn site. A standardized brass bar was used to create uniform full-thickness "comb" burns on 10 rat backs. Topical petrolatum (N = 2), 2% nitroglycerin (N = 4), and 5% flurbiprofen (N = 4) was applied to the burns at 2 and 4 hours postinjury. The vascular patency of dermal vessels was visualized directly by latex vascular casts made 24 hours after the burn injury. The vascular casts showed an absence of patent vessels within the direct burn sites in all treatment groups, and within the burn interspaces of the petrolatum-treated rats. Interspacial dermal vessel patency was seen in the 2% nitroglycerin and 5% flurbiprofen-treated rats. Topical 2% nitroglycerin and 5% flurbiprofen applied 2 and 4 hours postinjury effectively prevented interspacial dermal vessel thrombosis at 24 hours postinjury.

The authors carried out experiments to advance the midface in growing sheep using a distraction force across the zygomaticomaxillary sutures. They wished to assess the possibility of performing distraction osteogenesis across intact sutures as well as distraction after Le Fort osteotomies. Their results demonstrate that the technique of gradual distraction after osteotomy is successful in the growing animal. Bilateral distraction across intact sutures did not advance the midface or change the dental relationship. Unilateral distraction was successful in angulating the midface away from the distracting force in the intact growing animal. Alternating unilateral distraction or "waltzing" was surprisingly effective in advancing the midface in one of the animals studied and may become applicable in some craniofacial deformities. In all intact animals there was some expansion of the zygomaticomaxillary suture as well as a substantial migration of the distraction devices through the bone.

Introduction: The applications of Minimally Invasive Surgery (MIS) and Laparoscopy are rapidly expanding. Despite this expansion, the technology related to our understanding of the importance of haptic feedback related to laparoscopic surgery remains in its infancy. While many surgeons feel that the use of minimally invasive techniques eliminates force feedback and tactile sensation, the importance of haptics in MIS has not been fully evaluated. Moreover, there is considerable interest in the development of haptic simulators for MIS even though the importance of force feedback remains poorly understood. This study was designed to determine the ability of novice surgeons to interpret haptic feedback with respect to texture, shape and consistency of an object., Method: Subjects were presented objects in a random order and participants were blinded as to their identity. Inspection by direct palpation, palpation with conventional instruments, and palpation with laparoscopic instruments was performed on all objects. Statistical analysis of the data was performed using a Fischer exact probability test., Results: Direct palpation provided the greatest degree of haptic feedback and was associated with the highest accuracy for texture discrimination, shape discrimination, and consistency discrimination. A significant decrease in the ability to identify shapes was noted with both CI and LI. A significant decrease in the ability to differentiate consistency was noted for LI only. When comparing palpation with conventional instruments to palpation with laparoscopic instruments, there was no significant difference in shape or texture discrimination. There was, however, a significant decrease in consistency discrimination., Conclusion: This data indicates that laparoscopic instruments do in fact provide the surgeon with haptic feedback. While the instruments change the information available to the surgeon, interpretation of the texture, shape and consistency of objects can be performed. Our ongoing work is directed at further defining force interactions. Through the use of force feedback impulse devices in VR simulators, one should be able to create a more realistic theatre in which the novice surgeon can learn operative skills that will readily translate into the operating room.

Minimally invasive procedures are becoming much more common in surgical practice because of the many advantages for patient comfort and convenience, and improved surgical access. However some of the major problems leading to occasional surgical errors with this minimal access method are restricted vision, limited sense of touch, difficulties in identification in 3D space of the position of the instrument tips, and their handling during delicate, short-distance movements toward the surgical target area. These factors emphasize the need for computer simulated training in surgical manipulations and procedures in preparation for conducting them in patients. The key new feature of our proof-of-concept training simulator is a preventive mechanism that serves at least two functions. As the surgical target (or a critical structure) is approached, a haptically generated preventive force forewarns the surgeon, making it possible to abort those maneuvers that may lead to adverse results. By announcing a potential collision of a virtual instrument tip with a surgical target, the time used for searching for the target is shortened, and the haptic signal minimizes the potential of tissue damage. This real-time, interactive, virtual reality based, haptic breast biopsy-training simulation is a PC/NT based multitasking, multithreading system. It is based upon an advanced force feedback device. The system monitors and indirectly guides the surgeon's movements, while providing high fidelity visual and force feedback cues as the area of surgical interest is approached. Our first application is with human breast.