Rewarding Procedure Research Articles

Commentary on: Influence of the Pectoralis Major Muscle Sling in Chest Wall-Based Flap Suspension After Vertical Mammaplasty: Ten-Year Follow-Up

Reduction mammaplasty continues to remain a rewarding procedure with high satisfaction rates among patients of all Body Mass Indes, due to improvement in quality life.1-3 When an inferior pedicle or one of its variations is utilized, loss of upper pole fullness, pseudo-ptosis (bottoming out), and upwards rotation of nipple-areola complex (star gazing deformity) are the most feared concerns. This occurs due to the effect of gravity and lack of lower pole support that lead to downward movement of the breast parenchyma infero-laterally. The authors in this article have demonstrated a technical pearl that can minimize one of the long-term concerns in breast reduction, bottoming out.4 By better supporting the lower pole, one can minimize all other sequale of bottoming out. Even though the number of patients is limited in this study, the design of it is unique and helps the readers understand the descent of the …

New Technique for Mandibular Symphyseal Distraction by a Double-Level Anchorage and Fixation System: Advantages and Results.

A surgical technique to widen the mandible is the mandibular midline distraction: the most common indications for mandibular midline distraction are severe mandibular anterior crowding, severe mandibular transverse deficiency, uni- or bilateral crossbite, impacted anterior teeth with inadequate space, and tipped teeth. Commonly used distraction devices can be divided into 2 systems: bone-borne distraction system appliance, dental-borne distraction systems. Each system has peculiar advantages, disadvantages, and different indications. To combine advantages of both systems we developed a new technique adopting an immediate basal bone widening with fixation after osteotomy and a dental borne rigid lingual system for distraction. The aim of this work is to show a new technique for symphysis mandibular distraction based on a double-level anchorage and fixation system on clinical patients showing final results and advantages. Two patients affected by dento-alveolar and basal bone maxillary and mandibular transversal collapse even in association with other skeletal malocclusion were selected. Patients were clinically and radiographically studied and analyzed at different times before and after surgery. Dental and basal bone measurements were performed clinically and radiographically. The results were optimal with perfect dental arches alignment followed by closing of the open bites with multiple-segmented surgery in a second surgical time. No misalignment of the 2 mandibular halves was noticed during the distraction procedure. Dental-bone discrepancies correction is mandatory before orthodontic treatment alignment. Transversal jaw expansion can be achieved safely and stably by distraction of both maxillae for the combination of osteogenesis and histogenesis with augmentation of both bone and soft tissue. Bone-borne distraction will result in more stable results; dental-borne devices will result in more simple and aesthetically rewarding procedures. Hybrid techniques usually show mixed results depending on the characteristics of the device. For this reason we developed a combination of both the aforementioned systems which is not a hybrid system but the combination of an immediate expansion of the symphysis and fixation by 1 miniplate with only 2 screws acting like hinges during distraction, combined with a lingual distraction system at the alveolar bone level. Bone-borne distraction systems result in more efficient basal bone mandibular widening with increased stability for dental results. For dental-borne appliance the advantages consist in no second surgery need for their removal, no transmucosal hardware emergence and better aesthetic, especially when lingual devices were used. Our technique combines advantages of both procedures.

A Comparison of Cost and Reward Procedures With Interdependent Group Contingencies.

The present study evaluated the effectiveness of two variations of a token economy for reducing disruptive behavior within a general education classroom. One variation involved a group contingency in which tokens were removed contingent on disruptive behavior (response cost), and the other variation involved a group contingency in which tokens were gained according to a differential reinforcement of other behavior schedule. Two elementary school teachers and their students participated. Results indicated that both procedures were effective in reducing the overall number of students disrupting; however, both teachers and students indicated a greater preference for the response cost condition. Implications for the use of these behavior management strategies in the classroom are discussed in terms of effectiveness and ease of implementation.

Effects of the Good Behavior Game on Challenging Behaviors in School Settings

Challenging behavior at school remains a concern for teachers and administrators. Thus classroom management practices to prevent challenging behavior are sorely needed. The Good Behavior Game (GBG) has been found to be useful to positively change student behavior. However, previous reviews of the GBG have not quantified effects, have not focused solely on school and classroom behaviors, and have not examined study features that facilitate greater outcomes. Twenty-two peer-reviewed journal articles were reviewed. Study data were analyzed using effect sizes, percent of nonoverlapping data, percent of all nonoverlapping data, and hierarchical linear modeling to determine intervention effectiveness as well as study features that facilitated greater outcomes. Findings suggested that (a) moderate to large effects were found on challenging behaviors and these effects were immediate; (b) the GBG was most commonly used for disruptive behavior, off-task behavior, aggression, talking out, and out-of-seat behaviors; (c) the GBG has been implemented primarily in general education elementary school settings; and (d) correct application of reward procedures are important for intervention effectiveness. Study limitations, implications for practice, and areas for future research are presented.

Tips and tricks for deep jejunal enteral access: modifying techniques to maximize success.

Endoscopic insertion of enteral feeding tubes is a major advance in the delivery of nutrition therapy. Since the first report of percutaneous endoscopic gastrostomy (PEG) in 1980 (Gauderer et al. J Pediatr Surg. 15:872-5, 1980), insertion techniques and equipment have been refined and improved. Despite this progress, deep jejunal enteral access remains a difficult procedure, and many endoscopists do not have experience with the techniques of nasojejunal (NJ) placement, percutaneous endoscopic gastrojejunostomy (PEGJ), or direct percutaneous endoscopic jejunostomy (DPEJ) (Shike and Latkany, Gastrointest Endosc Clin N Am. 8:569-80, 1998). The difference between an exasperating experience and a rewarding procedure lies in mastering the "tips and tricks" that make insertion easy. While the basic techniques are described elsewhere (McClave and Chang 2011), we review several universal basic principles to enhance deep jejunal access, which should promote a more efficient and successful procedure.

Avulsion Brachioplasty

Popularity of arm-contouring procedures, once coveted by the massive weight loss population, has grown among society at large. The technique has evolved with the goal of producing a predictable and thin scar in a location that is acceptable for interpersonal interaction. All consecutive brachioplasty patients from May of 2008 to May of 2013 were reviewed retrospectively at a private surgery center. Data collected included age, body mass index, amount of fat removed by liposuction, weight of resected tissue, hematoma or seroma, wound dehiscence, revision procedures, and length of follow-up. The authors reviewed 44 consecutive brachioplasties over 5 years. Average age was 53 years and body mass index was 26. Average amount of liposuctioned fat was 342 ml per arm using 867 ml of tumescent and an average skin specimen weight of 90 g. The follow-up period averaged 446 days. Fourteen patients had wound dehiscence requiring dressing changes. There were no return trips to the operating room for serious concerns such as bleeding or infection. One patient had a seroma. Nine patients underwent scar revision within 1 year. Overall complication rate was 50 percent. Overall revision rate was 21 percent. Brachioplasty is a rewarding procedure with consistent results and low risk of major complications. The potential for minor complications is substantial, and patients should receive preoperative counseling regarding this risk. In the authors' 5-year study of consecutive patients, 50 percent of patients needed dressing changes for small-wound dehiscence or scar revision within 1 year. Therapeutic, IV.

Nd:YAG Laser Posterior Capsulotomy and Visual Outcome

Background: Neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy is a relatively noninvasive procedure that is used in the treatment of posterior capsular opacification (PCO). PCO is caused by proliferation of lens epithelial cells which causes fibrotic changes and wrinkling of the posterior capsule and results in decreased vision, glare, and other symptoms similar to that of the original cataract. Objective: To find out the visual outcome after performing Nd:YAG laser capsulotomy for PCO. Materials and method: A prospective clinical trial was carried out in National Institute of Ophthalmology (NIO), Dhaka, Bangladesh from January 2010 to June 2011 on purposively selected 70 adult subjects of both sexes who developed PCO within 2 months to more than 2 years after extracapsular cataract extraction with posterior chamber intra ocular lens implant. After thorough pre laser assessment Nd:YAG laser capsulotomy was carried out with Zeis VISULAS YAG II through Zeiss slit lamp under topical anesthesia. Data were recorded and expressed as proportion. Results: Out of the 70 subjects 40 were male and 30 were female. The average time interval of cataract surgery and Nd: YAG laser capsulotomy was 23 months. Capsular fibrosis (57.04%) was the predominant type of PCO. The pre laser visual acuity (VA) of more than 61.06% of eyes was 6/36 or below while 41.12% had VA hand movements to finger count. After Nd:YAG laser capsulotomy VA of 6/18 or better was achieved in 63.9% of eyes while 9.94% recovered to 6/9 and 11.36% achieved 6/6. None of these eyes showed further deterioration in VA. Conclusion: Nd:YAG laser capsulotomy for PCO is safe, effective and a rewarding procedure for improvement of vision.DOI: http://dx.doi.org/10.3329/dmcj.v1i1.14971 Delta Med Col J. Jan 2013;1(1):16-19

Geht auch weniger? Stand der Diskussion in Schweden

The question "Is it possible to do less?" and the claim "Less is more!" can be answered and construed in different ways. One possible interpretation, which is well established in the Swedish health system, is "Accomplishing more (of the things that are important) by doing less (of the things that are dispensable)". Essentially, this is the basis of prioritisation in Swedish health care. While the concept of prioritisation is very well established in Sweden, the discussion about prioritising in Germany has always been difficult. It is, from a Swedish perspective, unclear why, of all things, health care should be exempted from prioritisation which otherwise is a necessity concerning all aspects of human and societal life. Some conditions complicate prioritisation in German health care, including the system of private and statutory health insurance and economic incentives which do not reward procedures based on indications. It will be argued that the Swedish health care system is more effective than the German not at least because of the system of prioritisation that allows for providing more necessary and essential health care instead of offering unnecessary and dubious procedures, thereby also improving patient outcome. (As supplied by publisher).

Hyperleukocytosis: Emergency Management

Hyperleukocytosis is defined as peripheral blood leukocyte count exceeding 100,000/mm(3). Acute leukemia is the most common etiology in pediatric practice. Hyperleukocytosis is a medical emergency. The increased blood viscosity, secondary to high white cell count and leukocyte aggregates, results in stasis in the smaller blood vessels. This predisposes to neurological, pulmonary or gastrointestinal complications. In addition, patients are at risk for tumor lysis syndrome due to the increased tumor burden. Initial management includes aggressive hydration, prevention of tumor lysis syndrome, and correction of metabolic abnormalities. A red cell transfusion is not indicated in a hemodynamically stable child, as it adversely affects the blood viscosity. Leukapheresis is the treatment of choice for a very high count, or in patients with symptomatic hyperleukocytosis. The technical expertise required, a relative difficult venous access in younger children, risk of anticoagulation and possible non-availability of the procedure in emergency hours are limitations of leukapheresis. However, it is a rewarding procedure and performed with relative ease in centers that perform the procedure frequently. An exchange transfusion is often a practical option when hyperleukocytosis is complicated with severe anemia. The partial exchange aids in correcting both, without the risk of volume overload or hyperviscosity, which are the limitations of hydration and blood transfusion, respectively. Etiology and management of hyperleukocytosis in relevance to the pediatric emergency room is outlined.

Nasal reconstruction

The nose is the central feature that defines one's face. Acquired nasal defects arise from a variety of pathologic and traumatic etiologies and reconstructive surgeons may be called upon to restore form and function when the nose has been altered in some way. Nasal reconstruction is one of the most challenging and rewarding procedures performed by the plastic surgeon. A detailed knowledge of the anatomy of the nose - the lining, support and cover - is essential in designing the reconstructive effort. Surgical planning involves, first, identifying the extent of the acquired defect, followed by the application of an intricate knowledge of the tissues that will provide a functional and aesthetically pleasing yet durable reconstruction. In this article, the reader will find a description of the clinically important anatomic features of the nose as they relate to various reconstructive procedures aimed at restoring nasal appearance and maintaining airway patency.

Three-piece inflatable penile prosthesis: Surgical techniques and pitfalls

Penile prosthesis surgery plays a vital role in the treatment of erectile dysfunction (ED). As far as outcome is concerned, it is one of the most rewarding procedures for both patients and surgeons. We describe our surgical technique for implantation of the three-piece inflatable penile prosthesis and point out the major surgical pitfalls accompanying this procedure and their specific management. The psychological outcome of penile prosthesis surgery is also discussed. Different surgical approaches are available when performing the procedure. A number of procedure-related problems can be encountered and a thorough knowledge of these is of paramount importance. Penile prosthesis surgery has a favorable psychological outcome. Surgery for implantation of an inflatable penile prosthesis is a rewarding procedure, with a high yield of patient satisfaction. Urologists should have thorough understanding of the surgical pitfalls peculiar to this procedure and their management.

LONG TERM RESULTS OF MATCHED HEMIRESECTION INTERPOSITION ARTHROPLASTY FOR DRUJ ARTHRITIS IN RHEUMATOID PATIENTS

The distal radioulnar joint (DRUJ) is commonly affected in rheumatoid arthritis and is associated with significant functional morbidity. The aim of our study is to review our results with matched hemi-resection interposition arthroplasty in patients with DRUJ arthritis. This was a retrospective study of 39 patients with 51 wrists that were treated at Queen Mary Hospital in Hong Kong from 1989 to 2007. All patients underwent matched hemi-resection interposition arthroplasty and dorsal wrist synovectomy. Long arm hinged elbow brace was used for three weeks followed by intensive rehabilitation up to twelve weeks. The indicators of outcome included range of motion assessment, pain, wrist stiffness, grip of strength and need for revision assessed during follow-up. Statistical analysis was performed with student t-test. The average age of patients was 50.5 years (25 to 77 years) and there was a 35:4 female to male ratio. The average follow up was 4.5 years ranging from 1 to 18 years. Associated extensor tendon ruptures were found in 31.4% patients. The average increase in supination was from 73 degrees preoperatively to 81 degrees at long term follow up (p = 0.10 at 1 year and 0.13 at long term follow-up). The average increase in pronation was from 68 degrees preoperatively to 74 degrees on long term follow up (p = 0.57 at 1 year and 0.02 at long term follow-up). There was evidence of painless, relatively stiff but functional wrist in 37.25% of patients. There was an increase in grip strength from an average of 6.1 kilogram force preoperatively to an average of 11.5 kilogram force at follow-up (p = 0.004 at 1 year and 0.15 at long term follow-up). Complete relief of ulnar sided pain was seen in 43 wrists (84%), partial relief was seen in 7 wrists (13.7%) and no relief was found in one wrist (1.9%). DRUJ arthroplasty is a rewarding procedure and most of the patients obtain pain free movement.

The Interaction of Haloperidol and Imipramine on Cost-benefit Decision Making in Rats

Organisms constantly assess the cost and benefit of the possible future outcomes of their behavior and use the information to guide the future behavior,a process called cost-benefit decision making.The current study used a T-maze delayed reward procedure to examine the effects of the non-selective dopamine receptor antagonist haloperidol and the norepinephrine/serotonin reuptake inhibitor imipramine on decision making(choice between a delayed high reward [HR] and an immediate low reward),and how delay on access to the HR alters the decision making.Six groups of rats(n=8 per group) were treated with saline,haloperidol,imipramine(3,8 or 10 mg/kg),or a combination of haloperidol(0.2mg/kg) and imipramine(8mg/kg).The experiment comprised three periods:initial training period during which animals had free access to the rewards located in both arms of the T-maze for each of the 10 daily trials;forced training period during which animals were allowed to have access to each of the two arms for the first two forced trials followed by 10 choice trials(access to both arms) with a delay imposed on the HR;and test period which was similar with the forced training period except that animals received drug treatment before the test session.Haloperidol decreased choice to HR when 15 or 30 s delay was applied to HR.In contrast,imipramine increased choice to HR.The decreased HR choice induced by haloperidol was reversed by imipramine.Increasing delay to HR decreased choice to HR.In conclusion,these data suggest that delay is an important factor for determining choice behavior,and that haloperidol and imipramine have opposing effects on decision making.

Our Experience with Secondary Reconstruction of External Rotation in Obstetrical Brachial Plexus Palsy

Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy. From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed. There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees). Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

Decreasing inappropriate vocalizations using classwide group contingencies and color wheel procedures: A component analysis

AbstractTeacher referrals for consultation resulted in two independent teams collecting evidence that allowed for a treatment component evaluation of color wheel (CW) procedures and/or interdependent group‐oriented reward (IGOR) procedures on inappropriate vocalizations in one third‐ and one first‐grade classroom. Both studies involved the application of B‐C‐D‐C designs, with the initial B phase involving the application of independent group‐oriented punishment (IGOP) procedures that were applied in all classrooms at the respective schools and maintained across all phases of the studies. In Study I, the C phase involved that application of IGOP, IGOR, and CW; CW was withdrawn in the D phase and reinstated in the subsequent C phase. In Study II, IGOP procedures were supplemented with CW procedures (first C phase), then IGOR procedures were added (D phase) and withdrawn (second C phase). Results from the two studies converge and provide evidence that CW procedures are effective when applied with IGOP procedures and that supplementing them with IGOR procedures may have little classwide impact on inappropriate vocalizations. © 2010 Wiley Periodicals, Inc.

Intra-articular corticosteroid injection for osteoarthritis

Efficacy Intra-articular corticosteroid injection is quick and simple to carry out and in RCTs it has a large effect size (ES) of 1.27 at 7 days postinjection for pain relief against placebo for knee OA [101]. It produces relatively rapid relief of severe pain within a few hours or days. Although this benefit is relatively short lasting, in RCTs (1–4 weeks), individual patients may derive benefit for 2–3 months or longer. When used with other treatments, this relatively large ES is likely to improve confidence in, and adherence to, other treatments including core nonpharmacological interventions. For these reasons, the UK regulatory body, NICE, recommends intraarticular corticosteroid injection as a useful adjunct to core treatment for the relief of moderate-to-severe pain in OA patients [101]. Many guidelines suggest that patients having a ‘flare’, or those with a joint effusion, may particularly benefit from a steroid injection, which seems logical for a drug with a potent anti-inflammatory effect. However, there is little objective evidence that the presence of clinically assessed joint inflammation is a predictor of clinical outcome, although the presence of an effusion may improve the accuracy of injection, which itself is a predictor of response [8,16]. Although not all patients respond, it is a rewarding procedure for the vast majority who do. It may even work well for patients with advanced radiographic change. Some patients receive three-monthly injections as an integral part of their management plan, providing excellent supplemental symptom relief [19]. In addition, the predictable benefit can be used to an advantage for special events, Intra-articular corticosteroid injection Intra-articular injection of corticosteroid is an effective, safe and rewarding procedure. Osteoarthritis (OA) is a condition that only affects joints so it seems logical to target therapy directly to the joint and thus, bypass the potential side effects of systemic administration. Following the first report of the use of intraarticular corticosteroid in 1951 by Hollander et al. [1], the procedure has become popular with both clinicians and patients [2]. Injection of long-acting insoluble corticosteroids into the knee produces rapid improvement in symptoms and can be repeated with predictable benefit in suitable patients [3–8].

How do African grey parrots (Psittacus erithacus) perform on a delay of gratification task?

Humans and other animals often find it difficult to choose a delayed reward over an immediate one, even when the delay leads to increased pay-offs. Using a visible incremental reward procedure, we tested the ability of three grey parrots to maintain delay of gratification for an increasingly valuable food pay-off. Up to five sunflower seeds were placed within the parrot's reach, one at a time, at a rate of one seed per second. When the parrot took a seed the trial was ended and the birds consumed the accumulated seeds. Parrots were first tested in daily sessions of ten trials and then with single daily trials. For multiple trial sessions, all three parrots showed some limited improvement across 30 sessions. For single trial sessions, only one parrot showed any increase in seed acquisition across trials. This parrot was also able to consistently obtain two or more seeds per trial (across both multiple and single trial conditions) but was unable to able to wait 5 s to obtain the maximum number of seeds. This parrot was also tested on a slower rate of seed presentation, and this significantly reduced her mean seed acquisition in both multiple and single trial conditions, suggesting that both value of reward available and delay duration impact upon self-control. Further manipulation of both the visibility and proximity of seeds during delay maintenance had little impact upon tolerance of delays for both parrots tested in this condition. This task demanded not just a choice of delayed reward but the maintenance of delayed gratification and was clearly difficult for the parrots to learn; additional training or alternative paradigms are required to better understand the capacity for self-control in this and other species.

Rhinolift: A Uniquely Simple Technique to Address the Ptotic Nasal Tip

In patients with nasal tip ptosis due to senile elastosis, both the soft tissue envelope and underlying cartilaginous framework must be properly addressed to achieve satisfactory results. The rhinolift, when performed on properly selected patients, is one the most rewarding procedures in any facial plastic surgeon’s armamentarium. The procedure is simple to master, expeditious, and has little morbidity.

Hyperresponsiveness to social rewards in children and adolescents with attention-deficit/hyperactivity disorder (ADHD)

BackgroundCurrent research suggests that attention-deficit/hyperactivity disorder (ADHD) is associated with larger behavioral sensitivity to reinforcement contingencies. However, most studies have focused thus far on the enhancing effects of tangible rewards such as money, neglecting that social-emotional stimuli may also impact task performance in ADHD patients.MethodsTo determine whether non-social (monetary) and social (positive facial expressions) rewards differentially improve response inhibition accuracy in children and adolescents with ADHD, we applied an incentive go/no-go task with reward contingencies for successful inhibition and compared ADHD subjects with typically developing individuals.ResultsBoth social and monetary contingencies improved inhibition accuracy in all participants. However, individuals with ADHD displayed a particularly higher profit from social reward than healthy controls, suggesting that cognitive control in ADHD patients can be specifically improved by social reinforcement. By contrast, self-rated motivation associated with task performance was significantly lower in ADHD patients.ConclusionOur findings provide evidence for hyperresponsiveness to social rewards in ADHD patients, which is accompanied by limited self-awareness. These data suggest that social reward procedures may be particularly useful in behavioral interventions in children with ADHD.

Hermann Senator and albuminuria--forgotten pioneering work in the 19th century

Testing urinary albumin concentration by immune detection methods has recently turned out to be a highly rewarding procedure, as low level albumin excretion has turned out to be a powerful predictor of cardiovascular and renal risk in diabetic and nondiabetic patients. In the following we discuss a text dating back to the 19th century in order to make today's nephrologists aware of the remarkable and prescient, but meanwhile completely forgotten investigations on urinary albumin excretion in individuals without primary kidney disease. The treatise of Hermann Senator convincingly disproved the then held dogma that albuminuria was always a sign of primary renal disease. These observations are all the more remarkable since he was forced to use relatively simple and not absolutely specific methods. He further provided an explanation of the renal handling of albumin which to a large extent is still valid today.