Technical skills assessment as part of the selection process for a fellowship in minimally invasive surgery

Introduction

Selection of candidates for surgical fellowships has traditionally been based on subjective evaluations by the program directors and references from previous positions. The introduction of well-validated objective methods of assessment has allowed us to evaluate candidates’ technical skills and base the selection process on objective, reliable, and transparent criteria. The aim of the study was to assess the applicability of such methods in current practice.

Materials and methods

Prospective study. Eight surgeons, applying for a fellowship position in minimally invasive surgery (MIS), performed a previously validated assessment curriculum using a Virtual-Reality Laparoscopic Trainer (LapSim^® 3.0, Surgical Science, Gothenburgh, Sweden). Technical performance was evaluated using criteria registered by the simulator, i.e., time, error score, and efficiency of movements score. Candidates performed all the tasks in easy end medium level until reaching predefined criteria. If proficiency criteria were not achieved on easy or medium level after nine repetitions the test was considered as failed. Additionally, all applicants underwent an interview by two independent attending surgeons. Each applicant received a grade on a ten-point scale.

Results

Five out of the eight candidates failed the technical skills assessment test. One candidate failed to achieve proficiency criteria on easy level, one on medium, and three on difficult level. Evaluation scores, based on the interview of the candidates showed a good interrater reliability (Cronbach’s α = 0.8). There was no significant correlation between the interviewers rating, and the applicants technical skills demonstrated during the test on the VR trainer (Spearman’s ρ = 0.182, p = 0.696).

Conclusions

Evaluations by senior surgeons are reproducible and reliable. The introduction of technical skills assessment has the potential to improve the current method of candidate selection, making it more valid, objective, and transparent.     

A prospective,cluster-randomized controlled trial of exercise program to prevent low back pain in office workers

Purpose

The objective of this study was to evaluate the effects of an exercise program focusing on muscle stretching and endurance training on the 12-month incidence of low back pain (LBP) in office workers.

Methods

A 12-month prospective cluster-randomized controlled trial was conducted in healthy office workers with lower-than-normal trunk extension flexibility or trunk muscle endurance. Healthy office workers (n = 563) were randomly assigned at the cluster level into either intervention (n = 282) or control (n = 281) groups. Participants in the intervention group received an exercise program that included daily stretching exercise and twice-a-week muscle endurance training. Those in the control group received no intervention. The 12-month incidence of LBP was the primary outcome. Secondary outcome were pain intensity, disability level, and quality of life and health status. Analyses were performed using the Cox proportional hazard models.

Results

Over the 12-month follow-up, 8.8 % of participants in the intervention group and 19.7 % in the control group developed incidence of LBP. Hazard rate ratios showed a protective effect of the exercise program for LBP (HR = 0.37, 95 % CI 0.22–0.64) after adjusting for biopsychosocial factors. There was no significant difference in pain intensity, disability, and quality of life and health status between those who reported incidence of LBP in the intervention and control groups.

Conclusion

An exercise program consisting of muscle stretching and endurance training is an effective intervention to reduce incident LBP for office workers with lower-than-normal trunk extension flexibility or trunk muscle endurance.     

Virtual Reality Does Not Meet Expectations in a Pilot Study on Multimodal Laparoscopic Surgery Training

Background

The purpose of the present study was to determine the value of virtual reality (VR) training for a multimodality training program of basic laparoscopic surgery.

Materials and methods

Participants in a two-day multimodality training for laparoscopic surgery used box trainers, live animal training, and cadaveric training on the pulsating organ perfusion (POP) trainer in a structured and standardized training program. The participants were divided into two groups. The VR group (n = 13) also practiced with VR training during the program, whereas the control group (n = 14) did not use VR training. The training modalities were assessed using questionnaires with a five-point Likert scale after the program. Concerning VR training, members of the control group assessed their expectations, whereas the VR group assessed the actual experience of using it. Skills performance was evaluated with five standardized test tasks in a live porcine model before (pre-test) and after (post-test) the training program. Laparoscopic skills were measured by task completion time and a general performance score for each task. Baseline tests were compared with laparoscopic experience of all participants for construct validity of the skills test.

Results

The expected benefit from VR training of the control group was higher than the experienced benefit of the VR group. Box and POP training received better ratings from the VR group than from the control group for some purposes. Both groups improved their skill parameters significantly from pre-training to post-training tests [score +17 % (P < 0.01), time ?29 % (P < 0.01)]. No significant difference was found between the two groups for laparoscopic skills improvement except for the score in the instrument coordination task. Construct validity of the skills test was significant for both time and score.

Conclusions

At its current level of performance, VR training does not meet expectations. No additional benefit was observed from VR training in our multimodality training program.     

Thoracoscopic lobectomy: is a training program feasible with low postoperative morbidity?

Objective

To evaluate the feasibility of training program in video assisted thoracic surgery (VATS) lobectomy comparing intraoperative and postoperative data of patients operated on by an established consultant and trainees.

Methods

Retrospective analysis of 100 consecutive patients who underwent VATS lobectomies between May 2008 and May 2012. 66 patients were operated on by an established consultant (Group A) and 34 by trainees (Group B).

Results

The groups were comparable for clinical characteristics and pathological staging. The mean operating time in Group A was 125 ± 30 min and in Group B was 133 ± 26 min (p = 0.18). The rate of conversion was similar in both groups: 9.1 % in Group A and 8.8 % in Group B (p = 0.6). The complication rate was comparable (p = 0.4): 36.3 % in Group A and 32.3 % in Group B. Median time to drain removal and median length of hospital stay was 3 and 5.5 days in Group A and 3 and 5 days in Group B, showing no statistical differences between the two groups (p = 0.3 and 0.5). There were no differences in term of long-term complications between the two groups.

Conclusion

Our study showed that a training program in VATS lobectomy is feasible, without increasing the operative time, conversion rate, postoperative complication, time to drain removal, and length of hospital stay.     

A study on comparative outcomes of percutaneous nephrolithotomy in prone, supine, and flank positions

Purpose

To compare percutaneous nephrolithotomy (PCNL) safety and efficacy in prone, supine, and flank positions.

Methods

A total number of 150 candidates for PCNL were randomly assigned into prone, supine, and flank groups. Patients in groups 1 and 2 underwent fluoroscopy-guided PCNL in prone and supine positions, respectively, while patients in group 3 underwent ultrasonography-guided PCNL in lateral position.

Results

The success rates were 92, 86, and 88 % in prone, supine, and flank positions, respectively (P = 0.7). The mean access duration was 6.9 ± 4.2, 11.1 ± 5.8, and 10.8 ± 4.1 min (P = 0.08), and the mean operation time was 68.7 ± 37.4, 54.2 ± 25.1 and 74.4 ± 26.9 min (P = 0.04) in prone, supine, and flank groups, respectively. Pyelocaliceal perforation occurred in 2 (4 %), 2 (4 %), and 3 (6 %) patients in prone, supine, and flank positions, respectively (P = 1).

Conclusion

We believe that PCNL in both supine and flank positions are as safe and relatively effective as prone position in experienced hands. Preference of the surgeon and proper case selection for each procedure is very important and necessary.     

Early rehabilitation versus conventional care after laparoscopic rectal surgery: a prospective, randomized, controlled trial

Background

Although early rehabilitation programs have been reported to be effective after laparoscopic colectomy, there is no report of the efficacy of rehabilitation programs after rectal cancer surgery. This study was designed to evaluate the efficacy of an early rehabilitation program after laparoscopic low anterior resection for mid or low rectal cancer in a randomized, controlled trial.

Methods

Ninety-eight patients who had undergone a laparoscopic low anterior resection with defunctioning ileostomy were randomized on a 1:1 basis to an early rehabilitation program (n = 52) or conventional care (n = 46). The primary endpoint was recovery rate at 4 days postoperatively. The secondary endpoints were recovery time, postoperative hospital stay, complications, readmission rates, pain on a visual analogue scale, and quality of life (QOL) according to Short Form 36.

Results

The recovery rates were not different in both groups (rehabilitation, 25 % vs. conventional, 13 %, p = 0.135). Recovery time and postoperative hospital stay was similar between the groups (rehabilitation, 137 h [107–188] vs. conventional, 146.5 h [115–183], p = 0.47; 7.5 days [7–11] vs. 8.0 days [7–10], p = 0.882). The complication rates did not differ between the two groups, but more complications were noted in the rehabilitation program group (42.3 vs. 24.0 %, p = 0.054), which was related to postoperative ileus (28.8 vs. 13.0 %, p = 0.057) and acute voiding difficulty (19.6 vs. 4.7 %, p = 0.032). There was no readmission within 1 month of surgery. Pain and QOL were similar in both groups.

Conclusions

This randomized trial did not show that an early rehabilitation program is beneficial after laparoscopic low anterior resection. Our results confirm that postoperative ileus and acute voiding difficulty are major obstacles to fast-track surgery for mid or low rectal cancer. This study was registered (registration number NCT00606944).     

Impact of surgical training and surgeon’s experience on early outcome in kidney transplantation

Purpose

The purpose of this study was to assess the impact of surgical training and surgeon’s experience on surgical quality and early outcome parameters.

Methods

The outcomes of 184 deceased donor kidney transplant procedures were retrospectively reviewed. Intraoperative quality parameters, complication rates, and early outcome parameters were analyzed with respect to surgeon’s experience. Surgeons were grouped according to their level of experience: trainees (n?=?5), who were senior residents in their transplant rotation; low-experience surgeons (n?=?4), who had an individual caseload of at least 30 supervised procedures; medium-experience surgeons (n?=?5), who had an individual caseload of a minimum of 30 unsupervised (+30 supervised) procedures; and high-experience surgeons (n?=?2), who had an individual caseload of more than 200 procedures.

Results

Surgical training was offered in 20 % of all cases. Surgeons with a high experience in kidney transplantation had a significantly lower warm ischemic time (30 versus 35 min, p?=?0.01) and total operation time (135 versus 155 min, p?=?0.43) as compared to the other study groups. However, this did not translate into a better outcome after transplantation. The complication rate and early outcome parameters such as length of hospital stay, serum creatinine at discharge, and graft and patient survival at 3 months post TX did not show any significant difference between the groups.

Conclusion

We conclude that hands-on training of residents in kidney transplantation is feasible and surgical experience can be safely gained within a staged surgical training program.     

Impact of Surgery on Quality of Life in Patients with Hepatocellular Carcinoma

Background

Liver resection is the mainstay of curative treatment for localized hepatocellular carcinoma (HCC). However, the impact of surgery for HCC on quality of life (QOL) has not been well assessed.

Methods

Health-related QOL was assessed using the Short Form-36 questionnaire in 108 patients who underwent a liver resection for HCC between January 2004 and January 2008. The QOL assessment was scheduled before and every 3 months after the operation. Patients were divided into two groups based on patient-, tumor-, and surgery-related variables. The physical component summary (PCS) and mental component summary (MCS) were compared between the two groups.

Results

Altogether, 69 patients (64 %) completed the consecutive QOL assessments until 6 months after surgery. At 3 months, the PCS scores were significantly lower for women and for patients who had undergone thoracotomy than among men (p = 0.010) and patients who had not undergone thoracotomy (p = 0.048), respectively. No significant differences in any of the PCS scores were observed at 6 months. No significant differences in the MCS scores were observed between the groups throughout the investigation, and improvement relative to the preoperative status was observed at 6 months.

Conclusions

Physical impairments in the QOL after surgery had returned to the baseline at 6 months, and the postoperative mental QOL improved relative to the preoperative state. The surgical candidates were expected to have a satisfactory QOL regardless of the preoperative status and surgical outcomes. A thoracoabdominal approach had a transient negative impact on the physical health status.     

Axis I Disorders in Adjustable Gastric Band Patients: the Relationship Between Psychopathology and Weight Loss

Background

Bariatric surgery candidates have higher rates of co-morbid psychological illnesses than those in the general population. The effect of weight loss on these illnesses is unclear.

Methods

This prospective observational study explored psychiatric co-morbidities and weight loss outcomes in 204 gastric banding surgery candidates. Psychiatric co-morbidities were assessed prior to surgery and 2 years post-surgery. One hundred and fifty patients (74 %) completed assessments at both time points.

Results

At baseline, 39.7 % of the patients met the criteria for a current axis I disorder as defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). Mood disorders were the most frequent (26.5 %), followed by anxiety disorders (15.2 %) and binge eating disorder (13.2 %). Preoperative psychopathology predicted clinical psychopathology at 2 years. No preoperative or post-operative axis I disorder was significantly related to weight loss at 2 years. The frequency of current axis I disorders decreased significantly from 39.7 % preoperatively to 20 % 2 years post-surgery.

Conclusions

The point prevalence of psychopathology in this sample of Australian bariatric candidates is high. Psychopathology, preoperatively and at 2 years of follow-up, was not associated with weight loss at 2 years.     

A Randomized Prospective Study Comparing Acquisition of Laparoscopic Skills in Three-Dimensional (3D) vs. Two-Dimensional (2D) Laparoscopy

Background

We aimed to compare the performance of novices with three-dimensional (3D) versus two-dimensional (2D) laparoscopy using Fundamentals of Laparoscopic Surgery (FLS) tasks.

Methods

Fifty-six novices with no uncorrected visual problems were randomly allocated to 2D and 3D groups. All candidates practiced FLS tasks on a box trainer until they achieved proficiency. Their performance was assessed by considering completion time, number of repetitions, and number of errors following the validated FLS proficiency criteria.

Results

Twenty-five participants in each group completed the training curriculum. The median performance time (in minutes) for the 3D group was 216, which was less than that of the 2D group of 247 min (P = 0.266). The median numbers of repetitions and errors were lower for the 3D group versus the 2D group: 108 versus 121 (P = 0.008) and 27 versus 105 (P < 0.001), respectively.

Conclusion

Stereoscopic vision improved accuracy in laparoscopic skills for novices, which was manifested in reduced numbers of repetitions and errors. However, it does not affect the global performance time across all tasks.     

Outcome of kidney paired donation transplantation to increase donor pool and to prevent commercial transplantation: a single-center experience from a developing country

Background

Economic constraints in operating an effective maintenance dialysis program leaves renal transplantation as the only viable option for end-stage renal disease patients in India. Kidney paired donation (KPD) is a rapidly growing modality for facilitating living donor (LD) transplantation for patients who are incompatible with their healthy, willing LD.

Materials and methods

The aim of our study was to report a single-center feasibilities and outcomes of KPD transplantation between 2000 and 2012. We performed KPD transplants in 70 recipients to avoid blood group incompatibility (n = 56) or to avoid a positive crossmatch (n = 14).

Results

Over a mean follow-up of 2.72 ± 2.96 years, one-, five- and ten-year patient survival were 94.6, 81, 81 %, and death-censored graft survival was 96.4, 90.2, 90.2 %, respectively. Ten percent of patients were lost, mainly due to infections (n = 4). There was 14.2 % biopsy-proven acute rejection, and 5.7 % interstitial fibrosis with tubular atrophy eventually leading to graft loss.

Conclusion

The incidences of acute rejection, patient/graft survival rates were acceptable in our KPD program and, therefore, we believe it should be encouraged. These findings are valuable for encouraging participation of KPD pairs and transplant centers in national KPD program. It should be promoted in centers with low-deceased donor transplantation. Our study findings are relevant in the context of Indian government amending the Transplantation of Human Organs Act to encourage national KPD program. To our knowledge, it is largest single-center report from India.     

Impact of specialty and level of training on CT measurement of femoral version: an interobserver agreement analysis

Background

To determine the interobserver agreement on femoral version measurements between an orthopedic attending, orthopedic senior and junior residents, and an attending radiologist.

Materials and methods

Postoperative computed tomography (CT) scanograms of 267 patients who underwent femoral intramedullary (IM) nailing with corresponding radiology attending reads for femoral version were collected and de-identified. Femoral version measurements performed by a trauma fellowship-trained attending orthopedic surgeon (ORTHO), a senior orthopedic resident (PGY4), a junior orthopedic resident (PGY1), and a musculoskeletal fellowship-trained attending radiologist (RADS) were compared via Pearson’s interclass correlation coefficient to assess interobserver level of agreement.

Results

Version measurements provided by the two attending physicians exhibited the highest level of agreement (r = 0.661, p < 0.01). The orthopedic attending and the senior resident had the next highest level of agreement (r = 0.543, p < 0.01). The first-year orthopedic resident had the weakest agreement across the board: with the orthopedic attending, the radiology attending, and the senior resident.

Conclusion

Regardless of specialty, experience and higher levels of training produce stronger agreement when measuring femoral version. Residents in training, especially those who are junior, produce weak agreement when compared to their senior colleagues.

Level of evidence

Level III, diagnostic study.     

Development and evaluation of a simulator-based laparoscopic training program for surgical novices

Background

The use of simulation to train novice surgeons in laparoscopic skills is becoming increasingly popular. To maximize benefit from simulation, training needs to be delivered and assessed in a structured manner. This study aimed to define performance goals, demonstrate construct validity of the training program, and evaluate whether novice surgeons could reach the preset performance goals.

Methods

Nine expert laparoscopic surgeons established performance goals for three basic modules of an augmented-reality laparoscopic simulator. The three laparoscopic modules were used by 40 novice surgeons and 40 surgical trainees (postgraduate years [PGYs] 1–4). The performance outcomes were analyzed across the different groups (novice, PGYs 1 and 2, PGYs 3 and 4, expert) to determine construct validity. Then 26 recruited novices trained on the three modules with the aim of reaching the performance goals.

Results

The results demonstrated a significant difference in performance between all levels of experience for time (p < 0.001), motion analysis (p < 0.001), and error score (p < 0.001), thus demonstrating construct validity. All 26 novice surgeons significantly improved in performance with repetition for the metrics of time (p < 0.001) and motion analysis (p < 0.001). For two of the modules, the proficiency goals were reached in fewer than 10 trials by 80 % of the study participants.

Conclusion

Basic skills in laparoscopic surgery can be learned and improved using proficiency-based simulation training. It is possible for novice surgeons to achieve predefined performance goals in a reasonable time frame.     

Introduction of cardiac surgery residency program at an earlier stage in surgical training

Objective

Reform of the Japanese postgraduate residency program has dramatically influenced the recruitment system. Because shortage of young cardiac surgeons is anticipated, an effective program for residents who want to become cardiac surgeons must be established at an earlier stage in surgical training.

Methods

A 3-year cardiac surgery residency curriculum was developed for senior residents. The surgical training program includes harvesting of the saphenous vein, radial artery and internal thoracic artery, and repair of abdominal aortic aneurysm and specifies the target number of surgical procedures for each training. Academic training is provided in addition to clinical skills training. Nine residents completed the 3-year program between 2004 and 2012. The number of surgical procedures performed, presentations made at scientific meetings, and scientific papers published were investigated and analyzed.

Results

Each resident participated in 438 operations during 3-year program, 25.9 ± 8.3 (5.9 %) as main operator and 182.2 ± 15.8 (42 %) as first assistant. The average number of procedures per resident over the 3 years was 43.0 ± 6.7 for saphenous vein harvest, 14.4 ± 3.9 for radial artery harvest, 27.9 ± 13.0 for internal thoracic artery harvest, 7.1 ± 4.6 for abdominal aortic aneurysm. In addition, over the 3 years, the mean number of presentations at scientific meetings was 13.2 ± 3.2 and the mean number of publication of scientific papers was 1.9 ± 1.4.

Conclusion

The new cardiac surgery training curriculum for residents worked fairly well. A system for assessment of the program by an authoritative body should be established in the future.     

Construct and concurrent validity of a Nintendo Wii video game made for training basic laparoscopic skills

Background

Virtual reality (VR) laparoscopic simulators have been around for more than 10 years and have proven to be cost- and time-effective in laparoscopic skills training. However, most simulators are, in our experience, considered less interesting by residents and are often poorly accessible. Consequently, these devices are rarely used in actual training. In an effort to make a low-cost and more attractive simulator, a custom-made Nintendo Wii game was developed. This game could ultimately be used to train the same basic skills as VR laparoscopic simulators ought to. Before such a video game can be implemented into a surgical training program, it has to be validated according to international standards.

Methods

The main goal of this study was to test construct and concurrent validity of the controls of a prototype of the game. In this study, the basic laparoscopic skills of experts (surgeons, urologists, and gynecologists, n = 15) were compared to those of complete novices (internists, n = 15) using the Wii Laparoscopy (construct validity). Scores were also compared to the Fundamentals of Laparoscopy (FLS) Peg Transfer test, an already established assessment method for measuring basic laparoscopic skills (concurrent validity).

Results

Results showed that experts were 111 % faster (P = 0.001) on the Wii Laparoscopy task than novices. Also, scores of the FLS Peg Transfer test and the Wii Laparoscopy showed a significant, high correlation (r = 0.812, P < 0.001).

Conclusions

The prototype setup of the Wii Laparoscopy possesses solid construct and concurrent validity.     

Insights into fast-track colon surgery: a plea for a tailored program

Background

This retrospective study compared the fast-track colon surgery program to conventional perioperative care and assessed factors that influence postoperative length of stay.

Design

This retrospective study included 124 fast-track and 119 conventional care colon surgical patients. Exclusion criteria were primary rectal disease, stoma, American Society of Anesthesiologists score IV, and Association Française de Chirurgie index 3 or 4. Laparoscopy was the preferred approach. Variables influencing length of stay were analyzed by multivariate linear and logistic regression.

Results

Overall mortality and complication rates were not significantly different between groups (fast-track vs. controls 0 vs. 0.8 %, 30.6 vs. 38.6 % respectively). As expected, median length of stay was significantly reduced in fast-track patients (3 vs. 6 days, p < 0.001), but emergency readmission rate was higher (16.9 vs. 7.6 %, p = 0.026), although rehospitalization rates were similar (8 vs. 4.2 %, not significant). Independent risk factors of increased length of stay were identified as age >69 years (p = 0.001), laparotomy (p = 0.011), and conventional perioperative care (p < 0.001).

Conclusions

The introduction of a fast-track program reduced postoperative length of stay without increasing complication rate. This study proposes a modulation of the program according to patient age and surgical approach.     

The efficacy of laparoscopic skills training in a Mobile Simulation Unit compared with a fixed site: a comparative study

Background

Laparoscopic skills development via simulation-based medical education programs has gained support in recent years. However, the impact of training site type on skills acquisition has not been examined. The objective of this research was to determine whether laparoscopic skills training outcomes differ as a result of training in a Mobile Simulation Unit (MSU) compared with fixed simulation laboratories.

Methods

An MSU was developed to provide delivery of training. Fixed-site and MSU laparoscopic skills training outcomes data were compared. Fixed-site participants from three Australian states were pooled to create a cohort of 144 participants, which was compared with a cohort derived from pooled MSU participants in one Australian state. Data were sourced from training periods held from October 2009 to December 2010. LapSim and Fundamentals of laparoscopic surgery (FLS) simulators were used at the MSU and fixed sites. Participants self-reported on demographic and experience variables. They trained to a level of competence on one simulator and were assessed on the other simulator, thus producing crossover scores. No participants trained at both site types.

Results

When FLS-trained participants were assessed on LapSim, those who received MSU training achieved a significantly higher crossover score than their fixed-site counterparts (p < 0.001). Compared with baseline data, MSU LapSim-trained participants assessed on FLS displayed a performance increase of 23.1 %, whereas MSU FLS-trained participants assessed on LapSim demonstrated a 12.4 % increase in performance skills. Participants at fixed sites displayed performance increases of 5.2 and 10.9 %, respectively.

Conclusions

Mobile Simulation Unit-delivered laparoscopic simulation training is not inferior to fixed-site training.     

Use of a combination of biomarkers in serum and urine to improve detection of prostate cancer

Objective

To measure a combination of novel molecular biomarkers in urine/blood samples of consecutive patients referring lower urinary tract symptoms (LUTS) not previously diagnosed, to improve prostate cancer diagnosis.

Methods

Serum and urine samples from 113 men who went consecutively to the Department of Urology of our Institution. Biomarkers analyzed were AMACR and MMP-2 levels, and GSTP1/RASSF1A methylation status, in addition to PSA levels. Sensitivity, specificity, area under the ROC (AUROC) curves, and discriminant function analysis were assessed to determine the diagnostic potential of each variable alone or in combination.

Results

Of the patients, 30.08% had PCa and the remaining ones were tumor free. Areas under the ROC (AUROC) curves were as follows: 0.476 for PSA, 0.532 for AMACR, and 0.706 for MMP-2. Sensitivity and specificity for methylation status were 53.3 and 45.9%, respectively. The combination of these biomarkers resulted in an AUROC curve of 0.788, which significantly outperformed AUROC curves for PSA (P = 0.0033) and AMACR (P = 0.0375). Sensitivity, specificity, positive and negative predictive values for the combination of biomarkers were 57.1, 96.6, 88.9, and 82.4%, respectively.

Conclusion

We conclude that analysis of this biomarker combination in body fluids improves very significantly the diagnosis of PCa compared to the PSA test.     

Endoscopic simulator curriculum improves colonoscopy performance in novice surgical interns as demonstrated in a swine model

Introduction

The purpose of this study was to determine whether independent virtual endoscopic training accelerates the acquisition of endoscopic skill by novice surgical interns.

Methods

Nine novice surgical interns participated in a prospective study comparing colonoscopy performance in a swine model before and after an independent simulator curriculum. An independent observer evaluated each intern for the ability to reach the cecum within 20 min and technical ability as determined by Global Assessment of Gastrointestinal Endoscopic Skills—Colonoscopy (GAGES-C) score and performance compared. In addition, at the conclusion of training, a post test of two basic simulated colonoscopy modules was completed and metrics evaluated. As a control, three attending physicians who routinely perform colonoscopy also completed colonoscopy in the swine model.

Results

Prior to endoscopic training, one (11 %) intern successfully intubated the cecum in 19.56 min. Following training, six (67 %) interns reached the cecum with mean time of 9.2 min (p < 0.05). Statistically significant improvement was demonstrated in four out of five GAGES-C criteria. All three experts reached the cecum, with a mean time of 4.40 min. Comparison of expert and post-curriculum intern times demonstrated the experts to be significantly faster (p < 0.05). Comparison of interns who were and were not able to reach the cecum following the simulator curriculum demonstrated significantly improved GI Mentor? performance in the efficiency (79 vs. 67.1 %, p = 0.05) and time to cecum (3.37 vs. 5.59 min, p = 0.01) metrics. No other significant difference was demonstrated in GAGES-C categories or other simulator parameter.

Conclusion

Simulator training on the GI Mentor? alone significantly improved endoscopic skills in novice surgical interns as demonstrated in a swine model. This study also identified parameters on the GI Mentor? that could indicate ‘clinical readiness’. This study supports the role for endoscopic simulator training in surgical resident education as an adjunct to clinical experience.     

Orthopedic surgeon perspectives on appropriate referral of trauma patients to physical therapy (PT)

Objectives

To evaluate orthopedic surgeon referral of trauma patients to PT.

Design

Cross-sectional survey.

Setting

Alberta, Canada.

Participants

Orthopedic surgeons and residents.

Methods

A web-based survey was utilized to poll orthopedic surgeons and residents on referral practices. Statistical analysis using Kruskal–Wallis One-Way Analysis of Variance by Ranks; Post hoc analysis using the minimum significant difference method for multiple comparisons and nonparametric correlations using Spearman’s rho.

Results

The overall response rate was 48 %. Key indications for referral were range of motion deficits, failure to progress, strength and gait training. Of those surveyed, 72.5 and 26.1 % felt that there was either moderate or significant improvement following PT, respectively. Years in practice had a significant effect on survey responses. Residents and surgeons in practice for >20 years viewed PT as being less important in orthopedic trauma (p < 0.05) and were less likely to refer orthopedic trauma patients to PT (p < 0.05). Residents were less likely to view PT in orthopedic trauma as evidence-based (0.05) and more likely to disagree with the statement that formalized PT results in better outcomes than a prescribed home exercise program (p < 0.05).

Conclusions

There are potential differences in the referral practices of orthopedists of varying levels of experience. Although outcome is viewed as positive following PT, it appears that many orthopedists view a prescribed home exercise program as an acceptable equivalent to formalized PT in the setting of orthopedic trauma. Future research should be directed at determining indicators for formalized PT.