Background: Teleradiology is currently being explored to enhance services for patients seeking emergency neurosurgical diagnoses in Ontario, Canada. Design: Systematic review of literature and cost-consequence analysis. Data sources: Medline, Embase, Cochrane, and Database of Abstracts of Reviews of Effects. Methods: Studies published between 1950 and 2008 describing remote consultations for neurosurgical assessments were retrieved. Two reviewers selected studies through multi-staged content screening and extracted data. Results 12 of 3765 studies met the inclusion criteria: two were randomized controlled trials and ten were case series. Teleradiology [88% (207/236)] and video-conferencing [89% (213/239] consultations produced higher diagnostic accuracy than telephone consultations [64% (150/235), p<0.001]. Savings varied by location and were based on avoided costs for ground and air transportation and hospitalization. Conclusions: There is limited evidence of clinical benefit of teleradiology. Savings associated with reduction in patient transfer rates depend on transportation mode and may be attenuated by higher operational costs.

Background: Teleradiology is currently being explored to enhance services for patients seeking emergency neurosurgical diagnoses in Ontario, Canada. Design: Systematic review of literature and cost-consequence analysis. Data sources: Medline, Embase, Cochrane, and Database of Abstracts of Reviews of Effects. Methods: Studies published between 1950 and 2008 describing remote consultations for neurosurgical assessments were retrieved. Two reviewers selected studies through multi-staged content screening and extracted data. Results 12 of 3765 studies met the inclusion criteria: two were randomized controlled trials and ten were case series. Teleradiology [88% (207/236)] and video-conferencing [89% (213/239] consultations produced higher diagnostic accuracy than telephone consultations [64% (150/235), p<0.001]. Savings varied by location and were based on avoided costs for ground and air transportation and hospitalization. Conclusions: There is limited evidence of clinical benefit of teleradiology. Savings associated with reduction in patient transfer rates depend on transportation mode and may be attenuated by higher operational costs.

Recent clinical studies have demonstrated that photoacoustic imaging (PAI) provides important diagnostic information for breast cancer staging. Despite these promising studies, PAI remains an unfeasible option for clinics due to the cost to implement, the required large modification in user conduct and the inflexibility of the hardware to accommodate other applications for the incremental enhancement in diagnostic information. The research described in this dissertation addresses these issues by designing attachments to clinical ultrasound probes and incorporating custom detectors into commercial ultrasound scanners. The ultimate benefit of these handheld devices is to expand the capability of current ultrasound systems and facilitate the translation of PAI to enhance cancer diagnostics and neurosurgical outcomes. Photoacoustic enabling devices (PEDs) were designed as attachments to two clinical ultrasound probes optimized for breast cancer diagnostics. PAI uses pulsed laser excitation to create transient heating (<1°C) and thermoelastic expansion that is detected as an ultrasonic emission. These ultrasonic emissions are remotely sensed to construct noninvasive images with optical contrast at depths much greater than other optical modalities. The PEDs are feasible in terms of cost, user familiarity and flexibility for various applications. Another possible application for PAI is in assisting neurosurgeons treating aneurysms. Aneurysms are often treated by placing a clip to prevent blood flow into the aneurysm. However, this procedure has risks associated with damaging nearby vessels. One of the developed PEDs demonstrated the feasibility to three-dimensionally image tiny microvasculature (<0.3mm) beyond large blood occlusions (>2.4mm) in a phantom model. The capability to use this during surgery would suggest decreasing the risks associated with these treatments. However, clinical ultrasound arrays are not clinically feasible for microsurgical applications due to their bulky size and linear scanning requirements for 3D. Therefore, capacitive micromachined ultrasound transducer (CMUT) two-dimensional arrays compatible with standard ultrasound scanners were used to generate real-time 3D photoacoustic images. Future probes, designed incorporating CMUT arrays, would be relatively simple to fabricate and a convenient upgrade to existing clinical ultrasound equipment. Eventually, a handheld tool with the ability to visualize, in real-time 3D, the desired microvasculature, would assist surgical procedures. The potential implications of PAI devices compatible with standard ultrasound equipment would be a streamlined cost efficient solution for translating photoacoustics into clinical practice. The practitioner could then explore the benefits of the enhanced contrast adjunctive to current ultrasound applications. Clinical availability of PAI could enhance breast cancer diagnostics and cerebrovascular surgical outcomes.

Introduction: Trauma centers (TC) are the only institutions with resources to manage patients with severe traumatic brain injury (TBI). We chose to examine potential barriers to access to TC care for TBI patients. Methods: Administrative datasets were used to evaluate access to TC among patients with severe TBI. We examined triage practices of EMS in TBI. Finally, we analyzed surveys to capture the beliefs, perceptions and knowledge of ED physicians with respect to TBI. Results: 57% of patients in Ontario had any access to a TC following TBI. Of patients who had potential access to a TC from the scene of injury as defined by pre-hospital triage guidelines, 60% of patients were undertriaged. Challenges that ED physicians faced with managing TBI, included lack of beds at TC and difficulty attaining transport resources. Conclusion: Access to TC care for patients with TBI is impeded by patient and system level factors.

A retrospective review was made of the case records, angiograms and computed tomography (CT) relating to a total of 263 patients with subarachnoid haemorrhage (SAH) due to ruptured berry aneurysms who were admitted to the Department of Neurosurgery, Wentworth Hospital during the four years 1983-1986. The part of the thesis concerning vasospasm (VS) includes two independent studies on calcium blocker Nimodipine (NO) in the prevention and treatment of VS done by the author. The aim of the thesis is to analyse the management problems of aneurysmal SAH, and investigate factors influencing outcome in order to establish the best possible management policy. The results are discussed and related to the recent data from literature. The main factors influencing outcome were: clinical condition of the patient, the timing of admission and surgery, hypertension and hyperglycaemia on admission, presence of vasospasm and related CT appearance of a thick layer of blood or clot in subarachnoid haemorrhage (CT-Fisher 3). The systemic administration of the calcium blocker nimodipine did not reverse or prevent delayed vasospasm and caused serious adverse effects i.e. hypotension and hyperglycaemia. The results of the thesis suggest a change in management policy and timing of surgery should depend. on clinical condition of the patient on admission (Hunt & Hess grading)(HH I/II grade (HH as possible regardless of timing of admission and results of radiological investigations (CT, angiography). Early surgery (1-3 days) should be the aim of the effort including referral, transport and hospital organisation. III grade (HH surgery should be performed soon after day 10 post-SAH. Particular attention should be paid to the careful preparation and selection of patients for angiography. IV/V grade (HH in specialised units as s000n as possible, preferably neurological or neurosurgical wards, and operated on as soon as their grade improves or, in selected (by surgeon, radiologist and anaesthetist) cases by delayed surgery ( after day 10 post-SAH). / Thesis (M.Med.)-University of Natal, Durban, 1988.

No description available.

Introduction: Trauma centers (TC) are the only institutions with resources to manage patients with severe traumatic brain injury (TBI). We chose to examine potential barriers to access to TC care for TBI patients. Methods: Administrative datasets were used to evaluate access to TC among patients with severe TBI. We examined triage practices of EMS in TBI. Finally, we analyzed surveys to capture the beliefs, perceptions and knowledge of ED physicians with respect to TBI. Results: 57% of patients in Ontario had any access to a TC following TBI. Of patients who had potential access to a TC from the scene of injury as defined by pre-hospital triage guidelines, 60% of patients were undertriaged. Challenges that ED physicians faced with managing TBI, included lack of beds at TC and difficulty attaining transport resources. Conclusion: Access to TC care for patients with TBI is impeded by patient and system level factors.

- / -

- / -

This thesis presents a literature review of the diagnosis and treatment of lumbar spinal stenosis (LSS), including a brief description of the patient history and non-surgical options while focusing mainly on the current array of surgical techniques. LSS is defined as a narrowing of any part of the lumbar spinal canal. This narrowing places excessive pressure on both the spinal cord and peripheral nerves resulting in pain, numbness and weakness in the lower extremities. LSS has a large spectrum of potential treatment options since the disease itself has a wide range of severities. An extensive physical exam, using the appropriate clinical surveys, physical manipulations, and imaging studies, is of paramount importance in the successful diagnosis. Currently, conservative treatment, while an important first step in managing LSS, seems to be limited to a first line of defense, lasting only a short period of time. Physical therapy results appear to be beneficial for only six months to a year, and despite their increased usage in recent years, management through the use of non-steroidal anti-inflammatory drugs, opiates, and corticosteroid injections seem to provide very little benefit. Surgical treatment for LSS ultimately appears to be the most effective method in reducing pain and disability for the patient who fits the clinical and radiological findings indicative of LSS. Although current surgical options available are numerous, including different types of fusion, bone grafts, and innovative joint replacements, the most promising procedures appear to be minimally invasive lumbar disk replacement surgery and dynamic stabilization. These procedures offer the benefits of a minimally invasive surgical approach, while reducing stenosis though hardware that not only reduces pain but also allows patients to maintain spinal flexibility and natural functional motion.