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Journal of Otolaryngology - Head & Neck Surgery
The McGill simulator for endoscopic sinus surgery (MSESS): a validation study
Original research article
Rickul Varshney1,7,
Saul Frenkiel1,
Lily HP Nguyen1,2,
Meredith Young2,3,
Rolando Del Maestro4,
Anthony Zeitouni1,
Elias Saad5,
W Robert J Funnell1,5,
Marc A Tewfik1 &
Journal of Otolaryngology - Head & Neck Surgery volume 43, Article number: 40 (2014) Cite this article
Endoscopic sinus surgery (ESS) is a technically challenging procedure, associated with a significant risk of complications. Virtual reality simulation has demonstrated benefit in many disciplines as an important educational tool for surgical training. Within the field of rhinology, there is a lack of ESS simulators with appropriate validity evidence supporting their integration into residency education. The objectives of this study are to evaluate the acceptability, perceived realism and benefit of the McGill Simulator for Endoscopic Sinus Surgery (MSESS) among medical students, otolaryngology residents and faculty, and to present evidence supporting its ability to differentiate users based on their level of training through the performance metrics.
10 medical students, 10 junior residents, 10 senior residents and 3 expert sinus surgeons performed anterior ethmoidectomies, posterior ethmoidectomies and wide sphenoidotomies on the MSESS. Performance metrics related to quality (e.g. percentage of tissue removed), efficiency (e.g. time, path length, bimanual dexterity, etc.) and safety (e.g. contact with no-go zones, maximum applied force, etc.) were calculated. All users completed a post-simulation questionnaire related to realism, usefulness and perceived benefits of training on the MSESS.
The MSESS was found to be realistic and useful for training surgical skills with scores of 7.97 ± 0.29 and 8.57 ± 0.69, respectively on a 10-point rating scale. Most students and residents (29/30) believed that it should be incorporated into their curriculum. There were significant differences between novice surgeons (10 medical students and 10 junior residents) and senior surgeons (10 senior residents and 3 sinus surgeons) in performance metrics related to quality (p < 0.05), efficiency (p < 0.01) and safety (p < 0.05).
The MSESS demonstrated initial evidence supporting its use for residency education. This simulator may be a potential resource to help fill the void in endoscopic sinus surgery training.
Endoscopic sinus surgery (ESS) requires specialized technical skills involving complex spatial, perceptual and psychomotor performances [1]. Expertise in this minimally invasive surgery necessitates bimanual dexterity within a small 3-dimensional space [1], avoidance of key vital structures (i.e. orbits, brain and carotid artery), thorough applied knowledge of the intricate anatomy, and proficiency in maneuvering with the indirect visual aid of a 2-dimensional monitor [2]. Given the proximity of the paranasal sinuses to critical structures such as the orbits and skull base, it can be understood why ESS is the most frequent reason for otolaryngic surgical litigation in the United States [3], and why the rate of complications during ESS is higher in trainees when compared to attending physicians [4].
Those teaching ESS have found alternative modalities to the traditional apprenticeship training model such as cadaveric dissections and 3D silicone models [1]. However, the latter have substantial limitations with regards to the complex needs of ESS training, such as the lack of tissue mobility of rigid silicone models [5] and the inadequate representation of tissue strength in cadavers [6]. Virtual reality (VR) simulators solve these deficiencies, as well as offer a standardized environment for a trainee to repeat a procedure multiple times until proficiency is achieved [7]. Additional benefits of VR simulation documented in other surgical domains include the ability to objectively assess surgical skills without the need of a tutor [8], reduction of patient risk, and the standardization of residency training regardless of a particular institution¿s practice profile or access to a cadaver laboratory [9]. VR simulation has been demonstrated to be beneficial in many surgical disciplines [2],[10]-[12], including otolaryngology [13],[14].
In the field of ESS, the first VR sinus surgery simulator, the ES3, was developed between 1995 and 1998 [15]. To date, rigorous published validation studies supporting use of ESS simulators in resident training derive uniquely from the ES3 [1],[3]. However, it is no longer commercially available and there are only a few devices in existence [15]. Other simulators, such as the Dextroscope endoscopic sinus simulator [16] and the VOXEL-MAN [17], have yet to demonstrate evidence to support their use for training. Thus, there is an obvious need for a VR simulator with evidence of acceptability and validity to fill the void in ESS training.
The McGill Simulator for Endoscopic Sinus Surgery (MSESS) is a VR simulator that aims to address this issue. The objectives of this study were to assess the feasibility, usability, perceived value, and initial evidence supporting the validity of the simulator.
Description of the participants
Ethical approval was obtained from the Institutional Review Board at McGill University. Between May and October 2013, the following participants were recruited into the study: senior medical students (third or fourth year) and otolaryngology residents. The residents were divided into two groups: junior residents (PGY1-3 s) and senior residents (PGY4-5). The junior residents were grouped together as they had limited or no operative experience in ESS with less than 5 cases, whereas the senior residents had more than 5 cases. Furthermore, in order to have performance metrics from expert surgeons, 3 attending staff proficient in ESS (fellowship trained in rhinology or that perform an average of one day of ESS or skull base procedures every week) were also recruited.
Each user was given a brief tutorial concerning the functionality of the tools, as well as a video demonstrating the tasks to be performed and the danger zones within the nasal cavity. They were also given a 5-minute period to familiarize themselves with the movement and haptic feedback of the tools and the use of the pedals prior to beginning the simulated tasks.
Description of the MSESS
The MSESS was created by the Department of Otolaryngology ¿ Head and Neck Surgery at McGill University and the National Research Council of Canada. It was developed upon the NeuroTouch platform, which is a neurosurgery simulator made by the National Research Council of Canada [18],[19]. Validity of the neurosurgery simulator as a training tool has previously been described [20]. The simulated 3D nasal model was rendered using a single patient¿s CT scan. Each anatomic structure within the simulated 3D nasal model was coded separately as to allow specific measurements of performance at each point within the nasal cavity.
By providing a 0-degree endoscope in the non-dominant hand and a microdebrider in the dominant hand, the MSESS allowed the user to perform basic ESS tasks while viewing a virtual representation of the nasal cavity and the instrument tip on a flat panel display (Figure 1). A10-member panel of sinus surgeons and education experts opted to develop a microdebrider as the first simulated tool as it is commonly used in ESS, can perform a variety of tasks, and has a potential for serious complications [21]. The user received haptic feedback from the instruments, such as resistance from the contact of nasal tissues and vibration from the microdebrider activation.
Hardware of the MSESS. View of the endoscope and the microdebrider handles (above) with VR view seen on the display monitor (below).
A novel feature of the MSESS was its ability to simulate visual field blurring caused by soiling of the tip of the endoscope with nasal tissue contact. In this instance, the user had to activate an endonasal wash function via a foot pedal in order to regain clear visualization.
Simulation tasks
The tasks chosen to be evaluated on the MSESS included: 1) passing the endoscope from the nasal vestibule to the nasopharynx, 2) anterior ethmoidectomy, 3) posterior ethmoidectomy and 4) wide sphenoidotomy (Figure 2). The four tasks were chosen by the panel because they represented increasing levels of difficulty, and mimicked the step-wise approach found in sinus surgery where the surgeon typically addresses first the maxillary sinus, then the ethmoids, and finally the sphenoid sinus. The uncinectomy and maxillary antrostomy were not assessed since it cannot be safely performed with a microdebrider and other instruments have not yet been simulated.
VR representation of sinonasal cavity. Views of an ethmoidectomy (left) and sphenoidotomy (right) using the microdebrider.
Dimensions of quantitative data generated include constructs of quality, efficiency, and safety. Many of the metrics used to compare groups have previously been validated on the NeuroTouch platform [20]. A list of the metrics and their definitions can be found in Table 1.
Table 1 Description of the performance metrics
Post-simulation questionnaire
After their simulation session, participants answered a questionnaire regarding their perceptions of simulator realism, potential educational benefits and skills practiced. Responses were collected via both a 10-point rating scale, anchored as appropriate for the question, and open-ended questions. Prior to implementation, this questionnaire had been sent to 5 faculty members on the research team to ensure that it was appropriate, intelligible, unambiguous, unbiased, complete, appropriately coded and aligned with our constructs of interest. Thereafter, a panel of 5 otolaryngologists and education experts assessed the questionnaire independently to validate it. Finally, residents and physicians were recruited to perform the initial pilot testing including assessment of intra-rater reliability for a final review of the post-simulation questionnaire.
An average for each metric was calculated per group of participants (medical students, junior residents, senior residents, attending faculty), and used for comparison across participant groups.
Differences between groups¿ performance metrics were first investigated using the analysis of variance - Kruskal Wallis Test. All metrics that showed a difference between groups were then sub-analyzed using the Mann-Whitney test to demonstrate which groups showed a difference (p < 0.05 was considered significant). Descriptive statistics were used to analyze the quantitative portion of the questionnaire, while content analysis and thematic description was applied to qualitative data.
10 medical students, 10 junior residents, 10 senior residents and 3 attending staff agreed to participate in the study. All the participants completed the required simulation tasks, as well as the post-simulation questionnaire.
Data relating to the assessment of perceived realism and educational value of the MSESS are presented in Tables 2 and 3, respectively. Participants across all groups, on average, rated items related to the realism of the MSESS at least 7 on a 10 point-rating scale, corresponding to the anchor ¿realistic¿ (Mean =7.97 ± 0.29). Similarly, participants across all groups rated items related to the perceived educational value of the MSESS at least 7 on a 10, corresponding to ¿useful¿ (Mean =8.57 ± 0.69).
Table 2 Perceived assessment of the realism of the MSESS
Table 3 Perceived educational value of the MSESS
All medical students (n = 10/10) felt that the MSESS would be useful for their level of training, as compared to 80% of junior residents (n = 8/10) and 80% (n = 8/10) of senior residents. Similarly, 100% of medical students (n = 10/10) stated that the MSESS would be a useful adjunct to their surgical curriculum, as did 80% of junior residents (n = 8/10) and 80% of senior residents (n = 8/10). Finally, when asked if the MSESS should be readily available for their rhinology surgical education, 29/30 students and residents responded yes.
The responses to open-ended questions for strengths of the simulator were grouped into three main themes: the realism of the VR model, the ability to practice bimanual technical skills and the necessity for such simulators to complement traditional teaching modalities. Weaknesses related to perceived imprecision of fine tool movements and the lack of bleeding in the VR model.
There was no statistically significant difference (Figure 3) between all 4 groups with respect to the surgical completeness of the anterior ethmoidectomy, posterior ethmoidectomy and wide sphenoidotomy (p > 0.05). However, when combining the groups into novices (medical students and junior residents) and senior surgeons (senior residents and attending faculty), there was a significant tendency towards making a wider sphenoidotomy with increasing level of expertise (p = 0.01).
Percentage of tissue removed during simulation tasks. The graph represents means +/- SD. There was no statistically significant difference (p > 0.05) between all 4 groups for all three surgical tasks. When combining the groups into novices (students and junior residents) and senior surgeons (senior residents and attending faculty), there was a statistically significant difference for the wide sphenoidotomy (p = 0.01).
Time required to complete the tasks is presented in Figure 4. The only significant difference was between the junior residents group and the senior residents (p < 0.005). With regards to path lengths for the endoscope and the microdebrider (Figure 5), both metrics demonstrated a statistically significant difference between junior residents and senior residents (p < 0.001).
Time to complete the simulation tasks. The graph represents means +/- SD. Statistically significant difference (p < 0.005) between junior residents and senior residents. No difference between medical students and junior residents, nor between senior residents and attending faculty.
Path length (Distance travelled within nasal cavity). The graph represents means +/- SD. Statistically significant difference between junior residents and senior resident for both the endoscope (p < 0.001) and the microdebrider (p < 0.001). No difference between medical students and junior residents, nor between senior residents and attending faculty.
The average fluctuation in distance between the tips of the endoscope and the microdebrider for the medical students, junior residents, senior residents and attending faculty were 12.64 ± 3.04 mm, 12.23 ± 3.91 mm, 9.91 ± 2.45 mm and 6.98 ± 2.39 mm, respectively. There was a statistically significant difference between junior residents and senior residents (p < 0.01). A graphical illustration of distance between tool tips for users of different levels of expertise is presented in Figure 6.
Distance between tool tips through the simulation tasks. The senior residents and attending faculty demonstrate far less fluctuation than medical students and junior residents.
The frequencies of activation of the microdebrider pedal for medical students, junior residents, senior residents and attending faculty were 188 ± 65, 173 ± 64, 87 ± 37 and 104 ± 17 times, respectively. There was a significant difference between junior residents and senior residents (p < 0.001). With regards to the frequency of use of the endonasal wash, there was a tendency towards less use with increased training: 17 ± 12, 12 ± 10, 7 ± 3 and 2 ± 2 times, respectively. Again, there was a statistically significant difference between junior residents and senior residents (p < 0.01) for these metrics.
All the metrics related to efficiency showed a difference between junior residents and senior residents. However, there were no significant differences between medical students and junior residents, nor between senior residents and attending faculty.
With regards to violation of the no-go zones (Figure 7), there was a significant difference between junior residents and senior residents with regards to the percentage of lamina papyracea mucosa removed (p < 0.005). With respect to the skull base, all four groups removed a minute amount of tissue (<0.25%), with no significant difference (p > 0.05). Medical students and junior residents removed 0.02% and 0.08% of the mucosa surrounding the optico-carotid recess, whereas seniors and attending faculty had no contact with that region.
Percentage of no-go zones removed. The graph represents means. Statistically significant difference between junior residents and senior residents for the percentage of lamina papyracea removed (p < 0.005). No difference between medical students and junior residents, nor between senior residents and attending faculty. No statistical difference for other no-go zones.
Medical students and junior residents applied a maximal force of 0.75 ± 0.67 N and 0.15 ± 0.31 N on the lamina papyracea, respectively. The senior residents and attending faculty applied a negligible force on the lamina. The maximal force applied on the skull base was 0.93 ± 0.54 N, 0.53 ± 0.68 N, 0.24 ± 0.49 N and 0 N, respectively, with increasing level of training. The only significant differences were between junior residents and senior residents (p < 0.05).
Attributes available on the MSESS include increasing task difficulties, blurring of the camera field with tissue contact, an endonasal wash function, a microdebrider, and mobility of the nasal tissues. Compared to previous sinus simulators, we believe that a combination of these attributes allow the user to experience a more realistic, higher fidelity physical and visual environment. Furthermore, measurement of performance metrics from both hands independently, including measures of bimanual dexterity, as well as the ability to identify contact with danger zones allow a more elaborate performance assessment.
Given the lack of available ESS simulators with enough data supporting validity as a training tool, the current initial validation study of the MSESS is the first step towards filling this void. In fact, we demonstrated that participants from all levels of training found the simulator to be realistic in terms of visual appearance and content. They also responded that the simulator allowed them to practice the technical skills required for ESS. Furthermore, through analysis of the performance metrics, not unexpectedly, novices fared significantly worse than senior surgeons in measures of operative efficiency, which echoes previous reports in studies of surgical simulators [22],[23]. Similarly, within the field of ESS simulation, Edmond showed that novice surgeons without ESS experience performed worse on simulation training [24].
The inability of the performance metrics to differentiate medical students from junior residents is likely related to the fact that residents do not routinely perform ESS until their senior years. Moreover, the lack of difference between senior residents and attending faculty on the performance metrics may be related to the small number of attending faculty (n = 3), as some metrics, namely those related to efficiency, demonstrated a tendency towards improved performance by the attending faculty compared to senior residents. Nevertheless, these findings may indicate that the learning curve for performing simple ESS tasks is relatively steep and that the MSESS may be most valuable for junior residents prior to direct patient contact.
Research has demonstrated that recognition of anatomy with an endoscopic view is one of the more challenging parts of ESS [25]. In fact, authors have reported that a strong familiarity with intranasal 3D relationships and spatial boundaries are more vital for operative success than the technical skills of sinus surgery [1],[24] Thus, one of the main focuses during the development of the MSESS was to develop a simulated nasal model that was as realistic as possible, reflected by the participants¿ high assessment scores on the questionnaire.
Furthermore, the MSESS was tailored to help train users on complex technical skills, such as bimanual dexterity and hand-eye coordination, which are prerequisite skills for ESS [2]. The fact that there was decreasing fluctuation in the distance between the two tool tips with increasing degree of experience suggests that there is a notable learning curve for bimanual dexterity, which has previously been shown to vary with level of expertise [26]. In fact, Narazaki et al. demonstrated that experts outperformed novices in terms of bimanual dexterity skills significantly on a laparoscopic surgery simulator and advocated for its¿ testing as a means to objectively assess the proficiency of a surgeon [27].
In order to demonstrate validity as an educational tool, many studies on simulators have aimed to show a difference between users of different degrees of experience [28]. The latter shows that the simulator actually measures the technical skills that are intended to be measured [2]. Previous simulators have demonstrated this metric in support of ¿construct validity¿, including simulators for surgical skills in laparoscopic surgery [29], bone sawing skills [30], neurosurgery [20] and ESS [9],[31], as well as diagnostic skills such as coronary angiography [32], obstetrical ultrasonography [33] and colonoscopy [34].
The performance metrics recorded by the MSESS ¿ divided into measures of quality, efficiency and safety ¿ allowed us to test this form of validity. With regards to quality, users across all groups removed similar percentages of the anterior and posterior ethmoids. This is not surprising as removing tissue is not a difficult task in and of itself, but doing so efficiently and safely differentiates a novice from an experienced surgeon. Furthermore, a notable tendency was observed towards increasing extent of the sphenoidotomy with advancing level of expertise, most likely explained by the fact that more experienced surgeons had a heightened awareness of what is safe to remove in the sphenoid sinus and what are danger zones for injury to critical structures such as the optic nerve and carotid artery. In contrast, junior surgeons are more apprehensive in this region and thus elect to be more conservative.
Moreover, despite this suspected apprehensiveness demonstrated by juniors, users in the medical students and junior residents groups made contact with ¿no-go¿ zones such as the lamina papyracea and optico-carotid recess more commonly. Edmond demonstrated that the most discriminating performance factor during the novice mode on a previous ESS simulator was the ability to avoid hazards [24], which is a skill that senior surgeons learn with experience and thorough anatomy knowledge. Through recognition of these errors, novice surgeons may learn to avoid trauma to collateral tissue. In fact, decreased tissue injury during technical skills assessments after training on VR simulators has previously been demonstrated [7].
Endoscopic sinus surgeons are cognizant of the fact that the lamina papyracea and skull base are sensitive areas due to their fragility as well as the structures that they protect, thus it is important to be able to measure the amount of force that is applied upon them by our tools. Our study demonstrated that there was a significant difference in the maximal force applied between novice surgeons and more senior surgeons. The importance of force measurements also highlights a pitfall of training on cadaveric tissues, which do not adequately estimate the force necessary to perform endoscopic sinus procedures [6] and thus, do not show trainees the acceptable force allowed during ESS. Although novice surgeons applied more force in our study, the next step would be to determine the critical amount of force that would be needed to cause damage and assess whether the increased force applied by junior surgeons is truly clinically dangerous.
The benefits of simulation training are highlighted by the difference in efficiency between junior and senior surgeons. Simulation training allows residents to be more efficient, thus saving time in the operating room, where time is limited and expensive [35]. The premise of training on the MSESS is that if a junior can practice ESS on the simulator, he begins hands-on training at an earlier stage, prior to direct patient contact [24] and thus is better prepared when in the operating room. Furthermore, with decreased resident working hours [36], it is even more essential to have alternative methods for junior surgeons to practice their technical skills.
The MSESS demonstrated initial evidence supporting its use for residency education with regards to being a realistic and useful training tool. The performance metrics relating to quality, efficiency and safety also demonstrated a dichotomy between novice and senior surgeons. The next step in this validation process will be to compare the MSESS to other teaching modalities, including cadaveric dissection which is currently the gold standard of ESS training; to assess the predictive validity of the MSESS; and to demonstrate translation of technical skills in the setting of live patient interactions.
Authors¿ contributions
RV: Study design, creation and development of the MSESS, data collection, data analysis, manuscript preparation. SF: Study design, creation and development of the MSESS, manuscript preparation. LHPN: Study design, data analysis and interpretation, manuscript preparation. RDM: Study design, creation and development of the performance metrics, study coordination. AZ: Creation and development of the MSESS, data analysis, manuscript preparation. ES: Data analysis, creation of software to analyze the raw data into meaningful data, analysis of performance metrics. WRJF: Data analysis, creation of software to analyze the raw data into meaningful data, analysis of performance metrics. NRC: Creation and development of the MSESS, creation of performance metrics. MAT: Study design, creation and development of the MSESS, data collection, data analysis and interpretation, manuscript preparation. All authors read and approved the final manuscript.
Arora H, Uribe J, Ralph W, Zeltsan M, Cuellar H, Gallagher A, Fried MP: Assessment of construct validity of the endoscopic sinus surgery simulator. Arch Otolaryngol Head Neck Surg. 2005, 131: 217-221. 10.1001/archotol.131.3.217.
Fried MP, Satava R, Weghorst S, Gallagher AG, Sasaki C, Ross D, Sinanan M, Uribe JI, Zeltsan M, Arora H, Cuellar H: Identifying and reducing errors with surgical simulation. Qual Saf Health Care. 2004, 13 (Suppl 1): i19-i26. 10.1136/qshc.2004.009969.
Fried MP, Sadoughi B, Gibber MJ, Jacobs JB, Lebowitz RA, Ross DA, Bent JP, Parikh SR, Sasaki CT, Schaefer SD: From virtual reality to the operating room: the endoscopic sinus surgery simulator experiment. Otolaryngol Head Neck Surg. 2010, 142: 202-207. 10.1016/j.otohns.2009.11.023.
Gross RD, Sheridan MF, Burgess LP: Endoscopic sinus surgery complications in residency. Laryngoscope. 1997, 107: 1080-1085. 10.1097/00005537-199708000-00014.
Article PubMed CAS Google Scholar
Neubauer A, Wolfsberger S, Forster MT, Mroz L, Wegenkittl R, Buhler K: Advanced virtual endoscopic pituitary surgery. IEEE Trans Vis Comput Graph. 2005, 11: 497-507. 10.1109/TVCG.2005.70.
Joice P, Ross PD, Wang D, Abel EW, White PS: Measurement of osteotomy force during endoscopic sinus surgery. Allergy Rhinol. 2012, 3: e61-e65. 10.2500/ar.2012.3.0032.
Zhao YC, Kennedy G, Yukawa K, Pyman B, O'Leary S: Can virtual reality simulator be used as a training aid to improve cadaver temporal bone dissection? Results of a randomized blinded control trial. Laryngoscope. 2011, 121: 831-837. 10.1002/lary.21287.
Hogle NJ, Widmann WD, Ude AO, Hardy MA, Fowler DL: Does training novices to criteria and does rapid acquisition of skills on laparoscopic simulators have predictive validity or are we just playing video games?. J Surg Educ. 2008, 65: 431-435. 10.1016/j.jsurg.2008.05.008.
Fried MP, Sadoughi B, Weghorst SJ, Zeltsan M, Cuellar H, Uribe JI, Sasaki CT, Ross DA, Jacobs JB, Lebowitz RA, Satava RM: Construct validity of the endoscopic sinus surgery simulator: II. Assessment of discriminant validity and expert benchmarking. Arch Otolaryngol Head Neck Surg. 2007, 133: 350-357. 10.1001/archotol.133.4.350.
Beyer L, Troyer JD, Mancini J, Bladou F, Berdah SV, Karsenty G: Impact of laparoscopy simulator training on the technical skills of future surgeons in the operating room: a prospective study. Am J Surg. 2011, 202: 265-272. 10.1016/j.amjsurg.2010.11.008.
Seymour NE, Gallagher AG, Roman SA, O'Brien MK, Bansal VK, Andersen DK, Satava RM: Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002, 236: 458-463. 10.1097/00000658-200210000-00008. discussion 463-454
Park J, MacRae H, Musselman LJ, Rossos P, Hamstra SJ, Wolman S, Reznick RK: Randomized controlled trial of virtual reality simulator training: transfer to live patients. Am J Surg. 2007, 194: 205-211. 10.1016/j.amjsurg.2006.11.032.
Francis HW, Malik MU, Diaz Voss Varela DA, Barffour MA, Chien WW, Carey JP, Niparko JK, Bhatti NI: Technical skills improve after practice on virtual-reality temporal bone simulator. Laryngoscope. 2012, 122: 1385-1391. 10.1002/lary.22378.
Zhao YC, Kennedy G, Yukawa K, Pyman B, O'Leary S: Improving temporal bone dissection using self-directed virtual reality simulation: results of a randomized blinded control trial. Otolaryngol Head Neck Surg. 2011, 144: 357-364. 10.1177/0194599810391624.
Wiet GJ, Stredney D, Wan D: Training and simulation in otolaryngology. Otolaryngol Clin North Am. 2011, 44: 1333-1350. 10.1016/j.otc.2011.08.009. viii-ix
Caversaccio M, Eichenberger A, Hausler R: Virtual simulator as a training tool for endonasal surgery. Am J Rhinol. 2003, 17: 283-290.
Tolsdorff B, Pommert A, Hohne KH, Petersik A, Pflesser B, Tiede U, Leuwer R: Virtual reality: a new paranasal sinus surgery simulator. Laryngoscope. 2010, 120: 420-426.
Delorme S, Laroche D, DiRaddo R, Del Maestro RF: NeuroTouch: a physics-based virtual simulator for cranial microneurosurgery training. Neurosurgery. 2012, 71: 32-42. 10.1227/NEU.0b013e318249c744.
Rosseau G, Bailes J, del Maestro R, Cabral A, Choudhury N, Comas O, Debergue P, De Luca G, Hovdebo J, Jiang D, Laroche D, Neubauer A, Pazos V, Thibault F, Diraddo R: The development of a virtual simulator for training neurosurgeons to perform and perfect endoscopic endonasal transsphenoidal surgery. Neurosurgery. 2013, 73 (Suppl 1): 85-93. 10.1227/NEU.0000000000000112.
Gelinas-Phaneuf N, Choudhury N, Al-Habib AR, Cabral A, Nadeau E, Mora V, Pazos V, Debergue P, Diraddo R, Del Maestro RF: Assessing performance in brain tumor resection using a novel virtual reality simulator. Int J Comput Assist Radiol Surg. 2013, 9 (1): 1-9. 10.1007/s11548-013-0905-8.
Stankiewicz J: Complications of microdebriders in endoscopic nasal and sinus surgery. Curr Opin Otolaryngol Head Neck Surg. 2002, 10: 26-28. 10.1097/00020840-200202000-00007.
Hofstad EF, Vapenstad C, Chmarra MK, Lango T, Kuhry E, Marvik R: A study of psychomotor skills in minimally invasive surgery: what differentiates expert and nonexpert performance. Surg Endosc. 2013, 27: 854-863. 10.1007/s00464-012-2524-9.
Pellen MG, Horgan LF, Barton JR, Attwood SE: Construct validity of the ProMIS laparoscopic simulator. Surg Endosc. 2009, 23: 130-139. 10.1007/s00464-008-0066-y.
Edmond CV: Impact of the endoscopic sinus surgical simulator on operating room performance. Laryngoscope. 2002, 112: 1148-1158. 10.1097/00005537-200207000-00002.
Bakker NH, Fokkens WJ, Grimbergen CA: Investigation of training needs for functional endoscopic sinus surgery (FESS). Rhinology. 2005, 43: 104-108.
Hung AJ, Ng CK, Patil MB, Zehnder P, Huang E, Aron M, Gill IS, Desai MM: Validation of a novel robotic-assisted partial nephrectomy surgical training model. BJU Int. 2012, 110: 870-874. 10.1111/j.1464-410X.2012.10953.x.
Narazaki K, Oleynikov D, Stergiou N: Objective assessment of proficiency with bimanual inanimate tasks in robotic laparoscopy. J Laparoendosc Adv Surg Tech A. 2007, 17: 47-52. 10.1089/lap.2006.05101.
Downing SM: Validity: on meaningful interpretation of assessment data. Med Educ. 2003, 37: 830-837. 10.1046/j.1365-2923.2003.01594.x.
Rivard JD, Vergis AS, Unger BJ, Hardy KM, Andrew CG, Gillman LM, Park J: Construct validity of individual and summary performance metrics associated with a computer-based laparoscopic simulator. Surg Endosc. 2014, 28 (6): 1921-1928. 10.1007/s00464-013-3414-5.
Lin Y, Wang X, Wu F, Chen X, Wang C, Shen G: Development and validation of a surgical training simulator with haptic feedback for learning bone-sawing skill. J Biomed Inform. 2013, 48: 122-129. 10.1016/j.jbi.2013.12.010.
Steehler MK, Pfisterer MJ, Na H, Hesham HN, Pehlivanova M, Malekzadeh S: Face, content, and construct validity of a low-cost sinus surgery task trainer. Otolaryngol Head Neck Surg. 2012, 146: 504-509. 10.1177/0194599811430187.
Jensen UJ, Jensen J, Olivecrona GK, Ahlberg G, Tornvall P: Technical skills assessment in a coronary angiography simulator for construct validation. Simul Healthc. 2013, 8: 324-328. 10.1097/SIH.0b013e31828fdedc.
Burden C, Preshaw J, White P, Draycott TJ, Grant S, Fox R: Validation of virtual reality simulation for obstetric ultrasonography: a prospective cross-sectional study. Simul Healthc. 2012, 7: 269-273. 10.1097/SIH.0b013e3182611844.
Plooy AM, Hill A, Horswill MS, Cresp AS, Watson MO, Ooi SY, Riek S, Wallis GM, Burgess-Limerick R, Hewett DG: Construct validation of a physical model colonoscopy simulator. Gastrointest Endosc. 2012, 76: 144-150. 10.1016/j.gie.2012.03.246.
Schaefer JJ: Simulators and difficult airway management skills. Paediatr Anaesth. 2004, 14: 28-37. 10.1046/j.1460-9592.2003.01204.x.
Philibert I, Friedmann P, Williams WT: New requirements for resident duty hours. JAMA. 2002, 288: 1112-1114. 10.1001/jama.288.9.1112.
We would like to thank The National Research Council of Canada Engineering team (J. Hovdebo, N. Choudhury, P. Debergue, G. DeLuca, D. Jiang, V. Pazos, O. Comas, A. Neubauer, A. Cabral, D. Laroche, F. Thibault and R. DiRaddo) for their significant contribution in the development of the high fidelity simulator and performance metrics.
This work was supported by the Franco Di Giovanni Foundation, the B-Strong Foundation, the Tony Colannino Foundation, the English Montreal School Board, the Montreal Neurological Institute and Hospital, and the McGill Head & Neck Cancer Fund.
Department of Otolaryngology, Head and Neck Surgery, McGill University, Montreal, Canada
Rickul Varshney, Saul Frenkiel, Lily HP Nguyen, Anthony Zeitouni, W Robert J Funnell & Marc A Tewfik
Centre for Medical Education, McGill University, Montreal, Canada
Lily HP Nguyen & Meredith Young
Department of Medicine, McGill University, Montreal, Canada
Meredith Young
Neurosurgical Simulation Research Center, McGill University, Montreal, Canada
Rolando Del Maestro
Department of BioMedical Engineering, McGill University, Montreal, Canada
Elias Saad & W Robert J Funnell
Royal Victoria Hospital, 687 Ave Des Pins O., Rm E4.41, Montreal, H3A 1A1, Quebec, Canada
Rickul Varshney
Saul Frenkiel
Lily HP Nguyen
Anthony Zeitouni
Elias Saad
W Robert J Funnell
Marc A Tewfik
Correspondence to Rickul Varshney.
The National Research Council of Canada has property rights to the MSESS. The senior author and the Department of Otolaryngology ¿ Head and Neck Surgery of McGill University have no financial competing interests with this study.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Varshney, R., Frenkiel, S., Nguyen, L.H. et al. The McGill simulator for endoscopic sinus surgery (MSESS): a validation study. J of Otolaryngol - Head & Neck Surg 43, 40 (2014). https://doi.org/10.1186/s40463-014-0040-8
Technical abilities
Nasal model
Poliquin Resident Research Competition 2014
Submission enquiries: Access here and click Contact Us


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Pulau Banyak is een bestuurslaag in het regentschap Langkat van de provincie Noord-Sumatra, Indonesië. Pulau Banyak telt 2816 inwoners (volkstelling 2010).

Plaats in Noord-Sumatra

redpajama_set_name: RedPajamaWikipedia


The San Diego Chargers are an American Professional Football team based in San Diego, California. They are currently members of the Western Division of the American Football Conference (AFC) in the National Football League (NFL). The club began play in 1960 as a charter member of the American Football League. The club spent its first season in Los Angeles, California before moving to San Diego in 1961. The Chargers play their home games at Qualcomm Stadium.
The Chargers won one AFL title in 1963 and reached the AFL playoffs five times and the AFL Championship four times before joining the NFL (1970) as part of the AFL-NFL Merger. In the 34 years since then, the Chargers have made ten trips to the playoffs and four appearances in the AFC Championship game. At the end of the 1994 season, the Chargers faced the San Francisco 49ers in Super Bowl XXIX and fell 49-26. The Chargers have six players and one coach enshrined in the Pro Football Hall of Fame in Canton, Ohio: wide receiver Lance Alworth (1962-1970), defensive end Fred Dean (1975-1981), quarterback Dan Fouts (1973-1987), head coach/general manager Sid Gillman (1960-1969, 1971), wide receiver Charlie Joiner (1976-1986), offensive lineman Ron Mix (1960-1969) and tight end Kellen Winslow (1979-1987).
See what Dean's Cards has to offer on their Chargers Team Page!
Will the chargers win this year?


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Q: How to add a map as a class field? I want to add a dictionary that maps an object to a list of objects as an instance variable to a class. What is the idiomatic way to do it in Python? Here's how I've done it:
class MyClass:
    def __init__(self):
        self.myDict = { None : [None] }

A: You have already hit upon the idiomatic way to do it!

A: Personally, I'd do it this way, if you want the option of starting out with a certain number of objects, and you want it clearer what you're desiring.
class MyClass:
    def __init__(self, objlistdict=None):
        "Takes an optional initial dictionary with objects as keys and lists of objects as values"  # docstrings are very useful for documentation
        self.myDict = {} if objlist is None else objlist # sets `self.myDict` to be the initial dict, otherwise makes it an empty one

Note that the objects you use as keys do need to be hashable, and I believe it's recommended to use immutable objects even if the mutable object you're using still has a hash method defined, due to the fact that objects that compare equal are generally supposed to have the same hash, so changing something about the object will change the hash value, and that might cause problems with being unable to access the value for an original key.

redpajama_set_name: RedPajamaStackExchange


Simply GORGEOUS! Exclusive gated community on the lakeside of Oro Grande. Stunning pool home with 40' deep RV garage. Slab granite counters. Just Stunning! Immaculate home. Stop by today and see what you can call home tomorrow! Additional Guest Parking located at the end of the cul de sac.


There's a growing conversation about healthy consent among adults, which is a good thing—awareness is key. However, at the same time, the conversation is an opportunity to educate kids about the basics of consent so they can develop healthy lifelong relationships.
Today's Parent says permission regarding bodies can be taught right from the start, and you can actively take part by communicating your intentions to your children. For example, the source notes you can explain you're putting balm on their skin during a diaper change—which gives the child a clear reason why you're touching them.
On the same note, you can ask your child for permission for routine clothing changes—in the event they have wet pajamas, for example. "If you're pressed for time and wrestling with a toddler who absolutely won't get dressed, you can take control of the situation," it adds, but explains you need to tell them why (you're in a hurry).


Master Printer Cole Rogers with Jennifer Roberts, Faculty Director for the Arts, and Meg Rotzel, Arts Program Manager of Harvard's Radcliffe Institute for Advanced Study.
Highpoint Editions has been working with Jennifer Roberts, Faculty Director for the Arts, and Meg Rotzel, Arts Program Manager of Harvard's Radcliffe Institute for Advanced Study to curate the largest exhibition of Willie Cole's Beauties outside of Highpoint's gallery. From March 27 - June 29th 2019. Radcliffe will showcase a total of 25 prints by Cole, all printed with Highpoint Editions. Roberts will also be publishing a book with a large portion dedicated to this work. Primarily a sculptor, Willie Cole draws his subjects from personal iconography: in his past work irons recalled African tribal markings and shields, ironing boards represented slave ships, and numerous images are drawn from a history of domestic labor and other personal references.
Watch the opening night discussion with Jennifer Roberts, Willie Cole, and Cole Rogers here..
Cole Rogers, artist Willie Cole and Christina Taylor, Assistant Paper Conservator, Straus Center for Conservation and Technical Studies at the Harvard Art Museums discuss The Five Beauties suite.
Willie Cole and Cole Rogers with high school students who attended the opening night.
Jennifer Roberts, Willie Cole and Cole Rogers in discussion, opening night.


I think it could be considered a hybrid, a marriage of early and late. My first open crank, the aspirations of a young collector was a 2 HP Hit and Miss Bamford of the late 1920's. Once restored and moved on for a reasonable profit many more engines followed. This was the way I financed my Lister collection.
" caged valve " system that had been used on the early " headless " engines was great for de coking but if left for long periods of time became seized solid!
Bad Behavior has blocked 14846 access attempts in the last 7 days.


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Justin Timberlake's Cover Art for 'Tunnel Vision' Transforms His Nose into Sideboob
By Kaitlin Reilly
Vittorio Zunino Celotto/Getty Images Entertainment/Getty Images
Justin Timberlake's The 20/20 Experience constantly cranks out hit songs. But the cover art for his new single, "Tunnel Vision," is quite a miss. We're not sure whose brilliant idea it was to frame his face inside the silhouette of a naked woman, but the result is more disturbing than a Bond film starring Denise Richards.
Plus, turning Justin Timberlake's nose into sideboob will never let us look at Timberlake the same way again. Or a sideboob, for that matter.
Images: Getty Images, RCA Records

redpajama_set_name: RedPajamaCommonCrawl


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← Glenn Gould: extra hands
Saying #Uncle: more on AtG's latest →
#UncleJohn, or COC lite: a new way to do business
Against the Grain Theatre premiered #UncleJohn, their new adaptation of Don Giovanni tonight at The Black Box Theatre at the Great Hall on Queen St West after workshops out west at the Banff Centre. As much as anything this was the first night for a new concept as well as a new show.
AtG partnered with the Canadian Opera Company and the Banff Centre, and will do so again with A Little Too Cosy, their upcoming adaptation of Cosi fan tutte, to complete their survey of the da Ponte trilogy of Mozart operas. The business model is perhaps more exciting and original than the actual opera presented onstage –which wasn't too shabby—given that opera is in big trouble all over the world. Big companies are struggling with big overhead, in the salaries for orchestras, chorus and other staff members. Opera is understood to be the most expensive art form, so naturally this comes with the territory.
Left to right: Miriam Khalil, Sean Clark, Betty Allison and Cameron McPhail
Or does it? AtG offer something a little simpler. They don't have a permanent chorus or orchestra, even though they have been gradually tippy-toeing in that direction. While their Messiah last year used a chorus and (if I remember right) their largest orchestra yet, the important point to note is that they have not turned it into something permanent, tying them down with entitlements & pensions. The sound for tonight's performance was just about right, the small space of the Black Box Theatre filled comfortably by a string quartet plus piano, played by music director Milos Repicky, and no chorus. While the oomph of chorus might be welcome in a few places it would make no sense in Joel Ivany's modernized story. There are no mass groupings of peasants on an estate, just Torontonians.
There's no arguing with the business model. It works, or to put it another way, the other one is terribly precarious, depending heavily on private funding and government support. While the government is there in Austria & Germany –where opera has a huge audience and so remains viable—they're the exceptions to the gradual change to more austere models the world over, Canada included. AtG appear to be in better shape than their bigger parent –the COC—who are in a much more precarious position, balancing huge expenses with revenues from various places. I love the COC orchestra & chorus, but worry about the viability of the company in the long run.
Ivany's adaptation is every bit as remarkable as what he created with Figaro's Wedding (first of the trilogy) in 2013. There are aspects that I quibble with just as I did in 2013, yet overall this is new without feeling like Regietheater, where the director is like another author competing or overlaying texts upon the original. It's simply modernized but still largely faithful to the original text. I don't want to spoil it for anyone but suffice it to say that almost all the music you know and love is there, including an appearance by the Commendatore in the last scene.
Some of Ivany's touches are brilliant. By now I cringe whenever I see someone putting a mobile phone into an opera, even if people still titter at the effect. But this time it made wonderful sense when Leporello –who usually disguises himself as the Don to woo Donna Elvira early in Act II—communicates to Elvira through the phone: the perfect modern medium for this sort of dissembling. Neil Craighead is a messy foil to the tidiness of the Don, the man who gets the most punchlines all night and doesn't miss once. Putting the entire opera into the context of the wedding of Zerlina & Masetto, with Anna as the daughter of the caterer, helps to make up for the mixed blessing of the venue. At times it was bizarrely real to hear music from the other venue blasting into our space, exactly the way it would if we were in one of those rented banquet halls where so many weddings happen in this city.
The concentration of action around that wedding made some sense, even if it was accomplished at a price, namely reinventing Donna Anna & Don Ottavio without any of the nobility that they had in the 18th century version. It made the new version of "il mio tesoro" one of the highlights of the evening, wonderfully sung and acted by Sean Clark, now more of a soliloquy to anyone who will hear his complaint, concerning his manhood, and probing the numb passivity for which the character is known. Donna Anna became Anna, still a character who seems to have little ability to laugh at herself, making soprano Betty Allison's job extra challenging.
As a result #UncleJohn shuffles the key relationships ever so slightly. Anna and Ottavio are now a comic pair who seem even lower in the social hierarchy than Zerlina & Masetto; that's only jarring if you insist that AtG do it as written, a stipulation I'd never make. The two key figures are now Elvira and John (formerly Donna Elvira and Don Giovanni), which is perhaps a reflection of the brilliance of the two performers.
Miriam Khalil's centrality to the production might be a reflection of her centrality in Joel Ivany's life as his partner and the mother of his little boy. But she makes the most of every moment, including the most scintillating reading of "Mi tradi quell'alma ingrata", the big aria that usually tests audiences' ability to stay awake, coming as it does in the latter stages of the opera. It can seem like an add-on, it can seem like part of the battle between two divas seeking to one up each other. Or in this case, it's a wonderful affirmation of the empowerment that Elvira is seeking while hoping to redeem her relationship with John, and got one of the biggest ovations of the night.
And speaking of John, Cam McPhail demonstrated a level of star power in his singing & acting that suggests something very radical about the COC Lite business model: that there are wonderfully talented Canadian singers who can actually out-do what you see from the COC. This should be no surprise. It's an open secret, one that has been whispered in my ear repeatedly since I posted a diatribe about the bizarre spectacle of David Pomeroy's photo advertising a COC Madama Butterfly sung by a pair of imports who were inferior to the Canadian tenor who was busy singing in Manitoba instead.
Back to McPhail, this is a very intriguing reading of Don Giovanni –aka Uncle John (no hashtag because I'm speaking of the character this time, not the opera). He's cruel yet manages to be likeable. His charisma is genuine. The voice has nuances, including two brilliant re-makes of famous arias:
the champagne aria –"fin ch'han al vino" –becomes the cocaine aria, and suddenly the quickness of the aria makes incredible sense (and yes it's the fastest reading i think i've ever seen)
the serenade by the window –"deh vieni alla fenestre"—becomes a soliloquy about drugs (hm,…no wait, it's still a love song-serenade, but he's singing his little love song to the drugs)
Baritone Cameron McPhail
McPhail carries most of the darkness in the work, more intelligible in his enunciation of the English in this libretto than anyone else in the show, which is a good thing considering he had the most lines by far. But while he's the one who goes to the dark side, he's balanced by John Avey as The Commander (formerly the Commendatore), standing his ground musically and physically in this life and maybe the next.
It's lots of fun, above all. #UncleJohn continues December 13, 15, 17 and 19, 2014 at 7:30 p.m, at the Black Box Theatre at The Great Hall. I look forward to seeing more from this team, and more of this approach to an expensive art form. This business model seems to work.
This entry was posted in Opera, Reviews. Bookmark the permalink.
4 Responses to #UncleJohn, or COC lite: a new way to do business
Definitely the Opera says:
Damn it, even though I avoid reading you and John before I finish and post my review, among ourselves we always make a number of same observations. DG singing to drugs or under the influence of drugs I also found intriguing.
barczablog says:
I like to think we're part of a collective conversation, even if we only look at other reviews after posting.
Pingback: Saying #Uncle: more on AtG's latest | barczablog
Pingback: Cozy Fantastic | barczablog


Description: Poor and needy non-Muslims have the right to social security under Islamic Law. Examples from history where non-Muslims were provided from the public treasury.
Modern welfare states provide social benefits to their poor citizens, but Islam preceded all nations in establishing social security services. Islamic law set up financial provisions for needy Muslims through zakah (obligatory charity) and sadaqa (voluntary charity). Zakah was made obligatory on wealthy Muslims to take care of the poor, whereas sadaqa was left on individual discretion to help the needy. Social security provided by Islam includes non-Muslims as well. Islamic Law requires the state to provide for its citizens with disabilities – Muslim or non-Muslim - that prevent them from employment. They are provided for by the public treasury and the ruler is negligent if he does not do so. Many instances of Muslims providing social security to the non-Muslim citizens are recorded in history. Umar ibn al-Khattab the second caliph of Islam, once passed by a old, blind man begging in front of a house. Umar asked him which religious community he belonged to. The man said he was Jewish. Umar then asked him, 'What has brought you to this?' The old man said, 'Do not ask me; ask …poverty, and old age.' Umar took the man to his own home, helped him from his personal money, and then ordered the head of the treasury, 'You must look after this man and others like him. We have not treated him fairly. He should not have spent the best years of his life among us to find misery in his old age.' Umar also relieved him and others in his situation of paying the jizya.
In another instance, Umar ibn al-Khattab, the Muslim Caliph, was visiting Damascus. He passed by a group of Christian lepers. He ordered that they be given charity and regular stipends for food.
 Public Regulations Relevant to non-Muslims, p. 43-58.


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MDMA-assisted psychotherapy is the use of prescribed doses of MDMA as an adjunct to psychotherapy sessions. Research suggests that MDMA-assisted psychotherapy for post-traumatic stress disorder (PTSD), including Complex PTSD, might improve treatment effectiveness. In 2017, a Phase II clinical trial led to "breakthrough therapy" designation by the US Food and Drug Administration (FDA).

The research is controversial in part because recreational MDMA use has been associated with harmful effects among some users.

Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) is most commonly treated by cognitive behavioral therapy (particularly prolonged exposure and cognitive processing therapy), eye movement desensitization and reprocessing, and psychodynamic psychotherapy. However, over half of these patients continue to have PTSD after completing therapy, with results from military PTSD being especially poor.

PTSD is best treated when a patient is in the 'optimal arousal zone'. This is the zone in which emotions are engaged, yet not overwhelming. In this zone, four symptom clusters of PTSD are sedated: These are:

re-experiencing
avoidance
negative alterations in cognition/mood
alterations in arousal and reactivity

Subjects with PTSD exhibit extreme emotional numbing or anxiety and struggle to remain in the optimal arousal zone during conservative therapies. Threatening interpretations of memories are reinforced when patients are in low emotional states. If traumatic memories are revisited in therapy when a patient is not within the optimal arousal state, therapy for PTSD can actually increase the patient's trauma.

When used in therapy MDMA has been reported to increase empathy, closeness between patient and therapist, relaxation, motivation to engage with therapy and introspective thought, and to reduce depression and anxiety. MDMA makes it easier for a patient to stay in the optimal arousal zone by decreasing feelings of anxiety and defensiveness when revisiting traumatic memories. It also increases feelings of closeness and empathy, improving the patient's trust in the therapist, and encourages introspective thought to reassess memories and actions. These factors may increase the success rate of psychotherapy. With the approval of the FDA  in 2017, MDMA has been cleared for the use in assisting with psychotherapy. A phase 3 study indicated that MDMA-assisted therapy represents a potential breakthrough treatment for severe PTSD that merits expedited clinical evaluation. However, given the lack of blinding, several researchers have postulated that the results of the phase 3 trial might be heavily influenced by expectancy effects, and there are no trials comparing MDMA-assisted psychotherapy to already existing first-line psychological treatments for PTSD, which based on indirect evidence seems to attain similar or elevated symptom reduction compared with that due to MDMA-assisted psychotherapy.

Adverse effects, which can last from a few hours to several days, include diminished appetite, anxiety, headache, jaw tightness, tinnitus, nausea, asthenia, fatigue, acute sinusitis, nasopharyngitis, upper respiratory tract infection, disturbance in attention, tremor, tics, dysuria, erythema, and depression.

Rationale for MDMA treatment
PTSD inhibits a subject's ability to respond appropriately to trauma-related stimuli. The current model of PTSD proposes that it results from amplified and uncontrolled responses from the amygdala to trauma-specific cues. Oxytocin, which is increased by MDMA, has been found to increase trust and emotional awareness and reduce amygdala responses as well as reduce coupling of the amygdala to brainstem regions associated with autonomic and behavioral characteristics of fear. It has been proposed that these effects foster memory reconsolidation by allowing the patient to access the traumatic memory while feeling detached from the sense of imminent threat.

Breakthrough therapy designation
In 2017, the treatment was granted breakthrough therapy designation by the FDA, a designation that indicates that there is preliminary evidence that an intervention might offer a substantial improvement over other options for a serious health condition.

Society and culture
The use of psychedelics for therapy has been characterized as 'countercultural' in Western cultures.

Legality
MDMA was first synthesized by German pharmaceutical company Merck KGaA in 1912 as an intermediate in the synthesis of another compound. Its psychoactive effects were not noted until the early 1960s. In the 1960s and 1970s, the drug was used in psychotherapy, although it was not an approved drug and no clinical trials had been performed. The drug was studied in Switzerland for use in individual, couple, and group therapies until 1993, when the Swiss Ministry of Health withdrew permission to use MDMA and LSD by psychiatrists due to concerns about lack of research methodology.

In 1986, MDMA was classed as a Schedule 1 drug by the United Nations according to its Convention on Psychotropic Substances of 1971 due to its high potential for abuse, and most research was stopped. Researchers interested in MDMA for use in psychotherapy founded and funded the Multidisciplinary Association for Psychedelic Studies (MAPS) in response. The US Food and Drug Administration (FDA) and Drug Enforcement Administration (DEA) granted approval for researching MDMA's efficacy as an adjunct to psychotherapy in 2004, and the first trial was carried out in 2011.

Controversy
MDMA's effects vary across people and settings and include adverse outcomes. The drug causes neurotransmitter activation across the main neural pathways (including serotonin and dopamine, noradrenaline) that can result in large mood swings. The memories that emerge under the influence of MDMA can evoke unwanted emotions. Side effects of MDMA use by recreational users include appetite fluctuations, food cravings, and disordered eating.

Once the effects of MDMA wear off, there is a "period of neurochemical depletion" that invokes anhedonia, lethargy, anger, depression, irritability, brooding, greater everyday stress, altered pain thresholds, changes in sleep, and bad dreams, especially in female participants. The symptoms are thought to be due to depletion of serotonin, as a result of the large release of serotonin triggered by MDMA, and have been called "neurotoxic in terms of causing serotonergic dysfunction".

There are also concerns surrounding "drug-dependent learning" — the theory that patients will return to the drug to access the state they were in when on the drug in therapy.

There were 92 MDMA related deaths in England and Wales in 2018, up from 56 the year before, and 10,000 hospitalizations for MDMA related illness/injury in 2011 in the US. However no such cases have (as of 2021) been reported for clinical settings.

Media reports and statements of academic authors have often transmitted the view of MDMA as a possible medicine or treatment rather than as an adjunct to psychotherapy. This has been considered as dangerous, because it could lead people to believe that MDMA is an effective treatment alone, without concomitant psychotherapy.

See also
 Improving Access to Psychological Therapies
 Convention on Psychotropic Substances
 List of Psychotherapies

References

External links
 MDMA Facts and Statistics National Institute on Drug Abuse
 Methylenedioxymethamphetamine (MDMA or 'Ecstasy') drug profile European Monitoring Centre for Drugs and Drug Addiction
 MDMA-Assisted Psychotherapy Multidisciplinary Association for Psychedelic Studies
 Dead Dog on the Left Documentary about MDMA-assisted treatment for military PTSD
 Is MDMA psychiatry's antibiotic? Tedx Talk by Ben Sessa.
 MDMA, Psychotherapy, and the Future of PTSD Treatment TEDx talk by Brad Burge

Psychotherapy, MDMA-assisted
Psychotherapy


Heavy Bag holder with 360 degree rotation that gives you full range of movement for your heavy bag workouts.
An essential tool for heavy bags, the UFC Wood Beam Heavy Bag Hanger is durable and reliable. Made of solid steal with a powder-coated enamel it has a clean sleek look and quality you can feel. The 360 degrees rotation gives you full range of movement for your heavy bag workouts.


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John Rolfe - The First Tobacco Baron
John Rolfe (1585–1622) was one of the early English settlers of North America. He is credited with the first successful cultivation of tobacco as an export crop in North America, in the Colony of Virginia starting in 1611. In 1609, Rolfe and his young family joined the Third Supply relief fleet to the Colony, embarking on the Sea Venture, which was run aground in Bermuda during a hurricane. Ten months later, the remnants of the fleet set off again for Jamestown on re-built ships; Rolfe's wife and infant daughter had not survived, and were buried in Bermuda. In 1612, he established the Varina plantation upstream from Jamestown. and in 1614 the first harvest of tobacco leaf was exported to England. Soon afterwards, Rolfe and others were exporting vast quantities of the new cash crop, turning the Virginia Colony into a highly profitable enterprise, the jewel of New England.
Rolfe married Pocahontas, daughter of a Native American leader, on 5 April 1614 after she had been forced to convert to Christianity, taking the baptismal name Rebecca. The strategic marriage between the planter and the high-born native created for many years a climate of peace between the Jamestown colonists and the local tribes, led by Rebecca's father, Powhatan. Unfortunately, in 1617, Rebecca died in Gravesend as they returned from a voyage to London, although their infant son Thomas survived. The peace pact also survived, and under it tobacco commerce grew, as did the Colony of Virginia, as did the New World.
John Rolfe (1585–1622) was one of the early English settlers of North America. He is credited with the first successful cultivation of tobacco as an export crop in the Colony of Virginia in 1611.
John Rolfe is believed to have been born in Heacham, Norfolk, England, in about 1585. At that time, Spain held a virtual monopoly on the lucrative tobacco trade. Most Spanish colonies in the New World were located in southern climates more favorable to tobacco growth than the English settlements (founded in the early 17th century, notably Jamestown in 1607). As the consumption of tobacco had increased, the balance of trade between England and Spain began to be seriously affected. Rolfe was one of a number of businessmen who saw the opportunity to undercut Spanish imports by growing tobacco in England's new colony in Virginia. He had somehow obtained seeds to take with him from a special popular strain, then being grown in Trinidad, South America, even though Spain had declared a penalty of death to anyone selling such seeds to a non-Spaniard.
At one point in time it was believed that John was the son of John Rolfe and his wife Dorothy Mason Rolfe, however, historians have now determined that this relationship is incorrect. One major inconsistence, which shows they are not his parents is that John is known to have had a brother named Henry. After John's death, his brother Henry Rolfe petitioned the Virginia Company for funds from John's Virginia estate, to help pay for the care of John's son Thoms Rolfe who was then in Henry's care. Dorothy Mason Rolfe and her husband John Rolfe are not known to have had a son named Henry.
Sailing with Third Supply to Virginia
A project of the proprietary Virginia Company of London, Jamestown had been established by an initial group of settlers on 14 May 1607. This colony proved as troubled as earlier English settlements. Two return trips with supplies by Christopher Newport arrived in 1608, while another large relief fleet was dispatched in 1609, carrying hundreds of new settlers and supplies across the Atlantic. Heading the Third Supply fleet was the new flagship of the Virginia Company, the Sea Venture, carrying Rolfe and his wife, Sarah Hacker.
The Third Supply fleet left England in May 1609 destined for Bermuda with seven large ships, towing two smaller pinnaces. In the southern region of the North Atlantic, they encountered a three-day-long storm, thought to have been a severe hurricane. The ships of the fleet became separated. The new Sea Venture, whose caulking had not cured, was taking on water faster than it could be bailed. The Admiral of the Company, Sir George Somers, took the helm and the ship was deliberately driven onto the reefs of Bermuda to prevent its foundering. All aboard, 150 passengers and crew, and 1 dog, survived. Most remained for ten months in Bermuda, subsequently also known as "The Somers Isles", while they built two small ships to continue the voyage to Jamestown. A number of passengers and crew, however, did not complete this journey. Some had died or been killed, lost at sea (the Sea Venture's long boat had been fitted with a sail, and several men sent to take word to Jamestown, and they were never heard from again), or left behind to maintain England's claim to Bermuda. Because of this, although the Virginia Company's charter was not extended to Bermuda until 1612, the Colony at Bermuda dates its settlement from 1609. Among those left buried in Bermuda were Rolfe's wife and his infant daughter, Bermuda Rolfe.
In May 1610, the two newly constructed ships set sail from Bermuda, with 142 castaways on board, including Rolfe, George Somers, Stephen Hopkins, and Sir Thomas Gates. On arrival at Jamestown, they found the Virginia Colony almost destroyed by famine and disease during what has become known as the Starving Time. Very few supplies from the Third Supply had arrived because the same hurricane that caught the Sea Venture badly affected the rest of the fleet. Only 60 settlers remained alive. It was only through the arrival of the two small ships from Bermuda, and the arrival of another relief fleet commanded by Lord De La Warr on 10 June 1610, that the abandonment of Jamestown was avoided and the colony survived. After finally settling in Rolfe began his long-delayed work with tobacco.
Orinoco tobacco: a cash crop
In competing with Spain for European markets, there was another problem beside the warmer climates the Spanish settlements enjoyed. The native tobacco from Virginia was not liked by the English settlers, nor did it appeal to the market in England. However, Rolfe wanted to introduce sweeter strains from Trinidad, using the hard-to-obtain Spanish seeds he brought with him. In 1611, he was the first to commercially cultivate Nicotiana tabacum tobacco plants in North America; export of this sweeter tobacco beginning in 1612 helped turn the Virginia Colony into a profitable venture. He named his Virginia-grown strain of the tobacco "Orinoco", possibly in honour of tobacco popularizer Sir Walter Raleigh's expeditions in the 1580s up the Orinoco River in Guiana in search of the legendary City of Gold, El Dorado. The appeal of Orinoco tobacco was in its nicotine, and the conviviality of its use in social situations.
In 1612, Rolfe established Varina Farms, a plantation along the James River about 30 miles (50 km) upstream from Jamestown and across the river from Sir Thomas Dale's progressive development at Henricus. The first harvest of four barrels of tobacco leaf was exported from Virginia to England in March 1614. Soon afterwards, Rolfe and others were exporting vast quantities of the new cash crop. New plantations began growing along the James River, where export shipments could use wharfs along the river.
Rolfe married Pocahontas, daughter of the local Native American leader Powhatan, on 5 April 1614. Earlier that same year, Pocahontas was forced to convert to Christianity, she was baptized by Alexander Whitaker and chose "Rebecca" as her new baptismal name. Richard Buck officiated their wedding. Powhatan gave the newlyweds property just across the James River from Jamestown. They never lived on the land, which spanned thousands of acres, and instead lived on Rolfe's plantation, Varina Farms.
Their marriage created a climate of peace between the Jamestown colonists and Powhatan's tribes for several years; in 1615, Ralph Hamor wrote that "Since the wedding, we have had friendly commerce and trade not only with Powhatan but also with his subjects round about us." Their son, Thomas Rolfe, was born in January 1615.
John Rolfe and Rebecca continued cultivating tobacco with success. In 1616 they were sent to England as guests of the Virginia Company to promote colonization and investment in Virginia. They were accompanied by baby Thomas as well as by deputy-governor of the colony, Sir Thomas Dale, and 12 members of Rebecca's tribe, including her brother-in-law Uttamatomakkin. They sailed aboard the Treasurer, commanded by Captain Samuel Argall, and arrived at the port of Plymouth, England on 12 June, 1616. They toured England, promoting the colony, Queen Anne and others were reportedly charmed by Rebecca, and investment in the Virginia Company increased. During their visit, John Rolfe wrote "A True Relation of the state of Virginia Lefte by Sir Thomas Dale Knight in May Last 1616" the manuscript was published in 1617 and further touted the viability of the colony in Virginia. After nine months in England, the party prepared to return to Virginia but were delayed by bad weather. Finally setting sail in March of 1617, the party had to immediately make port in Gravesend because Rebecca was gravely ill. Sadly, Rebecca died and was buried at St George's Church, Gravesend on 21 March, 1617. Their small son Thomas was sick as well, it was determined he was too ill to survive a voyage. Pressured to return to Virginia, John Rolfe appointed Sir Lewis Stukley as guardian to his son and returned to Virginia with Uttamatomakkin. Stukley had custody of Thomas Rolfe until his uncle Henry Rolfe could take over his care. It was intended that Thomas would return to Virginia once he recovered his health. Unfortunately, John Rolfe would never see his son again. Thomas did recover his health but remained in England until reaching adulthood.
Later life, death, and descendants
Rolfe returned to Virginia and resumed his work with tobacco. In 1617 20,000 pounds of Orinoco tobacco was sent to England and in 1618 an additional 40,000 pounds were sent. About 1619, Rolfe married Jane Pierce, daughter of English colonist Captain William Pierce, who had survived the shipwreck of the Sea Venture along with John in 1609. They had a daughter, Elizabeth, in 1620, who married John Milner of Nansemond, Virginia, and died in 1635. John Rolfe died in March of 1622, immediately before the Indian massacre of 1622. His widow Jane later married English Captain Roger Smith.
The land given by Powhatan (now known as Smith's Fort Plantation, located in Surry County) was willed to Thomas Rolfe, who in 1640 sold at least a portion of it to Thomas Warren. Smith's Fort was a secondary Fort to Jamestown, begun in 1609 by John Smith.
Thomas Rolfe, who had grown up in England, returned to Virginia as an adult and married Jane Poythress. Poythress's English parents were Francis Poythress and Alice Payton. Thomas and Jane Rolfe had one child, Jane Rolfe, who married Robert Bolling and had a son, John Bolling, in 1676. Jane Rolfe died shortly after giving birth. John Bolling married Mary Kennon, daughter of Richard Kennon and Elizabeth Worsham of Conjurer's Neck. The couple had six surviving children, each of whom married and had surviving children.
John Rolfe
William Adams - Advisor to the Shogun
John Cabot - North American Trail-blazer
Ranulph Fiennes - Our Greatest Living Explorer
Freya Stark - Intrepid Middle East Traveller
Martin Frobisher - In Search of the North-West Passage


text:
package com.geekcattle.core.redis;

import org.slf4j.Logger;
import org.slf4j.LoggerFactory;
import org.springframework.beans.factory.annotation.Value;

import org.springframework.boot.autoconfigure.AutoConfigureAfter;
import org.springframework.boot.autoconfigure.data.redis.RedisAutoConfiguration;
import org.springframework.cache.CacheManager;
import org.springframework.cache.annotation.CachingConfigurerSupport;
import org.springframework.cache.annotation.EnableCaching;
import org.springframework.context.annotation.Bean;
import org.springframework.context.annotation.Configuration;
import org.springframework.data.redis.cache.RedisCacheConfiguration;
import org.springframework.data.redis.cache.RedisCacheManager;
import org.springframework.data.redis.cache.RedisCacheWriter;
import org.springframework.data.redis.connection.lettuce.LettuceConnectionFactory;
import org.springframework.data.redis.core.*;
import org.springframework.data.redis.serializer.Jackson2JsonRedisSerializer;
import org.springframework.data.redis.serializer.JdkSerializationRedisSerializer;
import org.springframework.data.redis.serializer.StringRedisSerializer;

/**
 * @author geekcattle
 */
@Configuration
@EnableCaching
@AutoConfigureAfter(RedisAutoConfiguration.class)
public class RedisConfiguration extends CachingConfigurerSupport{

    private Logger logger = LoggerFactory.getLogger(this.getClass());

    @Value("${shiro.session.session-prefix}")
    private String sessionPrefix;

    @Value("${shiro.session.session-time}")
    private int sessionTime;

    @Value("${shiro.cache.cache-prefix}")
    private String cachePrefix;

    @Value("${shiro.cache.cache-time}")
    private int cacheTime;

    @Bean
    public CacheManager cacheManager(LettuceConnectionFactory redisConnectionFactory) {
        if(logger.isDebugEnabled()){
            logger.info("cacheManager注入成功!!");
        }

        RedisCacheConfiguration redisCacheConfiguration = RedisCacheConfiguration.defaultCacheConfig();
        RedisCacheWriter redisCacheWriter = RedisCacheWriter.nonLockingRedisCacheWriter(redisConnectionFactory);
        RedisCacheManager redisCacheManager = new RedisCacheManager(redisCacheWriter, redisCacheConfiguration);
        return redisCacheManager;
    }

    @Bean(name = "redisTemplate")
    public RedisTemplate<String, Object> getRedisTemplate(LettuceConnectionFactory redisConnectionFactory) {
        if(logger.isDebugEnabled()){
            logger.info("redisTemplatet注入成功!!");
        }
        RedisTemplate<String, Object> redisTemplate = new RedisTemplate<>();
        redisTemplate.setKeySerializer(new StringRedisSerializer());
        redisTemplate.setValueSerializer(new JdkSerializationRedisSerializer());
        redisTemplate.setHashKeySerializer(new StringRedisSerializer());
        redisTemplate.setHashValueSerializer(new Jackson2JsonRedisSerializer(Object.class));
        redisTemplate.setConnectionFactory(redisConnectionFactory);
        return redisTemplate;
    }

    public String getSessionPrefix() {
        return sessionPrefix;
    }

    public void setSessionPrefix(String sessionPrefix) {
        this.sessionPrefix = sessionPrefix;
    }

    public String getCachePrefix() {
        return cachePrefix;
    }

    public void setCachePrefix(String cachePrefix) {
        this.cachePrefix = cachePrefix;
    }

    public int getSessionTime() {
        return sessionTime;
    }

    public void setSessionTime(int sessionTime) {
        this.sessionTime = sessionTime;
    }

    public int getCacheTime() {
        return cacheTime;
    }

    public void setCacheTime(int cacheTime) {
        this.cacheTime = cacheTime;
    }
}

redpajama_set_name: RedPajamaGithub


text:
Speech by Federal Foreign Minister Heiko Maas on climate change and security at the UN Security Council (video conference)
As diplomats and politicians, we tend to think that everything is negotiable. This is also the underlying idea behind the Security Council: building international consensus.
But, ladies and gentlemen, we cannot negotiate with nature. And the physical, chemical and geographical realities of global warming will not compromise with us.
Climate change is happening. And its consequences for peace and security are already real: from the Sahel to the islands of the Pacific and the Caribbean.
Sooner rather than later, climate change will be a catalyst in almost every conflict that we are dealing with. Our briefers have made this very clear today.
So, the defining question for us is this: will we finally live up to that challenge?
The answer given by the vast majority of the members of this Council and the United Nations as a whole is clear: they expect us to take action. And so do future generations.
Today, we are proposing three steps that can be taken right away:
First, the Security Council needs better information on climate-related security risks. This should include early warning indicators, allowing us to act before it is too late. At an international conference in Berlin last month, we launched a Global Climate Security Risk and Foresight Assessment. It can become a reference point for our work in this Council, and also a tool to strengthen UN efforts on mediation and preventive diplomacy as a whole. This will also require better training and expertise within UN missions and mediation teams. As an example, Germany is funding an expert who advises the country team in Somalia on the security implications of climate change. This should become a standard practice in all UN operations.
Second, it is time to give climate and security a face.
We call on the Secretary-General to appoint a Special Representative on Climate and Security as soon as possible. He or she could ensure that climate change is placed where it belongs: at the heart of this Council's work, which is to maintain international peace and security in the 21st century.
And, third, the United Nations needs to be ready to act when climate-related security risks hit. Such risks must therefore be addressed in all mandates and conflict prevention strategies. Together with our partners, we will convene an Informal Expert Group of the Security Council on climate and security as soon as possible. Our goal is to enshrine this topic in the Council's work – once and for all.
Today, I invite all of you to join us! And I am grateful and confident that our joint initiative will be carried forward by those who succeed us in this Council.
The fight against climate change should not divide us.
We fight it to save ourselves. And we fight it for the people around the world who are already facing violence and displacement as a result of climate change. They cannot afford to wait.
And therefore, ladies and gentlemen, the time for diplomatic patience is over. This Council cannot negotiate with the realities of nature.
Action is all that counts.
Federal Foreign Minister Maas
German seat in the Security Council in 2019/2020