A Comparative Study of Laparoscopic with Conventional Open Donor Nephrectomy in Renal Transplantation

Background

Laparoscopic donor nephrectomy (LDN) has been gaining popularity among kidney donors. There have been concerns about the safety and efficacy of the procedure as compared to open donor nephrectomy (ODN). We compare our results on LDN with ODN.

Methods

We retrospectively analysed our data of LDN and ODN. Duration of surgery, blood loss, period of hospitalisation, per oral intake and analgesic requirements.

Result

22 LDNs were done, the operation time ranged from 220-300 minutes, and blood loss from 100-150ml. In the first 10 laparoscopic operations four cases required conversion to open surgical dissection. Only one case was converted to open surgery in the subsequent 12 laparoscopic cases. Oral intake was started on the first postoperative day. Analgesic requirement in laparoscopy cases was less. Patients were mobilised on the first day after surgery. Patients were discharged by seventh day. There was no significant difference in the functioning of the graft after revascularisation in the recipient.

Conclusion

Laparoscopic donor nephrectomy is a safe and effective technique of donor nephrectomy.Key Words: Laparoscopy, Laparoscopic donor nephrectomy, Living kidney donors, Kidney transplantation     

The use of chicken legs for teaching wound closure skills

Objective

Training models are required to impart surgical skills, like wound closure techniques, prior to practice in patients. In an ideal case, the tissue characteristics of the model are close to those of humans, easy to create and of low cost.

Methods

Here, we describe a model to train students in wound closure technique using conventional chicken legs obtained from the supermarket.

Results

The described model has good tissue characteristics, does not require any lavish preparation and is of minimal cost (0.62 Euro or 0.78 USD).

Conclusions

Chicken legs appear to be an appropriate tool for teaching wound closure techniques.     

Laparoscopic Suture Rectopexy: An Effective Treatment for Complete Rectal Prolapse

Background

The study was undertaken to validate the efficacy of laparoscopic suture rectopexy as the treatment modality of choice for complete prolapse of rectum.

Methods

Data was prospectively collected and analyzed on 36 patients who underwent laparoscopic suture rectopexy for full thickness rectal prolapse between May 2006 to May 2008. There were 10 male and 26 female patients in this study with a mean age of 43.5 years. The pre and postoperative course of each patient was followed up with attention paid to ano-rectal manometery pressures, first bowel movement, hospital stay, duration of surgery, faecal incontinence, constipation, recurrence and morbidity. Mean follow up period was 12 months (range 1–24 months).

Result

One patient had conversion from laparoscopic to open surgery. while another had recurrence of prolapse in the follow up period. Mean duration of surgery was 115 (range 100–150) minutes. Postoperatively, the mean time for the first bowel movement was 40 (range 24–64) hours. Mean hospital stay was five (range 4–7) days. There was no significant postoperative complication except for one port site infection and one pelvic collection. Of the 20 patients who had varying degree of incontinence preoperatively, 16 (80%) showed improvement after surgery. Constipation was present in 15 (41%) patients preoperatively. Nine of these 15 patients (60%) improved as regards constipation after surgery.

Conclusion

Laparoscopic suture rectopexy is both safe and effective operation for the management of complete prolapse rectum. The procedure carries minimal morbidity and helps improve the problems of incontinence and constipation.Key Words: Laparoscopic, Suture rectopexy, Rectal prolapse     

Development of a standardized laparoscopic caecum resection model to simulate laparoscopic appendectomy in rats

Background

Laparoscopic appendectomy (LA) has become one of the most common surgical procedures to date. To improve and standardize this technique further, cost-effective and reliable animal models are needed.

Methods

In a pilot study, 30 Wistar rats underwent laparoscopic caecum resection (as rats do not have an appendix vermiformis), to optimize the instrumental and surgical parameters. A subsequent test study was performed in another 30 rats to compare three different techniques for caecum resection and bowel closure.

Results

Bipolar coagulation led to an insufficiency of caecal stump closure in all operated rats (Group 1, n = 10). Endoloop ligation followed by bipolar coagulation and resection (Group 2, n = 10) or resection with a LigaSure™ device (Group 3, n = 10) resulted in sufficient caecal stump closure.

Conclusions

We developed a LA model enabling us to compare three different caecum resection techniques in rats. In conclusion, only endoloop closure followed by bipolar coagulation proved to be a secure and cost-effective surgical approach.     

Comparison of training in neonatal resuscitation using self inflating bag and T-piece resuscitator

Background

Both the self inflating bag and the T-piece resuscitator are recommended for neonatal resuscitation, but many health care workers are unfamiliar with using the latter. A prospective, comparative, observational study was done to determine the ease and effectiveness of training of health care personnel in the two devices using infant training manikins.

Methods

100 health care workers, who had no prior formal training in neonatal resuscitation, were divided into small groups and trained in the use of the two devices by qualified trainers. Assessment of cognitive skills was done by pre and post MCQs. Psychomotor skill was assessed post training on manikins using a 10-point objective score. Acceptance by users was ascertained by questionnaire. Assessments were also done after 24 h and 3 months. Comparison was done by Chi square and paired t-tests.

Results

Pre-training cognitive tests increased from 3.77 (+1.58) to 6.99 (+1.28) on day of training which was significant. Post training assessment of psychomotor skills showed significantly higher initial scores for the T-piece group (7.07 + 2.57) on day of training. Reassessment after 24 h showed significant improvement in cognitive scores (9.89 + 1.24) and psychomotor scores in both groups (8.86 + 1.42 for self inflating bag and 9.70 + 0.57 for T-piece resuscitator). After 3–6 months the scores in both domains showed some decline which was not statistically significant. User acceptability was the same for both devices.

Conclusion

It is equally easy to train health care workers in both devices. Both groups showed good short term recall and both devices were equally acceptable to the users.     

Effectiveness of early cardiology undergraduate learning using simulation on retention,application of learning and level of confidence during clinical clerkships

INTRODUCTION

This study aimed to assess the effectiveness of the use of a cardiopulmonary patient simulator in the teaching of second-year medical students. Effectiveness was measured in terms of the extent of knowledge retention and students’ ability to apply the skills learned in subsequent real-life patient contact.

METHODS

In this study, ten third-year medical students who had previously undergone simulator training as part of their second-year curriculum underwent an objective structured clinical examination (OSCE) and a multiple-choice question (MCQ) test to assess their ability to apply the knowledge gained during the simulator training when dealing with real patients. The performance of this group of students was compared with that of a group of ten fourth-year medical students who did not undergo simulation training.

RESULTS

Although the third-year medical students performed well in the OSCE, they were outperformed by the group of fourth-year medical students, who had an extra year of clinical exposure. The MCQ scores of the two groups of students were similar. Post-simulation training survey revealed that students were generally in favour of incorporating cardiopulmonary simulator training in the preclinical curriculum.

CONCLUSION

Cardiopulmonary simulator training is a useful tool for the education of preclinical medical students. It aids the translation of preclinical knowledge into real-life clinical skills.     

Major laparoscopic surgery under regional anesthesia: A prospective feasibility study

Background

Laparoscopic surgeries have attained the status of a gold standard for most of the abdominal pathology; we therefore performed this study to assess feasibility and safety of major laparoscopic surgeries like laparoscopic cholecystectomy (LC) and laparoscopic assisted vaginal hysterectomy (LAVH)/total laparoscopic hysterectomy (TLH) under regional anesthesia that is combined spinal epidural anesthesia (CSE) with normal pressure pneumoperitoneum using intrathecal fentanyl with bupivacain.

Methods

In a zonal government hospital, 50 patients were selected prospectively for LC and LAVH/TLH, under normal pressure (12 mmHg) pneumoperitoneum and under CSE over a span of fifteen months. Injection bupivacaine (0.5%) and 20 μg of fentanyl were used for spinal anesthesia. Plain bupivacaine (0.5%) was used for epidural anesthesia.

Results

We successfully performed the operations in 48 patients without major complications. CSE was converted to general anesthesia in two patients due to distressing shoulder tip pain. Age varied between 25 and 70 years. Duration of operation time (skin to skin) was between 50 and 170 min. Five patients had urinary retention and one developed localized pruritis. There was no incidence of respiratory depression, aspiration or headache.

Conclusion

Laparoscopic surgeries with normal pressure CO₂ pneumoperitoneum are feasible and safe under CSE. Incidence of postoperative shoulder pain was minimal due to use of intrathecal fentanyl and complications were less and easily manageable.     

Laparoscopic Cardiomyotomy for Achalasia: A Single Unit study

Aims

Achalasia is a rare incurable neuromuscular disorder of the oesophagus. A number of treatment options are available. We reviewed our results of laparoscopic cardiomyotomy over a 30 month period.

Methods

18 patients with manometric features of achalasia underwent surgery between 2004 and 2006. Pre and postoperative weight and dysphagia scores were recorded (maximum score 45=normal, 0=complete dysphagia). Change in the Body Mass Index (BMI) was measured. Other symptoms (heartburn, epigastric pain, regurgitation, odynophagia and sleep disturbance) were scored on a 0–4 scale of increasing severity.

Results

At mean follow up of 16.2 months the mean dysphagia score was significantly improved from 7.5 to 33.9 (p<0.005). BMI was significantly increased from 22.3 to 25.8 kg/m² (p<0.05). Scores for heartburn, epigastric pain, regurgitation, odynophagia and sleep disturbance were also significantly improved. The average inpatient stay was 3.1 days and average operating time 111 minutes. One mucosal perforation occurred which was repaired intraoperatively. No patients required secondary operative intervention.

Conclusions

Laparoscopic cardiomyotomy is a safe, highly effective, minimally invasive treatment for achalasia.     

Training Multidisciplinary Biomedical Informatics Students: Three Years of Experience

Objective

The European INFOBIOMED Network of Excellence ¹ recognized that a successful education program in biomedical informatics should include not only traditional teaching activities in the basic sciences but also the development of skills for working in multidisciplinary teams.

Design

A carefully developed 3-year training program for biomedical informatics students addressed these educational aspects through the following four activities: (1) an internet course database containing an overview of all Medical Informatics and BioInformatics courses, (2) a BioMedical Informatics Summer School, (3) a mobility program based on a ‘brokerage service’ which published demands and offers, including funding for research exchange projects, and (4) training challenges aimed at the development of multi-disciplinary skills.

Measurements

This paper focuses on experiences gained in the development of novel educational activities addressing work in multidisciplinary teams. The training challenges described here were evaluated by asking participants to fill out forms with Likert scale based questions. For the mobility program a needs assessment was carried out.

Results

The mobility program supported 20 exchanges which fostered new BMI research, resulted in a number of peer-reviewed publications and demonstrated the feasibility of this multidisciplinary BMI approach within the European Union. Students unanimously indicated that the training challenge experience had contributed to their understanding and appreciation of multidisciplinary teamwork.

Conclusion

The training activities undertaken in INFOBIOMED have contributed to a multi-disciplinary BMI approach. It is our hope that this work might provide an impetus for training efforts in Europe, and yield a new generation of biomedical informaticians.     

Evaluation of Posterior Capsular Opacification following Phacoemulsification,Extracapsular and Small Incision Cataract Surgery

Background

Posterior capsular opacification is the most common complication of modern cataract surgery.

Methods

A prospective study was conducted on 150 patients (150 eyes) out of which 50 eyes each underwent cataract surgery by extracapsular cataract extraction, small incision cataract surgery and phacoemulsification technique. On postoperative follow up posterior capsular opacification and Neodymium: Yttrium Aluminium Garnet laser capsulotomy rate was evaluated.

Result

Posterior capsular opacification rate was significantly less (p=0.03) in eyes which had undergone phacoemulsification as compared to extracapsular cataract extraction. However capsulotomy rate was not statistically significant after comparison of the three surgical techniques of cataract surgery.

Conclusion

Posterior capsular opacification following cataract surgery can be minimized by the use of small incision cataract surgery and phacoemulsification.Key Words: Posterior capsular opacification, Capsulorrhexis, Hydrodissection     

Role of Prophylactic Antibiotics in Laparoscopic Cholecystectomy

Background

Antibiotic prophylaxis is routinely administered in laparoscopic cholecystetomy but its role is debatable. Methods: From January 2004 to August 2008, 417 patients were randomized into 208 in antibiotic group (AG) and 209 in non antibiotic group (NAG). AG received one dose each of injection ciprofloxacin (200 mg) and metronidazole (500mg) preoperatively. NAG was given only intravenous fluids. Besides routine care, all underwent abdominal sonography and liver function tests at least once during the 30 postoperative days.

Result

Age, sex and co-morbidity distribution were similar in both the groups. One patient who was on weekly 5mg methotraxate (NAG) had erythema around umbilical port. Other three having umbilical discharge recovered without antibiotics. Nine patients had subhepatic collection (5 AG and 4 NAG). One from NAG underwent re-laparoscopy and drainage. Ten patients had fever. Two from AG had basal lung collapse and were given antibiotics.

Conclusion

Antibiotic prophylaxis is not needed for laparoscopic cholecystectomy.Key Words: Laparoscopic cholecystectomy, Antibiotics     

What do Malawi Polytechnic first year students know and do about HIV and AIDS?

Background

The Polytechnic introduced a “WHY WAIT?” course to equip first year students with skills to help reduce transmission of Human Immune-deficiency Virus (HIV). Training is conducted during the first week of arrival at college. The study aimed to explore existing knowledge, beliefs and attitudes in order to tailor the training programme to students'' needs.

Methods

This was a cross sectional study. During first day of arrival, first year students available on campus were given a structured self-administered questionnaire which was filled and submitted before the course. Out of 320 questionnaires distributed, 295 were returned representing 92% response rate.

Results

Ten percent (30) had more than one girlfriend or boyfriend. Ninety-seven percent (286) indicated that condoms are not 100% effective towards prevention of HIV while 72% (169) reported that they had never had sexual intercourse before. Of 66 students who had had sexual intercourse before, 30% indicated that they used condoms always during sexual intercourse, 40% used it occasionally while 30% never used condoms. Thirty-two percent (94) reported having an HIV test before and 19% (56) would feel uncomfortable to share a room with an HIV infected person.

Conclusion

The Polytechnic first year students have varying knowledge and practices about HIV and AIDS. There is need to intensify “WHY WAIT?” course to first years during first week at College to help equip them with necessary knowledge and skills to protect themselves against HIV and AIDS.     

Perioperative blood loss in open retropubic radical prostatectomy - is it safe to get operated at an educational hospital?

Introduction

Blood loss during radical prostatectomy has been a long term issue. The aim of this study was to investigate the influence of the training level of the first assistant regarding blood loss in open retropubic radical prostatectomy at an educational hospital.

Material and methods

364 patients underwent radical prostatectomy from 11/2006 to 10/2007 at one institution operated by one surgeon. In 319 patients all predefined parameters were obtained. Training level was determined by year of residency (1-5 yrs) or consultant status. Perioperative blood loss was calculated using three parameters: Hemoglobin level before and after surgery, postoperative sucker volume and weight of compresses. Furthermore the influence of prostatic size and BMI was analyzed.

Results

The Hb-decrease 24 h postoperatively was 2.4 g/dl median (-0.4-7.6 g/dl); sucker volume was 250 ml median (10-1500 ml); weight of compresses and swabs was 412 g median (0-972 g). One patient needed a transfusion with two erythrocyte concentrates one day after the surgery. There was no significant correlation regarding Hb-decrease (p = 0.86) or sucker volume plus weight of compresses (p = 0.59) in regard to the years of residency of the assisting physician. Also the number of assisted operations (n = < or > 20) had no significant influence on calculated blood loss (p = 0.38).

Conclusions

For an experienced surgeon the impact of the assistant regarding blood loss seems negligible. The training level of the assistant was not significantly correlated to a rise or decrease of perioperative blood loss. In our data radical prostatectomy could be safely performed at an educational hospital independent of the training level of the first assistant.     

Manual Small Incision Cataract Surgery: Experience at a Military Hospital

Background

Small incision cataract surgery came into practice with the advent of phacoemulsification. However, manual small incision cataract surgery (SICS) is a useful alternative for those who do not have access to phacoemulsification machine.

Method

A total of 69 cases of cataract were undertaken for manual incision cataract surgery and intra ocular lens (IOL) implantation using 6mm straight incision. The surgical technique and postoperative results are compared with the results of phacoemulsification and IOL implantation.

Result

Average postoperative astigmatism was ± 0.75 dioptres. Postoperative uncorrected visual acuity (UCVA) of 6/18 or better was observed in 51(71.9%) cases after first week of the surgery.

Conclusion

The study concludes that both phacoemulsification and small incision cataract surgery with intraocular lens (IOL) implantation are effective methods. However SICS with IOL implantation is a useful alternative in the absence of phacoemulsification machine.Key Words: Manual Small Incision Cataract Surgery (SICS), Extra Capsular Cataract Extraction (ECCE), Phacoemulsification, Intraocular lens implantation     

Effects of librarian-provided services in healthcare settings: a systematic review

Objective

To assess the effects of librarian-provided services in healthcare settings on patient, healthcare provider, and researcher outcomes.

Materials and methods

Medline, CINAHL, ERIC, LISA (Library and Information Science Abstracts), and the Cochrane Central Register of Controlled Trials were searched from inception to June 2013. Studies involving librarian-provided services for patients encountering the healthcare system, healthcare providers, or researchers were eligible for inclusion. All librarian-provided services in healthcare settings were considered as an intervention, including hospitals, primary care settings, or public health clinics.

Results

Twenty-five articles fulfilled our eligibility criteria, including 22 primary publications and three companion reports. The majority of studies (15/22 primary publications) examined librarians providing instruction in literature searching to healthcare trainees, and measured literature searching proficiency. Other studies analyzed librarian-provided literature searching services and instruction in question formulation as well as the impact of librarian-provided services on patient length of stay in hospital. No studies were found that investigated librarians providing direct services to researchers or patients in healthcare settings.

Conclusions

Librarian-provided services directed to participants in training programs (eg, students, residents) improve skills in searching the literature to facilitate the integration of research evidence into clinical decision-making. Services provided to clinicians were shown to be effective in saving time for health professionals and providing relevant information for decision-making. Two studies indicated patient length of stay was reduced when clinicians requested literature searches related to a patient''s case.     

A study to determine factors influencing outcomes of paediatric cochlear implants

Background

Cochlear implantation is a powerful tool for helping children with severe to profound sensorineural hearing loss to gain the ability to hear, achieve age appropriate communication skills. However patient selection is of utmost importance to achieve optimum results.

Method

A cross sectional study was done on 75 children who had undergone unilateral cochlear implantation. Hearing was assessed by, The Meaningful Auditory Integration Scale (MAIS) and speech perception was assessed by the Meaningful Use of Speech Scale (MUSS) as a parent reported scale in an interview format.

Results

The cochlear implantation improved auditory skills and speech perception of the children who underwent cochlear implantation. Children who had less than 40 months auditory deprivation and those who had higher educated parents had better auditory skills and speech perception.

Conclusion

Early cochlear implantation and good auditory verbal therapy have better outcomes of hearing and speech.     

Resuscitation competencies in paediatric specialist registrars

Background

Despite the increased availability of resuscitation courses and guidelines requiring optimal training for acute situations, little is known on the actual qualification of house staff with in‐hospital on‐call duties for critically ill newborns and children.

Objective

To assess (1) the characteristics of education and training; (2) the level of experience; and (3) factors that may hamper optimal performance of paediatric specialist registrars caring for acute critically ill newborns and children.

Methods

A structured questionnaire was completed by a national cohort of all paediatric specialist registrars in their fourth year (ie pre‐final) of training.

Results

Important shortcomings in training and assessment of actual qualifications of resuscitation competencies were identified in paediatric specialist registrars. In 17 of 57 (30%) specialist registrars, competencies in acute care had never been assessed or reconfirmed when starting on‐call duties while in the others, 40 (70%), substantial heterogeneity was found regarding the type of assessment of qualifications for on‐call duties. In acute situations, occasionally untrained and unsupervised resuscitation procedures were performed. Individual responsibility was the most important stressor that may hamper optimal performance. Despite these findings, adequate reported levels of self‐confidence were found; self confidence was higher in newborns as compared to children (7.8 and 7.0 respectively on scale 1‐10, p<0.05).

Conclusions

Successful completion of a resuscitation course does not ensure adequate qualifications by on‐call residents, unless regular refresher sessions are provided. Teaching hospitals should establish and implement uniform guidelines for training and assessment of competencies regarding acute care for critically ill children and newborns.     

Does user-centred design affect the efficiency,usability and safety of CPOE order sets?

Background

Application of user-centred design principles to Computerized provider order entry (CPOE) systems may improve task efficiency, usability or safety, but there is limited evaluative research of its impact on CPOE systems.

Objective

We evaluated the task efficiency, usability, and safety of three order set formats: our hospital''s planned CPOE order sets (CPOE Test), computer order sets based on user-centred design principles (User Centred Design), and existing pre-printed paper order sets (Paper).

Participants

27staff physicians, residents and medical students.

Setting

Sunnybrook Health Sciences Centre, an academic hospital in Toronto, Canada.

Methods

Participants completed four simulated order set tasks with three order set formats (two CPOE Test tasks, one User Centred Design, and one Paper). Order of presentation of order set formats and tasks was randomized. Users received individual training for the CPOE Test format only.

Main Measures

Completion time (efficiency), requests for assistance (usability), and errors in the submitted orders (safety).

Results

27 study participants completed 108 order sets. Mean task times were: User Centred Design format 273 s, Paper format 293 s (p=0.73 compared to UCD format), and CPOE Test format 637 s (p<0.0001 compared to UCD format). Users requested assistance in 31% of the CPOE Test format tasks, whereas no assistance was needed for the other formats (p<0.01). There were no significant differences in number of errors between formats.

Conclusions

The User Centred Design format was more efficient and usable than the CPOE Test format even though training was provided for the latter. We conclude that application of user-centred design principles can enhance task efficiency and usability, increasing the likelihood of successful implementation.     

Research and applications: The intended and unintended consequences of communication systems on general internal medicine inpatient care delivery: a prospective observational case study of five teaching hospitals

Background

Effective clinical communication is critical to providing high-quality patient care. Hospitals have used different types of interventions to improve communication between care teams, but there have been few studies of their effectiveness.

Objectives

To describe the effects of different communication interventions and their problems.

Design

Prospective observational case study using a mixed methods approach of quantitative and qualitative methods.

Setting

General internal medicine (GIM) inpatient wards at five tertiary care academic teaching hospitals.

Participants

Clinicians consisting of residents, attending physicians, nurses, and allied health (AH) staff working on the GIM wards.

Methods

Ethnographic methods and interviews with clinical staff (doctors, nurses, medical students, and AH professionals) were conducted over a 16-month period from 2009 to 2010.

Results

We identified four categories that described the intended and unintended consequences of communication interventions: impacts on senders, receivers, interprofessional collaboration, and the use of informal communication processes. The use of alphanumeric pagers, smartphones, and web-based communication systems had positive effects for senders and receivers, but unintended consequences were seen with all interventions in all four categories.

Conclusions

Interventions that aimed to improve clinical communications solved some but not all problems, and unintended effects were seen with all systems.