Telesurgical mentoring. Initial clinical experience

BACKGROUND: Minimally invasive surgical techniques yield significant individual, economic, and social benefits when performed by experienced surgeons. Unfortunately, many of these techniques, such as laparoscopy, are associated with steep learning curves, and the incidence of complications has clearly been shown to be inversely related to experience. The initial high complication rate and the dearth of experienced endoscopic surgeons have raised concerns over training, granting of hospital privileges, and most importantly patient safety. The goal of this study was to employ current telecommunications technology in a system for the mentoring of relatively inexperienced surgeons. Therefore, we created a telesurgical system that would allow an endoscopic specialist at a central site to offer guidance and assistance to a surgeon during a laparoscopic procedure. METHODS: We developed a system that connected a central site and an operative site, a distance of approximately 3.5 miles, via a single T1 (1.54 Mbs) point-to-point communications link. The system provided real-time video display from either the laparoscope or an externally mounted camera located in the operating room, full duplex audio, telestration over live video, control of a robotic arm that manipulated the laparoscope, and access to electrocautery for tissue cutting or hemostasis. RESULTS: Seven patients underwent laparoscopic procedures using the telesurgical consultation system over the communications link. In all cases, the primary surgeon had limited experience with the laparoscopic approach but still had the basic skills required to obtain intraperitoneal access. All seven cases were completed successfully without complications. CONCLUSION: These initial studies have demonstrated the feasibility, effectiveness, and safety of telementoring. Telesurgical applications have the potential to greatly improve surgical education credentialing, and patient care by offering patients and their surgeons global access to surgical specialists.     

Ethics consultation

Hospices in the U.S. were surveyed in 1990 to find out whether service to blacks and Hispanics was affected by admission criteria and hospice service characteristics of hospices located in or near these populations. Hospice characteristics such as reimbursement patterns, staff interventions, and admission criteria were different depending upon the percent of blacks and/or Hispanics in the hospice service area or actually served by the hospice. Care for Hispanics was more dependent on Medicaid and free care than blacks whose care was financed primarily by Medicare and Medicaid. Hospices identified problems in serving Hispanics as language, reimbursement, and severity-of-illness issues. Hospice admission criteria, especially the primary caregiver requirement, were identified as impeding access for blacks. Hispanics were perceived as presenting the most access and service problems and as the most underserved.     

Pre-ECT cardiology consultation

A case of multiple primary Carcinomas of the gastrointestinal tract is reported in a man presenting with Carcinomas of the rectum and oesophagus.     

Rule-based consultation systems]

This paper overviews the architecture of rule-based consultation systems and illustrates how such systems work by an Antibiotic Advisor. Knowledge representation and the inference engine implemented in the program are briefly described along with a sample consultation with the system. The paper is concluded with an analysis of the advantages and limitations of rule-based reasoning in clinical decision support.     

Outcome-based consultation for supervisors.

Presented a case study of a consultant who used outcome-based consultation with a female supervisor (aged 38 yrs) of a medical diagnosis unit for improving her interaction with 15 supervisees (aged 19–43 yrs). Outcome-based consultation was the strategy used during a 40-hr consultation. This method included the stages of establishing a working relationship, assessing attitudes and behaviors, setting goals, implementing supervisory strategies, and evaluating outcomes. During a 2-wk feedback and evaluation period, the supervisor had 22 positive, 12 neutral, and 0 negative interactions with 15 supervisees. Even so, overall negative perceptions of the supervisor's relationship with 5 supervisees persisted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatric consultation among hospitalized arthritis patients

Fifty consecutive psychiatric consultations on 48 patients over an 18-month period in an arthritis hospital are analyzed. The range of psychiatric disorders and their relationship to characteristics of the patient population, such as age, sex, and medical diagnosis, are described. Approximately 2% of patients admitted to the hospital during this period elicited psychiatric consultation. This rate is one-third of the consultation rate of an acute medical and surgical hospital serviced by the same consultants. The relative distribution of psychiatric diagnoses--depression 59%, personality disorders and drug abuse 15%, psychosis 10%, conversion reaction 10%, and "other" 6%--was similar to that encountered in an acute general hospital setting. Although depression was the most prevalent psychiatric problem, it was severe enough to elicit consultation only in 1% of the total hospitalized population; its severity did not correlate directly with the severity of rheumatoid arthritis, the most common medical diagnosis encountered. Neither a particular medical illness nor sex accounted for a disproportionate share of the psychiatric consultations.     

Can patients predict consultation time?

This study examines the ability of patients to estimate how long they need to spend with the doctor. It investigates the effect of a patient making such an estimate on his or her satisfaction with the consultation and participation in the doctor-patient relationship.     

Continence consultation for the rural homebound

Because an estimated 10 million Americans have urinary incontinence, home care continence services are in demand. In March 1992, the Agency on Health Care Policy and Research recommended behavioral therapy as a first step in treatment options for urinary incontinence. Nurses are best prepared to meet the challenges of providing behavioral therapy to people who are incontinent and are being cared for in their homes. This article describes the development of a nursing practice that provides assessment and treatment of urinary incontinence to people who are homebound in rural Northern Vermont.     

Paradigms for clinical ethics consultation practice

The effects of lipoproteins on ion channel-mediated catecholamine secretion were investigated in cultured bovine adrenal medullary cells. Low density lipoprotein (LDL: 20-80 mg/dl) and lipoprotein(a) [Lp(a); 10-80 mg/dl] inhibited catecholamine secretion induced by carbachol, an activator of nicotinic acetylcholine receptor-ion channels. LDL and Lp(a) suppressed carbachol-induced 22Na+ influx as well as 45Ca2+ influx in a concentration-dependent manner similar to that of catecholamine secretion. The inhibition of catecholamine secretion by Lp(a) was not overcome by increasing the concentration of carbachol. On the other hand, high density lipoprotein (HDL; < 150 mg/dl) had no effect on 22Na+ influx, 45Ca2+ influx, and catecholamine secretion. Like LDL and Lp(a), a synthetic peptide homologous to human plasma apolipoprotein B (apoB), apoB fragment(3358-3372)-amide (3-60 microM), attenuated 22Na+ influx, 45Ca2+ influx, and catecholamine secretion caused by carbachol. The apoB fragment also suppressed 22Na+ influx induced by veratridine (an activator of voltage-dependent Na+ channels) and 45Ca2+ influx induced by 56 mM K+ (an indirect activator of voltage-dependent Ca2+ channels). These findings suggest that atherogenic lipoproteins such as LDL and Lp(a) suppress catecholamine secretion by interfering with Na+ influx through nicotinic acetylcholine receptor-ion channels, in which apoB, a structural component common to both LDL and Lp(a), plays an important role. The inhibition by atherogenic lipoproteins of catecholamine secretion may influence the progression of atherosclerosis induced by these lipoproteins.     

Medical views of psychological consultation.

A questionnaire was mailed to 500 physicians in a five-state rural region in an effort to obtain their views, concerns, and attitudes about the utility of psychological consultations. The 500 physicians were randomly selected in equal numbers per state from national directories of internal medicine physicians and family practitioners. Of the 500 physicians surveyed, 139 (28%) responded by completing and returning the questionnaire. The results suggest that physicians generally view psychological consultations as helpful and necessary; however, they expressed concern about what training psychologists received as consultants. Physicians also expressed strong concern about the perceived lack of feedback from psychologists during and after consultations. The implications of the return rate and results are discussed. Recommendations to establish greater credibility and to improve interactions between physicians and psychologists are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychiatric consultation: concepts and controversies

There are two major models of consultation in the field of psychiatry, differing in their goals, participants, settings, and methods. The psychiatric-therapeutic model entails provision of optimal care for the individual patient; the community mental health model involves provision of assistance to mental health caregivers. The author believes that to enhance the value of consultation the consultation should restrict his or her role to that for which he or she has been trained. Current social needs, coupled with a limited supply of consultants, suggest that psychiatric consultation should be provided within comprehensive health care systems. There is a pressing need to clarify the concepts of formulations concerning the criteria of outcome of psychiatric consultation so that evaluation of its effectiveness can be advanced.