Learning Points Research Articles

Total laparoscopic hysterectomy – Learning curve and its impact on surgical outcome of 773 case series from a single center

Abstract Study Objective: The objective of this study was to assess the learning curve of total laparoscopic hysterectomy (TLH) and its impact on surgical outcome of 773 consecutive cases between two decades. Design: This was a retrospective observational comparative study of 773 consecutive cases of TLH. Setting: This study was conducted at ILS Hospital, Kolkata, India, a private tertiary referral center for endoscopic surgery. Patients: Total 773 women with benign pelvic pathologies from 2000 to 2019 having similar demographic characteristics irrespective of uterus size and previous surgery were included while patients with malignancy and second-degree uterus prolapse were excluded. Interventions: TLH by ipsilateral technique. Materials and Methods: The study period was divided into two decades with 386 and 387 surgeries of TLH in the first and second decades, respectively, maintaining homogeneity within the periods. The CUmulative SUMmation (CUSUM) technique was used to construct a learning curve of operative time where learning point. Results: Learning Point was found at the 118th surgery. Overall complications decreased from 4.39% to 1.33% (P = 0.0096) between two decades, and major and minor complications decreased from 3.36% to 0.52% (P = 0.0042) and from 1.03% to 0.78% (P = 0.1416), respectively. No major vessel injury occurred. Five ureter injuries occurred in the first decade and none in the second decade. In-spite of significant increase in uterus size and double the number of Lower Uterine Caesarian Section (LUCS) in 2nd decade (P<0.00001), bladder injuries occurred in 1st decade & 2nd decade was 7 (1.81%) and 1 (0.26%) respectively (P=0.033). Total 56 conversions (7.56%) occurred: the first decade was 27 (6.97%) and the second decade 29 (7.51%) (P = 0.7814). Conclusion: Laparoscopic hysterectomy can be safely done by ipsilateral technique with low complication if one achieves a learning curve under supervised training. In our study, gained experience helped us to decrease major bladder, bowel, and ureteric injuries drastically by 90.91% in spite of increased complexity of cases in the second decade.

Tafro Syndrome - Mimicker of SLE

Background: TAFRO SYNDROME mimics SLE. Differentiating both is essential for correct manangement. Case report: 40 year old lady came with complaints of fever, insidious onset of painless abdominal distension which was gradually progressive to form tense ascities in a span of 2 months. On examination she was pallor, having pedal edema, tense ascities and cervical and axillary lymph node enlargement (mazimum 1* 1 cm). Lymph nodes were firm, non matted, not fixed. On evaluation found to have pancytopenia. (Hb: 5.3 gm%, platelet count, Wbc-3600/cu mm, 90,000/cu mm), Her LFT -alkaline phosphate -639 U/L, Hyperbilirubinemia with total Bil of 1.73 mg/dl and direct fraction of 1 mg/dl and LDH of 139 U/L. Renal - 24 hour urine protien = 301 mg. She had malena at presentation and her Hb dropped to 3.2 gm% platelets count of 10,000. Ct abdomen showed -Mild to moderate ascites, mild hepatomegaly. Ascitic Tap of 3 litre was done which showed high SAAG and High protein. Ugi endoscopy was done which showed Antral gastritis and no feature of porat hypertension. Infective workup including tuberculosis came negative. Autoimmune work ANA - 2+ speckled. (1:100 dilution) Coombs test direct - 3+ C3 = 115 (90 to 180) C4 = 39.8 (10 to 40) Ds DNA = 121 (< 100 IU/ ml) Urine UP/UC = 0.48 24 hour urine protien = 301 mg Anti SSA ELISA test - 63 (< 20 RU/ml) Anti SM ELISA test 1 (< 20 Ru/ml) ELISA Anti RNP - 2 Ru/ml (< 20) APLA work up was within normal limit and lupus anticoagulant was mildy positve. She was satifying the ACR EULAR 2019 classification criteria for SLE and SLE can have lymphadenopathy features suggestive of castle man disease. She was intially diagnosed as SLE and treated with Sle protocol and was not reposnding. Lymphnode biopsy later was done suggestive of Hypervascular type of castle man disease and intiated on R - CEP (Rituximab, Cyclophosphamide, etosposide, prednsiolone) LEARNING POINT 1) SLE is a great mimicker of variety of other diseases and rheumatologist should be aware of the disease that mimics SLE. 2) TAFRO syndrome is variety of castleman disease. T-Thrombocytopenia A-Ascities F-Fever R-renal dysfunction O-Organomegaly 3) TAFRO syndrome has autoimmune manifestations that mimics SLE and it an aggressive variety of castleman disease

The post-COVID design studio: new tools, new rules?

Abstract The reorientation to remote teaching due to the impact of COVID-19 restrictions proved to be both challenging and compromising, particularly in the context of delivering practice-based design education. Central to the challenges faced by many design tutors was the loss of the design studio as a focal point for engagement and learning. However, delivering teaching remotely through a period of enforced separation also proved that through adversity comes new insights, with the accelerated use of emergent technologies to support distributed working revealing new behaviours and opportunities for learning to take place. In response to COVID-19 restrictions, Miro, the digital whiteboard platform was widely adopted within the UK creative industries and universities alike to facilitate remote engagement. Following a return to campus-based delivery through the Autumn/Fall of 2021, it became evident that some of the pragmatic approaches adopted through necessity had the potential to hold lasting value beyond crisis modes of teaching. This position paper presents a series of reflective studies gathered over three academic years with the aim of (1) understanding the impacts of remote learning as experienced by design students (2) establish clear benefits for the application of online platforms within a blended campus-based delivery and (3) identify emergent characteristics in students’ navigation of the post-COVID design studio.

THE ATTRIBUTE AND THE CONTENTMENT OF THE 12TH GRADE STUDENTS OF NINO CONE SANTANA SCHOOL OF GLENO ERMERA TIMOR-LESTE (2024).

Introduction: In the attempt to respond to the various challenges and demands that have arisen in the community and secondary education in Gleno Ermera Timor-Leste, there is a growing need to participate in the quality of education and specifically in the area of training in Secondary School Nino Cone Santana School of Gleno Ermera. The contentment or satisfaction of the students is an essential indicator to appreciate this quality of education, with benefits for the Secondary School system formation and for the entire community. Objective: To investigate the quality of teaching and the contentment of 12th grade students in effective learning and study at the Nino Cone Santana School of Gleno Ermera Timor-Leste. Research of Methodology: Quantitative, descriptive-analytical study; Sample or sample: 177 students attending the Nino Cone Santana School of Gleno secondary school training study as a basis of research carried out in the teaching and learning process- Namely, in the process the data collection was carried out through tools in applied questionnaires. Results: The quality of teaching and learning, with an average value of 3, influences the success of students' training and the joy of meeting their expectations, translated by the level of contentment of students and the determination of the critical educational points of teaching and learning in secondary schools of implementation. Conclusion: we found that although there is a coherence in the students' answers, leveled in its vast majority by good or contentment and satisfied, there is still a long and hard work to develop in the future of training, strengthening good educational practices and evaluating new bets, to develop a teaching adapted to the needs of students and the contexts of course or training appropriate in our country cited by (Tilman CB & Oqui M., 2024).

Predictors of academic achievement in distance learning for Sudanese nursing students

Objective: To investigate the factors that influence undergraduate Sudanese nursing students' academic achievement. Methods: An online survey was conducted among 235 Sudanese nursing students using several scales and questionnaires to assess cognitive, affective, and psychomotor domains of academic achievement, self-regulated learning (S.R.L.), engagement, academic stress, and grade point average (GPA). A hierarchical multiple linear regression model was used to identify the predictors of academic achievement. Results: Academic achievement was significantly correlated with SRL (r = 0.588, p<0.001), engagement in distance learning (r = 0.476, p < 0.001), academic stress (r = 0.355, p<0.001), and GPA (r = 0.162, p=0.02). No significant correlation was found between academic achievement level and demographic or learning experience variables, participating in a learning support program, voluntary study meetings, and receiving learning counseling. Engagement in distance learning and SRL were identified as significant predictors of academic achievement, with adjusted R2 values of 0.216 and 0.377, respectively. Conclusion: The study highlights the importance of engagement in distance learning and SRL among Sudanese nursing students in the context of distance learning. The nursing institutions need to develop effective strategies to enhance students' engagement and SRL skills to promote academic success in distil learning.

Automatic part segmentation for full newborn skeleton-articulated geometries using geometric deep learning and 3D point cloud

Automatic part segmentation for full newborn skeleton-articulated geometries using geometric deep learning and 3D point cloud

Automatic Part Segmentation for Full Newborn Skeleton-Articulated Geometries using Geometric Deep Learning and 3D Point Cloud

Automatic Part Segmentation for Full Newborn Skeleton-Articulated Geometries using Geometric Deep Learning and 3D Point Cloud

Diagnosis Challenges when Substance Use and Trauma are Part of the Narrative: An Examination of Human Trafficking Cases Among Women and Critical Points of Learning for the Mental Health Community

Diagnosis Challenges when Substance Use and Trauma are Part of the Narrative: An Examination of Human Trafficking Cases Among Women and Critical Points of Learning for the Mental Health Community

The evolving perspective of menopause management in the United Kingdom.

The use of menopausal hormone therapy (MHT) was significantly reduced following the publication of the Women's Health Initiative study results and has remained low ever since. However, from 2015 onwards, the UK has seen a substantial increase in MHT prescribing compared to other European countries. To evaluate the factors contributing to the shift in women's and healthcare professionals' (HCPs) perception of MHT in the United Kingdom and to provide learning points for other European countries. An exploratory, descriptive and qualitative study. An interactive virtual panel discussion in which seven UK-based HCPs with a special interest in the menopause discussed the evolution of its management in the United Kingdom. In the last 8 years, there has been a substantial increase in MHT prescriptions in the United Kingdom due to improved menopause awareness and acceptance of MHT. Accessibility to accurate, scientific, information and guidance from respected institutions is one of the main drivers of this change. Social media has increased that reach with 'influencers' empowering women to seek help. Women are demanding access to menopause health care so that they can receive holistic and individualized treatment based on their clinical conditions and needs. Standardized education of HCPs is an essential pillar to provide appropriate and equitable care to menopausal women and to guarantee safe prescribing of MHT. Furthermore, up to date and factually correct menopausal education would benefit all the population. Publication of new scientific data reporting a more favourable benefit/risk ratio with MHT, production of national guidance and an increased awareness via social media have led to the significant rise in MHT prescribing and improvement of menopause care in the United Kingdom. The lessons learned may benefit other European countries.

Giant Left Atrial Aneurysm In A Three Year Old

Background: The PA to the LA fistula is a rare cause of central cyanosis. Embryologically, incomplete degeneration of septum between the arterial and venous plexus of the pulmonary vascular bed or defective capillary loop leads to formation of thin-walled sacs resulting in formation of pulmonary arteriovenous fistula. The more restrictive the fistula is, the more subtle is the extent of cyanosis and the less evident is the clinical presentation Case Description We describe the case of three years-old patient, who presented with unresolving pneumonia, that necessitated CT imaging. CT imaging revealed a mass in the posterior mediastinum that was communicating with the left atrium. Originally it was thought that this is an aneurysmal dilation of one of the pulmonary veins, that could have resulted from mitral regurge. Echocardiography showed an aneurysmal dilation of the left atrium, with an abnormal retrograde flow across the roof of the left atrium, pulmonary hypertension and mitral regurge were excluded. 3D CT angiographic reconstruction revealed the presence of a fistulous communication between the RPA and left atrium, this explains the low normal oxygen saturations of this patient due to mixing (90-92%) and the high hemoglobin concentration (160) due to chronic subclinical hypoxia. Conclusion and learning points Aneurysmal dilation of left atrium is commonly encountered with severe mitral regurge, rare causes such as PA to LA fistulae should be thought of especially if clinical or subclinical hypoxia or polycythemia is present.

A Case of Tooth Aspiration in the Left Bronchus During a Boat Trip: A Potential Life-Threatening Condition

Introduction The foreign body aspiration represents a life-threatening event, especially when huge sizes, and it is considered the most frequent cause of accidental home deaths in infancy, while uncommon in adults. Case Report Herein we describe a case of asymptomatic tooth aspiration in a 58-year-old-female undergoing chemotherapy for bowel adenocarcinoma during a boat trip. Conclusion This report highlights four important learning points: the importance of suspecting a tooth aspiration in an oncological patient during chemotherapy; the management of a potential emergency during a boat trip; the chest X Ray could be sufficient; a fibrobronchoscopy is possible even if the foreign body lies in a less accessible position.

Staphylococcal aureus outbreaks in neonatal intensive care units: strategies, nuances, and lessons learned from the frontline.

Methicillin-resistant Staphylococcus aureus (MRSA) infections in neonates can result in significant morbidity and mortality. However, comparatively to adults, neonatal MRSA data remains relatively scarce. Additionally, while evidence-driven practices for adults have seen considerable progress, neonatal infection prevention strategies remain poorly described. The Leeds Newborn Service adopted a series of infection prevention and control (IPC) measures following a rise in MRSA cases in 2008-2009. This narrative review presents IPC measures for neonatal MRSA and methicillin-sensitive Staphylococcus aureus (MSSA) infections and reflects upon local challenges and successes of these interventions. Our experience underscores the importance of an adaptive, evidence-based strategy, tailored to the neonatal population. Effectively addressing MRSA/MSSA requires continuous monitoring with sustained targeted interventions. Our key learning points highlight the intertwined difficulties of specific neonatal requirements and lack of definitive IPC guidance, suggesting a holistic approach is key for successful IPC outcomes in the neonatal intensive care unit setting.

Organizing Health Camp: Opportunities for Building Public Health Skills.

Health camps are one of the commonly performed activities by different organizations with different intentions. The purpose ranges from reaching out to unreached populations to increasing client base and thus increasing revenue generation. A multi-speciality health camp was organised at Rural Health & Training Centre (RHTC), Mendhasala, Khurdha. We describe the camp profile and utilization of different specialties in this study. The camp was attended by mostly adults and elderly (90.3%) and inhabitants of the same village (80.5%). General medicine (30.6%) and orthopedics (31.9%) were the two specialties most consulted at the said camp. The success of a health camp is described by the number of attendees, which looks only at resource utilization. We have documented the lessons learned from organizing a health camp from a public health learning point of view. A 10-point checklist is recommended for the successful organization of a health camp.

Using paleopathology to provide a deep-time perspective that improves our understanding of one health challenges: Exploring urbanization

Abstract The question posed is how deep-time perspectives contribute to tackling contemporary One Health challenges, improving understanding and disease mitigation. Using evidence from the field of paleopathology, it is possible to explore this question and highlight key learning points from the past to focus the minds of those making healthcare policy decisions today. In previous centuries urbanization led to poorer health for a wide range of indicators, including life expectancy, sanitation and intestinal parasites, airway disorders such as maxillary sinusitis, metabolic diseases such as rickets, and even conditions resulting from clothing fashions such as bunions. Modern concerns regarding the quality of urban air and rivers show we have still to incorporate these lessons. When we consider major infectious diseases affecting past societies such as bubonic plague, tuberculosis and leprosy, interaction between humans and wild mammal reservoirs was key. Wild red squirrels in Britain today remain infected by the medieval strain of leprosy that affected people 1,500 years ago. It is clear that the One Health focus on the interaction between humans, animals and their environment is important. Eradicating zoonotic infectious diseases from humans but not these reservoirs leaves the door open to their spread back to people in the future.

Introduction to the special issue on positive psychology and wellbeing

Abstract This introduction to the Special Issue on ‘Positive Psychology and Wellbeing’ begins by outlining the history and relevance of Positive Psychology (PP) for ELT. A key construct in PP is wellbeing, which all the papers in this Special Issue focus on. In this introductory article, we describe how the term wellbeing has been used and how it is defined in this collection. We discuss why wellbeing matters in language learning and teaching and point out some of the key controversies surrounding this term. We then introduce the nine articles highlighting their unique contributions to furthering our understandings in this field. We conclude by reflecting on key practical implications derived from the contributions and by presenting possible avenues for future research in this area. Our hope is that this collection of papers will serve as an impetus for innovations in practice, research, and theoretical thinking about this vitally important topic.

The Alfred Health Covid Community Pathway (AHCCP): development of a multidisciplinary, collaborative, and integrated model of care for supporting covid positive patients in the community during the Covid-19 pandemic.

Background: The second wave of Covid-19 in Victoria in July 2020 revealed health system vulnerabilities including access to primary care and community readiness to provide care in the home to large numbers of Covid-19 positive patients. The health system risked being overwhelmed, and patients risked deteriorating at home with unmet clinical and psychosocial needs. The requirement for isolation of positive cases necessitated a rapid switch to remote and virtual models of care. In response to a successful pilot in Northwest Melbourne [1], the Department of Health (DH) implemented the Covid Positive Pathways program, which directed health services to provide a similar service in their local catchment areas.
 Purpose of this report: To describe the design, implementation and evolution of the AHCCP, including challenges, lessons learnt and opportunities for use of such an integrated model of care in future epidemic/pandemic situations, as well as to support broader health and social care needs beyond covid.
 Methods: This descriptive study describes the model of care developments and changes, and commentary with descriptive statistics from the cohort of patients who were referred to the pathway, and key learning points.
 Service aim, stakeholders and implementation: In September 2020, the AHCCP was established with the aim of providing comprehensive care to patients in isolation with Covid-19. The service was established as a partnership between several stakeholders, including:
 
 Alfred Health, a quaternary hospital in south-east Melbourne.
 Connect Health and Star Health, community health orgsanisations.
 South East Melbourne Primary Health Network.
 Victorian DH, and the South East Melbourne Public Health Unit.
 South East Melbourne Health Service Partnership, Monash Health and Peninsula Health.
 
 Patients referred from the Victoria DH were triaged and risk-stratified. Clinical monitoring was provided by the health service (medium pathway) or community health team in partnership with GPs (low pathway), with clear escalation pathways for management of acute deterioration. Support for psychosocial needs was also provided, including for those unable to safely meet isolation requirements.
 Results: 91 patients were referred in the first nine months of the pathway’s operation, however subsequent surges in cases have resulted in 172,306 referrals as of 31st August 2022. Rapid upscaling, changing public health directives, and the availability of vaccination and treatments led to major challenges and need for constant redesign. Significant developments included: the introduction of web-based symptom surveys, risk stratification modifications incorporating vaccinations and variants of concern, streaming lower-risk patients to usual care outside the pathway, and use of logistics services to aid distribution of monitoring equipment and medications. Significant opportunities for hospital avoidance were observed, along with minimal adverse outcomes and a high level of acceptability for patients and carers as well as staff.
 Learnings: Collaboration across the partner organisations, including daily huddles with a non-hierarchical structure, was key to the success of the program. Virtual care, including use of information systems (Covid Monitor platform) emerged as essential to scalability. The pathway was successfully decentralised and integrated within community health and Alfred Health’s core models of care in September 2022 to ensure sustainability.

Local Service Centres as Facilitator and Driving Force For Caring Neighbourhoods In The City Of Antwerp: An Important Key To Realise Integrated Care

Summary: Local service centres (LSC) play an essential role in realising a caring neighbourhood, which relies on three pillars (1) neighbourhood participation and inclusion, (2) linking informal and formal care, (3) intersectoral cooperation between welfare and care partners and partners from other domains in a network aimed at prevention, health promotion and the provision of integrated care and support with a focus on quality of life.
 A caring neighbourhood for everyone and all ages: Living at home in the familiar neighbourhood for as long as possible is an ambition for most people, including those with care and support needs. Preferably in a safe, social and inviting neighbourhood where all basic facilities are available (GP, home care, bakery, butcher, pharmacy, bank, etc.). Today, this is no longer obvious in both rural and urban settings. 
 Today, when care and support are needed, we face an ever-increasing shortage of professional care staff. Therefore, besides professional care, informal care and support in the broad sense has become indispensable. 
 LSC as a facilitator and driving force for caring neighbourhoods:To keep people independent and self-reliant for as long as possible, a kind of platform or hub is ideally needed in every neighbourhood or district, on the one hand to keep people active and alert (socially, physically and psychologically) through activities in various areas and, on the other, to initiate, support and stimulate informal care and support; and to ensure that all initiatives in this area can be secured and perpetuated. 
 The LSC can play a central role in this, among other things as a meeting centre where social encounters and social participation are facilitated and stimulated; as a platform for consultation between welfare and care actors, but also as an advice and information centre where, among other things, health skills are strengthened and, where necessary, referral to the appropriate care and welfare actor takes place.
 The LSC is therefore an important lever in developing a caring neighbourhood. 
 LSC in the city of Antwerp as an example
 
 Almost every neighbourhood in the city of Antwerp has a local service centre. Based on the results of a quantitative and qualitative neighbourhood analysis, a multi-year planning is drawn up in cooperation with all relevant actors in the neighbourhood. This also takes into account local social policy priorities.
 The LSC acts as a platform where initiators can meet and cooperate. This may concern initiatives on informal care support; organising and coordinating volunteer work; supporting civic initiatives; initiating and stimulating a caring attitude among citizens. But also around activities that can prevent loneliness e.g. taking lunch or participating in recreational, informational or exercise activities.
 Key learning points and concerns: 
 - Diversity in a city and the importance of a culture-sensitive operation 
 - Quantitative and qualitative staffing of LSC
 - A caring attitude between citizens as a basic requirement
 - Informal and formal actors: a symbiotic relationship

A General Deep Learning Point–Surface Fusion Framework for RGB Image Super-Resolution

Hyperspectral images are usually acquired in a scanning-based way, which can cause inconvenience in some situations. In these cases, RGB image spectral super-resolution technology emerges as an alternative. However, current mainstream spectral super-resolution methods aim to generate continuous spectral information at a very narrow range, limited to the visible light range. Some researchers introduce hyperspectral images as auxiliary data. But it is usually required that the auxiliary hyperspectral images have the same spatial range as RGB images. To address this issue, a general point–surface data fusion method is designed to achieve the RGB image spectral super-resolution goal in this paper, named GRSS-Net. The proposed method utilizes hyperspectral point data as auxiliary data to provide spectral reference information. Thus, the spectral super-resolution can extend the spectral reconstruction range according to spectral data. The proposed method utilizes compressed sensing theory as a fundamental physical mechanism and then unfolds the traditional hyperspectral image reconstruction optimization problem into a deep network. Finally, a high-spatial-resolution hyperspectral image can be obtained. Thus, the proposed method combines the non-linear feature extraction ability of deep learning and the interpretability of traditional physical models simultaneously. A series of experiments demonstrates that the proposed method can effectively reconstruct spectral information in RGB images. Meanwhile, the proposed method provides a framework of spectral super-resolution for different applications.

Identifying slow learners in an e-learning environment using k-means clustering approach

Currently, the majority of e-learning lessons created and disseminated advocate a “one-size-fits-all” teaching philosophy. The e-learning environment, however, includes slow learners in a noticeable way, just like in traditional classroom settings. Learning analytics of educational data from a learning management system (LMS) have been considered by the researchers as a potential means of identifying slow e-learners and supporting, contesting, and altering present educational practices in e-learning. We used the students’ rates of learning and grade points along with the total learning time, which is calculated from the time series log data, to cluster the learners. The rate at which a student learns determines whether he or she is a slow learner, an average learner, or a gifted learner. For classifying learners, we followed a step-by-step procedure that included instructional design to create a dataset, learning analytics of the dataset, and a machine learning strategy to cluster e-learners. The system has been adequately integrated with the methods for measuring student learning. A strategy based on the revised Bloom’s Taxonomy is offered for the assessment of learners. The K-Means clustering approach is used to group learners who have similar performance without collecting a learner’s previous academic records or demographic information. In the experimental evaluation, 7.7% of e-learners are grouped as slow learners, while advanced learners make up 61.3 percent of the student body and average learners make up 31 percent. According to the study, there is a correlation between learning rate and academic success, with fast learners having a lower learning rate.

Transcutaneous ultrasound level check for selective dorsal rhizotomy.

Single-level selective dorsal rhizotomy (SDR) surgery requires an intra-operative level check to identifythe L1 vertebral level or the conus medullaris. Typically, this requires a pre-operative or intra-operative x-ray. We present our experience using initial transcutaneous ultrasound as an alternative to x-ray level check. A prospective SDR database was used to identify patients. The operation notes were reviewed to identify the level check method and any complications or wrong-level surgery. Data are reported for the first 160 SDR surgeries performed within our centre, mean age 6.47 years (range 2.5-19 years). The first 11 patients had combined x-ray and transcutaneous ultrasound for pre-incision level check. This allowed the neurosurgeon to assess the accuracy and feasibility of using transcutaneous ultrasound instead of x-ray. The subsequent 149 patients had ultrasound alone for transcutaneous pre-incision level check. An intra-operative ultrasound level check was performed for all patients following skin incision and dissection down to the spinal lamina. In this way, the conus level was confirmed before dural opening. For all patients at all ages, the combination of initial transcutaneous ultrasound followed by intra-operative ultrasound allowed accurate identification of the conus. There were no instances of wrong-level surgery. Learning points are presented within this paper. Combined use of transcutaneous ultrasound followed by intra-operative ultrasound can allow accurate identification of the conus, saving radiation exposure and potentially improving theatre efficiency. Appropriate training and experience are required for any neurosurgeon using these techniques.