Participants' opinions of laparoscopic training devices after a basic laparoscopic training course

BACKGROUND: Basic laparoscopic skills are initially best taught and practiced in an inanimate setting. Various devices are used to aid in this education of laparoscopic skills. These devices range from simple box trainers to sophisticated virtual reality trainers. This investigation tested the hypothesis that participants would prefer one trainer to another trainer. METHODS: Preclinical medical students volunteered for this study. All underwent a porcine laboratory. The students were then divided into 3 groups by method of training: group A--a virtual reality trainer (MIST-VR), group B--an inanimate box trainer (LTS 2000), and group C--both trainers. Each group participated in 10 laboratories with the assigned trainer(s). After completion of the laboratories, all students underwent a similar porcine laboratory. During this laboratory, opinions of each trainer and specific tasks were ascertained from each student. RESULTS: No statistical difference was seen between groups A and B when asked if their specific trainer helped their skills, was realistic, helped in the animal laboratory, and was interesting. When group C was asked the same questions about each trainer, no statistical difference was seen except that 47% thought the MIST-VR was not realistic as opposed to 0% who thought the LTS 2000 was not realistic (P <.003). The level of difficulty of each task correlated with how much the specific task helped in development of skills for both trainers (P <.0001). In group C, 89% of the participants thought the LTS 2000 helped more that the MIST-VR and 56% thought the LTS 2000 was more interesting than the MIST-VR. In addition, 83% of students in group C chose LTS 2000 when asked to pick only one trainer. CONCLUSIONS: While virtual reality trainers may have some advantages, most participants feel that inanimate box trainers help more, are more interesting, and should be chosen over virtual reality trainers if only one trainer is allowed. Further studies need to investigate if the opinions affect participants' utilization of these trainers.     

Preoperative Carbohydrate "Addiction" Does Not Predict Weight Loss after Laparoscopic Gastric Bypass

Background: Weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies. Dietary habits that exist preoperatively may continue after surgery and affect weight loss. This study investigated the hypothesis that preoperative carbohydrate addiction would predict weight loss after laparoscopic gastric bypass. Methods: 104 consecutive patients in our LRYGBP program were included in the study. A preoperative survey was used to determine level of carbohydrate craving. This survey was scored from 0 to 60. A higher score indicated a higher level of carbohydrate addiction. Percentage of excess weight loss (%EWL) was determined after at least 1 year postoperatively in all patients. Results: Data were available in 95 (91%) of the patients. There was no correlation seen between level of carbohydrate addiction and %EWL at 1 year (r=0.02; P=NS). In addition, we looked at patients with successful weight loss (>50% %EWL; n=83) versus those patients who were considered unsuccessful (<50% EWL; n=12). There was no statistical difference in the level of preoperative carbohydrate craving between these 2 groups (36±13 vs 33±15; P=NS). Conclusions: Consistently large carbohydrate intake preoperatively does not predict weight loss after LRYGBP. High level of carbohydrate addiction is not a contraindication to LRYGBP.     

Vitamin and Trace Mineral Levels after Laparoscopic Gastric Bypass

Background: Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results. Results: Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B₁₂ 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%. Conclusions: Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.     

Laparoscopic Revision of the Gastrojejunostomy for Recurrent Bleeding Ulcers after Past Open Revision Gastric Bypass

Late complications of open gastric bypass can include malnutrition, weight gain, stomal stenosis, and recurrent bleeding ulcers. Herein, we describe the case of a woman who had recurrent bleeding ulcers, after an open revision of a stenotic gastric bypass. She now underwent an uneventful laparoscopic revision of her gastrojejunostomy and was discharged within 72 hours. Laparoscopic revision of a gastrojejunostomy, even after an open revision following an open gastric bypass, can be done safely.     

Viral hepatitis in India

Viral hepatitis is a major public health problem in India, which is hyperendemic for HAV and HEV. Seroprevalence studies reveal that 90%-100% of the population acquires anti-HAV antibody and becomes immune by adolescence. Many epidemics of HEV have been reported from India. HAV related liver disease is uncommon in India and occurs mainly in children. HEV is also the major cause of sporadic adult acute viral hepatitis and ALF. Pregnant women and patients with CLD constitute the high risk groups to contract HEV infection, and HEV-induced mortality among them is substantial, which underlines the need for preventive measures for such groups. Children with HAV and HEV coinfection are prone to develop ALF. India has intermediate HBV endemicity, with a carrier frequency of 2%-4%. HBV is the major cause of CLD and HCC. Chronic HBV infection in India is acquired in childhood, presumably before 5 years of age, through horizontal transmission. Vertical transmission of HBV in India is considered to be infrequent. Inclusion of HBV vaccination in the expanded programme of immunization is essential to reduce the HBV carrier frequency and disease burden. HBV genotypes A and D are prevalent in India, which are similar to the HBV genotypes in the West. HCV infection in India has a population prevalence of around 1%, and occurs predominantly through transfusion and the use of unsterile glass syringes. HCV genotypes 3 and 2 are prevalent in 60%-80% of the population and they respond well to a combination of interferon and ribavirin. About 10%-15% of CLD and HCC are associated with HCV infection in India. HCV infection is also a major cause of post-transfusion hepatitis. HDV infection is infrequent in India and is present about 5%-10% of patients with HBV-related liver disease. HCC appears to be less common in India than would be expected from the prevalence rates of HBV and HCV. The high disease burden of viral hepatitis and related CLD in India, calls for the setting up of a hepatitis registry and formulation of government-supported prevention and control strategies.     

Anterior chamber collapse following vitreoretinal surgery with gas tamponade in aphakic eyes: incidence and risk factors

PURPOSE: To report the risk factors associated with occurrence of anterior chamber collapse in aphakic eyes that underwent vitrectomy with gas tamponade. METHODS: A total of 314 eyes of 314 patients who underwent vitrectomy with gas tamponade and who were aphakic or were made aphakic intraoperatively were studied prospectively. Factors such as iris and pupillary integrity, depth of anterior chamber, gonioscopic grading, behavior of the anterior chamber on the operation table during fluid-air exchange, removal of crystalline lens or intraocular lens during surgery, and type of internal tamponade were noted. The anterior chamber was assessed postoperatively in supine and sitting position and with head bent forward. Statistical methods were used to identify risk factors for development of postoperative anterior chamber collapse using SPSS soft ware. RESULTS: Anterior chamber collapse occurred in 13 eyes (3.14%). Presence of preoperative shallow anterior chamber, removal of intraocular lens as a part of the procedure, occurrence of intraoperative anterior chamber collapse, and use of sulfur hexafluoride (SF6) were associated with higher risk of anterior chamber collapse postoperatively. CONCLUSIONS: The identification of potential risk factors in a given eye can alert the surgeon to the possibility of development of anterior chamber collapse postoperatively.     

Barriers to acceptance of intervention among patients with trachomatous trichiasis or entropion presenting to a teaching hospital

PURPOSE: To determine the barriers to therapeutic intervention in patients with trachomatous trichiasis or entropion. METHODS: Prospective study over one year in 60 patients with trachomatous trichiasis or entropion presenting to a teaching hospital. The outcome measure was reported barriers to uptake of intervention using a questionnaire. The data were analysed using chi-square and Fisher's exact tests. Patient characteristics were correlated with barriers using univariate and multivariate analysis. RESULTS: The major barriers (operative in > 60% of patients) were illiteracy (66.7%), ignorance regarding treatment (65.0%), and fear of surgery (63.3%). Duration of symptoms in 43 females and 17 males ranged from 0.5 to 240 months (mean 30.2 +/- 45.82). Females reported significantly more barriers (average 5.8 +/- 1.88) than males (average 4.6 +/- 1.97; p = 0.03). Shorter duration was significantly related to perceived expense (p = 0.008). Patients aged =55 years more often cited young children as a barrier (p = 0.02). CONCLUSIONS: Encouraging patients who have undergone intervention to share their experiences with community members, providing intervention in patients' villages, community involvement with patients who live alone and making gender-sensitive medical programmes might be useful in reducing the fear of surgery and enhancing awareness and uptake of intervention. Future studies must identify barriers in their regions so that attempts can be directed to overcoming them so as to reduce the blinding and non-blinding burden of trachoma.     

Vitamin D receptor ligands for osteoporosis

1alpha,25-Dihydroxyvitamin D3 (1,25-(OH)2D3), the biologically active metabolite of vitamin D, mediates its actions via the vitamin D receptor (VDR), a member of the superfamily of steroid/thyroid hormone/retinoid receptors. 1,25-(OH)2D3 is required for calcium and phosphorus homeostasis, and for normal skeletal development as well as maintenance of skeletal architecture. Two VDR ligands, calcitriol (1,25-(OH)2D3) and its synthetic analog alfacalcidol (1alpha-hydroxyvitamin D3), have been approved for the treatment of osteoporosis. However, the use of calcitriol and alfacalcidol is limited by their major side effect, hypercalcemia, which is mediated mainly by VDR activity in the small intestine. In order to identify VDR ligands with less hypercalcemia liability, a number of pharmaceutical companies are pursuing efforts to develop synthetic vitamin D analogs. This review discusses the mechanism of action of vitamin D, and summarizes the currently approved anti-osteoporotic VDR agonists and compounds that are under development. The future directions of vitamin D research for the discovery of novel VDR agonists for osteoporosis are also discussed.     

Transcriptional profiling of keratinocytes reveals a vitamin D-regulated epidermal differentiation network

1alpha,25-dihydroxyvitamin D(3) [1,25(OH)(2)D(3)] regulates mineral homeostasis and exhibits potent anti-proliferative, prodifferentiative, and immunomodulatory activities. It mediates these effects by binding to the vitamin D receptor (VDR), which belongs to the superfamily of steroid/thyroid hormone nuclear receptors. As a result of keratinocyte differentiation and anti-proliferation activities, 1,25(OH)(2)D(3) and its synthetic analogs are therapeutically effective in psoriasis and show promise for the treatment of actinic keratosis and squamous cell carcinoma. To elucidate the VDR signaling pathway in keratinocytes, we examined the gene expression profile with 1,25(OH)(2)D(3) treatment using oligonucleotide microarrays. Out of the 12,600 genes investigated, 82 were upregulated and 16 were downregulated and many of these were involved in differentiation, proliferation, and immune response. We have identified three vitamin D-responsive chromosomal loci (1p36, 19q13, and 6p25) and show the induction of various class II tumor suppressor/growth-regulatory genes in response to 1,25(OH)(2)D(3). Finally, quantitative differences in gene expression revealed a vitamin D-regulated differentiation network and identified peptidylarginine deiminases, kallikreins, serine proteinase inhibitor family members, Kruppel-like factor 4, and c-fos as vitamin D-responsive genes, whose protein products may play an important role in epidermal differentiation in normal and diseased state.