Randomized double-blinded trial investigating the impact of a curriculum focused on error recognition on laparoscopic suturing training

BACKGROUND: Error recognition predicts technical skill. A curriculum including error recognition may improve laparoscopic suturing performance. METHODS: Thirty novices were randomized into 2 groups. Each viewed an instruction videotape and underwent timed objective structured assessments of technical skills. Group A practiced the task, group B viewed an error-instruction video, practiced, followed by re-assessment. Participants counted errors on a videotape. Data were analyzed with the Fisher exact text, the Wilcoxon test, and the Kendall tau test. RESULTS: The improvement in task time was greater in group A than in group B (P < .001). The objective structured assessments of technical skills scores improved for both groups, but did not reveal differences between the groups. Group B recognized significantly more errors than group A (P < 0.001). CONCLUSIONS: The additional error instruction showed a negative impact on performance speed, but improved cognitive error recognition. Whether visual memory overload influenced the outcome requires further examination.     

Symptomatic coronary obstruction due to Kawasaki disease in an adult

Kawasaki disease is the most common cause of pediatric ischemic heart disease in the world, but it is unusual in adults. We present a case of Kawasaki disease in a young adult. This 20-year-old man presented with angina. Coronary angiography revealed aneurysmal obstructive lesions consistent with remote Kawasaki disease. The patient underwent coronary artery bypass grafting with arterial conduits. Postoperative echocardiography was normal and stress myocardial perfusion imaging showed no ischemia. He remained asymptomatic 12 months after surgery. There is controversy regarding optimal therapy, choice of conduit, treatment of proximal aneurysms, and surveillance in adults with Kawasaki disease.     

Metformin use in decompensated heart failure

Metformin is associated with decreased mortality and morbidity in stable heart failure patients with diabetes mellitus type II. Diabetic heart failure patients with elevated systolic blood pressure are at increased risk for developing acute decompensated heart failure, which is often associated with decreased kidney function. Metformin-associated lactic acidosis is a rare but fatal side effect that may occur when kidney function is decreased. During acute decompensated heart failure, timely treatment may prevent the decrease in kidney function to the threshold associated with an increased risk of metformin-associated lactic acidosis. Metformin should not be withheld in diabetic patients with stable heart failure who do not have other risk factors for acute decompensated heart failure or lactic acidosis.     

The value of interhospital transfer and emergency MRI for suspected cauda equina syndrome: a 2-year retrospective study

INTRODUCTION

The timing of surgery in cauda equina syndrome due to prolapsed intervertebral disc remains controversial. Assessment of these patients requires magnetic resonance imaging (MRI), which is of limited availability outside normal working hours in the UK.

PATIENTS AND METHODS

We reviewed radiological results in all patients undergoing emergency MRI within our unit for suspected cauda equina syndrome over a 2-year period, and all subjects undergoing emergency lumbar discectomy for cauda equina syndrome within the same period. Outcome measures were: proportion of positive findings in symptomatic patients and proportion of patients referred with diagnostic MRI scans undergoing emergency surgery. We also assessed outcomes of patients having surgery for cauda equina syndrome in terms of improvement of pain, sensory and sphincter disturbance.

RESULTS

A total of 76 patients were transferred for assessment and ‘on-call’ MRI; 27 were subsequently operated upon. Only 5 proceeded to emergency discectomy that night (prior to next scheduled list). This may be due to delays in timing – from referral to acceptance, to arrival in the department, to diagnostic scan and to theatre. With the second group of patients, 43 had emergency discectomy for cauda equina syndrome during the study period. Of these, 6 patients had an out-of-hours MRI at our hospital for assessment (one patient living locally). Most surgically treated patients experienced improvement in their pain syndrome, with approximately two-thirds experiencing improvement in sensory and sphincter disturbance.

CONCLUSIONS

These data support a policy of advising MRI scan for cauda equina syndrome at the earliest opportunity within the next 24 h in the referring hospital, rather than emergency transfer for diagnostic imaging which has a relatively low yield in terms of patients operated on as an emergency.     

Percutaneous versus surgical tracheotomy: an updated meta-analysis

OBJECTIVE: Perform an updated meta-analysis investigating differences in complication rates, procedure times, and costs between percutaneous dilational tracheotomy (PDT), operating room surgical tracheotomy (ST), and bedside surgical tracheotomy (BST). METHODS: Meta-analysis using the Mantel-Haenszel fixed effects model. Prospective and randomized trials comparing ST with PDT from 1999 to present were identified through two independent searches. Outcome measures analyzed included mortality, early complications, late complications, procedure times, and cost. RESULTS: Fourteen studies were identified (1,273 patients) that satisfied the search criteria. Analysis of randomized studies demonstrated significantly more minor early complications with PDT compared with ST (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.01-2.66). Randomized studies comparing PDT with BST demonstrated significantly more early complications with PDT (OR, 4.66; 95% CI, 1.46-14.91). There was no significant difference in late serious complications in studies that randomized patients to ST or PDT (OR, 1.39; 95% CI, 0-16,000). PDT is significantly faster to perform than ST (OR, 0.51; 95% CI, 95% 0.49-0.53). BST and PDT have similar costs, and both are less expensive than ST. CONCLUSIONS: Although significantly faster than ST, PDT has more early complications compared with open tracheotomy in the operating room or at the bedside. The long-term complications of the two techniques appear comparable but have not been thoroughly investigated. These findings suggest that a team approach between surgeons and critical care specialists is essential to select the appropriate tracheotomy technique for a given patient.     

Perception of temporally processed speech by listeners with hearing impairment

OBJECTIVES: The purpose of this study was to assess a new signal-processing strategy, Spatiotemporal Pattern Correction (SPC), for a group of listeners with varying degrees of sensorineural hearing loss. SPC is based on a physiological model of the level-dependent temporal response properties of auditory nerve (AN) fibers in normal and impaired ears. SPC attempts to "correct" AN response patterns by introducing time-varying group delays that differ across frequency channels. Listeners' speech intelligibility and preference judgments were obtained at different strengths of SPC processing. DESIGN: Fifteen listeners, 12 with bilateral sensorineural hearing loss and 3 with normal hearing, participated in this study. Listeners with hearing impairment were separated into 3 groups (mild, moderate, and moderate-to-severe), based on their pure-tone averages at 0.5, 1, 2, and 4 kHz. All preference judgments were made using sentences from the Hearing-In-Noise-Test (HINT). The sentences were processed at five SPC strengths (1.0, 1.1, 1.2, 1.3, and 1.4). At an SPC strength of 1.0, the speech was processed through the SPC signal processor, becoming bandlimited, but no dynamic group delays were added to the signal. On each trial, listeners were presented a single sentence at two different SPC strengths, 1.0 (uncorrected) and a randomly selected SPC strength. Listeners were instructed to identify which of the two sentences they preferred. Sixteen vowel-consonant syllables, a subset of the Nonsense Syllable Test (NST), were used to assess speech intelligibility at three SPC strengths (1.0, 1.1, and 1.2). Listeners were asked to push one of 16 buttons on a response box that corresponded to the vowel-consonant syllable they heard. The moderate-to-severe hearing loss group was also tested using the low-probability sentences of the Speech-Perception-In-Noise (SPIN) test. RESULTS: Listeners with normal hearing and listeners with mild hearing loss preferred the quality of uncorrected sentences (SPC strength of 1.0) compared with SPC-processed sentences. As the strength of SPC increased, listeners' preference for uncorrected sentences also increased. Listeners with moderate and moderate-to-severe hearing loss had difficulty differentiating between uncorrected and lower strength SPC-processed sentences but strongly preferred the uncorrected sentences as compared with high strength SPC-processed sentences. Vowel-consonant intelligibility was not improved or degraded by SPC. Sentence recognition scores for listeners with moderate-to-severe hearing loss decreased with SPC processing. CONCLUSIONS: Although SPC-processed speech was not preferred by listeners with hearing loss, the listeners with a more moderate degree of impairment could not differentiate the unprocessed sentences from the SPC processed sentences. Speech intelligibility was not improved by SPC processing.     

Ectopic decidual cell reaction in para-aortic and pelvic lymph nodes in the presence of cervical squamous cell carcinoma during pregnancy

Bilateral para-aortic lymphadenectomy is routine prior to radical surgery in cancer of the cervix. A pregnant patient with invasive cancer of the cervix and ectopic decidual cell reaction in para-aortic and pelvic nodes is presented. A decidual cell reaction in frozen sections of para-aortic lymph nodes could be confused with metastatic disease. Pathogenesis of ectopic decidual cell reaction is discussed.     

Safety of treatment for subclinical osteomalacia in the elderly

Forty one elderly patients admitted to hospital for acute illnesses were also found to have subclinical osteomalacia. Immediately before discharge, therefore, all were randomised to receive either vitamin D2 25 micrograms daily, alfacalcidol 0.5 micrograms daily, or placebo. Treatment was given for at least three months, those allocated to placebo then being switched to an active drug. Within the first three months of treatment with either of the active drugs most patients had exhibited a fall to normal in osteoid values. In only four treatment periods was there a mild increase in serum calcium concentration, and in no patient was this accompanied by deterioration in renal function. Any increase in serum creatinine concentration was invariably attributable to the underlying disease for which the patient had been admitted in the first place. Subclinical osteomalacia in the elderly may be corrected by relatively low doses of alfacalcidol (0.5 micrograms daily) or vitamin D2 (25 micrograms daily) given for three months. Such treatment is safe and not accompanied by a serious risk of hypercalcaemia or renal impairment.