Prospective randomized study of contrast reaction management curricula: Computer-based interactive simulation versus high-fidelity hands-on simulation

Purpose

We developed a computer-based interactive simulation program for teaching contrast reaction management to radiology trainees and compared its effectiveness to high-fidelity hands-on simulation training.

Materials and methods

IRB approved HIPAA compliant prospective study of 44 radiology residents, fellows and faculty who were randomized into either the high-fidelity hands-on simulation group or computer-based simulation group. All participants took separate written tests prior to and immediately after their intervention. Four months later participants took a delayed written test and a hands-on high-fidelity severe contrast reaction scenario performance test graded on predefined critical actions.

Results

There was no statistically significant difference between the computer and hands-on groups’ written pretest, immediate post-test, or delayed post-test scores (p > 0.6 for all). Both groups’ scores improved immediately following the intervention (p < 0.001). The delayed test scores 4 months later were still significantly higher than the pre-test scores (p ≤ 0.02). The computer group's performance was similar to the hands-on group on the severe contrast reaction simulation scenario test (p = 0.7). There were also no significant differences between the computer and hands-on groups in performance on the individual core competencies of contrast reaction management during the contrast reaction scenario.

Conclusion

It is feasible to develop a computer-based interactive simulation program to teach contrast reaction management. Trainees that underwent computer-based simulation training scored similarly on written tests and on a hands-on high-fidelity severe contrast reaction scenario performance test as those trained with hands-on high-fidelity simulation.     

Arthroscopic diagnosis and treatment of septic arthritis of the hip joint

Septic arthritis of the hip joint can be difficult to detect clinically and usually requires a formal arthrotomy for adequate drainage and debridement of the joint. This case report presents a patient for whom the diagnosis and treatment were performed arthroscopically. This technique allows isolation of the organism as well as the opportunity to irrigate, lavage, and debride the joint through a small puncture wound only.     

Correction of the overshortened nose

Excessive shortening of the nose is often successfully corrected by the undermining or release of the soft tissue lining. It may also need free cartilage grafts to the tip columella or septum to supplement this release of the soft tissue liming and to prevent recurrent retraction.In extreme cases there is a shortage of lining as well as cartilage. Such cases may be successfully treated with the use of a composite graft taken from the concha of the ear with skin lining preserved on both sides.     

Pitfalls and progress in the management of abdominal aortic aneurysms

Based on a review of the literature and 241 cases of abdominal aortic aneurysm (AAA) operated at the Mannheim Surgical Clinic, the progress and pitfalls in the management of this lesion are discussed. Progress in diagnosis is based on noninvasive imaging procedures, e.g., ultrasound, which lead to the detection of more aneurysms before they rupture. Ultrasound also plays a role in the observation of small asymptomatic aneurysms in high-risk patients, helping some to avoid operation as well as rupture. Progress in the treatment of AAA means simplification: rapid clamping of the aorta in case of rupture, minimal dissection, and aneurysmal repair with straight-tube interposition by the inlay technique. The pitfalls of trash foot, colon, or renal ischemia as well as graft infection can be mostly circumvented by observance of technical detail. In this series, the mortality following repair of asymptomatic AAA was 3.7%; for symptomatic aneurysms, it was 8%; and for ruptured aneurysms, it amounted to 55%.

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Resumen En este resumen se discuten los avances y peligros en el manejo del aneurisma de la aorta abdominal, con base en la revisión de la literatura y el análisis de 241 casos de pacientes con esta lesión operados en la Clínica Quirúrgica de Mannheim.Los avances en el diagnóstico se fundamentan en los procedimientos de diagnóstico no invasivos por imágenes, tales como el ultrasonido, que hacen posible la detección de números crecientes de aneurismas antes de su ruptura. El ultrasonido también es de importancia en la observación y seguimiento de aneurismas pequenos y asintomáticos en pacientes de alto riesgo, con lo cual se logra evitar la operación en algunos y la ruptura en otros.El avance en el tratamiento de los aneurismas de la aorta abdominal ha sido logrado con la simplificación de la técnica operatoria, tanto en los aneurismas rotos, como en las operaciones electivas: oclusión rápida de la aorta en caso de ruptura, mínima disección, y reparación mediante la interposición de una prótesis tubular sobre el lecho del aneurisma. Los peligros y complicaciones que representan la isquemia en parches del pie (trash foot syndrome) probablemente producida por embolización de pequeños fragmentos de material trombótico, la isquemia del colon y del riñón, y la infection del injerto, pueden ser evitadas mediante cuidadosa observación de los detalles técnicos.Esta serie comprende 183 operaciones electivas, 108 para aneurismas asintomáticos y 75 para aneurismas sintomáticos, y 58 operaciones de urgencias por aneurismas rotos, un total de 241 pacientes (228 hombres y 13 mujeres) intervenidos entre enero de 1973 y agosto de 1987. La mortalidad fue de 3.7% para los aneurismas asintomáticos, 8% para los sintomáticos, y 55% para los aneurismas rotos.

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Résumé Se basant sur une revue de la littérature et sur 241 cas d'anévrismes de l'aorte abdominale (AAA), opérés dans la Clinique Chirurgicale de Mannheim, les progrès et les échecs dans le traitement de ce type de lésion sont discutés.Les progrès dans le diagnostic sont basés sur les méthodes d'investigation non invasives, c'est-à-dire, l'échographie, qui permet de détecter de plus en plus d'anévrismes avant leur rupture. L'échographie joue un rôle important dans la surveillance des anévrismes de petite taille, asymptomatiques, chez le patient à haut risque, ce qui aide à éviter l'intervention en même temps que la rupture.Les progrès dans le traitement des AAA proviennent de la simplification: clampage rapide de l'aorte en cas de rupture, dissection minime et réparation de l'anévrisme par la technique de mise à plat et interposition par un tube droit. Les conséquences néfastes comme le pied poubelle, l'ischémie colique ou rénale, ainsi que l'infection de la prothèse peuvent être évitées le plus souvent en observant une technique parfaite.Dans cette séries, la mortalité après réparation d'un AAA asymptomatique était de 3.7%, d'un AAA symptomatique, de 8%, et d'une rupture d'AAA, de 55%.

     

Abdominoperineal excision of the rectum—An endangered operation

PURPOSE: This study was undertaken to test the efficacy of an extreme policy of sphincter conservation by combining precise total mesorectal excision with low stapling techniques and endoluminal lavage to guard against implantation. METHODS: A total of 136 consecutive operations for cancer below 5 cm from the anal verge has been prospectively documented and followed for a mean of 7.7 (range, 1–18) years. A total of 105 of the operations were anterior resections (77 percent), and 31 were abdominoperineal excisions (23 percent). RESULTS: The oncologic results in the 105 patients who underwent anterior resections appear greatly superior to those of the patients who underwent abdominoperineal excisions, although the number of abdominoperineal excisions was small (31). Actuarial local recurrence at six years for anterior resection and total mesorectal excision was 1 percent for 85 curative procedures and 4 percent for all cases (n=100), compared with 33 and 47 percent for abdominoperineal excisions (n=15 and 31). Only four recurrences were observed below the level of the levators, three in the wound of an abdominoperineal excision and one in a stapled anastomosis after a palliative excision. No cases of nodal metastasis in the ischiorectal fossa were observed. CONCLUSION: In a unit specializing in sphincter conservation, precise total mesorectal excision from above appears oncologically superior to abdominoperineal excision. Three-fourths of patients with carcinoma of the lower one-third of the rectum can be offered sphincter-conserving surgery, although temporary defunctioning is probably prudent in such cases. The wound of an abdominoperineal excision may be a prerequisite for perineal recurrence, which may often be caused by implantation.Supported by the Wessex Cancer Trust and United States Surgical Corporation, Norwalk, Connecticut.Norman Nigro Research Lectureship at the meeting of the American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.