African neurosurgery part II: current state and future prospects

A survey conducted among African neurosurgeons shows that there are now 500 neurosurgeons in Africa; that is, one neurosurgeon for 1,350,000 inhabitants, and 70,000 km2. The distribution of these neurosurgeons shows a striking regional disparity: North Africa has 354 neurosurgeons for 119 million inhabitants; that is, one neurosurgeon for 338,000 inhabitants; and South Africa has 65 neurosurgeons for 40 million inhabitants; that is, one neurosurgeon for 620,000 inhabitants. Between these two areas where neurosurgery is developing quite well, we have the majority of African countries with a scant density of neurosurgeons (81 neurosurgeons for 515 million inhabitants; that is, one neurosurgeon for 6,368,000 inhabitants). The Panafrican Association of Neurological Sciences (PAANS) brings together African neurosurgeons. This continental African association represents African neurosurgeons in the World Federation of Neurosurgical Societies (WFNS). In addition to this continental association, there are national societies of neurosciences. However, there are only six societies of neurosurgery. Two systems of training exist in Africa: (1) local training, and (2) training abroad. These two systems have unequal quality and specific difficulties that are pointed out. Among the optimistic elements that make us believe in the development of neurosurgery in Africa, are the existence of a quite good level of neurosurgery at the two extremities of the continent (North Africa and South Africa), the development of neurosciences in African universities, and the increasing interest that the international community bears to Africa in the last years. However, the real factor of optimism is the African neurosurgeons who should promote neurosurgery in their continent, at the level of their own countries by developing information and health education, setting their specialty in the education syllabus and health planning, and settling into active and performing societies. At the continental and international level, African neurosurgeons should institutionalize inter-African cooperation, expedite their continental association (PAANS), and further exchanges with the other continents through the WFNS. The latter, together with other associations such as the European Association of Neurosurgical Societies (EANS) could provide help to the development of neurosurgery in Africa as far as training, exchanges, research, and organization are concerned.     

The origin and evolution of the University of Pittsburgh Department of Neurological Surgery

Neurological surgery at the University of Pittsburgh began more than 60 years ago with the arrival of Stuart Niles Rowe. During the years, the department has been led by four men, each of whom guided the department into the future in his unique way. These men and many other dedicated physicians, nurses, and staff members have contributed to this organization and created an environment where neurosurgery flourishes. This article describes the development of neurosurgery within the "Steel City" and outlines the origin and growth of the Department of Neurological Surgery at The University of Pittsburgh Medical Center.     

Application of biomedical engineering to neurosurgery

Biomedical engineering is increasingly becoming very important also in neurosurgery. This article describes some examples of neurosurgical applications of biomaterials which play a central role in biomedical engineering. Since a large number of biomaterials are currently used in neurosurgery, only the biomaterials that have been developed in our laboratories in collaboration with neurosurgeons are briefly presented here. The biomaterials developed include devices used for interventional neurosurgery and bioabsorbable scaffolds for regeneration of dura mater and skull bone. We developed an immediately electrically detachable coil using a poly(vinyl alcohol) junction between the coil and the delivery wire. This is the first detachable coil developed in Japan and is currently under clinical trial. In addition to the coil used for interventional neurosurgery, the development of an embolic liquid is presented. As an alternative to allografts such as Lyodura, we developed a dural substitute from synthetic bioabsorbable polymers which are completely free from potential risk of latent virus infection. Finally, our experience in tissue engineering for skull bone regeneration using growth factors coupled with polymeric carriers is presented to demonstrate the promise of tissue engineering in the future.     

On vision, values, and cushy management.

Contends that the August 1996 archival issue of the American Psychologist , which focuses on the state of APA's management and governance, sends mixed, incomplete, and disturbing messages about that state. Horai asserts that the 1995 annual report of Chief Executive Officer R. D. Fowler (see record 83-38233) does not provide a sense of what happened during the year related to where APA is, where it is going, and what challenges and opportunities are ahead. She also contends that APA's management team is unresponsive to membership and indifferent toward the Council of Representatives and its work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The development of pediatric neurosurgery in Paris. How to create something out of nothing: reflexions on the methodology

Up to 1960, children in need of neurosurgical treatment in France were treated either in neurosurgical departments where anesthetists, nurses and neurosurgeons had no specialized training in pediatrics or in departments of pediatric surgery in which the specific aspect of neurosurgery was ignored. Clearly a mutation was needed before any progress could be made: the development of pediatric neurosurgery services. This essay tells the story of the creation of the first pediatric neurosurgery service in France, of the difficulties encountered and of the strategies applied to overcome them. It also recalls the discussions about what size such a service should be and whether it should be located in a general hospital or in a pediatric hospital. During the second half of the twentieth century, progress in neurosurgery, and more specifically in pediatric neurosurgery, has been tremendous. The contribution of the pediatric neurosurgery service at Les Enfants Malades in Paris is briefly summarized.     

Development of neurosurgery in Greece: past, present, and future

In this study the authors examine the historical tradition as well as current features of neurosurgery in Greece and compare the available data with international standards. In particular, they describe the organizational structure of neurosurgery with reference to manpower, unit distribution, training, and qualification. They discuss problems such as overproduction of neurosurgeons and the poor control of training and qualification procedures in the neurosurgical profession. The findings are examined in a critical way and solutions are proposed that could improve the present situation.     

A postmodern reconstruction of psychotherapy: Orienteering, religion, and the healing of the soul.

In this article, psychotherapy is likened to conversational orienteering: helping others to understand the topography of meaning and goods "all around," and to find out where they are in the present, where they are going in the future, and directions for how to get there. Historically, religion has provided orienteering within a culture. The religious features of psychotherapy are discussed, and a case is made that modern psychotherapy is simply one form of religious orienteering that has been unusually successful in vying for therapeutic supremacy in 20th-century Western culture and, like modernism in general, unusually unaware of its religious function. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Different fibroblast growth factor 1 (FGF-1) transcripts in neural tissues, glioblastomas and kidney carcinoma cell lines

The significant factors in the development of the neurosurgery program at the University of Florida have been the funding for 10 endowed chairs and a Brain Institute, the achievement of departmental status in the College of Medicine, the collaborative research with a strong Department of Neuroscience, and the strong commitment by the faculty to subspecialty neurosurgery and to service in the national neurosurgical organizations.     

The clinical psypsychologist's opportunities and obligations in the community.

A discussion of the role of the clinical psychologist in working within society, in the community, to apply his abilities to the molding of social structure, for "only by going where society is can we maintain ourselves." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neurosurgery at the Montreal Neurological Institute and McGill University Hospitals

For the past 60 years, the Montreal Neurological Institute and Hospital and three associated McGill University teaching hospitals have provided a broad course of instruction in neurosurgery and the related neurosciences. This integrated program offers a wealth of experience in adult and pediatric neurosurgery, based on a total of 140 beds, covering a full range of general and subspecialty neurosurgery. The institute, recognized for many years as a world center for epilepsy surgery, has traditional strengths in the treatment of brain tumors and cerebrovascular and spinal disorders; it has been at the cutting edge of brain imaging in all modalities applied to neurosurgical diagnosis and cerebral localization, including three-dimensional monitoring in the operating room. New approaches to stereotactic procedures have been developed in conjunction with imaging technology, including functional neurosurgery and the versatile McGill double rotation method for radiosurgery with a linear accelerator. Experience in managing trauma, pediatric cases, and general neurosurgical problems is gained at the Montreal General Hospital, the Montreal Children's Hospital, and the Jewish General Hospital. Well-established research units, including burgeoning groups in neurogenetics, molecular neurobiology, and neural regeneration, provide a wide variety of academic opportunities to provide trainees with a sound basis for coping with the rapidly advancing field of neurosurgery.     

Patellar reconstruction of the condyles in giant cell tumours of the knee

Training in vascular surgery is inevitably going to change radically over the next few years and we no longer have the luxury of an apprenticeship where the trainee matures and develops by prolonged contact with patients and senior colleagues. The EEC and Department of Health are insisting on a more focused training, by reducing the hours to 72 per week and suggesting accreditation as a surgical specialist after 6 years in higher surgical training. These goals, which have already been accepted by the Royal Colleges (and have been welcomed by the trainees), will inevitably lead to an entirely different approach to training, offering vascular surgeons an opportunity to develop coherent and more uniform programmes. To date many trainees have complained that their experience has been patchy, and sometimes poorly supervised. The task of developing a practical scheme is daunting, but we must start with the patient. Clearly, the patients' needs come first so that the training programme must lock on to the best standards of care. Only in this way can we ensure that the trainee is exposed to the best practice and modern techniques.     

The robotization of neurosurgery: state of the art and future outlook

Neurosurgery is by excellence a field of application for robots, based on multimodal image guidance. Specific motorized tools have been already developed and routinely applied in stereotaxy to position a probe holder or in conventional neurosurgery to hold a microscope oriented towards a given target. The potentialities of these approaches have triggered industrial developments currently commercially available. These systems use data bases, primarily coming from multimodal numerical images from X-ray radiology to magnetic resonance imaging. These spatially encoded data are transferred through digital networks to workstations where images can be processed and surgical procedures are preplanned, then transferred to the robotic systems to which they are connected. We have been using a stereotactic robot since 1989 and a microscope robot since 1995 in various surgical routine procedures. The future of these applications mainly rely on the technical progress in informatics, about image recognition to adapt the preplanning to the actual surgical situation, to correct brain shifts for instance, about image fusion, integrated knowledge such such as brain atlases, as well as virtual reality. The future developments, covering surgical procedure, research and teaching, will sure be far beyond our wildest expectations.     

The Richard C. Schneider Lecture. New dimensions of neurosurgery in the realm of high technology: possibilities, practicalities, realities

Fueled by a buoyant economy, popular attitudes and demands, and parallel progress in transferable technical and biological areas, neurosurgery has enjoyed a remarkable quarter of a century of progress. Developmental trends in the discipline have included the following: 1) a refinement of preoperative definition of the structural substrate, 2) miniaturization of operative corridors, 3) reduction of operative trauma, 4) increased effectiveness at the target site, and 5) incorporation of improved technical adjuvants and physical operative tools into treatment protocols. In particular, the computer has become a formidable ally in diagnostic and surgical events. Trends in technical development indicate that we are entering an exciting era of advanced surgery of the human cerebrum, which is heralded by the following: 1) current developments in areas of imaging, sensors, and visualization; 2) new devices for localization and navigation; 3) new capabilities for action at the target point; and 4) innovative concepts related to advanced operative venues. Imaging has provided structurally based surgical maps, which now are being given the new dimension of function in complex and integrated formats for preoperative planning and intraoperative tactical direction. Cerebral localization and navigation based on these advances promise to provide further refinement to the field of stereotactic neurosurgery, as linked systems are superseded by more flexible nonlinked methodologies in functionally defined volume-oriented navigational databases. Target point action now includes not only ablative capabilities through micro-operative methods and the use of stereotactically directed high-energy forms but also the emergence of restorative capabilities through applications of principles of genetic engineering in the areas of molecular and cellular neurosurgery. Complex, dedicated, and self-contained operative venues will be required to optimize the emergence and development of these computer-oriented micro/stereotactic capabilities, which appear to be unavoidably required as locales for the practice and development of virtual reality-based stations for operative rehearsal, simulation, training, and, ultimately, enhancement of operative events through robotic interfaces. Primary impetus for progress has relied upon new combinations of technologies, disciplines, and industries. Philosophical and practical problems include the spectrum of availability of these methods to the population at large, the training of individuals to properly administer these methods, defining the acceptable envelope of expertise, and maintaining suitable delivery and progress while containing spiraling costs. Advanced neurological surgery and the use and development of high-technology adjuvants require a robust economy that has a populace willing to invest in the luxury of such developments. The current socioeconomic situation is fragile from the standpoint of both economics and attitudes of the patients and health care providers, with diversion of economic resources, redistribution of funding bases, modification of patient referrals, practice styles, and service attitudes undermining progress. Economic pressures have brought high-technology methods under great scrutiny regarding their effectiveness and cost-effectiveness. Reform proposals have specifically targeted technology-oriented services, and the Office of Technology Assessment has recommended increasing the use of managed care providers who look to information on cost-effectiveness and clinical practice guidelines to establish efficient management strategies and issue "report cards." Although the premise is laudable and "gimmickry" needs to be identified, it might be argued that such scrutiny and control might be overbearing and overused, impeding appropriate delivery and progress.     

Use of intraoperative ultrasound in neurosurgery

Intraoperative ultrasound (US) is a device which is a great help to neurosurgeon in intracerebral lesions localization, in the definition of inner tumors structure, in its relation to the surrounding structures, as well as during stereotaxic operations. We report our experiences with US in more than 500 operations. Its maximum usage is during gliomas and metastases operations because of their subcortical localization. Choosing this optimal approach to the tumor, the surrounding brain is minimally damaged. Using modern devices we are able to distinguish edema from infiltrative gliomas, which was not possible using former devices (both edema and gliomas are hyperechoic). In vascular neurosurgery we use US mostly in the localization of small arteriovenous malformations (AVMs). In pediatric neurosurgery the usage is very often in drainage operations for ventricular catheter placement control. The main US shortage is lower image resolution, and the basic advantage is real time imaging. It enables our prompt intervention in every unfavorable situation.     

Errors in MR stereotaxy due to undetected extraneous metal objects

MR stereotaxic procedures are being increasingly used, particularly in functional neurosurgery where very high levels of localization accuracy are required. Whilst many studies have investigated intrinsic causes of non-linearity, potential errors due to an extrinsic cause are not generally appreciated. It is not uncommon to find objects such as hair clips, paper clips and pins inside high-field magnets. They can remain undetected for long periods because they can reach positions not open to visual inspection and because they often do not produce observable deterioration in routine image quality. In this study we measured the maximum absolute positional shifts caused by such objects and found that these can be significant (> 1 mm, even up to 200 mm from one such object). Additional measurements were performed using an MR compatible Leksell stereotaxic frame to calculate actual stereotaxic coordinate errors. The encompassing nature of the frame is such that some degree of compensation for such nonlinearities is inherent, and so errors for areas of the brain more proximal to the object are found to be reduced but not eliminated. Stereotaxic coordinate errors will not be reduced in nonencompassing designs and in frameless stereotaxy. The prevalence of such objects in clinical systems and the measures required to detect their presence are discussed. The need for quality control testing before each stereotaxic procedure is highlighted.     

Stress responses of sheep to routine procedures: changes in plasma concentrations of vasopressin, oxytocin and cortisol

Try to tailor your advice to the individual family. Keep it simple and practical. Find out who is going, where and whether the family has any particular health needs. Encourage the family to plan ahead, finding out as much as they can about facilities for young children at their destination. Likely discussion points are vaccinations, infant and toddler feeding, managing the journey, avoiding sunburn and diarrhoea, and contraception. Depending on destination it may be advisable for the family to take some items with them from the UK, e.g. infant formula and feeding equipment, contraceptives, sun protection and insect repellents.     

Tumor suppressor genes: at the crossroads of molecular carcinogenesis, molecular epidemiology, and human risk assessment

BACKGROUND AND PURPOSE: Marfan syndrome is a heritable disorder of connective tissue caused by a deficiency of the glycoprotein fibrillin. In several publications and neurological textbooks, a relationship between Marfan syndrome and intracranial aneurysms has been assumed. METHODS: The records of 135 patients classified as having Marfan syndrome who visited the Amsterdam Marfan clinic or were admitted to the departments of neurology and neurosurgery and the records of all patients with a subarachnoid hemorrhage or intracranial aneurysm who visited or were admitted to the departments of neurology and neurosurgery between January 1, 1982, and January 1, 1994, were retrieved. The literature was reviewed regarding Marfan syndrome and intracranial aneurysms. RESULTS: No patient visiting the Marfan clinic had a symptomatic intracranial aneurysm. No patient with Marfan syndrome had been admitted with a ruptured intracranial aneurysm at the departments of neurology or neurosurgery in this period, while during that period 826 patients with symptomatic intracranial aneurysms had been admitted. During follow-up of 129 of the 135 patients with Marfan syndrome (2850 retrospective patient observation years and 581 prospective patient observation years), none presented a symptomatic intracranial aneurysm. The suggested relationship between Marfan syndrome and intracranial aneurysms is based mainly on 10 case reports. However, the diagnosis of Marfan syndrome is doubtful in several of these reports. Several large studies of patients with Marfan syndrome did not mention a ruptured intracranial aneurysm as a clinical manifestation. CONCLUSIONS: We conclude that there is insufficient evidence to presume a relationship between symptomatic intracranial aneurysms and Marfan syndrome on the basis of currently available data.     

Correspondence of salivary and plasma concentrations of atrazine in rats under variable salivary flow rate and plasma concentration

We present a suite of neurosurgery supporting tools developed around (i) the Virtual Workbench, a productive environment for the control of 3-D data, in which delicate work can be performed for hours on end without strain, and (ii) the Electronic Brain Atlas, integrating the major print brain atlases in day-to-day clinical use. We describe in detail the Brain Bench, a surgical planning system for stereotactic frame neurosurgery. Its objective is to prepare faster plans; have a better and more accurate choice of target points; improve the avoidance of sensitive structures; have fewer sub-optimal frame attachments and speedier, more effective planning and training. If validated by a clinical study now under way, this will improve medical efficacy and reduce costs.     

An exploration of the value of specialist neurosurgical nurses

The differences in the knowledge and skills of 75 nurses working in a variety of practice settings were examined using a case study vignette of a neurosurgical patient developed by researchers. The case study tested nursing care throughout a patient's hospital experience, including admission, presurgery, postsurgery and discharge preparation. The findings showed that nurses who had specialised in neurosurgery scored markedly higher, in all aspects of practice knowledge, than expert nurses in other specialties and general nurses. Patients undergoing neurosurgery are safer if they have nurses who are experienced, skilled and knowledgeable to care for them.