“GIOSAT”: a tool to assess CanMEDS competencies during simulated crises

Purpose

Our objective was to develop and evaluate a Generic Integrated Objective Structured Assessment Tool (GIOSAT) to integrate Medical Expert and intrinsic (non-medical expert) CanMEDS competencies with non-technical skills for crisis simulation.

Methods

An assessment tool was designed and piloted using two pediatric anesthesia scenarios (laryngospasm and hyperkalemia). Following revision of the tool, we used previously recorded videos of anesthesia residents (n = 50) who managed one of two intraoperative advanced cardiac life support (ACLS) scenarios (ventricular tachycardia or ventricular fibrillation). Four independent trained raters, blinded to the residents’ level of training, analyzed the video recordings using the GIOSAT scale. Inter-rater reliability was calculated using intraclass correlations (ICCs) for single raters (single measure) and the average of the four raters (average measure), and construct validity was investigated by correlating GIOSAT scores with postgraduate year of residency (PGY).

Results

Total GIOSAT scores for the ACLS scenarios had single measure ICCs of 0.62 and average measure ICCs of 0.85. Inter-rater reliability was substantial for both Medical Expert and intrinsic competencies (single measure ICCs 0.69 and 0.62, respectively; average measure ICCs 0.90 and 0.82, respectively). We found significant correlations between PGY level and total GIOSAT score (r = 0.36; P = 0.011) and between PGY level and Medical Expert competencies (r = 0.42; P = 0.003); however, correlations were not found between PGY level and intrinsic CanMEDS competencies (r = 0.24; P = 0.09).

Conclusion

Inter-rater reliability of the total GIOSAT scores using four trained raters was substantial. Significant correlation between PGY and (i) total GIOSAT score and (ii) Medical Expert competencies supports construct validity. Evidence of validity was not obtained for intrinsic CanMEDS competencies.     

Comparison between single-incision and conventional laparoscopic cholecystectomy: a prospective trial of the Club Coelio

Background

The aim of this study was to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC).

Method

Patients’ inclusion criteria were uncomplicated gallstones, BMI ≤30, ASA score ≤2, and no past surgery in the upper abdomen. Five surgeons performed only SILC and seven only CLC. Data analyzed included operative time, morbidity, quality of life (QOL), cosmetic result, and global patient satisfaction. The last three parameters were evaluated 3 months after surgery. QOL was assessed with the Gastrointestinal Quality of Life Index (GIQLI) questionnaire. Cosmetic result and patient satisfaction were rated using a 5-grade Likert scale.

Results

This study included 104 patients operated on between April and June 2010. A SILC was performed in 35 patients and a CLC in 69. The preoperative characteristics of the two groups were similar. Median operative time for SILC was higher than that for CLC: 55 versus 40 min (p < 0.001). Postoperative complications (0 vs. 2) and postoperative GIQLI scores (123 ± 13 vs. 121 ± 18) were not significantly different between groups. Cosmetic result and patient satisfaction were better for SILC than for CLC. The percentages of results rated as excellent were 68 versus 37 % (p < 0.006) and 80 versus 57 % (p < 0.039), respectively. For the whole group, multivariate statistical analysis revealed that postoperative GIQLI score and cosmetic result were independent predictive factors of patient satisfaction. The percentages of satisfaction rated as excellent were greater in patients who had a postoperative GIQLI score ≥130 (92 vs. 49 %, odds ratio [OR] = 4, p < 0.001) and in patients who had an excellent cosmetic result (82 vs. 47 %, OR = 7, p < 0.001).

Conclusions

Compared to CLC, SILC is associated with a longer operative time, an equivalent morbidity and QOL, and a better cosmetic result. The improved aesthetic result also leads to a better global patient satisfaction.     

“Plasma Cell Hepatitis” in Liver Allografts: Identification and Characterization of an IgG4‐Rich Cohort

Plasma cell hepatitis (PCH), also known as “de novo autoimmune” hepatitis, is an increasingly recognized, but suboptimally named and poorly understood, category of late allograft dysfunction strongly resembling autoimmune hepatitis (AIH): They share plasma‐cell‐rich necro‐inflammatory activity on biopsy, autoantibodies and steroid responsiveness, but overlap with rejection is problematic. A retrospective study of clinical, serological, histopathological and IgG4 immunohistological features of PCH (n = 20) in liver allograft recipients, native liver AIH (n = 19) and plasma‐cell‐rich renal allograft rejection (n = 20) showed: (1) high frequency (44%) of HLA‐DR15; (2) less female predominance (p = 0.03) and (3) n = 9/20 PCH recipients showed >25 IgG4+ plasma cells/high‐power field (IgG4+ PCH) versus AIH (n = 1/19, p = 0.008) or plasma‐cell‐rich kidney rejection (n = 2/20, p = 0.03). The IgG4+ PCH (n = 9) subgroup showed lower alanine transaminase (ALT) (p < 0.01) and aspartate transaminase (AST) (p < 0.05) at index biopsy but (a) higher plasma cell number/percentage, (b) more aggressive‐appearing portal/periportal and perivenular necro‐inflammatory activity and (c) more severe portal/periportal fibrosis than IgG4? PCH (n = 11). Significant demographic, histopathologic and plasma cell phenotype differences between PCH and AIH suggest distinct pathogenic mechanisms for at least the IgG4+ PCH subgroup likely representing an overlap between allo‐ and auto‐immunity. IgG4+ PCH was associated with fibrosis, but also highly responsive to increased immunosuppression.

     

Vascular effects of nonsteroidal antiinflammatory drugs

The effect of nonsteroidal antiinflammatory drugs (NSAIDs) on the risk of cardiovascular events remains controversial. Among NSAIDs, only low-dose aspirin exerts protective vascular effects. Low-dose aspirin has been proven effective for secondary prevention. For primary prevention, the usefulness of low-dose aspirin is debated, as illustrated by the differences in recommendations across countries. NSAIDs other than aspirin, whether COX-2 selective or nonselective, increase the risk of cardiovascular events. Among them, naproxen is associated with the smallest risk increase. In patients with a history of coronary artery disease, diclofenac seems to carry the greatest risk, but all NSAIDs should be avoided. Uncertainties persist about aspirin interactions with other NSAIDs and with proton pump inhibitors. An adverse effect of acetaminophen on the risk of cardiovascular disease cannot be completely ruled out.     

Convergent Validity Analysis between the Profile of Emotional Competences Full-Form and the Trait Emotional Intelligence Questionnaire Full-Form

International Journal of Mental Health and Addiction - Emotional dispositions have been found to influence outcomes and have applications in many areas, such as in the clinical, health, social,...     

Minimally invasive surgery versus percutaneous radio frequency ablation for the treatment of single small (≤3 cm) hepatocellular carcinoma: a case–control study

Background

Patients with single small hepatocellular carcinoma (HCC) can be managed by surgical resection or radio frequency ablation (RFA), with similar recurrence and survival rates. Recently, minimally invasive surgery (MIS) has been introduced in liver surgery, and the advantage/drawback balance between surgery and RFA needs reassessment.

Methods

Patients with Child-Pugh class A or B cirrhosis, and with single 1–3 cm HCC, undergoing MIS (laparoscopic or robot-assisted) or RFA from July 1998 to December 2012 were compared.

Results

Overall, 45 patients underwent MIS, and 60 underwent RFA. Groups were not statistically different regarding type of underlying liver disease, HCC size, and AFP. However, RFA patients showed worse liver synthetic function with lower albumin and higher bilirubin serum levels, and higher ASA scores. Patients with HCC in segments 2–6 were more often treated by MIS. The incidence of complications was similar between groups (RFA: 6/60, 10 % vs. MIS: 5/45, 11 %, p = 0.854), and there was no measurable difference in the rate of procedure-related blood transfusions (RFA: 1/60, 1.7 % vs. MIS: 3/45, 6.7 %, p = 0.185). Local recurrence was only detected after RFA (11.7 %, p = 0.056, log-rank). Overall survival was higher in the MIS group (p = 0.042), with median survivals of 100 ± 13.5 versus 68 ± 15.9 months.

Conclusion

The present data need further validation. Selected patients with single ≤3-cm HCCs can be safely treated by MIS, without increased risk of perioperative complication, and with a lower risk of local recurrence. MIS should be especially favoured in patients with peripheral HCCs in segments 2–6, and/or when a histological assessment is desirable.