Laparoscopic Suturing Skills Acquisition: A Comparison Between Laparoscopy-Exposed and Laparoscopy-Naive Surgeons

Background:

Laparoscopic suturing is a difficult skill to master but can be acquired with extensive training outside the operating room. This study was done with the primary aim of assessing whether prior exposure to laparoscopic surgery helped trainees in acquiring laparoscopic suturing skills more quickly than trainees with no prior exposure to laparoscopic surgery.

Materials and Methods:

Twenty laparoscopy-exposed and 20 laparoscopy-naïve surgeons performed 5 laparoscopic gastrojejunostomies each on a phantom porcine model. The performance was evaluated for operation time, overall anastomotic score (calculated by adding scores of anastomotic leak, size of the anastomosis, suture placement, and mucosal approximation), and the level of difficulty. The performance at the beginning of training (baseline) was compared to the performance at the end of training.

Results:

All participants showed statistically significant improvement in operation time, overall anastomotic score, and difficulty level. Laparoscopy-exposed surgeons had a significantly better operation time than laparoscopy-naïve surgeons at the beginning of training; however, the difference became insignificant by the end of training. The difference in overall anastomotic score was not significant between laparoscopy-exposed and naïve-surgeons. Laparoscopy-exposed surgeons showed significant improvements in anastomotic leak rate and size of the anastomosis, whereas laparoscopy naïve surgeons showed improvements in all the parameters, although these were not significant statistically.

Conclusion:

Training improves the laparoscopic suturing skills of laparoscopy-exposed as well as laparoscopy-naïve surgeons. Prior experience in laparoscopic surgery does not seem to influence the acquisition of laparoscopic suturing skills as laparoscopic-naïve surgeons manage to catch up with the skills of the laparoscopy-exposed surgeons.     

Kumbh Mela 2013: Healthcare for the millions

Mass gatherings pose challenges to healthcare systems anywhere in the world. The Kumbh Mela 2013 at Allahabad, India was the largest gathering of humanity in the history of mankind, and posed an exciting challenge to the provision of healthcare services. At the finale of the Mela, it was estimated that about 120 million pilgrims had visited the site.Equitable geospatial distribution of adhoc health care facilities were created on a standardised template with integrated planning of evacuation modalities. Innovative and low cost response measures for disaster mitigation were implemented. Emergency patient management kits were prepared and stocked across the health care facilities for crisis response. Dynamic resource allocation (in terms of manpower and supplies) based on patient volumes was done on a daily basis, in response to feedback.An adhoc mega township created on the banks of a perennial river (Ganga) in the Indian subcontinent for accommodating millions of Hindu pilgrims. Conventional mindset of merely providing limited and static healthcare through adhoc facilities was done away with. Innovative concepts such as riverine ambulances and disaster kits were introduced. Managing the medical aspects of a mass gathering mega event requires allocation of adequate funds, proactive and integrated medical planning and preparedness.     

Effect of membrane composition on cytokine production and clinical symptoms during hemodialysis: a crossover study

BACKGROUND: Intradialytic symptoms including hypotension have been reported during dialysis and it has been suggested that these are related to the release of cytokines like IL-1beta and TNFalpha by blood mononuclear cells when they get activated either due to contact with the dialyzer membrane or by compliment activation. OBJECTIVE: To study the relationship between hemodialysis symptoms, cytokine production, and dialyzer membrane composition. METHOD: In a randomized prospective crossover study, 20 ESRD patients on maintenance hemodialysis were studied over cuprophan (CU) and polysulfone (PS) low flux dialyzer membranes for three weeks each undergoing a biweekly dialysis schedule of 4 h sessions. Serial IL-1beta and TNFalpha levels were measured over 0, 15, 240 min during the first use of the dialyzer for all patients on both membranes. Intradialytic symptoms were monitored in a total of 240 dialysis sessions. RESULTS: IL-1beta levels increased from 16.6 +/- 2.2 to 64.8 +/- 25.1 pg/mL on CU and 21.5 +/- 3.7 to 103.5 +/- 30.7 pg/mL on PS membrane over the 4-h dialysis session. Similarly TNFalpha increased from 42.8 +/- 4.5 to 354.9 +/- 80.4 pg/mL on CU and 117.1+/- 53.7 to 387.0 +/- 78.0 pg/mL on PS membrane. IL-1beta levels increased significantly with PS membrane while TNFalpha rise was significant with both the membranes. Nausea was the most common symptom occurring in 138 dialysis sessions (57.5%). Vomiting, chest pain, fever, chills, and breathlessness occurred significantly more during dialysis with CU membrane as compared with PS membrane (P < 0.01). Nausea, cramps, back pain, itching, restlessness, post dialysis fatigue, and hypotension did not differ between the two membranes. The mean rise in the cytokine levels during the first 15 min of sessions where the symptoms occurred, when compared with the mean rise in sessions where the symptoms did not occur, did not reveal any significant difference. Cytokine release did not correlate with the occurrence of intradialytic symptoms. CONCLUSION: Both CU and PS membranes increase circulating cytokine levels. More intradialytic clinical symptoms are seen in dialysis with CU as compared with PS membrane but the rise in cytokines IL-1beta and TNFalpha does not appear to be responsible for them.     

Ex vivo evaluation of dye penetration associated with various dentine bonding agents in conjunction with different irrigation solutions used within the pulp chamber

Aim To compare the effect of sodium hypochlorite (NaOCl), chlorhexidine, povidone iodine and sodium ascorbate on dye penetration associated with various dentine adhesives used within the pulp chamber. Methodology One hundred and sixteen mandibular molar teeth were divided into eight groups of 12 teeth each by irrigation regimen and adhesive system. The roof of pulp chambers and roots were removed under water cooling. The pulp chambers in the experimental groups were irrigated with 5.25% NaOCl, 0.2% chlorhexidine, 5% w/v povidone iodine or 5.25% NaOCl followed by sodium ascorbate and restored with Surefil using either Prime & Bond NT or Xeno III with each irrigation regimen. Twenty teeth were used as control specimens in which no disinfectant was used before bonding. Ten teeth from each group were immersed in 2% methylene blue dye and assessed for dye penetration. The data were statistically analysed by Kruskal–Wallis and Mann–Whitney U‐tests. Two samples in each group were observed under scanning electron microscopy for interfacial gap evaluation. Results No significant difference was found in dye leakage between control and groups with 5.25% NaOCl pretreatment with both adhesive systems. Chlorhexidine and povidone iodine pretreatment resulted in significantly less dye penetration with Xeno III as compared with Prime & Bond NT. Sodium ascorbate treatment following NaOCl application significantly reduced microleakage and improved the marginal adaptation with both adhesive systems. Conclusions The type of irrigant affected the sealing ability of bonding agents inside the pulp chamber and was material specific. Xeno III had less dye penetration with CHX and povidone iodine whilst sodium ascorbate pretreatment after NaOCl reduced dye penetration with both PBNT and Xeno III.     

Von-Recklinghausen’s disease a rare presentation

A rare presentation of Von Recklinghausen’s desease in a 8 year old boy is reported. Disease was confined to right side and involved eye, palate, gingiva, face, and external auditory canal.     

Cavernosography in conjunction with artificial erection for evaluation of venous leakage in impotent men

Twenty men with incomplete penile erection or inability to maintain an erection were evaluated to determine if venous leakage was a cause. Cavernosography was performed in conjunction with artificial erection induced by infusion of saline into the corpus cavernosa. Thirteen patients requiring higher than normal rates of saline infusion to achieve or maintain erection showed filling of superficial veins in the flaccid state as well as during erection. In five of the seven patients with normal saline requirements there was no filling of superficial veins, and two showed filling in the flaccid state only. Of the thirteen patients whose conditions were diagnosed as venous leakage, seven underwent surgical ligation of superficial veins and deep penile vein arterialization by a saphenous vein bypass graft between the superficial femoral artery and deep penile vein. All these patients had reduced saline requirements postoperatively. When cavernosography is performed in the flaccid state only, filling of superficial veins can occur normally; therefore, these studies should be performed with artificial erection.     

Reversible inhibition of oligodendrocyte progenitor differentiation by a monoclonal antibody against surface galactolipids.

We have hypothesized that oligodendrocyte (OL) surface glycolipids, specifically galactocerebroside and sulfatide, play a role in the regulation of OL development by acting as sensors/transmitters of environment information. In support of this hypothesis we report here a reversible inhibition of OL progenitor cell differentiation by a monoclonal antibody [Ranscht mAb (R-mAb); Ranscht, B., Clapshaw, P. A. & Seifert, W. (1982) Proc. Natl. Acad. Sci. USA 79, 2709-2713] that reacts with these glycolipids. When isolated OL progenitors or mixed primary cultures are grown in the presence of the antibody, myelinogenic development is blocked in a dose-dependent manner at concentrations as low as 2 micrograms of IgG per ml. The inhibited cells express the OL progenitor markers O4 and vimentin but are negative for galactosylcerebroside, sulfatide, 2',3'-cyclic nucleotide 3'-phosphohydrolase, myelin basic protein, and myelin basic protein RNA expression. In contrast, the levels of total cellular protein and the expression of astrocytic glial fibrillary acidic protein in mixed cultures are not affected. Antibody-blocked cells have a distinctive morphology in which long, sparsely branched processes emanate from round cell bodies. Upon removing the perturbing antibody, the cells rapidly resume differentiation. Reverted mixed primary cultures, in which OL progenitors of several sequential developmental stages are present at the time of plating, differentiate more rapidly than control cultures, suggesting that the antibody-induced block results in a synchronization of developmental progression along the OL lineage by accumulating cells at the inhibition point. However, the normal temporal sequence of marker expression is maintained. Control studies with several other antibodies recognizing OL cell surface antigens, including HNK-1, neural cellular adhesion molecule (N-CAM), 1A9, anticholesterol, and O1, did not inhibit development. Since the inhibition occurs in highly enriched populations of OL progenitors, the inhibition does not involve cell-cell interactions between OLs and other cell types but concerns interactions of OLs with themselves, soluble factors, or OL extracellular matrix molecules and adhesion factors that provide essential environmental signals required for normal myelinogenic development.