The temporal bone is an anatomically complex region within the skull. Current training for temporal bone surgery includes cadaveric, physical and virtual haptic simulations and apprenticeships. Cadavers are limited by low supply. Haptic devices are limited by their force and stiffness ratings and thus cannot adequately simulate rigid materials. Physical simulations excel at simulating stiff materials but do a poor job of soft tissue. The research objective was to develop a mixed reality (MR) temporal bone surgical haptic simulation. This novel concept would utilize physical models to simulate bone and haptic forces to simulate soft tissue. A surgical drill was attached to a Quanser® High Definition Haptic DeviceTM (HD2) via a clamp. An algorithm was implemented to simulate a force at the drill tip and to negate the weight of the clamp. This modified haptic system was interfaced to a temporal bone haptic simulation. Haptic chatter unique to the modified haptic system was observed and low-pass filters were used to mitigate this issue. Due to the poor positional accuracy of the HD2, MR simulation was not achieved. However, VR haptic simulation was achieved. Six expert surgeons were recruited to investigate the following questions: "What is the impact of different haptic hardware on surgical realism?" and "Would end users prefer a surgical drill over a standard haptic manipulandum?" Three cases were compared: a Phantom Omni®, a standard HD2 and a modified HD2 with attached drill. Expert surgeons rated the standard HD2 and Phantom Omni equivalently whilst preferring the modified HD2 with attached drill. Though the modified HD2 scored higher in all categories only “Acoustics” and “Overall Appreciation” displayed statistical significance. This implies that drill acoustics is critical for realism. / February 2016

Este estudo refere-se a proposta de padrões de enfermagem em centro cirúrgico e de instrumentos para sua operacionalização. Sua elaboração tem como objetivos básicos: a definição de padrões de enfermagem em centro cirúrgico, para nortear as ações de enfermagem e avaliação da assistência no período perioperatório, a estruturação de instrumentos que auxiliem a operacionalizacão desses padrões na prática e o estabelecimento de outros, que subsidiem a avaliação da assistência de enfermagem no período perioperatório. Foram definidos três tipos de padrões: os estruturais, compreendendo 6 padrões, os do processo de assistência de enfermagem, envolvendo 4 e os de resultados, composto por 3. Os instrumentos elaborados para a operacionalizacão dos padrões, são em número de três (1, 2 e 3), com duas partes distintas cada um (PARTE A e B) e os de avaliação da assistência, em número de 2, sendo que o número 4 apresenta parte A e B e o 5, A B e C. Tendo em vista a avaliação dos padrões e instrumentos propostos com a finalidade de detectar possíveis deficiências e propor medidas corretivas, foram elaborados questionários que foram respondidos por enfermeiras especialistas em centro cirúrgico, para a realização do ajuizamento da proposta. Este ajuizamento foi realizado, considerando-se a adequação, clareza, especificidade, objetividade, validade e viabilidade dos padrões e instrumentos. Com base nos resultados do ajuizamento, pode-se inferir que os padrões e instrumentos propostos, foram aceitos pela maioria das enfermeiras. Foram apontadas algumas deficiências e sugeridas medidas corretivas e estas, analisadas. / This work concerns to the proposition of nursing standards in operating roorn and the instruments for their efficiency. The work ellaboration has as basic goals: the definition of nursing standards in operating room to guide the nursing activities during the perioperative time, the instrument organization that may produce the efficiency of these practice standards and the establishment of others which may help the nursing assistance\'s evaluation during the perioperative period. There hinds of standards were defined, structural with 6 standards, standard process with 4 and the standard results formed by 3. The instruments prepared for the standards efficiency are theree (1, 2, 3) and each one has two differente parts (Part A and B) and the assistance\'s evaluation standards are two considering that the number 4 is divided into part A and B and number 5 A, B and C. For having a successful judgement of the proposal, questions were prepared in order to get the specialist nurses\'answers in operating roorn considering the evaluation of the standards and the instrurnents proposed with the objetive of making known some defficiencies and to propose correting actions as well. This judgement was gotten considering the adequacy clearness, specification, objectivity, vality and possibility of the standards and instruments. Based on the judgement results we may infer that the standards and the instruments proposed were accepted by most of the nurses. Some defficiencies and correcting actions were pointed and these analysed.

Orientadores: Rogerio de Fraga, Paulo Cesar Rodrigues Palma / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-12T22:24:52Z (GMT). No. of bitstreams: 1 Cardia_FishilerPimentelZitenfeld_M.pdf: 1370656 bytes, checksum: 9c1061423f4725bab06c637f1e6c0958 (MD5) Previous issue date: 2009 / Resumo: A crescente utilização de telas de polipropileno em cirurgia pélvica reconstrutiva levou ao aparecimento de complicações inerentes ao uso dos materiais sintéticos, tais como retração, exposição e infecção. Com o objetivo de avaliar a retração de telas de polipropileno de media gramatura e melhorar a incorporação da mesma através de orifícios de 5 mm de diâmetro, realizamos um estudo experimental "in vivo". Método: No presente estudo, avalia a morfologia e a densidade volumétrica das fibras de colágeno em malhas com e sem orifícios padronizados, bem como; a retração das mesmas, por meio de mensuração radiográfica e direta da tela. A amostra consistiu de 14 ratas fêmeas da raça Wistar, que foram sacrificadas 90 dias após o implante. O abdômen foi ressecado e radiografado antes de ser preparado o estudo histológico e estereológico. A distribuição do colágeno foi avaliada por estereologia nos três compartimentos: pele, fascia de Colles e na região do implante da Tela entre a fascia de Colles e a aponeurose dos músculos retos abdominais. Resultados: Não houve retração das telas de polipropileno nas aferições radiográficas e medidas diretas. A estereologia evidenciou deposição de fibras de colágenos organizadas nos orifícios. Ao contrário nas telas sem orifícios, a deposição de colágeno foi maior e desorganizada, com cistos de inclusão. Outro dado relevante foi que a estrutura das fibras de colágeno apresentou-se morfologicamente normal nos animais de tela com orifício, e houve uma maior proximidade entre a pele e a musculatura no local do orifício. Conclusões: A análise histológica revelou menor reação inflamatória nas telas com macro orifícios. A avaliação estereológica da densidade volumétrica das fibras de colágeno nas telas com e sem orifícios, permitiu observar que os macro orifícios agiram como fator facilitador da integração do enxerto e que poderá representar implicações na parte clinica médica. Palavras chaves: Polipropileno; Telas cirúrgicas / Abstract: The meshes in reconstructive pelvic surgery have led to complications inherent to the use of synthetic materials, such as retraction, exposure and infection. In order to improve mesh integration we created standardized orifices, 5 mm in diameter of monofilament polypropylene mesh and compared local tissue reaction with regular meshes in an animal study. Method: We evaluated the morphology and volumetric density of collagen fibers in meshes with and without standardized orifices, as well as its retraction through radiographic and direct measurement of the meshes. The sample consisted of 15 female Wistar rats, which were sacrificed 90 days after the implant. The abdominal wall was removed and x-ray was taked before its preparation for histological and stereological study (estimate the density of an element of a homogeneous area). The volumetric density of the collagen fibers was calculated by stereological tool in three compartments: skin, Colles' fascia and mesh, the latter located between the Colles' fascia and the aponeurosis of the rectus abdominalis muscles. Results: There was no retraction of the polypropylene meshes. The histological and stereological analysis disclosed organized collagen fiber deposition in the orifices and less inflammatory reaction than the control meshes with no orifices. Conclusions: There was no mesh retraction in both groups. The histological and stereological results suggest that the standardized orifices facilitated tissue integration and may have clinical application. Keywords: Polypropylene; Surgical meshes / Mestrado / Cirurgia / Mestre em Cirurgia

Orientadores: Cássio Luís Zanettini Riccetto, Benedicto de Campos Vidal / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T17:40:56Z (GMT). No. of bitstreams: 1 Siniscalchi_RodrigoTeixeira_D.pdf: 4712721 bytes, checksum: 84737665d5451453e82931eab2e748c4 (MD5) Previous issue date: 2012 / Resumo: Introdução: O material sintético (tela) mais utilizado atualmente no tratamento da Incontinência Urinária de Esforço (IUE) e dos prolapsos da parede vaginal, também conhecidos como Prolapsos dos Orgãos Pélvicos (POP) é o polipropileno monofilamentar, com índices de cura de até 90%. Porém, as complicações relacionadas à integração tecidual desses implantes são relativamente prevalentes. O colágeno, por ser um material biologicamente compatível, pouco imunogênico e com propriedades moduladoras do processo inflamatório, pode ser utilizado como um importante agente cicatrizante e, nesse sentido, poderia melhorar a integração das telas. Objetivo: Estudar os efeitos biomecânicos e histológicos do recobrimento de tela de polipropileno monofilamentar com gel purificado de colágeno, implantadas no tecido subcutâneo de ratas. Material e Métodos: Vinte ratas foram utilizadas para o estudo histológico e outras 20 para o estudo biomecânico. De um lado da parede abdominal do animal foi implantado um fragmento tela de polipropileno monofilamentar macroporosa medindo 20 x 10 mm, habitualmente utilizada no tratamento da IUE e dos POP (Grupo I), denominada PLP (tela de polipropileno) e do outro lado foi implantada uma tela com as mesmas dimensões recoberta com gel purificado de colágeno (Grupo II), denominada PLP+C (tela de polipropileno recoberta com o gel purificado de colágeno). De acordo com o tempo de eutanásia (7, 30, 90 ou 180 dias) após o implante os animais de cada grupo foram divididos em quatro subgrupos contendo cinco animais cada. Foi então realizada excisão em bloco da parede abdominal para as análises. O estudo biomecânico foi realizado em um tensiômetro de precisão, no qual a tela era tracionada em sentido uniaxial até que se desprendesse da interface tecidual. Para quantificar a aderência do material, em cada grupo, foi analisada a carga máxima necessária para este desprendimento. No estudo histológico foram analisadas as características relativas à inflamação aguda e crônica além do tecido de granulação, formação de granuloma e reação de corpo estranho em lâminas coradas com Hematoxilina-Eosina (HE), utilizando-se de método semiquantitativo. A organização supramolecular da deposição colágena em torno das telas foi estudada através de microscopia de polarização (birrefringência). Resultados: No estudo biomecânico observou-se que a aderência das telas de polipropileno aos tecidos circunvizinhos aumentou significativamente após o recobrimento com o gel purificado de colágeno, como demonstrado na análise dos valores encontrados para a Carga Máxima no 7º (p=0,0016), 14º (p=0,0039), 90º (p=0,0009) e 180º (p=0,0029) dias após o implante. Considerou-se nessa pesquisa, que o aumento da biocompatibilidade da tela de polipropileno seria alcançado quando, na interface tecidual, houvesse redução da intensidade do processo inflamatório. Verificou-se que a resposta inflamatória crônica e aguda (neutrofílica), assim como a formação de tecido de granulação foi menos intensa, respectivamente p=0,004, p<0,001 e p=0,001 nas telas recobertas com o colágeno na fase inicial (7º e 14º dias) e ausente, assim como nas telas não recobertas na fase tardia (90º e 180º dias). A inflamação granulomatosa foi observada de forma menos significativa aos sete dias após o implante nos animais do grupo II (p=0,029) e em ambos os grupos, de maneira similar, diminuiu ao longo do tempo não mostrando diferença significativa. A reação de corpo estranho foi menos intensa na fase inicial no grupo II (p<0,001) e semelhante entre os grupos na fase tardia. Nas análises de birrefringência foi observado no período inicial (sete dias) uma maior densidade média de brilho (transmitância) a favor das telas não recobertas (p=0,000), porém nos outros períodos analisados a densidade média de brilho foi maior nas tela do grupo II (PLP+C), 14 dias (p=0,000), 90 dias (p=0,000) e em 180 dias (p=0,000). Conclusão: O recobrimento das telas de polipropileno com o gel purificado de colágeno aumentou sua aderência aos tecidos, quando implantadas na interface da parede abdominal de ratas adultas, tanto precocemente quanto tardiamente; promoveu uma resposta inflamatória menos intensa e duradoura e na fase tardia do implante desencadeou maior organização e empacotamento das fibras de colágeno. Estes dados inferem que a tela recoberta com o gel purificado de colágeno quando locada em seu leito de implante terá, provavelmente, menor mobilidade e também uma melhor adaptação e integração ao corpo do hospedeiro resultando em menor chance de complicações / Abstract: Introduction: The synthetic material most currently used in the treatment of stress urinary incontinence (SUI) and vaginal wall prolapse, also known as pelvic organ prolapse (POP) is the monofilament polypropylene mesh (PLP). However, complications related to tissue integration of these implants are relatively prevalent. Collagen is the main structural protein of mammals, which modulates inflammatory process, and can be used as an important healing agent and, accordingly, could improve the integration of the meshes. Objetives: To study the biomechanical and histological effects of PLP, coated with purified collagen gel, implanted in the subcutaneous tissue of adult rats. Methods: Twenty rats were used for histological study and other 20 for the biomechanical study. At one side of the abdominal wall, PLP fragment measuring 20x10 mm was implanted (Group I), and in the other side a mesh fragment with the same dimensions coated with purified collagen gel PLP+C) was implanted (Group II). According to the time of euthanasia (7, 30, 90 or 180 days) after implantation the animals from each group were divided into four subgroups of five animals each. The biomechanical study was performed with a precision tension meter with in bloc fresh abdominal wall sample containing the mesh. The mesh was pulled up in uniaxial direction until complete detachment of the tissue interface and the maximum load required for the detachment was analyzed in each group. In the histological study, it was examined characteristics of the acute and chronic inflammatory reaction, granulation tissue, granuloma formation, and foreign body reaction on slides stained with hematoxylin-eosin. The supramolecular organization of the collagen deposition around the meshes was studied with polarizing microscopy (birefringence analysis). Results: In biomechanical study it was observed that the adhesion of PLP to surrounding tissues increased significantly after coating with purified collagen gel, as shown in the analysis of the maximum load at the 7th (p=0.0016), 14th (p=0.0039), 90th (p=0.0009) and 180th (p=0.0029) days after implantation. It was considered in this research, that increased biocompatibility of PLP would be achieved when, in tissue interface, there was a reduction of the intensity of the inflammatory process. It was found that the acute and chronic inflammatory response, as well as the formation of granulation tissue were less intense, respectively p=0.004, p<0.001 and p=0.001 for PLP+C in the initial phase (7th and 14th days) and missing, as well as on the meshes not covered in late phase (90th and 180th days). Granulomatous inflammation was less significant seven days after implantation in animals of Group II (p=0.029) and in both groups, similarly, decreased over time showing no significant difference. The foreign body reaction was less intense in the initial phase in Group II (p<0.001) and similar between the groups in the late phase. In the birefringence analyses, it was noted a greater average density of brightness (transmittance) in PLP (p=0.000) in the initial period (seven days), but in other periods it was greater for PLP+C [14 days (p=0.000); 90 days (p=0.000) and 180 days (p=0.000)]. Conclusions: Coating of polypropylene meshes with purified collagen gel increased their adhesion to the tissues, when implanted in the subcutaneous of the abdominal wall of adult rats and promoted a less intense and lasting inflammatory response and, in the late stage of the implant, triggered greater organization and packaging of collagen fibers. Based on that, one can suppose that mesh coated with purified collagen gel can fix better to the host tissues preventing its displacing, and can elicit fewer integration defects, resulting in less chance of complications / Doutorado / Fisiopatologia Cirúrgica / Doutor em Ciências

We present a case of a woman with a history of Congenital Adrenal Hyperplasia (CAH) diagnosed at the age of 12, who was referred to our unit for surgical treatment. Despite the initial diagnosis was an indirect inguinal hernia, it was a misdiagnosis. Once in our service, this was corrected into clitoromegaly secondary to CAH. Physical examination and imaging test discarded other abnormalities, such as secondary effects androgenization. Regarding surgical treatment, the techniques used were Spencer and Allen combined with Kumar, which are the most used for clitoroplasty but also less used in Peru.

M.Cur. / Please refer to full text to view abstract

Magister Chirurgiae Dentium - MChD / To compare the use of a piezoelectric with a standard surgical handpiece in third molar surgery. Thirty patients requiring removal of third molars were included in the study. Panoramic radiographs were used to assess the third molars. The patients were randomly subdivided and the split-mouth technique applied. In split-mouth design, divisions of the mouth, such as right (upper and lower) and left (upper and lower) quadrants constitute the experimental units, which are randomly assigned to two treatment groups. Each patient serves as his or her own control, which increases statistical efficiency (Siddiqi et al. 2010). Each side was operated with either a piezoelectric or a conventional handpiece. All aspects of preoperative care, general anaesthesia, surgery and postoperative care were standardized for the groups. / South Africa

Magister Scientiae (Physiotherapy) - MSc(Physio) / Clubfoot is one of the congenital and structural conditions that lead to physical impairment in children globally. Service providers have different perceptions on the various methods of management of clubfoot. This has led to adoption of various approaches of management of clubfoot. Although there is a wide range of experiences of parents/caregivers of children with clubfoot regarding medical management of this condition, there is no documented data on these experiences. The study therefore aimed at exploring the perceptions regarding the medical management of clubfoot in Kenya. The objectives of this study were to explore the service providers and parents/caregivers perceptions on the use of the different methods of medical management of clubfoot; explore the process followed before and after the commencement of management from the service providers and parents/caregivers when using surgical and conservative methods of management as well as exploring the barriers and enabling factors that the service providers experience during the management of clubfoot. Methodology: This study was conducted at talipes clinic of Mbagathi District Hospital, Kenyatta National Hospital and Kijabe Mission Hospital in Kenya. The study utilized a qualitative design and purposive convenient sampling was utilized to recruit participants. Twenty participants were recruited; the sample consisted of ten parents/caregivers of children with clubfoot and ten service providers. Semi-structured interview and probes were used for data collection, interviews were audiotaped and a research assistant took notes, data was collected until saturation. Data was transcribed verbatim and analyzed by thematic-content analysis. The results indicated that most of the service providers perceived Ponseti method as the most effective method of clubfoot management with early intervention. Surgery was found to be the second most utilized method which was indicated for complex and neglected clubfoot. The factors that affected service providers in clubfoot management included: Shortage of trained staff in Ponseti management, missed diagnosis at birth; poor referral system and poor compliance with treatment appointments. The factors that affected parents/caregivers compliance with the treatment regime included: (i) unaffordable transport expenses; (ii) long distance; (iii) little or no social/family support; culture/tradition and stigmatization while compliance was facilitated by (i) good communication between the parents/caregivers and the clinician; (ii) availability of free services (iii) social/ family support. Conclusion: The current study concluded that medical management of clubfoot was a success while majority of parents/caregivers agreed that they were faced with several challenges as fore mentioned which affected the outcome. Recommendation: the study therefore recommends the need to empower the community and service provider with knowledge on clubfoot and its management. There is also need for decentralisation of services and increase the number of health care givers in health facilities who are trained in clubfoot management. Finally physiotherapy academic institutions need to put emphasis on teaching clubfoot management in order to produce effective service providers.

Exposure to certain bloodborne pathogens can prematurely end a person’s life. Healthcare workers (HCWs), especially those who are members of surgical teams, are at increased risk of exposure to these pathogens. The proper use of personal protective equipment (PPE) during operative/invasive procedures reduces that risk. Despite this, some HCWs fail to consistently use PPE as required by federal regulation, accrediting agencies, hospital policy, and professional association standards. The purpose of this mixed methods survey study was to (a) examine factors surgical team members perceive influence choices of wearing or not wearing PPE during operative/invasive procedures and (b) determine what would influence consistent use of PPE by surgical team members. Using an ex post facto, non-experimental design, the memberships of five professional associations whose members comprise surgical teams were invited to complete a mixed methods survey study. The primary research question for the study was: What differences (perceptual and demographic) exist between surgical team members that influence their choices of wearing or not wearing PPE during operative/invasive procedures? Four principal differences were found between surgical team members. Functional (i.e., profession or role based) differences exist between the groups. Age and experience (i.e., time in profession) differences exist among members of the groups. Finally, being a nurse anesthetist influences the use of risk assessment to determine the level of PPE to use. Four common themes emerged across all groups informing the two study purposes. Those themes were: availability, education, leadership, and performance. Subsidiary research questions examined the influence of previous accidental exposure to blood or body fluids, federal regulations, hospital policy and procedure, leaders’ attitudes, and patients’ needs on the use of PPE. Each of these was found to strongly influence surgical team members and their use of PPE during operative/invasive procedures. Implications based on the findings affect organizational policy, purchasing and distribution decisions, curriculum design and instruction, leader behavior, and finally partnership with PPE manufacturers. Surgical team members must balance their innate need to care for patients with their need to protect themselves. Results of this study will help team members, leaders, and educators achieve this balance.

Surgical observation is an integral part of surgical training. Junior residents, who have limited understanding of the procedure being performed, frequently engage in observation in order to gain exposure to surgical techniques. This limited experience, and the relative lack of guidance currently provided to them, might limit their ability to learn by observing. This thesis examines learners’ perceptions of the value of surgical observation, the barriers to learning in the surgical environment, and the factors that facilitate learning within the context of the operating room. An intervention, employing predefined objectives in the form of sets of questions, was introduced and the impacts of this intervention in terms of junior residents’ attitudes toward observation were explored. Two rounds of focus groups examined learners’ perceptions: one before introducing the intervention and one after it. Transcripts from these focus groups were analyzed using a qualitative interpretative approach and focus group participants provided considerable insight into observational learning. Many barriers were identified, including logistical constraints and lack of guidance. The surgical culture, within which observation is perceived as less effective than performing the surgery itself, was also mentioned as a factor that impedes learning during observation. Following the intervention, participants felt more validated as learners in the operating room and appreciated having clear objectives when observing procedures. Participants did mention that their busy clinical obligations would likely limit their use of any educational intervention. It was also noted that interventions to promote learning through observation would have to be fully supported by their program to be used on a regular basis. In conclusion, many factors that impact learning during surgical observation were identified. While trainees felt that increased guidance for observation was helpful, the environment in which learning takes place would have to be optimized to facilitate junior trainees’ learning.