Laparoscopic radical prostatectomy: six months of fellowship training doesn't prevent the learning curve when incorporating into a lower volume practice

IntroductionTo assess whether 6 months of standard laparoscopic radical prostatectomy (LRP) training reduces the learning curve.MethodsA single urologist (JAB) performed two 3-month fellowships at medical centers with high-volume LRP surgeons (Thomas Jefferson University, 2002 and Massachusetts General Hospital, 2003). He participated in 29 transperitoneal and 23 extraperitoneal LRPs, performing part or all (2) of 28 cases. He subsequently initiated a LRP program at our institution in July 2003, performing 32 procedures between July 2003 and June 2006 (excluding a 3-month 2004 robotic surgery sabbatical). Six residents served as assistant.ResultsMedian patient age, BMI, and preoperative PSA were 58 (46–71) years, 30 (21–37), and 5.4 (3.2–13.6) ng/ml, respectively. Median estimated blood loss (EBL) and operative time were 400 (50–1700) ml and 411 (282–652) minutes. Median hospital stay, catheterization, and follow-up were 2 (1–12) days, 15 (8–52) days, and 10 (1–30) months, respectively. Ten (31%) and 6 (19%) underwent pelvic lymphadenectomy and open conversion. Five patients (16%) received transfusion. Twenty-three (72%) were pathologic stage pT2 and 9 (28%) pT3. Thirteen, 15, and 3 specimens were Gleason 6, 7, and ≥8, respectively. Fifteen (47%) had positive surgical margins (14 apical and 7 other sites). Nineteen (59%) had complications and 4 (12.5%) salvage radiation therapy. Of 20 patients followed 12 months, 12 (60%) are continent (pad free) and 4 (27%) potent patients remain so with or without PDE5 inhibitor.ConclusionSix months of training (52 cases, 28 as surgeon for part or all) did not alleviate the LRP learning curve.     

Postoperative analgesia after total hip arthroplasty: patient-controlled analgesia versus transdermal fentanyl patch

STUDY OBJECTIVE: To determine whether a new transdermal fentanyl patch (TFP) is a good choice for the postoperative pain management of patients undergoing primary total hip arthroplasty compared with patient-controlled analgesia (PCA). DESIGN: Randomized, prospective study. SETTING: University hospital. PATIENTS: 30 patients undergoing primary total hip arthroplasty. INTERVENTIONS: Patients received either a TFP (group T; Duragesic 50 microg/h, matrix fentanyl patch, Janssen-Cilag) applied approximately 10 hours before induction of general anesthesia and PCA programmed in the postanesthesia care unit (PACU), or PCA programmed in the PACU (group P). MEASUREMENTS: Intraoperative sufentanil and additional postoperative morphine administration were recorded, as well as visual analog scores and routine vital signs at predetermined intervals during the first 48 hours. MAIN RESULTS: Morphine consumption on arrival in the PACU was 3.5+/-3 mg in group T versus 13+/-5 mg in group P (P<0.0001). Visual analog scores on arrival in the PACU were 37+/-22 mm in group T versus 73+/-13 mm in group P (P<0.0001). Cumulative morphine consumption at the 24th hour was 43+/-16 mg in group P and 4+/-3 mg in group T (P<0.0001). Cumulative morphine consumption at the 48th hour was 54+/-26 mg in group P and 5+/-4 mg in group T (P<0.0001). Intraoperative sufentanil consumption was 38+/-15 microg in group T versus 30+/-5 microg in group P (not significant). The sedation score was 0 in both groups during the first 48 postoperative hours. CONCLUSIONS: Preoperative TFP application decreases pain scores and morphine consumption in the PACU and appears to have prolonged effects spanning the first 48 postoperative hours.     

Radiologic case study. Abrasion chondroplasty mimicking avascular necrosis

Arthroscopic abrasion arthroplasty, subchondral drilling, and microfracture continue to be performed with some frequency in younger patients with focal chondral defects and occasionally for patients with moderate degenerative knee arthritis. The plain radiographic appearance after those procedures may mimic avascular necrosis, but MRI is a sensitive method used to exclude the diagnosis of avascular necrosis and evaluate the extent to which fibrocartilaginous repair tissue has formed. When combined with an appropriate clinical history, dedicated articular cartilage imaging sequences improve the sensitivity and specificity that MRI provides in these patients with chondral knee injuries.     

Greater trochanteric preserving hip arthroplasty in the treatment of infantile septic arthritis: long-term results

Background  

Balanced forces around the hip joint are critical for normal development of the hip joint, so it should be considered in every hip reconstructive procedure.     

Is the structure of anatomy curriculum adequate for safe medical practice?

IntroductionAnatomy has been considered a core subject within the medical education curriculum. In the current setting of ever-changing diagnostic and treatment modalities, the opinion of both students and trainers is crucial for the design of an anatomy curriculum which fulfils the criteria required for safe medical practice.MethodsMedical students, trainees and specialist trainee doctors and specialists from the London (England) area were surveyed to investigate the how curriculum changes have affected the relevance of anatomical knowledge to clinical practice and to identify recommendations for optimum teaching methods. The survey employed 5-point Likert scales and multiple-choice questions. Where the effect of training level was statistically significant (p < 0.05), post-hoc analysis was carried out using Mann–Whitney U tests. Significance levels were modified according to the Bonferroni method.ResultsTwo hundred and twenty-eight individuals completed the survey giving a response rate of 53%. Medical students, trainees and specialists all agreed (mean Likert score 4.51, 4.79, 4.69 respectively) that knowledge of anatomy is important for medical practice. Most of the trainees (88.4%) and specialists (81.3%) used dissection to learn anatomy, but only 61.4% of medical students used this approach. Dissection was the most commonly recommended approach for learning anatomy across all the groups (41.7%–69.3%).ConclusionsKnowledge of anatomy is perceived to be important for safe clinical practice. Anatomy should be taught with other relevant system or clinical modules. Newer tools for anatomy teaching need further validation before incorporation into the curriculum.     

Predicting iatrogenic gall bladder perforation during laparoscopic cholecystectomy: a multivariate logistic regression analysis of risk factors

BACKGROUND: Seventeen independent risk factors were examined using multivariate logistic regression analysis to develop a profile of patients most likely at risk from iatrogenic gall bladder perforation (IGBP) during laparoscopic cholecystectomy. METHODS: Since 1989, a prospectively maintained database on 856 (women, 659; men, 197) consecutive laparoscopic cholecystectomies by a single surgeon (R. J. F.) was analysed. The mean age was 48 years (range, 17-94 years). The mean operating time was 88 min (range, 25-375 min) and the mean postoperative stay was 1 day (range, 1-24 days). There were 311 (women, 214; men, 97) IGBP. Seventeen independent variables, which included sex, race, history of biliary colic, dyspepsia, history of acute cholecystitis, acute pancreatitis and jaundice, previous abdominal surgery, previous upper abdominal surgery, medical illness, use of intraoperative laser or electrodiathermy, performance of intraoperative cholangiogram, positive intraoperative cholangiogram, intraoperative common bile duct exploration, presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively and success of the operation, were analysed using multivariate logistic regression for predicting IGBP. RESULTS: Multivariate logistic regression analysis against all 17 predictors was significant (chi(2) = 94.5, d.f. = 17, P = 0.0001), and the variables male sex, history of acute cholecystitis, use of laser and presence of a grossly inflamed gall bladder as seen by the surgeon intraoperatively were individually significant (P < 0.05) by the Wald chi(2)-test. CONCLUSION: Laparoscopic cholecystectomy, using laser, in a male patient with a history of acute cholecystitis or during an acute attack of cholecystitis is associated with a significantly higher incidence of IGBP.     

Association between preeclampsia and prostasin polymorphism in Pakistani females

Objectives:To investigate the relationship between a prostasin gene variations and the development of preeclampsia in a Pakistani female population.Methods:This was a case-control study carried out at University of Karachi, Karachi, Pakistan between May 2018 and 2019. A single nucleotide polymorphism (SNP) at rs12597511 locus was examined with polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) analyses in 76 preeclamptic and 74 normotensive expecting mothers.Results:We observed significantly increased risk of preeclampsia associated with the CC genotype of rs12597511 polymorphism as compared to TT (p<0.001, OR=8.08, 95% CI:1.28-31.19) and TT/TC (p<0.001, OR=14.66 and 95% CI: 3.31-65.07) genotypes carriers. Calculation of the allelic distribution revealed a higher frequency of the T allele (82%) among controls; however, the C allele was more prevalent in the preeclamptic group (36%) significantly.Conclusion:The significantly higher C allele frequency in the prostasin gene at the rs12597511 locus in the preeclamptic group indicates that the distribution of the C allele of the prostasin gene is a potential risk factor contributing to the development of preeclampsia.     

Pagetoid reticulosis (Woringer‐Kolopp disease)

Pagetoid reticulosis (Woringer‐Kolopp disease) is a rare subtype of cutaneous CD8‐positive T‐cell lymphoma. A 41‐year‐old man presented with a 7‐year history with a slowly progressive erythematous plaque on his right buttocks. With the working diagnosis of psoriasis, he was treated with topical corticosteroids which produced no improvement. Histological examination showed an epidermotropic T‐cell lymphoma with predominance of CD8‐ vs.CD4‐positive lymphocytes. Based on the clinical picture and the histological findings, we diagnosed pagetoid reticulosis. Excision of the plaque and cream PUVA photo‐chemotherapy produced long‐term remission.     

Neurotrophic factors minimize the retinal toxicity of verteporfin photodynamic therapy

PURPOSE: A prior study showed that brain-derived neurotrophic factor (BDNF) rescues photoreceptors from collateral retinal damage caused by photodynamic therapy (PDT). This study was conducted to determine whether ciliary neurotrophic factor (CNTF), a combination of BDNF and CNTF, or pigment epithelial cell-derived growth factor (PEDF) might protect photoreceptors and retinal function more effectively than BDNF. Also investigated was whether protection would be observed after a second round of PDT with adjunctive BDNF treatment. METHODS: Normal rats received intravitreal injections of BDNF, CNTF, a combination of BDNF and CNTF, or PEDF in one eye and PBS in the other 2 days before PDT. Retinal function and photoreceptor survival were assessed with multifocal ERG (mfERG) and histology 1 week after PDT. Another group of rats received two courses of PDT 3 months apart, with injection of BDNF 2 days before each treatment. RESULTS: All factors significantly increased photoreceptor survival. The combination of BDNF and CNTF rescued more photoreceptors than either factor alone. Only BDNF improved retinal function 1 week after PDT, with CNTF and the combination of BDNF and CNTF reducing mfERG responses. BDNF injection before a second round of PDT improved mfERG responses and retinal structure. CONCLUSIONS: BDNF is the most effective single factor among those tested for neuroprotection and improvement of retinal function after PDT, although a combination of BDNF and CNTF rescues more photoreceptors. Adjunctive treatment with BDNF also protects retinal structure and function through two rounds of PDT, suggesting its potential value for patients who require multiple treatments.