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Mark Stafford-Smith, MD, CM, FRCPC

• Professor of Anesthesiology
• Director of Fellowship Education
• Director of Cardiothoracic Anesthesia and Critical Care
• Medicine Fellowship
• Division of Cardiothoracic Anesthesia and Critical Care Medicine
• Department of Anesthesiology
• Duke University Medical Center
• Durham, North Carolina

Best practices for injection anxiety symptoms lightheadedness 75mg sinequan for sale, the collection and handling of blood samples anxiety symptoms feeling unreal purchase sinequan online, and waste management are discussed in the following chapter anxiety symptoms in cats discount sinequan 10 mg without prescription. The chapter outlines recommended practices anxiety zinc discount 25mg sinequan amex, skin preparation anxiety symptoms uk order sinequan 25 mg line, preparation and administration of injections anxiety symptoms grinding teeth buy generic sinequan 75 mg online, and related health procedures. Best injection practices described are aimed at protecting patients, health workers and the community. Hand hygiene should be carried out as indicated below, either with soap and running water (if hands are visibly soiled) or with alcohol rub (if hands appear clean. You may need to perform hand hygiene between injections, depending on the setting and whether there was contact with soil, blood or body fuids. Avoid giving injections if your skin integrity is compromised by local infection or other skin conditions (e. Note: this table provides information on glove use in relation to any type of injection. Practcal guidance on single-use personal protectve equipment When using single-use personal protective equipment, dispose of the equipment immediately after use. Wipe the area from the centre of the injection site working outwards, without going over the same area. Practcal guidance on use of injecton devices When using a sterile single-use device. If using an ampoule that requires a metal fle to open, protect your fngers with a clean barrier (e. Practcal guidance on preparing injectons Three steps must be followed when preparing injections. Keep the injection preparation area free of clutter so all surfaces can be easily cleaned. Before starting the injection session, and whenever there is contamination with blood or body fuids, clean the preparation surfaces with 70% alcohol (isopropyl alcohol or ethanol) and allow to dry. Procedure for septum vials Wipe the access diaphragm (septum) with 70% alcohol (isopropyl alcohol or ethanol) on a swab or cotton-wool ball before piercing the vial, and allow to air dry before inserting a device into the bottle. This chapter outlines the risks associated with unsafe phlebotomy, and summarizes best practice in phlebotomy, with the aim of improving outcomes for health workers and patients. The adverse events that have been best documented are in blood transfusion services, where poor venepuncture practice or anatomical abnormality has resulted in haematoma and injury to anatomical structures in the vicinity of the needle entry (35. Another issue for patients is that if a blood sample is poorly collected or destroyed during transportation, the results may be inaccurate and misleading to the clinician, or the patient may have to undergo the inconvenience of repeat testing (36. Poor infection-control practices can lead to bacterial infection at the site where the needle was inserted into the skin (37. Both patients and health workers can be exposed through phlebotomy to blood from other people, putting them at risk from bloodborne pathogens. An example of the spread of bloodborne pathogens through phlebotomy is the reporting of outbreaks of hepatitis B associated with the use of glucometers (devices used to determine blood glucose concentration) (38, 39. Another issue for health workers is sharps injuries; these commonly occur between the use and disposal of a needle or similar device. For example, the use of sharps protection devices and immediate disposal of the used syringe and needle as a single unit into a puncture-resistant sharps container. In home-based care, phlebotomy can be made safer by improving sharps disposal, to minimize the risk of exposure to hollow-bore and venepuncture needles (41. It should include an understanding of anatomy, awareness of the risks from blood exposure, and awareness of the consequences of poor infection prevention and control. The condition of the the condition of the sample should be such that the quality of the results is sample satisfactory. Safe transportation Making safe transportation of blood or blood products part of best practices will improve the quality of results from laboratory testing (42. A log book or register system should be established with accurate details of the incident, possible causes and management of the adverse events (43. If the needle is too large for the vein for which it is intended, it will tear the vein and cause bleeding (haematoma); if the needle is too small, it will damage the blood cells during sampling, and laboratory tests that require whole blood cells, or haemoglobin and free plasma, will be invalid. Blood collection for transfusion requires a larger gauge than is used for blood drawing. The donated blood is tested, and processed to ensure that it is free from major infections that are transmissible by transfusion, therefore ensuring that it will not harm the recipient of the blood. Blood donation should be voluntary; it should not involve duress, coercion or remuneration. Also, potential blood donors should be selected carefully, according to the national criteria for donor selection. Additional requirements for a collection system for blood donation are given below. Such equipment includes blood pressure monitors, scales, donor couches or chairs, blood collection monitors or mixers, blood bag tube sealers, blood transportation boxes and blood bank refrigerators. Containers used to transport supplies and specimens should also be cleanable by disinfectants, such as sodium hypochlorite bleach solutions. Some bags include diversion pouches to sequester the frst 20 ml of blood collected, to minimize contamination from skin fora and the skin core (52. If blood for haemoglobin testing is gathered with a capillary stick, a single-use sterile lancet should be used and then placed immediately in a sharps container (safety box. Ensure that the rack containing the sample tubes is close, but away from the patient, to avoid it being accidentally tipped over. The patient has a right to refuse a test at any time before the blood sampling, so it is important to ensure that the patient has understood the procedure. The median cubital vein lies between muscles and is usually the most easy to puncture. Under the basilic vein runs an artery and a nerve, so puncturing here runs the risk of damaging the nerve or artery and is usually more painful. Haemolysis, contamination and presence of intravenous fuid and medication can all alter the results (54. Nursing staff and physicians may access central venous lines for specimens following protocols. However, specimens from central lines carry a risk of contamination or erroneous laboratory test results. It is acceptable, but not ideal, to draw blood specimens when frst introducing an in-dwelling venous device, before connecting the cannula to the intravenous fuids. Note: alcohol is preferable to povidone iodine, because blood contaminated with povidone iodine may falsely increase levels of potassium, phosphorus or uric acid in laboratory test results (55, 56. Start from the centre of the venepuncture site and work downward and outwards to cover an area of 2 cm or more for 30 seconds. Some guidelines suggest removing the tourniquet as soon as blood fow is established, and always before it has been in place for two minutes or more. Ask the patient to hold the gauze or cotton wool in place, with the arm extended and raised. To prevent needle-sticks, use one hand to fll the tube or use a needle shield between the needle and the hand holding the tube. Do not press the syringe plunger because additional pressure increases the risk of haemolysis. As colour coding and tube additives may vary, verify recommendations with local laboratories. The label should be clearly written with the information required by the laboratory, which is typically the patients frst and last name, fle number, date of birth, and the date and time when the blood was taken. If a person was exposed to blood through nonintact skin, mucous membranes or a puncture wound, complete an incident report (see Section 4. The most frequent adverse events include haematoma, a vasovagal reaction or faint, and a delayed faint. Assemble equipment, and include needle and syringe or vacuum tube, depending on which is to be used. Check the label and forms and then give the patient a syringe or blood-sampling for accuracy. If can drip blood or body fuids using soap and water, dry into the infectious waste. Thus, such prevention is an important part of any comprehensive programme for protecting health workers and patients. They should be immunized either before training or as soon as possible when at work, unless they are already immunized (15. A schedule including three doses at 0, 1 and 6 months is highly effective; it provides long-term protection in most individuals. If they know their own status for these infections, health workers can access treatment and care if necessary. Any testing should be undertaken in conditions that respect the workers rights and is based on informed consent. A hierarchy of controls to prevent needle-stick injuries and other blood exposures is given below by order of effectiveness (most effective frst) (64, 65. They will prevent exposures to blood splashes but will not prevent needle-stick injuries (34, 70, 71. The exposure can occur through needle-stick and sharp injuries, and from splashes contaminated with blood or body fuids.

Surgical Procedure of Primary Site should be coded 98 for any tumor characterized by the specific sites and/or morphologies identified in the site-specific code instructions for Unknown and Ill-Defined Primary Sites and Hematopoietic/ Reticuloendothelial/Immunoproliferating/ Myeloproliferative Disease anxiety after eating order sinequan 10mg fast delivery. The item Surgical Procedure/Other Site is used to indicate whether surgery was performed for these tumors anxiety symptoms heart order sinequan toronto. Within groups of codes anxiety symptoms psychology generic sinequan 10 mg fast delivery, procedures are defined with increasing degrees of descriptive precision anxiety jacket for dogs buy generic sinequan from india. Succeeding groups of codes define progressively more extensive forms of resection anxiety symptoms and treatment buy line sinequan. Last-listed responses take precedence over earlier-listed responses (regardless of the code or numeric value anxiety symptoms on dogs cheap sinequan 25mg without prescription. As a result of added and modified codes, however, the numeric code sequence may deviate from the order in which the descriptions of the surgical procedures are listed. Example: A rectosigmoid primary surgically treated by polypectomy with electrocautery, which is listed after polypectomy alone, is coded 22. In order to compare contemporary treatment to previously published treatment based on the former codes, or to data still unmodified from pre-1998 definitions, the ability to differentiate surgeries in which four or more regional lymph nodes are removed is desirable. The compromise incorporated in the Scope of Regional Lymph Node Surgery [1292] codes separates removal of one to three nodes (code 4) from removal of four or more nodes in the response categories (code 5. It is very important to note that this distinction is made to permit comparison of current surgical procedures with procedures coded in the past when the removal of fewer than four nodes was not reflected in surgery codes. The distinction between fewer than four nodes and four or more nodes removed is not intended to reflect clinical significance when applied to a particular surgical procedure. Surgical Procedure/Other Site [1294] describes surgery performed on tissue or organs other than the primary site or regional lymph nodes. It is also used to describe whether surgery was performed for tumors having unknown or ill-defined primary sites or hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease morphologies. If any surgical treatment was performed on these cancers, Surgical Procedure/Other Site is coded 1. Surgical Procedure of Primary Site at this Facility [670], Scope of Regional Lymph Node Surgery at this Facility [672], and Surgical Procedure/Other Site at this Facility [674] are identical to Surgical Procedure of Primary Site [1290], Scope of Regional Lymph Node Surgery [1292], and Surgical Procedure/Other Site [1294], respectively, except they each refer solely to surgery provided by the respective facility. Six surgery items augment the information recorded in Surgical Procedure of Primary Site [1290]. When no surgical procedure of the primary site is performed, the reason is recorded in the item Reason for No Surgery of Primary Site [1340]. If only one first course surgical procedure was performed, then the date will be the same as that for Date of First Surgical Procedure [1200]. If more than one surgical procedure is performed by the facility, this item refers to the most definitive (most invasive) first course primary site surgery performed. This item in combination with Date Radiation Ended [3220] allows the duration of treatment to be calculated. Both dates can be used to describe lag time between diagnosis and initialization of specific aspects of treatment. Location of Radiation Treatment [1550] can be used to assess where therapy was provided. This item allows for the distinction between summary treatment and treatment given at the accessioning facility. Codes are provided that allow the description of where regional and boost dose therapy were provided, whether all the therapy was provided at the accessioning facility or if all or some of the radiation therapy was referred out to another treatment location. The treatment volume may be the same as the primary site of disease; however, the available code values provide descriptions of anatomic regions that may extend beyond the primary site of disease and may be used to describe the treatment of metastatic disease. If two distinct volumes are radiated, and one of those includes the primary site, record the radiation involving the primary site in all radiation fields. In addition to knowing the duration of treatment and the modalities and doses involved, it is critical to know the number of treatments to be able to gauge the intensity of the dose delivered to the patient. Two items augment the information recorded in the radiation modality, dose, volume, and number of treatment items. Radiation therapy can precede the surgical resection of a tumor and then be continued after the patients surgery, or radiation can be administered intraoperatively. Systemic Therapy Systemic therapy encompasses the treatment modalities captured by the items chemotherapy, hormone therapy, and immunotherapy. Hormone Cancer therapy that achieves its antitumor effect through changes in hormonal balance. This therapy type of therapy includes the administration of hormones, agents acting via hormonal mechanisms, antihormones, and steroids. Immunotherapy Cancer therapy that achieves its antitumor effect by altering the immune system or changing the hosts response to the tumor cells. Endocrine Cancer therapy that achieves its antitumor effect through the use of radiation or surgical therapy procedures that suppress the naturally occurring hormonal activity of the patient (when the cancer occurs at another site) and, therefore, alter or affect the long-term control of the cancers growth. Hematologic Bone marrow or stem cell transplants performed to protect patients from myelosuppression or transplants bone marrow ablation associated with the administration of high-dose chemotherapy or radiation therapy. For cases diagnosed prior to January 1, 2013, registrars have been instructed to continue coding these drugs as Chemotherapy. If a patient has an adverse reaction, the managing physician may change one of the agents in a combination regimen. If the replacement agent belongs to the same group as the original agent, there is no change in the regimen. However, if the replacement agent is of a different group than the original agent, the new regimen represents the start of subsequent therapy, only the original agent or regimen is recorded as first course therapy. Pleural/pericardial Injected directly into pleural or pericardial space to control malignant effusions. Hepatic artery Injected into a catheter inserted into the artery that supplies blood to the liver. Relationships among Systemic Therapy Items the data item Date Systemic Therapy Started describes the first date on which any first course systemic treatment was administered to the patient. Nine out of 10 patients treated with systemic therapy receive only a single class of drugs (chemotherapy, hormone therapy, or immunotherapy. Of the remaining patients who receive a combined regimen of systemic therapies, two-thirds begin these combined regimens simultaneously. For the purposes of clinical surveillance, the collection of multiple dates to describe the sequence of systemic therapy administration is not necessary. In the case of chemotherapy, additional distinction is allowed for instances where single or multiagent regimens were administered. Each of these three items includes code values that describe the reason a particular class of drugs is not administered to the patient and distinguishes a physicians not recommending systemic therapy due to contraindicating conditions from a patients refusal of a recommended treatment plan. Hematologic Transplant and Endocrine Procedures captures those infrequent instances in which a medical, surgical, or radiation procedure is performed on a patient that has an effect on the hormonal or immunologic balance of the patient. Hematologic procedures, such as bone marrow transplants or stem cell harvests, are typically employed in conjunction with administration of systemic agent(s), usually chemotherapy. The use of code 40 in response to this data item should be reviewed and confirmed with the managing physician(s. Other Treatment Other Treatment encompasses first course treatment that cannot be described as surgery, radiation, or systemic therapy according to the defined data items found in this manual. Consult the most recent version of the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual for instructions for coding care of specific hematopoietic neoplasms in this item. Palliative care provided to relieve symptoms may include surgery, radiation therapy, systemic therapy (chemotherapy, hormone therapy, or other systemic drugs), and/or other pain management therapy. The following items apply to all palliative care provided at this facility and at other facilities: Palliative Care [3270] Palliative Care at this Facility [3280] Any surgical procedure, radiation therapy, and/or systemic therapy that is provided to modify, control, remove, or destroy primary or metastatic cancer tissue, is coded in the respective first course of treatment fields and also identified in the Palliative Care items. Refer to the preceding discussion of the surgery, radiation and systemic therapy data items for specific coding guidelines. Because these treatments are less aggressive when given for palliation than for treatment, the treatment plan or treatment notes will indicate when they are performed for palliative purposes. For example, a patient with metastatic prostate cancer may receive an orchiectomy and systemic hormone therapy in combination with palliative radiation for bone metastasis. Treatment, Palliative, and Prophylactic Care Any first course radiation or systemic treatment that acts to kill cancer cells is to be reported as treatment. Second, it contributes to the patients treatment by destroying cancer cells in the bone marrow, though its use alone would generally not be sufficient to produce a cure. The situation is analogous to the use of breast-conserving surgery and adjuvant radiation when the surgery or radiation alone may not be sufficient to produce a cure, though together they are more effective. When first course surgery, systemic treatment, or radiation is undertaken to reduce the patients symptoms, that treatment should be coded as palliative care. An example is radiation to bone metastases for prostate cancer to reduce bone pain, which is palliative when there is no expectation that the radiation will effectively reduce the cancer burden. This treatment qualifies the patient as analytic if it is given as part of planned first course treatment. An action taken to prevent cancer from developing (such as a double mastectomy for a healthy woman who has several relatives diagnosed with breast cancer when they were young) is not reportable; there is no cancer to report. Embolization the term embolization refers to the intentional blocking of an artery or vein. The mechanism and the reason for embolization determine how and whether it is to be recorded. Chemoembolization is a procedure in which the blood supply to the tumor is blocked surgically or mechanically and anticancer drugs are administered directly into the tumor. This procedure permits a higher concentration of drug to be in contact with the tumor for a longer period of time. Code chemoembolization as Chemotherapy when the embolizing agent(s) is a chemotherapeutic drug(s) or when the term chemoembolization is used with no reference to the agent. Also code as Chemotherapy when the patient has primary or metastatic cancer in the liver and the only information about embolization is a statement that the patient had chemoembolization, tumor embolization or embolization of the tumor in the liver. However, if alcohol is specified as the embolizing agent, even in the liver, code the treatment as Other Therapy. Radioembolization is embolization combined with injection of small radioactive beads or coils into an organ or tumor. Code Radiation Modality as brachytherapy when tumor embolization is performed using a radioactive agent or radioactive seeds. Do not code presurgical embolization of hypervascular tumors with particles, coils or alcohol. These presurgical embolizations are typically performed to make the resection of the primary tumor easier. Examples where presurgical embolization is used include meningiomas, hemangioblastomas, paragangliomas, and renal cell metastases in the brain. Outcomes the outcomes data items describe the known clinical and vital status of the patient. Follow-up information is obtained at least annually for all living Class of Case 10-22 patients included in a cancer registrys database. Recorded follow-up data should reflect the most recent information available to the registry that originates from reported patient hospitalizations, known patient readmissions, contact with the patients physician, and/or direct contact with the patient. The paragraphs below describe the range of follow-up information that should be obtained. Therefore, it is important to continue follow-up efforts to be certain the necessary treatment information is collected. If the Type of First Recurrence [1880] is coded 70 (never cancer free), when the patient was last seen, but treatment was still underway, then check at follow-up to see whether the patient subsequently became cancer-free. Occasionally, if first course treatment ends due to disease progression, it may be the second course or subsequent treatment that results in a cancer-free status. If the Type of First Recurrence is coded 00 (became cancer-free and has had no recurrence), then continue to follow for recurrence and record the type and date when it occurs. In order to facilitate research on cancer recurrence, two new follow-up data items have been added for 2018 that allow for the recording of the last date on which the patients cancer status has been updated. Class of Case 00 patients that are not followed will have the most recent information as of the Date of Last Contact or Death [1750]. Once the patients death has been recorded and all care given prior to death is recorded, no further follow-up is performed. Case Administration Correct and timely management of case records in a registry data set are necessary to describe the nature of the data in the cancer record and to facilitate meaningful analysis of data, and it is necessary to understand each items respective purpose to ensure their accuracy and how to use them in facility analysis. In a registry with more than one abstractor or serving more than one facility, it will ordinarily be necessary to enter these three numbers only when they change. For these edits, an override flag can be set if, upon review, the unusual combination is verified as being correct. If correction of data entry errors resolves the problem, do not make an override entry. If no comment regarding the unusual circumstances can be found in the record, it may be necessary to check with the managing physician or pathologist to determine whether it is appropriate to override the edit. Because registries cover many years of cases, registry data will be recorded according to many different coding systems.

It was also well that you can talk to about your failures anxiety symptoms crying buy discount sinequan 25mg online, fears anxiety in college students purchase 10mg sinequan, known for Juha to travel to other countries to 305 8 | Visiting Helsinki Neurosurgery | Mansoor Foroughi perform major operations anxiety symptoms panic attacks order sinequan line. Months after my arrival in Helsinki following very limited socialising outside of work anxiety symptoms in women buy sinequan in india, I met a young lady in a social gathering anxiety 5 things you see sinequan 25 mg sale. Her name was Anisa and her father was a patient cared for by Professor Juha Hernesniemi more than a decade ago anxiety symptoms urinary purchase sinequan on line amex. It was inspiring and joyful to hear the gratitude and love felt towards Juha and the team by this lady. She expressed her great and lasting gratitude, and had only praise and admiration for the care and support they received from Juha Hernesniemi and his team. We provide this book as a brief revision and insight for those visitors coming to Helsinki and seeing Professor Hernesniemis methods. Hernesniemi to get of instruments or aneurysms clips was almost additional experience in complex intracranial always correct, and each instrument was used procedures before an open cerebrovascular fel- in a variety of ways before it was changed for lowship. The summation of all of these lit- to see perhaps one or two aneurysm cases per tle renements was rapid, nearly awless sur- week. Without a doubt, the highlight of my visit was Observing and discussing these high level op- the opportunity to scrub in for a basilar apex erations was the focus of my visit. Hernesniemi occasionally took the visitors on While this usually meant the fellows, the visi- afternoon teaching rounds, in English. The de- tors were allowed to scrub in when there were partment also met each morning at 8:30 for no two fellows available. Her- the day to review the imaging for the impor- nesniemis operations was how quickly he tant cases. Drake, and their classic textbooks, or his experiences with them, was mentioned nearly every day. I spent many hours with him listening to his insights from the recent surgical cases or his past ex- perience. Five or six books, in particular, have received consider- able attention from the residents and visitors, and reading them in the context of Dr. These books included the volumes of Yasargils book series, the book on vertebrobasilar aneurysms that Dr. There were also a number of surgical videos and presentations that have been prepared by the department. There was also opportunity to prepare the videos and imaging from the cases that I observed during my time in Helsinki. Hernesniemis micro-instru- ment tray, and one of the scrub nurses helped me translate it from Finnish into English. Hernesniemi and the Helsinki Central Hospital Department of Neu- rosurgery was a one-of-a-kind opportunity to observe microneurosurgery at its best. I recom- mend it for anyone with an interest in opti- mizing their own cerebrovascular neurosurgery skills. He was using quick and clean sur- during the breaks between the operations and gical technique on very complicated cases. I was also involved in was able to perform a high number of micro- many research projects, especially on cerebral neurosurgerical operations. I thought to myself: "I should learn referral center for complicated cerebrovascular cerebrovascular neurosurgery from him". In Toolo Hospital, most of the aneurysms I went to Helsinki in November 2003 for the are clipped. I was lucky, and when es have also dedicated themselves to neuro- I got on the Finnair city bus, Prof. He called me a taxi and gave me a bus card kara University Department of Neurosurgery for the next day. I can in Turkey, which is famous for its intense cur- remember very well my rst day in Helsinki. He was sending emails to middle cerebral artery aneurysms, a craniophar- me about his daily work. Later on, I started as a important tricks during every step of the sur- 312 Ayse Karatas | Visiting Helsinki Neurosurgery | 8 gery. He was very helpful and empathetic for the visitors, since he had stayed abroad for many years himself. On that day, the hospital ag was at half-mast be- cause one of the nurses had died. We should pick young transform their work also into their hobby as people with so much dedication, determina- that helps in maintaining the interest in the tion and full of energy that one day they will eld for long periods of time. In my de- partment, this selection is mainly based on my I would like to share some of my thoughts and foresight that, one day, this particular young reect on some of my experience about the is- person will amaze me with both creativity and sues a young neurosurgeon should be aware of skillful performances. At the same time they must have a somewhat stubborn and tenacious character to fulll their goals, often against the wishes of other people, sometimes even the chairman. They must be able to travel, and they must be uent in the main languages of the international neurosurgical community, so as to be able to visit departments all over the world to learn new ideas and techniques. They have to be hard working and have good hands, irrespective of their glove size. It is extremely helpful to be in good physical and mental con- dition, by doing some sports or other hobbies which help to quickly recover from the many failures and complications encountered in eve- ryday work. A good healthy sense of humor helps, and it is important to have the support of the family or good friends in all the daily joys and sorrows. Cynicism and black humor alone, will probably not be able to carry someone through the years of hard work, rather he or she will experience 315 9 | Some career advice to young neurosurgeons Many of the movements we perform with our hands under the large magnication of the microscope should become automatic, with- out the need to concentrate on them, like. Read- the steps for any operation whether for vascu- ing the many textbooks available gives us the lar, tumor or spinal surgery in the laboratory opportunity to share the accumulated experi- setting. Not necessarily as a single procedure ence of several generations of neurosurgeons. Preparing yourself for some new or infrequent operation by reading, means that during the actual surgery your hands will be guided by 9. When beginning your career, select your own By reading frequently you may save, rst and heroes. They may be in your own institute, or foremost, your patient, but secondly also your far away, in other parts of the world. It is not enough to learn was visiting the maestros and sitting as an ob- the anatomy once, rather, one is forced to re- server in the corners of various cold operating visit the same topics over and over again before rooms around the Europe and North America acquiring appropriate expertise in the matter. The same the microsurgical laboratory to dissect animals happens in sports, arts, and technical develop- and cadavers if possible. Operat- from a new starting point, the point where ing under the microscope should be started in a these earlier giants nished. He or she does not have fatigue, burn-out and cynicism towards your to be the chairman of the institute, but he or work. Remain a ghter, never give up; if you she should be the one who has a great soul were thrown against a smooth wall, you should and understanding of life - and neurosurgery. Even close to or after your retire- geon, and almost impossible to make a real ment you can still be useful, as you can contin- academic career. Experienced neuro- ing several hundred operations a year is both surgeons, unlike experts in. Drake the responsibility for the patient, not for your to push aside the aneurysm dome) and trust untarnished surgical series. Be open to new techniques and instru- stitute one can easily build up a reputation of ments. Try them out and if you nd them good, excellent surgical results by avoiding the high- adopt them. He advised to make operations sim- patients will be excluded and die without ever pler and faster and to preserve normal anatomy being given a chance to survive - and this only by avoiding resection of the cranial base, the to save the good outcome gures for ones sur- brain or by sacricing the arteries and veins. Supercial analysis of results from this results in better outcome for the patients, some institution may give you the wrong pic- the only thing that really matters. You should ture regarding the skills of a particular neuro- try new treatment methods if you suspect that 318 Some career advice to young neurosurgeons | 9 they might beat the old ones. Ques- ing various reports on new techniques with tion, argue and discuss your daily routines. When you go to visit neurosurgeons with ex- Furthermore, dont change your methods if you cellent or new skills, you may learn much more are performing well! You more active approach towards microsurgery, should travel throughout your career, as a resi- intensive care, imaging, rehabilitation and dent, as a young neurosurgeon, and even later changes in mental attitude, we have made sig- on as an already experienced specialist - you nicant progress as compared to the 1970s, are never too old. Lectures in congresses give only a sim- top facilities, because it is the actual work that plied picture of the actual level of neurosur- counts the most. Unfortunately, Drake and Peerless, primitive from the present the true results are often worse than those pre- perspective, could still serve as a testimony of sented. When doing so you get surgical experience and techniques for the up- a great chance to learn and to be criticized by coming generations. Make videos and photographs, analyze them, With the constant presence of these observ- draw if you can, and discuss the cases with ers you will be forced to perform on a much other neurosurgeons, residents and students. Since 1997, I have been privileged to that you end up doing better and cleaner mi- have a large number of excellent international crosurgery. Analyze your cases also in your fellows and visitors, who have taught me often mind in the evenings or even during the sleep- 319 9 | Some career advice to young neurosurgeons less nights. Perform mental exercises in how to improve your surgery, which moves to omit or to add. Share your experience with others, es- pecially with younger people, and speak openly 9. Being open means Publish your results but dont publish every- honest surgery, and the truth helps always also thing! Writing and publishing is hard keep all of our experience in our memory and work, it has to be practiced in the same way as databases, analyze it and use it well. In neurosurgery, everybody is generally busy with his or her clinical work, You should keep track of your own results. Before putting any ideas on the paper, letters, telephone calls, and hospital records one is forced to analyze the problem to the and add this follow-up data to your database. The other ad- it is only fair to your future patients if you vantage that comes from writing is that one know what the risks are of you performing a becomes also a much better and more critical particular operation. If there is somebody close reader, who is able to distinguish a good pub- by who can do it better, let him or her operate lication from a poor one at a glance.

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References

• Clark PB: End-to-end ureteroileal anastomoses for ileal conduits, Br J Urol 51:105n109, 1979.
• Hund E. Neurological complications of sepsis: critical illness polyneuropathy and myopathy. J Neurol 2001;248(11):929-934.
• Boccasanta P, Venturi M, Stuto A, et al. Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial. Dis Colon Rectum 2004;47(8):1285-96; discussion 96-7.
• Tavazoie SF, Alvarez VA, Ridenour DA, et al. Regulation of neuronal morphology and function by the tumor suppressors Tsc1 and Tsc2.
• Henderson TO, Moskowitz CS, Chou JF, et al. Breast cancer risk in childhood cancer survivors without a history of chest radiotherapy: a report from the Childhood Cancer Survivor Study. J Clin Oncol 2016;34(9):910-918.
• Popp, L.W. Endoscopic patch repair of inguinal hernia in a female patient. Surg Endosc 1990;5:10-12.