Validation of low-cost models for minimal invasive surgery training of congenital diaphragmatic hernia and esophageal atresia

BackgroundMinimal invasive surgery (MIS) is increasingly used for the correction of congenital diaphragmatic hernia (CDH) and esophageal atresia (EA). It is important to master these complex procedures, preferably preclinically, to avoid complications. The aim of this study was to validate recently developed models to train these MIS procedures preclinically.MethodsTwo low cost, reproducible models (one for CDH and one for EA) were validated during several pediatric surgical conferences and training sessions (January 2017–December 2018), used in either the LaparoscopyBoxx or EoSim simulator. Participants used one or both models and completed a questionnaire regarding their opinion on realism (face validity) and didactic value (content validity), rated on a five-point-Likert scale.ResultsOf all 60 participants enrolled, 44 evaluated the EA model. All items were evaluated as significantly better than neutral, with means ranging from 3.7 to 4.1 (p < 0.001). The CDH model was evaluated by 48 participants. All items scored significantly better than neutral (means 3.5–3.9, p < 0.001), with exception of the haptics of the simulated diaphragm (mean 3.3, p = 0.054). Both models were considered a potent training tool (means 3.9).ConclusionThese readily available and low budget models are considered a valid and potent training tool by both experts and target group participants.Type of studyProspective study.Level of evidenceLevel II.     

Prevalence of multidrug-resistant organisms recovered at a military burn center

Infections caused by multidrug-resistant (MDR) pathogens are associated with significant morbidity and mortality in patients with burn injuries. We performed a 6-year antibiotic susceptibility records review from January 2003 to December 2008 to assess the prevalence of MDR isolates by pathogen at the US Army Institute of Surgical Research Burn Center. During the study period Acinetobacter baumannii (780 isolates [22%]) was the most prevalent organism recovered, followed by Pseudomonas aeruginosa (703 isolates [20%]), Klebsiella pneumoniae (695 isolates [20%]), and Staphylococcus aureus (469 isolates [13%]). MDR prevalence rates among these isolates were A. baumannii 53%, methicillin-resistant S. aureus (MRSA) 34%, K. pneumoniae 17% and P. aeruginosa 15%. Two isolates, 1 A. baumannii and 1 P. aeruginosa, were identified as resistant to all 4 classes of antibiotics tested plus colistin. A. baumannii isolates recovered from patients with burns greater than 30% of total body surface area (TBSA) were more likely to be MDR (61%) with no significant difference for P. aeruginosa and K. pneumoniae. A higher proportion of MDR P. aeruginosa isolates were recovered from respiratory specimens compared to blood specimens (24% vs. 9%) while the opposite was true for MRSA (35% vs. 54%). A comparison of A. baumannii recovered during hospitalization days 1–5 and 15–30 revealed higher MDR levels as length of stay increased (48% vs. 75%) while no significant trends were observed for P. aeruginosa and K. pneumoniae. A similar pattern was observed for MDR A. baumannii levels for the facility between 2003 and 2005 and 2006–2008 (39% vs. 70%), with no significant increase in MDR P. aeruginosa and MDR K. pneumoniae. Increasing antibiotic resistance patterns of the most prevalent isolates recovered during extended hospitalization, impact of % TBSA and other clinical parameters may affect empirical antimicrobial therapy and patient management decisions during treatment.     

Venting intraluminal drains in pancreaticoduodenectomy

The utility of placing biliary, pancreatic, or enteric "venting"tubes (externally draining devices traversing the bowel or bile duct that have their distal tip located intraluminally near the biliary or pancreatic anastomosis) when performing a pancreaticoduodenectomy has received little attention to date. We hypothesize that these venting tubes do not decrease the morbidity or mortality associated with pancreatico-duodenectomy and may actually be a source of additional morbidity. To characterize our use of and the effect of these drains, we retrospectively analyzed 136 pancreaticoduodenectomies (127 partial, 9 total) performed over a 24-month period. Venting drain use, drain type and size, drain location, duration of intubation, hospital course, and postoperative complications were noted. Venting tubes were used in 80 patients (59%). The use of these drains had no significant relationship to postoperative length of stay, the development of major complications, overall morbidity, or mortality (P >0.05). Such drains also did not significantly shorten the length of hospital stay (P >0.05) or improve outcome when available to augment local control following luminal leak (n = 6) or regional abscess (n = 7). These drains were removed at a median interval of 29 days postoperatively (range 6 to 77 days). Seven patients had complications that were directly related to the venting drain; four of these patients had a documented infra-abdominal luminal leak from the site of drain removal, whereas the other three were hospitalized for presumed leakage secondary to immediate, severe abdominal pain following removal of the drain. These seven patients were elderly (mean age 70 years) and often harbored pancreatic ductal carcinoma (n = 6). Intraluminal drains afford no distinct advantage in terms of shortening the postoperative length of stay, decreasing operative morbidity and mortality, or improving local control with regional sepsis in pancreaticoduodenectomies. Furthermore, they may add an additional source of morbidity and we no longer employ them routinely.     

Histological characterization of a delayed wound healing model in pig

Chronic wounds, such as venous ulcers and pressure ulcers, frequently remain unresponsive to currently available treatments. Several animal models of wound healing have been published, including models of impaired healing developed to mimic the clinical condition of chronic wounds better. We used a delayed wound healing model in the pig that uses irradiation of the skin prior to creation of the surgical wounds and characterized it histologically. Radiation was used on one side of the back prior to making four full-thickness wounds on each side. Clinical observations were performed to record granulation tissue, reepithelialization, and wound area as a function of time. Histology data were obtained at 1, 2, 3, and 4 weeks, and slides were stained with hematoxylin and eosin for general observations. Immunohistochemistry was performed using laminin as a marker for blood vessels, and the number, size, and circularity of blood vessels found in the granulation tissue were measured. Our results show that this model causes a delay in wound healing that is mostly apparent between days 7 and 15. Granulation tissue took more time to form and fill the wounds on the irradiated side, and blood vessels were slower to develop. Blood vessels were larger and more irregular in shape on the irradiated side than on the control side. After 2 weeks, healing resumed, indicating that the induced damage was not irreversible. These results suggest that this model can be used to test the effects of therapeutic approaches intended to treat chronic wounds.     

Evaluation of drugs for elimination of leukemic cells from the bone marrow of patients with acute leukemia

Relatively nonmyelotoxic drugs and drug combinations were investigated for their ability to eliminate malignant cells from human bone marrow. In vitro 90% inhibitory concentration (IC90) doses were established on granulocyte macrophage colony-forming units (GM-CFU) in culture of bone marrow by using the GM-CFU assay for the following drugs: 4- hydroperoxycyclophosphamide (4-HC), Adriamycin, L-asparaginase, bleomycin, hydrocortisone, VP-16, spirogermanium, Taxol, and vincristine. The leukemic cell kill efficiency of these drugs at IC90 doses was compared with that of 4-HC on acute lymphoid leukemia (ALL) cell lines by using the limiting-dilution assay. Under these conditions, no single drug was superior to 4-HC. To increase the in vitro effect in leukemic cell kill, combinations of vincristine with hydrocortisone, Adriamycin, VP-16, and 4-HC were investigated. Vincristine at 1 to 5 micrograms/mL increased the marrow cytotoxicity of hydrocortisone, Adriamycin, and VP-16, but it was protective (subadditive) with 4-HC. Vincristine and 4-HC in combination was additive to supraadditive on ALL cell lines, increased the leukemic cell kill by one to two logs above 4-HC alone at IC90 doses (P less than .05), and was not affected by the addition of excess marrow cells. The recommended doses for chemopurging in clinical studies are vincristine, 1 to 5 micrograms/mL, plus 4-HC, 5 micrograms/mL.     

Unique contribution of family functioning in caregivers of patients with mild to moderate dementia

The relationship between family functioning and dementia caregiving is complex. The present study examined the interrelationships between family functioning, caregiver burden, and patient characteristics. Participants were 72 live-in, family caregivers of patients with mild (n = 47) or moderate dementia (n = 25). Caregivers completed measures of burden, family functioning, depression, and anxiety. Ratings of patients' memory/behavior problems and patients' activities of daily living were also collected. Results indicated that higher levels of caregiver burden were significantly associated with increased caregiver depression and anxiety, greater frequency of memory and behavior problems in the dementia patient, worse activities of daily living, and poorer family functioning. Even after controlling for caregiver depression, caregiver anxiety, and frequency of memory/behavior problems in dementia patients, poorer family functioning continued to be associated with higher levels of caregiver burden. Caregivers with high levels of burden reported greater family dysfunction in communication and roles, regardless of their relationship to the patient (i.e., spouse or child). These findings suggest that including a family systems component in caregiver interventions may be beneficial in reducing burden in these very distressed individuals.     

The impact of selected organizational variables and managerial leadership on radiation therapists' organizational commitment

The purpose of this study was to examine the impact of selected organizational factors and the leadership behavior of supervisors on radiation therapists' commitment to their organizations.The population for this study consists of all full time clinical radiation therapists registered by the American Registry of Radiologic Technologists (ARRT) in the United States. A random sample of 800 radiation therapists was obtained from the ARRT for this study. Questionnaires were mailed to all participants and measured organizational variables; managerial leadership variable and three components of organizational commitment (affective, continuance and normative).It was determined that organizational support, and leadership behavior of supervisors each had a significant and positive affect on normative and affective commitment of radiation therapists and each of the models predicted over 40% of the variance in radiation therapists organizational commitment. This study examined radiation therapists' commitment to their organizations and found that affective (emotional attachment to the organization) and normative (feelings of obligation to the organization) commitments were more important than continuance commitment (awareness of the costs of leaving the organization). This study can help radiation oncology administrators and physicians to understand the values their radiation therapy employees hold that are predictive of their commitment to the organization. A crucial result of the study is the importance of the perceived support of the organization and the leadership skills of managers/supervisors on radiation therapists' commitment to the organization.