Tuesday, January 28, 2020

Transhiatal Approach Essay Example for Free

Transhiatal Approach Essay Abstract: Tethered cord syndrome (TCS) is a stretch-induced functional disorder of the spinal cord, which is directly related to filum fixation. Classic surgical approaches to the filum involve open surgery and include varying amounts of spinal bone removal. In an effort to reduce the morbidity and mortality of these procedures, we explored a less invasive method. We evaluated the ability, safety and feasibility for extradural endoscopic dissection of the filum terminale by performing upward orientated navigation in the sacral spinal canal through the sacral hiatus using a rigid endoscope. Four adult, phenol-formalin embalmed cadavers were used for extradural endoscopic dissection of the filum at the tip of thecal sac. After preparing the anatomical area of sacral hiatus, a rigid endoscope (Storz, of 3.8 mm external diameter with one working channel) was inserted into the sacral spinal canal and the filum was identified and cut easily. In all cases, it was possible to manipulate the rigid endoscope and inspect the full length of the extradural sacral spinal canal, especially at the S1-S2 level. Our results indicate that the tested transhiatal approach for upward orientated extradural endoscopy represents a minimally invasive procedure that provides an appropriate and feasible route to the extradural sacral spinal canal. Furthermore it is an attractive alternative for filum dissection in cases where tethered cord syndrome is not accompanied by any other pathology. Introduction Physicians and scientists have explored the clinical usefulness of spinal endoscopy over six decades. Endoscopic spinal surgery represents a major advance in the treatment of spinal disorders. It involves the use of small incisions that preserve normal tissues while allowing the spinal pathology to be fully treated. This technique carries interesting clinical benefits, and its utility continues to expand as technology advances. Tethered cord syndrome (TCS) is a manifestation of spina bifida occulta and can occur as a complication of surgically closed spina bifida aperta. The mechanical cause of TCS is an inelastic structure anchoring the caudal end of the spinal cord and preventing cephalad movements of the lumbosacral cord. Stretching of the spinal cord occurs in patients either when the spinal column grows faster than the spinal cord or when the spinal cord undergoes forcible flexion and extension. Symptomatic TCS can occur in adults as well as in children, manifesting with various clinical symptoms (Dachling, 1982; Kaplan, 1980; Klekamp et al. 1994), such as pain, neurological deficits, and bowel and bladder dysfunction. Further studies have shown that early surgical correction in adults is recommended because of the high risk for irreversible neurological deficits (Bermans et al. 2001). In recent years, further research efforts of scientists have ranged from full-fledged neurosurgery to minimally invasive approaches and have involved the use of flexible and rigid endoscopes for diagnosis and treatment of certain pathological entities (Heavner et al. 1991; Sabreski Kitahata, 1995 1996; Warnke et al. 2001, I, II; Warnke et al. 2003). Encouraging results from the performance of co-axial downward orientated thecaloscopic procedures, with flexible steerable endoscopes in the lumbar subarachnoid space in living humans (Warnke et al. 2003), prompted us to study further thecaloscopic procedures for filum terminale dissection by using a rigid endoscope. This procedure usually offers a better optical view of the studied anatomic structures. The aim of the present anatomic study was not only to determine if the tip of thecal sac could be clearly visualized. Based on the fact that epidural endoscopy through sacral hiatus was proved to be safe and possible (Sabreski Kitahata, 1995 1996; Sabreski Gerens, 1998), it also sought to explore the possibility of using a rigid endoscope to untether prefixed filum terminale. Materials and Methods For this study, four adult phenol-formalin embalmed male cadavers from the Anatomy Department of the Medical School of the University of Athens were dissected using microsurgical and endoscopic techniques. Neurosurgical   technique Fig.2Insertion-of-the-rig Fig.1Sacral-Hiatus Cadavers were placed in the prone position. A midline skin incision was centered over the sacral hiatus [fig. 1]. After anatomical preparation, the rigid endoscope [fig.2] was inserted through the sacral hiatus and directed into the sacral spinal canal cephalad. It was angled in that manner in order that it would face the tip of thecal sac. The filum, which was holding thecal sac, was identified and dissected [fig.3]. The rigid endoscope used was a Storz with a 3.8mm external diameter and one working channel. For the documentation, a video-tape (Fuji VHS) was used and digital photographs were taken using a Fuji AS-205.    Results With the help of a rigid endoscope, it is possible to visualize directly the tip of thecal sac and to perform a dissection of the filum terminale. A rigid endoscope was inserted into the sacral spinal canal and, with the benefit of the visibility it granted, was advanced cephalad with relative ease. The rigid endoscope provided a large field of view, which enabled the anatomical structures to be seen. The filum can be easily identified in fine detail, as it is the only structure adherent to the tip of thecal sac at the S1-S2 level. This procedure represents a minimally invasive method for direct visualization of the tip of thecal sac and dissection of filum terminale. Discussion Diseases of the spine predispose persons to chronic complaints ranging from mild discomfort to intense pain. Endoscopy of the anatomic structures contained within the spine makes possible thorough examinations for existing pathology and facilitates the application of appropriate methods of therapy (Warnke et al. 2003; Sabreski Kitahata, 1996). Use of neuroendoscopy has become widespread in spinal surgery for conditions ranging from degenerative disease to deformity correction (Heavner et al. 1991; Sabreski Gerens, 1998; Sabreski Kitahata, 1995 1996). The growth in the number of minimally invasive spine surgical procedures being performed has been spurred by both technical advances and by its associated reduction in operative morbidity (1998; 1995; 1996). However, minimally invasive techniques are primarily employed in extradural procedures. Transhiatal extradural filum untethering provides the ability to untether a prefixed filum in a minimally invasive way. When referred to a neurosurgical clinic, adult patients with tethered cord syndrome tend to show significant progressive neurological deficits (Klekamp et al. 1994; Dachling, 1982).   Some authors (van Leeuwen, et al. 2001) have advocated prophylactic surgical treatment for the prevention of progressive neurological symptoms, which is, in this case, related to low morbidity. As an alternative to the risky open surgical treatment procedure, we evaluated the extradural endoscopic procedure for untethering of filum in cadavers. Extradural filum untethering could be indicated in cases of prefixed filum without other accompanying pathology such as meningomyelocele, CSF fistula, or arachnoidal cysts. It could also be performed before a surgical intervention, which generally include dura opening and removal of various amounts of spinal bone. During inspection of the sacral spinal canal with the rigid endoscope, the declination of the sacral spinal canal did not bring difficulties for the upward manipulation of the endoscope. Following the physical inclination of the sacral spinal canal, the filum could be approached and dissected before reaching the lumbosacral angle. In some instances, it was difficult to dissect the filum because of its elasticity. However, the minimally invasive nature of neuroendoscopy provided by this procedure, and by the employment of the rigid endoscope, allows for a larger field of view at the sacral spinal canal through a smaller incision. This access and the ability to perform extradural inspection and filum dissection using this transhiatal approach are comparable with other therapeutic interventions used in neurosurgery, such as the endoscopic epidural placement of catheters in anaesthesiology. Conclusions This method of extradural endoscopic dissection of the filum terminale minimizes surgical trauma and provides excellent visualization of and access to the extradural sacral spinal canal. Furthermore, it enables the filum to be identified and thus provides a minimally invasive alternative to current open surgical procedures indicated for filum untethering. Utilization of this procedure could: (1) facilitate untethering of prefixed filum terminale without opening the dura and (2) minimize patient morbidity thereby presenting an overall attractive alternative to current methods of filum dissection. At present, neuroendoscopy is most widely used in minimally invasive spine surgery, but novel uses continue to emerge in the literature. As technology evolves and more experience is obtained, neuroendoscopy will likely achieve additional roles as a mainstay in spinal surgery. References Heavner JF, Cholkhavatia S, Kizelsheeyn G. (1991). Percutaneous evaluation of the   Ã‚  Ã‚  Ã‚  Ã‚   epidural and subarachnoid space with flexible endoscope. Reg. Anesth. 15 S1: 85. Iskandar BJ, Fulmer BB, Hadley MN, Oakes WJ. (2001). Congenital tethered spinal cord   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   syndrome in adults. Neurosurg. Focus 10(1): Article 7. Kaplan JQ, Quencer RM. (1980) The occult tethered conus syndrome in the adult.  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚   Radiology 137:387-391. Klekamp J, Raimpondi AJ, Samii M. (1994) Occult dysraphism in adulthood: clinical   Ã‚   course and management. Child Nerv Syst 10:312-320. van Leeuwen R, Notermans NC, Vandertop P. (2001). Surgery in adults with tethered   Ã‚   cord syndrome: outcome study with independent clinical review.   J. Neurosurg.   Ã‚  Ã‚   (spine) 94: 205-209. Pang D, Wilberger JE. (1982) Tethered cord syndrome in adults. J. Neurosurg. 57: 32-47. Sabreski LR, Gerens, F. (1998) Safety of epidural endoscopy. Reg. Anest. Pain Med.   Ã‚  Ã‚  Ã‚   23: 324-325. Sabreski LR, Kitahata LM. (1995) Direct visualization of the lumbosacral epidural   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   space through the sacral hiatus. Anest. Anal. 60: 839-840. Sabreski LR, Kitahata LM. (1996) Persistent radiculopathy diagnosed and treated with  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   epidural endoscopy. J. Anesth. 10: 292-295. Warnke JP, Tschabitscher M, Nobles A. (2001). Thecaloscopy Part I.: The endoscopy of   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   the lumbar subarachnoid space: Historical review and own cadaver studies.  Ã‚  Ã‚   Minim. Invas. Neurosurg. 42: 61-64 Warnke JP, Mourgela S, Tschabitscher M, Dzelzitis J. (2001) Thecaloscopy Part II:   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Anatomical Landmarks. Minim. Invas. Neurosurg 44:181-185. Warnke JP, Kà ¶ppert H, Bensch-Schreiter B, Dzelzitis J, Tschabitscher M. (2003)   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Thecaloscopy Part III: First Clinical Application. Minim. Invas. Neurosurg   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   46:94-99.

Monday, January 20, 2020

Comparison of the Presentation of Seduction in the Poems To His Coy Mis

Comparison of the Presentation of Seduction in the Poems To His Coy Mistress by Andrew Marvell and The Willing Mistress by Aphra Behn Both Marvell and Behn wrote during the Renaissance period and had different styles. However, they explored similar themes. In 'To His Coy Mistress', Marvell uses a cleverly structured argument called 'syllogism' to persuade his lover to 'seize the day' and make love before their passion fades. In the first section, Marvell speculates how he would adore his mistress. He compliments his mistress saying she deserves such praise. He uses hyperbole to illustrate the extent of his love. He uses many vast geographical and biblical allusions to tell the vastness of his love. The tone in the second section is desolate and threatening. Time is personified to show it's inevitable conclusion - death confronts us all. He uses a blunt reminder that 'times winged chariot' is 'hurrying near'. Threatening images of graves and decay emphasise his point. The imagery becomes morbid and disturbing as he reminds his lover, manipulatively, that death will inevitably destroy her virginity. In the third section of the poem, Marvell draws his triumphant conclusion. His lover is young and beautiful and they desire one another. He focuses on the urgency of seduction. In contrast, Aphra Behn is revolutionary and our expectations are challenged as she writes her willingness to receivevher lover's attention in a female persona. She presents seduction from a woman's point of view. She was one of the first women to write about a woman's sexual feelings in pre-1900 poems. Aphra Behn's humorous poem follows a narrative structure in which ... ... them to consummate their love and savour her 'fleeting youth'. The metaphorical description 'iron gates of life' tells us that life is hard and full of though restrictions that ought to be and can be broken by them. 'Iron gates of life' describes boundaries as barbaric. The way in which he wishes to break such a strong boundary with just their love for each other represents his confidence at the success of his words. I preferred 'To His Coy Mistress' to 'The Willing Mistress' because it had hidden depths and meanings. I liked the way in which the poetic techniques were used to produce such a powerful effect. I also like the way in which the tone changes so often to portray his point. I did like 'The Willing Mistress' because it is playful and humorous but it is only a simple story and not a cryptic piece of poetry.

Sunday, January 12, 2020

Importance and Evolution of Human Resource Accounting

Human resource accounting comprise accounting for outgos related to human resource as assets opposed to traditional accounting attack which treats these costs as disbursals that will cut down net incomes of organisation. Importance and engagement to growing in HRA to growing have been clear in figure of states. Human Resource Accounting ( HRA ) comprise accounting for outgos of human resources as assets on the other manus traditional accounting attack which treats costs of human resource as disbursals that will cut down net incomes of organisation importance and parts to growing in HRA have been plain in a figure of states Importance and engagement to growing in HRA to growing have been clear in figure of states. Since the constitution of globalisation of concern and services, human rudimentss are going more of import input for the success of any organisation. It helps the direction to construction policies for human resources. Human resource accounting is a procedure of placing and mensurating informations about human resources. Measurement of the investing in human resources will assist to measure the charges in human resource investing over a period of clip. HRA is non a new issue in the field of concern. Economists think about human capital as a production factor, and they explore different ways of mensurating its investing in instruction, wellness, and other countries. Accountants have accepted the value of human assets for at least 70 old ages. Cardinal words:Human Resource Accounting, Human Capital accounting, Human resource. Introduction The success of economic undertakings and accomplishing its ends depends mostly on the efficiency and effectivity of human resources, and as the human component is a existent provider of any undertaking, and material resources are contribution factors, adult male what owned the accomplishments and enjoyed by the desire to work is a important component to accomplish production efficiency and profitableness, the undertakings spent a batch of money in the enlisting and choice and preparation of workers. The traditional accounting position these charges treated as current outgos charged to the income of the fiscal period when ciphering the net net income, although it represents investing disbursement in order to make assets of the establishment, and hence to promote the an organisation to see human resources as Capital Assets. When doing determinations on the assets they expect to acquire all the future benefits, every bit good as promote the organisation to making an incorporate system o f human resources accounting. Need of HRA and its applications Human Resource Accounting provides helpful information to the disposal, fiscal analysts and human resources on the undermentioned issues. 1.Human Resource Accounting helps the direction in the Employment, turn uping and use of human resources. 2.It supports in make up one's minding the preparation, publicity, and retrenchment of human resources. 3.It provides a footing for planning of human resources. 4.It helps in measuring the costs incurred for leaving furthermore developing in employees. 5.It supports to find the causes of high labor turnover at assorted degrees and taking defensive steps to incorporate it. 6.It helps in turn uping the existent cause for low return on investing, like improper or under-utilization of physical assets or human resource or both. 7.It supports in apprehension and measuring the interior strength of an organisation and helps the direction to maneuver the company good through most inauspicious and unfavourable fortunes. 8.It provides valuable information for individuals interested in doing long term investing in the house. 9.It supports employees in bettering their public presentation and bargaining power. It makes each of them to understand his part towards the improvement of the house vis- & A ; agrave ; -vis the outgo incurred by the house on them. Develop of HRA reappraisal Although human resource accounting ( HRA ) is a comparatively new field, its development has already passed through several discernable phases. The first phase of growing, from 1960 to 1966, was distinct by involvement in HRA and the beginning of basic HRA constructs from related organic structures of theory, The initial impulse for the development of HRA came from a assortment of beginnings, including the economic theory of human capital, the new human resource point of view, and a concern for human assets as constituents of corporate ( flamholtz, 1999 ) .there was many phase during development of Human resource accounting as followers: First period ( 1960-66) : This characters the foundation of academic attending in the country of Human Resource Accounting. though, the centre was chiefly on derive Human Resource Accounting constructs from other surveies like the fiscal theory of capital, psychological theories of leadership-effectiveness, the lifting constructs of human resource as dissimilar from forces or human dealingss ; every bit good as the measuring of concern good will. Second period ( 1966-71 ): The focal point here was more on lifting and validates different theoretical accounts for HRA. These theoretical accounts enclosed both costs and the pecuniary and non-monetary value of HR. The seek was to develop some tools that would assist the organisations in measuring and organisation their human resource/assets in a more rational mode. One of the first surveies here was that of Roger Hermanson, who as portion of his Ph.D. studied the job of mensurating the value of human assets as an component of good will. Inspired by his work, a figure of research undertakings were undertaken by the research workers to develop the constructs and methods of accounting for human resource. Third period: ( 1971-76 ) This period was distinct by a extended attending in the field of HRA taking to a speedy growing of research in the country. The focal point in most instances was on the issues of application of HRA in concern organisations. R.G. Barry experiments contributed well during this phase. ( R.G.BarryCorporation:1971 ) Fourth period ( 1976-1980 ) : This was a period of diminution in the country of HRA chiefly because the multipart issues that needed to be explored needed much deeper experiential research than was required for the old simple theoretical accounts. The organisations, nevertheless, were non ready to back up such research. They set up the thought of HRA interesting but did non happen much usage in pump in great amounts or puting batch of clip and power in back uping the research. Fifth period ( 1980 onwards) : There was a unexpected regeneration of attending in the field of HRA to some extent cause of most of the developed economic systems had displacement from fabricating to service economic systems and perceived the criticalness of human plus for their organisations. Since the endurance, increase net incomes of the organisations were evident to be reliant more on the rational assets of the organisations than on the physical assets ; the demand was felt to hold more true steps for HR costs, investings and value. An of import result of this renewed involvement was that unlike the old decennaries, when the involvements were chiefly academic with some practical applications, from mid 90s the focal point has been on greater application of HRA to concern direction. Different types of theoretical accounts to accommodate the specific demands of the organisations have been developed integrating both the touchable and the intangible facets. Besides, larger figure of organisations really began to utilize HRA as portion of their managerial and fiscal accounting pattern. Today, human and rational capitals are perceived to be the strategic resources and hence, clear appraisal of their value has gained important importance. The increased force per unit areas for corporate administration and the corporate codification of behavior demanding transparence in accounting have farther supported the demand for developing methods of mensurating human value.