Fund raising, it is argued, needs sophisticated prospect research. Professional prospect researchers play an important role in helping to identify prospective donors and also in helping to stimulate interest in gift giving. A sample of an individual work-up on a donor and a bibliography are provided. (MLW)
Oyamada, Kiyoshi; Ikeda, Takao
This study developed minute estimation by adopting comprehensive sensitivity analytical program for reliability of TRU waste repository concepts in a crystalline rock condition. We examined each components and groundwater scenario of geological repository and prepared systematic bases to examine the reliability from the point of comprehensiveness. Models and data are sophisticated to examine the reliability. Based on an existing TRU waste repository concepts, effects of parameters to nuclide migration were quantitatively classified. Those parameters, that will be decided quantitatively, are such as site character of natural barrier and design specification of engineered barriers. Considering the feasibility of those figures of specifications, reliability is re-examined on combinations of those parameters within a practical range. Future issues are; Comprehensive representation of hybrid geosphere model including the fractured medium and permeable matrix medium. Sophistication of tools to develop the reliable combinations of parameters. It is significant to continue this study because the disposal concepts and specification of TRU nuclides containing waste on various sites shall be determined rationally and safely through these studies. (author)
A sophisticated player is an individual who takes the action of the opponents, in a strategic situation, as determined by decision of rational opponents, and acts accordingly. A sophisticated agent is rational in the choice of his action, but ignores the fact that he is part of a strategic
Discusses the thinking of the Greek Sophist philosophers, particularly Gorgias and Protagoras, and their importance and relevance for contemporary English instructors. Considers the problem of language as signs of reality in the context of Sophist philosophy. (HB)
Wakker, P.P.; Sarin, R.H.
Machina & Schmeidler (Econometrica, 60, 1992) gave preference conditions for probabilistic sophistication, i.e. decision making where uncertainty can be expressed in terms of (subjective) probabilities without commitment to expected utility maximization. This note shows that simpler and more general
Wren, Sherry M; Martin, Molinda; Yoon, Jung K; Bech, Fritz
Postoperative pneumonia can lead to increased morbidity, length of hospital stay, and costs. Pneumonia-prevention programs have been successfully implemented in ICU settings, but no program exists for surgical ward patients. A pilot prevention program was designed and implemented based on literature review. The program consisted of education of physicians and ward staff and a standardized postoperative electronic order set consisting of incentive spirometer, chlorhexidine oral hygiene, ambulation, and head-of-bed elevation. Quarterly staff meetings discussed the results of and compliance with the program. The intervention commenced in April 2007. Baseline incidence of inpatient ward pneumonia was calculated from the National Surgical Quality Improvement Program database for fiscal year (FY) 2006 and FY 2007. Postintervention incidence was calculated in the same manner from FY 2007 through FY 2008. Any patient who contracted pneumonia in the ICU was excluded from analysis. There was a significant decrease in ward pneumonia incidence from 0.78% in the preintervention group compared with 0.18% in the postintervention group (p = 0.006), representing an 81% decrease in incidence from 2006 to 2008. The pneumonia-prevention program was very successful in diminishing postoperative pneumonia on the surgical ward. There was a highly statistically significant 4-fold decrease in pneumonia incidence after program implementation. The interventions were not costly but did require ongoing communication and cooperation between physician and nursing leadership to achieve compliance with the measures. This program has great potential for dissemination to hospital surgical wards and could decrease inpatient postoperative pneumonias. Published by Elsevier Inc.
Allred, Sarah; Duffy, Sean; Smith, John
We study the relationship between the cognitive load manipulation and strategic sophistication. The cognitive load manipulation is designed to reduce the subject's cognitive resources that are available for deliberation on a choice. In our experiment, subjects are placed under a large cognitive load (given a difficult number to remember) or a low cognitive load (given a number which is not difficult to remember). Subsequently, the subjects play a one-shot game then they are asked to recall...
Farrokhyar, Forough; Amin, Nalin; Dath, Deepak; Bhandari, Mohit; Kelly, Stephan; Kolkin, Ann M; Gill-Pottruff, Catherine; Skot, Martina; Reid, Susan
To evaluate whether implementing the formal Surgical Research Methodology (SRM) Program in the surgical residency curriculum improved research productivity compared with the preceding informal Research Seminar Series (RSS). The SRM Program replaced the RSS in July 2009. In the SRM Program, the curriculum in Year-1 consisted of 12 teaching sessions on the principles of clinical epidemiology and biostatistics, whereas the focus in Year-2 was on the design, conduct, and presentation of a research project. The RSS consisted of 8 research methodology sessions repeated annually for 2 years along with the design, conduct, and presentation of a research project. Research productivity was measured as the number of peer-reviewed publications and the generation of studies with higher levels of evidence. Outcome measures were independently assessed by 2 authors to avoid bias. Student t test and chi-square test were used for the analysis. Frequencies, mean differences with 95% CI, and effect sizes have been reported. In this study, 81 SRM residents were compared with 126 RSS residents. The performance of the SRM residents was superior on all metrics in our evaluation. They were significantly more productive and published more articles than the RSS residents (mean difference = 1.0 [95% CI: 0.5-1.5], p research performance improved 11.0 grades (95% CI: 8.5%-13.5%, p research methodology is crucial to appropriately apply evidence-based findings in clinical practice. The SRM Program has significantly improved the research productivity and performance of the surgical residents from all disciplines. The implementation of a similar research methodology program is highly recommended for the benefit of residents' future careers and ultimately, evidence-based patient care. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Smith, D.; Lewins, J.D.
The art of the direct method of Liapunov to determine system stability is to construct a suitable Liapunov or V function where V is to be positive definite (PD), to shrink to a center, which may be conveniently chosen as the origin, and where V is the negative definite (ND). One aid to the art is to solve an approximation to the system equations in order to provide a candidate V function. It can happen, however, that the V function is not strictly ND but vanishes at a finite number of isolated points. Naively, one anticipates that stability has been demonstrated since the trajectory of the system at such points is only momentarily tangential and immediately enters a region of inward directed trajectories. To demonstrate stability rigorously requires the construction of a sophisticated Liapunov function from what can be called the naive original choice. In this paper, the authors demonstrate the method of perturbing the naive function in the context of the well-known second-order oscillator and then apply the method to a more complicated problem based on a prompt jump model for a nuclear fission reactor
McHugh, Seamus Mark; Corrigan, Mark; Dimitrov, Borislav; Cowman, Seamus; Tierney, Sean; Humphreys, Hilary; Hill, Arnold
Introduction: Surgical site infection accounts for 20% of all health care-associated infections (HCAIs); however, a program incorporating the education of surgeons has yet to be established across the specialty. Methods: An audit of surgical practice in infection prevention was carried out in Beaumont Hospital from July to November 2009. An…
de Dreu, J.|info:eu-repo/dai/nl/364537906; Bikker, J.A.|info:eu-repo/dai/nl/06912261X
This paper assesses the sophistication of pension funds’ investment policies using data on 748 Dutch pension funds during the 1999–2006 period. We develop three indicators of sophistication: gross rounding of investment choices, investments in alternative sophisticated asset classes and ‘home bias’.
Austin, Ryan E; Wanzel, Kyle R
Despite increases in medical school enrolment, applications to surgical residency programs in Canada have been in decline over the past decade, with an increasing number of unmatched surgical residency positions. We examined the current status of surgical residency in Canada and analyzed application trends (2002–2013) for surgical training programs across Canada. Our findings suggest that most undergraduate medical schools across Canada are having difficulty fostering interest in surgical careers. We propose that a lack of adequate early exposure to the surgical specialties during undergraduate training is a critical factor. Moving forward, we must examine how the best-performing institutions and surgical programs have maintained interest in pursuing surgical careers and adapt our recruitment methods to both maintain and grow future interest. As Mary Engelbreit said, "If you don't like something, change it; if you can't change it, change the way you think about it."
Rombouts, Jeroen; Stentoft, Lars; Violante, Francesco
We assess the predictive accuracies of a large number of multivariate volatility models in terms of pricing options on the Dow Jones Industrial Average. We measure the value of model sophistication in terms of dollar losses by considering a set of 444 multivariate models that differ in their spec....... In addition to investigating the value of model sophistication in terms of dollar losses directly, we also use the model confidence set approach to statistically infer the set of models that delivers the best pricing performances.......We assess the predictive accuracies of a large number of multivariate volatility models in terms of pricing options on the Dow Jones Industrial Average. We measure the value of model sophistication in terms of dollar losses by considering a set of 444 multivariate models that differ...
Poulin, Paule; Austen, Lea; Kortbeek, John B; Lafrenière, René
There is pressure for surgical departments to introduce new and innovative health technologies in an evidence-based manner while ensuring that they are safe and effective and can be managed with available resources. A local health technology assessment (HTA) program was developed to systematically integrate research evidence with local operational management information and to make recommendations for subsequent decision by the departmental executive committee about whether and under what conditions the technology will be used. The authors present a retrospective analysis of the outcomes of this program as used by the Department of Surgery & Surgical Services in the Calgary Health Region over a 5-year period from December 2005 to December 2010. Of the 68 technologies requested, 15 applications were incomplete and dropped, 12 were approved, 3 were approved for a single case on an urgent/emergent basis, 21 were approved for "clinical audit" for a restricted number of cases with outcomes review, 14 were approved for research use only, and 3 were referred to additional review bodies. Subsequent outcome reports resulted in at least 5 technologies being dropped for failure to perform. Decisions based on local HTA program recommendations were rarely "yes" or "no." Rather, many technologies were given restricted approval with full approval contingent on satisfying certain conditions such as clinical outcomes review, training protocol development, or funding. Thus, innovation could be supported while ensuring safety and effectiveness. This local HTA program can be adapted to a variety of settings and can help bridge the gap between evidence and practice.
Ahmad, Rima; Mullen, John T
There remains a debate as to whether nondesignated preliminary (NDP) positions in surgery ultimately translate into successful surgical careers for those who pursue them. We sought to identify the success with which our NDP residents were able to transition to their desired career and what, if any, factors contributed to their success. The records of all NDP residents accepted into the Massachusetts General Hospital General Surgery Residency Program from 1995 to 2010 were examined and long-term follow-up was completed. Thirty-four NDP residents were identified, including 26.5% US graduates and 73.5% international medical graduates. At the end of the initial preliminary year, 30 (88%) got placed in a postgraduate residency program, whereas 4 (12%) pursued other career paths. Of those who got placed, 25 (83%) attained surgical residency positions, including 17 (57%) who continued as preliminary residents at our institution and 8 (27%) who got placed in categorical surgical positions at other programs. After multiple preliminary years, 15 of 17 achieved a categorical position, of which, 93% were in surgical fields. Overall, 64.7% of all entering NDP residents eventually went on to have careers in general surgery (50%) or surgical subspecialties (14.7%), and 24 of 34 (71%) fulfilled their desired career goals. No factor predicted success. From 1995 to 2012 there have been 15 midlevel (11 postgraduate year 4) vacancies in our program, 4 of which were filled by preliminary residents, 2 from our program and 2 from elsewhere. All have gone on to board certifications and careers in surgery. More than 70% of NDP residents in our program successfully transitioned to their desired career paths, many achieving categorical surgical positions and academic surgical careers, thus demonstrating the benefit of this track to both residency programs and trainees. © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Dietl, Charles A; Russell, John C
The purpose of this article is to review the literature on current technology for surgical education and to evaluate the effect of technological advances on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification. A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, and Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: technology for surgical education, simulation-based surgical training, simulation-based nontechnical skills (NTS) training, ACGME Core Competencies, ABSITE scores, and ABS pass rate. Our initial search list included the following: 648 on technology for surgical education, 413 on simulation-based surgical training, 51 on simulation-based NTS training, 78 on ABSITE scores, and 33 on ABS pass rate. Further, 42 articles on technological advances for surgical education met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 33 of 42 and 26 of 42 publications on technological advances for surgical education showed objective improvements regarding patient care and medical knowledge, respectively, whereas only 2 of 42 publications showed improved ABSITE scores, but none showed improved ABS pass rates. Improvements in the other ACGME core competencies were documented in 14 studies, 9 of which were on simulation-based NTS training. Most of the studies on technological advances for surgical education have shown a positive effect on patient care and medical knowledge. However, the effect of simulation-based surgical training and simulation-based NTS training on ABSITE scores and ABS certification has not been assessed. Studies on technological advances in surgical education and simulation-based NTS training showing quantitative evidence that surgery residency
Ghiabi, Edmond; Taylor, K Lynn
This project aimed at documenting the surgical training curricula offered by North American graduate periodontics programs. A survey consisting of questions on teaching methods employed and the content of the surgical training program was mailed to directors of all fifty-eight graduate periodontics programs in Canada and the United States. The chi-square test was used to assess whether the residents' clinical experience was significantly (Pperiodontal plastic procedures, hard tissue grafts, and implants. Furthermore, residents in programs offering a structured preclinical component performed significantly more procedures (P=0.012) using lasers than those in programs not offering a structured preclinical program. Devising new and innovative teaching methods is a clear avenue for future development in North American graduate periodontics programs.
Marsily, G. de
Most countries agree to the necessity of burying high or medium-level wastes in geological layers situated at a few hundred meters below the ground level. The advantages and disadvantages of different types of rock such as salt, clay, granite and volcanic material are examined. Sophisticated studies are lead to determine the best geological confinement but questions arise about the time for which safety must be ensured. France has chosen 3 possible sites. These sites are geologically described in the article. The final place will be proposed after a testing phase of about 5 years in an underground facility. (A.C.)
Dietl, Charles A; Russell, John C
The purpose of this article is to review the literature on process changes in surgical training programs and to evaluate their effect on the Accreditation Council of Graduate Medical Education (ACGME) Core Competencies, American Board of Surgery In-Training Examination (ABSITE) scores, and American Board of Surgery (ABS) certification. A literature search was obtained from MEDLINE via PubMed.gov, ScienceDirect.com, Google Scholar on all peer-reviewed studies published since 2003 using the following search queries: surgery residency training, surgical education, competency-based surgical education, ACGME core competencies, ABSITE scores, and ABS pass rate. Our initial search list included 990 articles on surgery residency training models, 539 on competency-based surgical education, 78 on ABSITE scores, and 33 on ABS pass rate. Overall, 31 articles met inclusion criteria based on their effect on ACGME Core Competencies, ABSITE scores, and ABS certification. Systematic review showed that 5/31, 19/31, and 6/31 articles on process changes in surgical training programs had a positive effect on patient care, medical knowledge, and ABSITE scores, respectively. ABS certification was not analyzed. The other ACGME core competencies were addressed in only 6 studies. Several publications on process changes in surgical training programs have shown a positive effect on patient care, medical knowledge, and ABSITE scores. However, the effect on ABS certification, and other quantitative outcomes from residency programs, have not been addressed. Studies on education strategies showing evidence that residency program objectives are being achieved are still needed. This article addresses the 6 ACGME Core Competencies. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Baste, J-M; Riviera, C; Nouhaud, F-X; Rinieri, P; Melki, J; Peillon, C
Recent publications from North America have shown the benefits of robot-assisted thoracic surgery. We report here the process of setting up such a program in a French university centre and early results in a unit with an average treatment volume. Retrospective review of a single institution database. The program was launched after a 6-month preparation period. From January 2012 to January 2013, totally endoscopic, full robot-assisted procedures were performed on 30 patients (17 males). Median age was 54 [Q1-Q3, 48-63] years and ASA score 2 [1,2]. Operative procedures included thymectomy (9 ; 30%), lobectomy with nodes resection (11 ; 38%), segmentectomy (4 ; 14%), lymphadenectomy (3 ; 10%), Bronchogenic cyst (2, 5%) and posterior mediastinal mass resection (1 ; 3%). No conversion was required. Median blood loss was 50mL [10-100]. Median operating time was 135 min (105-165) including 30 min [20-40] for docking, 90min for robot-assisted operating [70-120] and 15 min [10-15] for lesion extraction. CO2 insufflation was used in 28 cases (93%). Hospital stay was 4 days [4-6] with 6 minor complications (20%) (Grade 1 according to the Clavien-Dindo classification). After a median 4 months follow-up [2-7], all patients were alive and demonstrated a good quality of life. This series suggests that full robotic thoracic procedures are safe and effective treatment for various pathologies, with low morbidity and without a significant learning curve, even in a lower volume centre. This technology should accompany the development of minimally invasive thoracic surgery. The importance of robotic training should be emphasized to optimize procedures and costs. Copyright © 2015 SPLF. Published by Elsevier Masson SAS. All rights reserved.
Adams, Simon; Ginther, David Nathan; Neuls, Evan; Hayes, Paul
We recently studied attrition in Canadian general surgical programs; however, there are no data on whether residents enrolled in other surgical residencies harbour the same intents as their general surgical peers. We sought to determine how many residents in surgical disciplines in Canada consider leaving their programs and why. An anonymous survey was administered to all residents in 9 surgical disciplines in Canada. Significance of association was determined using the Pearson χ2 test. The Canadian Post-MD Education Registry (CAPER) website was used to calculate the response rate. We received 523 responses (27.6% response rate). Of these respondents, 140 (26.8%) were either "somewhat" or "seriously" considering leaving their program. Residents wanting to pursue additional fellowship training and those aspiring to an academic career were significantly less likely to be considering changing specialties ( p = 0.003 and p = 0.005, respectively). Poor work-life balance and fear of unemployment/underemployment were the top reasons why residents would change specialty (55.5% and 40.8%, respectively), although the reasons cited were not significantly different between those considering changing and those who were not ( p = 0.64). Residents who were considering changing programs were significantly less likely to enjoy their work and more likely to cite having already invested too much time to change as a reason for continuing ( p work-life balance and limited employment prospects. Efforts to educate prospective residents about the reality of the surgical lifestyle and to optimize employment prospects may improve completion rates.
Pedron, Sara; Winter, Vera; Oppel, Eva-Maria; Bialas, Enno
Operating room (OR) efficiency continues to be a high priority for hospitals. In this context the concept of benchmarking has gained increasing importance as a means to improve OR performance. The aim of this study was to investigate whether and how participation in a benchmarking and reporting program for surgical process data was associated with a change in OR efficiency, measured through raw utilization, turnover times, and first-case tardiness. The main analysis is based on panel data from 202 surgical departments in German hospitals, which were derived from the largest database for surgical process data in Germany. Panel regression modelling was applied. Results revealed no clear and univocal trend of participation in a benchmarking and reporting program for surgical process data. The largest trend was observed for first-case tardiness. In contrast to expectations, turnover times showed a generally increasing trend during participation. For raw utilization no clear and statistically significant trend could be evidenced. Subgroup analyses revealed differences in effects across different hospital types and department specialties. Participation in a benchmarking and reporting program and thus the availability of reliable, timely and detailed analysis tools to support the OR management seemed to be correlated especially with an increase in the timeliness of staff members regarding first-case starts. The increasing trend in turnover time revealed the absence of effective strategies to improve this aspect of OR efficiency in German hospitals and could have meaningful consequences for the medium- and long-run capacity planning in the OR.
Pedron, Sara; Winter, Vera; Oppel, Eva-Maria
Operating room (OR) efficiency continues to be a high priority for hospitals. In this context the concept of benchmarking has gained increasing importance as a means to improve OR performance. The aim of this study was to investigate whether and how participation in a benchmarking and reporting...... program for surgical process data was associated with a change in OR efficiency, measured through raw utilization, turnover times, and first-case tardiness. The main analysis is based on panel data from 202 surgical departments in German hospitals, which were derived from the largest database for surgical...... the availability of reliable, timely and detailed analysis tools to support the OR management seemed to be correlated especially with an increase in the timeliness of staff members regarding first-case starts. The increasing trend in turnover time revealed the absence of effective strategies to improve this aspect...
Kim, Stanley Y; Dupree, James M; Le, Brian V; Kim, Dae Y; Zhao, Lee C; Kundu, Shilajit D
To determine a nationwide contemporary description of surgical Fournier gangrene (FG) and necrotizing fasciitis of the genitalia (NFG) outcomes because historically reported mortality rates for FG and NFG are based on small single-institution studies from the 1980s and the 1990s. The National Surgical Quality Improvement Program is a risk-adjusted surgical database used by nearly 400 hospitals nationwide, which tracks preoperative, intraoperative, and 30-day postoperative clinical variables. Data are extracted from patient charts by an independent surgical clinical reviewer at each hospital. Using the National Surgical Quality Improvement Program data from 2005 to 2009, we calculated 30-day mortality rates and identified preoperative factors associated with increased mortality. A total of 650 patients were identified with surgery for FG or NFG. Fourteen patients with do not resuscitate orders placed preoperatively were excluded from analyses. For the remaining 636 patients, the overall 30-day mortality was 10.1% (64 of 636). Fifty-seven percent of patients (360 of 636) were men, 70% (446 of 636) were white, and 13% (81 of 636) were African American. Multivariate logistic regression indicated that increased age (odds ratio [OR], 1.041; P = .004), body mass index (OR, 1.045; P <.001), and preoperative white blood cell count (OR, 1.061; P = .001), and decreased platelet count (OR, 0.993; P <.001) were all associated with increased risk of death. We determined a surgical mortality rate for FG-NFG of 10.1%. This rate is about half of historically published estimates and similar to recent studies. The lower rate may indicate improvements in therapy. Increased age, body mass index, and white blood cell count, and decreased platelet count were all associated with an increased risk of 30-day mortality. Copyright © 2015 Elsevier Inc. All rights reserved.
Describes the STAF (Science Teacher's Authoring Facility) computer-assisted instruction system developed at Leeds University (England), focusing on STAF language and major program features. Although programs for the system emphasize physical chemistry and organic spectroscopy, the system and language are general purpose and can be used in any…
Ditta, Lauren C; Pereiras, Lilia Ana; Graves, Emily T; Devould, Chantel; Murchison, Ebony; Figueroa, Ligia; Kerr, Natalie C
To report our experince in establishing a sustainable pediatric surgical outreach mission to an underserved population in Guatemala for treatment of strabismic disorders. A pediatric ophthalmic surgical outreach mission was established. Children were evaluated for surgical intervention by 3 pediatric ophthalmologists and 2 orthoptists. Surgical care was provided at the Moore Pediatric Surgery Center, Guatemala City, over 4 days. Postoperative care was facilitated by Guatemalan physicians during the second year. In year 1, patients 1-17 years of age were referred by local healthcare providers. In year 2, more than 60% of patients were prescreened by a local pediatric ophthalmologist. We screened 47% more patients in year 2 (132 vs 90). Diagnoses included congenital and acquired esotropia, consecutive and acquired exotropia, congenital nystagmus, Duane syndrome, Brown syndrome, cranial nerve palsy, dissociated vertical deviation, and oblique muscle dysfunction. Overall, 42% of the patients who were screened underwent surgery. We performed 21 more surgeries in our second year (58 vs 37), a 57% increase. There were no significant intra- or postoperative complications. Surgical outreach programs for children with strabismic disorders in the developing world can be established through international cooperation, a multidisciplinary team of healthcare providers, and medical equipment allocations. Coordinating care with local pediatric ophthalmologists and medical directors facilitates best practice management for sustainability. Copyright © 2015 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.
Ghiabi, Edmond; Taylor, K Lynn
This cross-sectional study was designed to document the methods utilized by North American graduate periodontics programs in assessing their residents' surgical skills. A survey of clinical skills assessment was mailed to directors of all fifty-eight graduate periodontics programs in Canada and the United States. Thirty-four programs (59 percent) responded. The data collected were analyzed using SPSS version 15.0. The results demonstrate that the most common practice for providing feedback and documenting residents' surgical skills in the programs surveyed was daily one-on-one verbal feedback given by an instructor. The next two most commonly reported methods were a standard checklist developed at program level and a combination of a checklist and verbal comments. The majority of the programs reported that the instructors met collectively once per term to evaluate the residents' progress. The results suggest that graduate periodontics programs provide their residents frequent opportunities for daily practice with verbal feedback from instructors. However, assessment strategies identified in other health professions as beneficial in fostering the integration of clinical skills practices are not employed.
Mabit, C; Marcheix, P S; Mounier, M; Dijoux, P; Pestourie, N; Bonnevialle, P; Bonnomet, F
Surveillance of surgical site infections (SSI) is a priority. One of the fundamental principles for the surveillance of SSI is based on receiving effective field feedback (retro-information). The aim of this study was to report the results of a program of SSI surveillance and validate the hypothesis that there is a correlation between creating a SSI surveillance program and a reduction in SSI. The protocol was based on the weekly collection of surveillance data obtained directly from the different information systems in different departments. A delay of 3 months was established before extraction and analysis of data and information from the surgical teams. The NNIS index (National Nosocomial Infections Surveillance System) developed by the American surveillance system and the reduction of length of hospital stay index Journées d'hospitalisation évitées (JHE). Since the end of 2009, 7156 surgical procedures were evaluated (rate of inclusion 97.3%), and 84 SSI were registered with a significant decrease over time from 1.86% to 0.66%. A total of 418 days of hospitalization have been saved since the beginning of the surveillance system. Our surveillance system has three strong points: follow-up is continuous, specifically adapted to orthopedic traumatology and nearly exhaustive. The extraction of data directly from hospital information systems effectively improves the collection of data on surgical procedures. The implementation of a SSI surveillance protocol reduces SSI. Level III. Prospective study. Copyright © 2012 Elsevier Masson SAS. All rights reserved.
Pollei, Taylor R; Barrs, David M; Hinni, Michael L; Bansberg, Stephen F; Walter, Logan C
Describe the procedure length difference between surgeries performed by an attending surgeon alone compared with the resident surgeon supervised by the same attending surgeon. Case series with chart review. Tertiary care center and residency program. Six common otolaryngologic procedures performed between August 1994 and May 2012 were divided into 2 cohorts: attending surgeon alone or resident surgeon. This division coincided with our July 2006 initiation of an otolaryngology-head and neck surgery residency program. Operative duration was compared between cohorts with confounding factors controlled. In addition, the direct result of increased surgical length on operating room cost was calculated and applied to departmental and published resident case log report data. Five of the 6 procedures evaluated showed a statistically significant increase in surgery length with resident involvement. Operative time increased 6.8 minutes for a cricopharyngeal myotomy (P = .0097), 11.3 minutes for a tonsillectomy (P operative time difference. Cost of increased surgical time was calculated per surgery and ranged from $286 (cricopharyngeal myotomy) to $2142 (mastoidectomy). When applied to reported national case log averages for graduating residents, this resulted in a significant increase of direct training-related costs. Resident participation in the operating room results in increased surgical length and additional system cost. Although residency is a necessary part of surgical training, associated costs need to be acknowledged.
Brindle, Mary E; Henrich, Natalie; Foster, Andrew; Marks, Stanley; Rose, Michael; Welsh, Robert; Berry, William
The role of the "debrief" to address issues related to patient safety and systematic flaws in care is frequently overlooked. In our study, we interview surgical leaders who have developed successful strategies of debriefing within a comprehensive program of quality improvement. Semi-structured interviews of four implementation leaders were performed. The observations, beliefs and strategies of surgical leaders are compared and contrasted. Common themes are identified related to program success and failure. Quality and safety researchers performed, coded and categorized the interviews and coordinated the analysis and interpretation of the results. The authors from the four institutions aided in interpretation and framing of the results. The debriefing programs evaluated were part of comprehensive quality improvement projects. Seven high-level themes and 24 subthemes were identified from the interviews. Themes related to leadership included early engagement, visible ongoing commitment and enforcement. Success appeared to depend upon meaningful and early debriefing feedback. The culture of safety that promoted success included a commitment to open and fair communication and continuous improvement. There were many challenges to the success of debriefing programs. The loss of institutional commitment of resources and personnel was the instigating factor behind the collapse of the program at Michigan. Other areas of potential failure included communication issues and loss of early and meaningful feedback. Leaders of four surgical systems with strong debriefing programs report success using debriefing to improve system performance. These findings are consistent with previously published studies. Success requires commitment of resources, and leadership engagement. The greatest gains may be best achieved by programs that provide meaningful debriefing feedback in an atmosphere dedicated to open communication.
Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors.
Antiel, Ryan M; Van Arendonk, Kyle J; Reed, Darcy A; Terhune, Kyla P; Tarpley, John L; Porterfield, John R; Hall, Daniel E; Joyce, David L; Wightman, Sean C; Horvath, Karen D; Heller, Stephanie F; Farley, David R
To describe the perspectives of surgical interns regarding the implications of the new Accreditation Council for Graduate Medical Education (ACGME) duty-hour regulations for their training. We compared responses of interns and surgery program directors on a survey about the proposed ACGME mandates. Eleven general surgery residency programs. Two hundred fifteen interns who were administered the survey during the summer of 2011 and a previously surveyed national sample of 134 surgery program directors. Perceptions of the implications of the new duty-hour restrictions on various aspects of surgical training, including the 6 ACGME core competencies of graduate medical education, measured using 3-point scales (increase, no change, or decrease). Of 215 eligible surgical interns, 179 (83.3%) completed the survey. Most interns believed that the new duty-hour regulations will decrease continuity with patients (80.3%), time spent operating (67.4%), and coordination of patient care (57.6%), while approximately half believed that the changes will decrease their acquisition of medical knowledge (48.0%), development of surgical skills (52.8%), and overall educational experience (51.1%). Most believed that the changes will improve or will not alter other aspects of training, and 61.5% believed that the new standards will decrease resident fatigue. Surgical interns were significantly less pessimistic than surgery program directors regarding the implications of the new duty-hour restrictions on all aspects of surgical training (P training under the new paradigm of duty-hour restrictions have significant concerns about the effect of these regulations on the quality of their training.
Jähne, J; Mittelstädt, A; Götzky, K
Due to a decreased interest in surgical training the German Society of Surgery (GSS) has provided a specially sponsored student program at its annual clinical congress for many years in order to increase the number of applicants for a career in surgery. It remains unclear if this goal is reached because an evaluation has not yet been performed. At the clinical congress in 2014, 200 medical students participated in a special student program with the aid of a congress grant totaling 100,000 €. By means of a questionnaire it was asked how many of the participants in this special program have started a residency in surgery. Almost 17% of the participants of the student program answered and 13 students (6.5% of all participants) stated that they had started a surgical residency. All of these students claimed an interest in surgery even before participation in the congress. Those students who had not yet decided what kind of residency they should choose did not vote for surgery despite their visit to the congress. The student program and the congress grant at the annual clinical congress of the GSS do not result in an increased number of applicants for a residency in surgery. Both incentives might be not more than a strategic marketing instrument. An increased number of medical students applying for a residency in surgery is only to be expected if social developments (e. g. attention to a work-life balance) and their concomitant challenges are reflected in surgical day to day work.
This paper examines whether the sophistication of market investors influences management's strategy on discretionary accounting choice, and thus changes the persistence of discretionary accruals. The results show that the persistence of discretionary accruals for firms face with naive investors is lower than that for firms face with sophisticated investors. The results also demonstrate that sophisticated investors indeed incorporate the implications of current earnings components into future ...
Fuchshuber, Pascal R; Greif, William; Tidwell, Chantal R; Klemm, Michael S; Frydel, Cheryl; Wali, Abdul; Rosas, Efren; Clopp, Molly P
The National Surgical Quality Improvement Program (NSQIP) of the American College of Surgeons provides risk-adjusted surgical outcome measures for participating hospitals that can be used for performance improvement of surgical mortality and morbidity. A surgical clinical nurse reviewer collects 135 clinical variables including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures. A report on mortality and complications is prepared twice a year. This article summarizes briefly the history of NSQIP and how its report on surgical outcomes can be used for performance improvement within a hospital system. In particular, it describes how to drive performance improvement with NSQIP data using the example of postoperative respiratory complications--a major factor of postoperative mortality. In addition, this article explains the benefit of a collaborative of several participating NSQIP hospitals and describes how to develop a "playbook" on the basis of an outcome improvement project.
Morháč, Miroslav; Matoušek, Vladislav
In the paper we present compact library for analysis of nuclear spectra. The library consists of sophisticated functions for background elimination, smoothing, peak searching, deconvolution, and peak fitting. The functions can process one- and two-dimensional spectra. The software described in the paper comprises a number of conventional as well as newly developed methods needed to analyze experimental data. Program summaryProgram title: SpecAnalysLib 1.1 Catalogue identifier: AEDZ_v1_0 Program summary URL:http://cpc.cs.qub.ac.uk/summaries/AEDZ_v1_0.html Program obtainable from: CPC Program Library, Queen's University, Belfast, N. Ireland Licensing provisions: Standard CPC licence, http://cpc.cs.qub.ac.uk/licence/licence.html No. of lines in distributed program, including test data, etc.: 42 154 No. of bytes in distributed program, including test data, etc.: 2 379 437 Distribution format: tar.gz Programming language: C++ Computer: Pentium 3 PC 2.4 GHz or higher, Borland C++ Builder v. 6. A precompiled Windows version is included in the distribution package Operating system: Windows 32 bit versions RAM: 10 MB Word size: 32 bits Classification: 17.6 Nature of problem: The demand for advanced highly effective experimental data analysis functions is enormous. The library package represents one approach to give the physicists the possibility to use the advanced routines simply by calling them from their own programs. SpecAnalysLib is a collection of functions for analysis of one- and two-parameter γ-ray spectra, but they can be used for other types of data as well. The library consists of sophisticated functions for background elimination, smoothing, peak searching, deconvolution, and peak fitting. Solution method: The algorithms of background estimation are based on Sensitive Non-linear Iterative Peak (SNIP) clipping algorithm. The smoothing algorithms are based on the convolution of the original data with several types of filters and algorithms based on discrete
Alkhayal, Abdullah; Aldhukair, Shahla; Alselaim, Nahar; Aldekhayel, Salah; Alhabdan, Sultan; Altaweel, Waleed; Magzoub, Mohi Elden; Zamakhshary, Mohammed
After almost a decade of implementing competency-based programs in postgraduate training programs, the assessment of technical skills remains more subjective than objective. National data on the assessment of technical skills during surgical training are lacking. We conducted this study to document the assessment tools for technical skills currently used in different surgical specialties, their relationship with remediation, the recommended tools from the program directors' perspective, and program directors' attitudes toward the available objective tools to assess technical skills. This study was a cross-sectional survey of surgical program directors (PDs). The survey was initially developed using a focus group and was then sent to 116 PDs. The survey contains demographic information about the program, the objective assessment tools used, and the reason for not using assessment tools. The last section discusses the recommended tools to be used from the PDs' perspective and the PDs' attitude and motivation to apply these tools in each program. The associations between the responses to the assessment questions and remediation were statistically evaluated. Seventy-one (61%) participants responded. Of the respondents, 59% mentioned using only nonstandardized, subjective, direct observation for technical skills assessment. Sixty percent use only summative evaluation, whereas 15% perform only formative evaluations of their residents, and the remaining 22% conduct both summative and formative evaluations of their residents' technical skills. Operative portfolios are kept by 53% of programs. The percentage of programs with mechanisms for remediation is 29% (19 of 65). The survey showed that surgical training programs use different tools to assess surgical skills competency. Having a clear remediation mechanism was highly associated with reporting remediation, which reflects the capability to detect struggling residents. Surgical training leadership should invest more in
Zhang, Linda P; Silverberg, Daniel; Divino, Celia M; Marin, Michael
Global surgery and volunteerism in surgery has gained significant interest in recent years for general surgery residents across the country. However, there are few well-established long-term surgical programs affiliated with academic institutions. The present report discusses the implementation process and challenges facing an academic institution in building a long-term sustainable global surgery program. As one of the pioneer programs in global surgery for residents, the Icahn School of Medicine at Mount Sinai global surgery rotation has been successfully running for the last 10 years in a small public hospital in the Dominican Republic. The present report details many key components of implementing a sustainable global surgery program and the evolution of this program over time. Since 2005, 80 general surgery residents have rotated through Juan Pablo Pina Hospital in the Dominican Republic. They have performed a total of 1239 major operations and 740 minor operations. They have also participated in 328 emergency cases. More importantly, this rotation helped shape residents' sense of social responsibility and ownership in their surgical training. Residents have also contributed to the training of local residents in laparoscopic skills and through cultural exchange. As interest in global surgery grows among general surgery residents, it is essential that supporting academic institutions create sustainable and capacity-building rotations for their residents. These programs must address many of the barriers that can hinder maintenance of a sustainable global surgery experience for residents. After 10 years of sending our residents to the Dominican Republic, we have found that it is possible and valuable to incorporate a formal global surgery rotation into a general surgery residency. Copyright © 2016. Published by Elsevier Inc.
Kyle, Kristopher; Crossley, Scott A.
This study explores the construct of lexical sophistication and its applications for measuring second language lexical and speaking proficiency. In doing so, the study introduces the Tool for the Automatic Analysis of LExical Sophistication (TAALES), which calculates text scores for 135 classic and newly developed lexical indices related to word…
Smith, Hyrum; Finke, Michael S.; Huston, Sandra J.
The influence of a financial sophistication scale on adjustable-rate mortgage (ARM) borrowing is explored. Descriptive statistics and regression analysis using recent data from the Survey of Consumer Finances reveal that ARM borrowing is driven by both the least and most financially sophisticated households but for different reasons. Less…
Naranjo Gil, David
Organizations are designing more sophisticated accounting information systems to meet the strategic goals and enhance their performance. This study examines the effect of accounting information system design on the performance of organizations pursuing different strategic priorities. The alignment between sophisticated accounting information systems and organizational strategy is analyzed. The enabling effect of the accounting information system on performance is also examined. Relationships ...
Simone Cerreia-Vioglio; Fabio Maccheroni; Massimo Marinacci; Luigi Montrucchio
We study the interplay of probabilistic sophistication, second order stochastic dominance, and uncertainty aversion, three fundamental notions in choice under uncertainty. In particular, our main result, Theorem 2, characterizes uncertainty averse preferences that satisfy second order stochastic dominance, as well as uncertainty averse preferences that are probabilistically sophisticated.
Jarratt, Susan C.
Reviews the history of intellectual views on the Greek sophists in three phases: (1) their disparagement by Plato and Aristotle as the morally disgraceful "other"; (2) nineteenth century British positivists' reappraisal of these relativists as ethically and scientifically superior; and (3) twentieth century versions of the sophists as…
Van Orden, Kathryn E; Talutis, Stephanie D; Ng-Glazier, Joanna H; Richman, Aaron P; Pennington, Elliot C; Janeway, Megan G; Kauffman, Douglas F; Dechert, Tracey A
This article provides a theoretical and practical rational for the implementation of an innovative and comprehensive social wellness program in a surgical residency program at a large safety net hospital on the East Coast of the United States. Using basic needs theory, we describe why it is particularly important for surgical residency programs to consider the residents sense of competence, autonomy, and belonging during residence. We describe how we have developed a comprehensive program to address our residents' (and residents' families) psychological needs for competence, autonomy, and belongingness.
Francesca Monn, M; Wang, Ming-Hsien; Gilson, Marta M; Chen, Belinda; Kern, David; Gearhart, Susan L
To determine the perceived effectiveness of surgical subspecialty training programs in teaching and assessing the 6 ACGME core competencies including research. Cross-sectional survey. ACGME approved training programs in pediatric urology and colorectal surgery. Program Directors and recent trainees (2007-2009). A total of 39 program directors (60%) and 57 trainees (64%) responded. Both program directors and recent trainees reported a higher degree of training and mentorship (75%) in patient care and medical knowledge than the other core competencies (pinterpersonal and communication, and professionalism training were perceived effective to a lesser degree. Specifically, in the areas of teaching residents and medical students and team building, program directors, compared with recent trainees, perceived training to be more effective, (p = 0.004, p = 0.04). Responses to questions assessing training in systems based practice ubiquitously identified a lack of training, particularly in financial matters of running a practice. Although effective training in research was perceived as lacking by recent trainees, 81% reported mentorship in this area. According to program directors and recent trainees, the most effective method of teaching was faculty supervision and feedback. Only 50% or less of the recent trainees reported mentorship in career planning, work-life balance, and job satisfaction. Not all 6 core competencies and research are effectively being taught in surgery subspecialty training programs and mentorship in areas outside of patient care and research is lacking. Emphasis should be placed on faculty supervision and feedback when designing methods to better incorporate all 6 core competencies, research, and mentorship. Copyright © 2012 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Ghaderi, Kimeya F; Schmidt, Scott T; Drolet, Brian C
Despite increased emphasis on systems-based practice through the Accreditation Council for Graduate Medical Education core competencies, few studies have examined what surgical residents know about coding and billing. We sought to create and measure the effectiveness of a multifaceted approach to improving resident knowledge and performance of documenting and coding outpatient encounters. We identified knowledge gaps and barriers to documentation and coding in the outpatient setting. We implemented a series of educational and workflow interventions with a group of 12 residents in a surgical clinic at a tertiary care center. To measure the effect of this program, we compared billing codes for 1 year before intervention (FY2012) to prospectively collected data from the postintervention period (FY2013). All related documentation and coding were verified by study-blinded auditors. Interventions took place at the outpatient surgical clinic at Rhode Island Hospital, a tertiary-care center. A cohort of 12 plastic surgery residents ranging from postgraduate year 2 through postgraduate year 6 participated in the interventional sequence. A total of 1285 patient encounters in the preintervention group were compared with 1170 encounters in the postintervention group. Using evaluation and management codes (E&M) as a measure of documentation and coding, we demonstrated a significant and durable increase in billing with supporting clinical documentation after the intervention. For established patient visits, the monthly average E&M code level increased from 2.14 to 3.05 (p coding and billing of outpatient clinic encounters. Using externally audited coding data, we demonstrate significantly increased rates of higher complexity E&M coding in a stable patient population based on improved documentation and billing awareness by the residents. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Ekdahl Charlotte S
Full Text Available Abstract Background Despite conflicting results after surgically treated ankle fractures few studies have evaluated the effects of different types of training programs performed after plaster removal. The aim of this study was to evaluate the effects of a 12-week standardised but individually suited training program (training group versus usual care (control group after plaster removal in adults with surgically treated ankle fractures. Methods In total, 110 men and women, 18-64 years of age, with surgically treated ankle fracture were included and randomised to either a 12-week training program or to a control group. Six and twelve months after the injury the subjects were examined by the same physiotherapist who was blinded to the treatment group. The main outcome measure was the Olerud-Molander Ankle Score (OMAS which rates symptoms and subjectively scored function. Secondary outcome measures were: quality of life (SF-36, timed walking tests, ankle mobility tests, muscle strength tests and radiological status. Results 52 patients were randomised to the training group and 58 to the control group. Five patients dropped out before the six-month follow-up resulting in 50 patients in the training group and 55 in the control group. Nine patients dropped out between the six- and twelve-month follow-up resulting in 48 patients in both groups. When analysing the results in a mixed model analysis on repeated measures including interaction between age-group and treatment effect the training group demonstrated significantly improved results compared to the control group in subjects younger than 40 years of age regarding OMAS (p = 0.028, muscle strength in the plantar flexors (p = 0.029 and dorsiflexors (p = 0.030. Conclusion The results of this study suggest that when adjusting for interaction between age-group and treatment effect the training model employed in this study was superior to usual care in patients under the age of 40. However, as only three
D'Agostino, Thomas A; Bialer, Philip A; Walters, Chasity B; Killen, Aileen R; Sigurdsson, Hrafn O; Parker, Patricia A
Patient safety in the OR depends on effective communication. We developed and tested a communication training program for surgical oncology staff members to increase communication about patient safety concerns. In phase one, 34 staff members participated in focus groups to identify and rank factors that affect speaking-up behavior. We compiled ranked items into thematic categories that included role relations and hierarchy, staff rapport, perceived competence, perceived efficacy of speaking up, staff personality, fear of retaliation, institutional regulations, and time pressure. We then developed a communication training program that 42 participants completed during phase two. Participants offered favorable ratings of the usefulness and perceived effect of the training. Participants reported significant improvement in communicating patient safety concerns (t 40 = -2.76, P = .009, d = 0.48). Findings offer insight into communication challenges experienced by surgical oncology staff members and suggest that our training demonstrates the potential to improve team communication. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Moore, Laura J; Moore, Frederick A; Todd, S Rob; Jones, Stephen L; Turner, Krista L; Bass, Barbara L
To document the incidence, mortality rate, and risk factors for sepsis and septic shock compared with pulmonary embolism and myocardial infarction in the general-surgery population. Retrospective review. American College of Surgeons National Surgical Quality Improvement Program institutions. General-surgery patients in the 2005-2007 National Surgical Quality Improvement Program data set. Incidence, mortality rate, and risk factors for sepsis and septic shock. Of 363 897 general-surgery patients, sepsis occurred in 8350 (2.3%), septic shock in 5977 (1.6%), pulmonary embolism in 1078 (0.3%), and myocardial infarction in 615 (0.2%). Thirty-day mortality rates for each of the groups were as follows: 5.4% for sepsis, 33.7% for septic shock, 9.1% for pulmonary embolism, and 32.0% for myocardial infarction. The septic-shock group had a greater percentage of patients older than 60 years (no sepsis, 40.2%; sepsis, 51.7%; and septic shock, 70.3%; P surgery resulted in more cases of sepsis (4.5%) and septic shock (4.9%) than did elective surgery (sepsis, 2.0%; septic shock, 1.2%) (P surgery, and the presence of any comorbidity. This study emphasizes the need for early recognition of patients at risk via aggressive screening and the rapid implementation of evidence-based guidelines.
Full Text Available Abdullah Alkhayal,1 Shahla Aldhukair,2 Nahar Alselaim,1 Salah Aldekhayel,1 Sultan Alhabdan,1 Waleed Altaweel,3 Mohi Elden Magzoub,4 Mohammed Zamakhshary1,21Department of Surgery, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; 2Public Health Section, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; 3Urology Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; 4Department of Medical Education, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi ArabiaBackground: After almost a decade of implementing competency-based programs in postgraduate training programs, the assessment of technical skills remains more subjective than objective. National data on the assessment of technical skills during surgical training are lacking. We conducted this study to document the assessment tools for technical skills currently used in different surgical specialties, their relationship with remediation, the recommended tools from the program directors’ perspective, and program directors’ attitudes toward the available objective tools to assess technical skills.Methods: This study was a cross-sectional survey of surgical program directors (PDs. The survey was initially developed using a focus group and was then sent to 116 PDs. The survey contains demographic information about the program, the objective assessment tools used, and the reason for not using assessment tools. The last section discusses the recommended tools to be used from the PDs’ perspective and the PDs’ attitude and motivation to apply these tools in each program. The associations between the responses to the assessment questions and remediation were statistically evaluated.Results: Seventy-one (61% participants responded. Of the respondents, 59% mentioned using only nonstandardized, subjective, direct observation for technical skills assessment. Sixty percent use only summative
Siletz, Anaar E.; Singer, Emily S.; Faltermeier, Claire; Hu, Q. Lina; Ko, Clifford Y.; Golladay, Gregory J.; Kates, Stephen L.; Wick, Elizabeth C.; Maggard-Gibbons, Melinda
Background: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study Design: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Results: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. Conclusion: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving
Childers, Christopher P; Siletz, Anaar E; Singer, Emily S; Faltermeier, Claire; Hu, Q Lina; Ko, Clifford Y; Golladay, Gregory J; Kates, Stephen L; Wick, Elizabeth C; Maggard-Gibbons, Melinda
Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery-a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/ Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and
Shifflette, Vanessa; Mitchell, Chris; Mangram, Alicia; Dunn, Ernest
Journal club (JC) is a well-recognized education tool for many postgraduate medical education programs. Journal club helps residents learn critical analytic skills and keep up to date with current medical practices. To our knowledge, there is minimal evidence in the current literature detailing modern JC practices of general surgery training programs. Our study attempts to define how general surgery residency programs are implementing JC in their training process. We distributed by mail a 14-question survey to general surgery program directors within the Southwestern Surgical Congress. These surveys were redistributed 1 month after the initial attempt. The responses were collected and analyzed. Survey questions aimed to define JC practice characteristics, such as where JC is held, when JC is held, who directs JC, what journals are used, the perceived importance of JC, and average attendance. The surveys were sent to 32 program directors (PDs), which included 26 university and 6 community-based programs. We received responses from 26 (81%) PDs. Ninety-two percent of the programs have a consistent journal club (JC). Most JCs meet monthly (64%) or weekly (16%). The meeting places ranged from conference rooms (60%), faculty homes (20%), restaurants (8%), or in the hospital (12%). The meeting times were divided between morning (29%), midday (29%), and evening (42%). Most JCs lasted between 1 and 2 hours (88%), reviewed 1-4 articles (88%), and are attended by more than 60% of residents routinely (75%). Half of the programs (50%) had 3-4 faculty members present during discussion; 29% of the programs had only 1-2 faculty present. The articles were selected from more than 10 different journals. Seventy-five percent of the programs used the American Journal of Surgery and Annals of Surgery to find articles; only 13% of the programs used evidence-based reviews in surgery. PDs believe JC is very beneficial (42%), moderately beneficial (42%), or only fairly beneficial (16
Chu, Quyen D; Nguyen, Thu; Nguyen, Phuong; Ho, Hung S
"Twinning" refers to a constructive partnership between hospitals in developed and developing nations. Such an effort may contribute immensely to capacity building for the developing nation, but one of the reasons given for the lack of sustainability is cost. We share a detailed operating cost analysis of our recent experience with an institution in Vietnam. We were awarded a 1-year $54,000 grant from the Vietnam Education Foundation (VEF) to conduct a live tele-video conferencing course on the "Fundamentals of Clinical Surgery" with Thai Binh Medical University (TBMU). In-country lectures as well as an assessment of the needs at TBMU were performed. Total financial assistance and expenditures were tabulated to assess up-front infrastructure investment and annual cost required to sustain the program. The total amount of direct money ($66,686) and in-kind services ($70,276) was $136,962. The initial infrastructure cost was $41,085, which represented 62% of the direct money received. The annual cost to sustain the program was approximately $11,948. We concluded that the annual cost to maintain a "twinning" program was relatively low, and the efforts to sustain a "twinning" program were financially feasible and worthwhile endeavors. "Twinning" should be a critical part of the surgical humanitarian volunteerism effort.
use of modern rhetorical theories but analyses the letter in terms of the clas- ..... If a critical reader would have had the traditional anti-sophistic arsenal ..... pressions and that 'rhetoric' is mainly a matter of communicating these thoughts.
Full Text Available Nonprice competition is increasingly important in world food markets. Recently, the expression ‘export sophistication’ has been introduced in the economic literature to refer to a wide set of attributes that increase product value. An index has been proposed to measure sophistication in an indirect way through the per capita GDP of exporting countries (Lall et al., 2006; Haussmann et al., 2007.The paper applies the sophistication measure to the Italian food export sector, moving from an analysis of trends and performance of Italian food exports. An original way to disentangle different components in the temporal variation of the sophistication index is also proposed.Results show that the sophistication index offers original insights on recent trends in world food exports and with respect to Italian core food exports.
Dexter, Franklin; Epstein, Richard H; Sun, Eric C; Lubarsky, David A; Dexter, Elisabeth U
We consider whether there should be greater priority of information sharing about postacute surgical resources used: (1) at skilled nursing facilities or inpatient rehabilitation hospitals to which patients are transferred upon discharge (when applicable) versus (2) at different hospitals where readmissions occur. Obtaining and storing data electronically from these 2 sources for Perioperative Surgical Home initiatives are dissimilar; both can be challenging depending on the country and health system. Using the 2013 US Nationwide Readmissions Database, we studied discharges of surgical diagnosis-related group (DRG) with US national median length of stay (LOS) ≥ 3 days and ≥ 10 hospitals each with ≥ 100 discharges for the Medicare Severity DRG. Nationwide, 16.15% (95% confidence interval [CI], 15.14%-17.22%) of discharges were with a disposition of "not to home" (ie, transfer to a skilled nursing facility or an inpatient rehabilitation hospital). Within 30 days, 0.88% of discharges (0.82%-0.95%) were followed by readmission and to a different hospital than the original hospital where the surgery was performed. Among all discharges, disposition "not to home" versus "to home" was associated with greater odds that the patient would have readmission within 30 days and to a different hospital than where the surgery was performed (2.11, 95% CI, 1.96-2.27; P < .0001). In part, this was because disposition "not to home" was associated with greater odds of readmission to any hospital (1.90, 95% CI, 1.82-1.98; P < .0001). In addition, among the subset of discharges with readmission within 30 days, disposition "not to home" versus "to home" was associated with greater odds that the readmission was to a different hospital than where the surgery was performed (1.20, 95% CI, 1.11-1.31; P < .0001). There was no association between the hospitals' median LOS for the DRG and the odds that readmission was to a different hospital (P = .82). The odds ratio per each 1 day decrease
Bruce Ian Carlin; Gustavo Manso
Investor sophistication has lagged behind the growing complexity of retail financial markets. To explore this, we develop a dynamic model to study the interaction between obfuscation and investor sophistication in mutual fund markets. Taking into account different learning mechanisms within the investor population, we characterize the optimal timing of obfuscation for financial institutions who offer retail products. We show that educational initiatives that are directed to facilitate learnin...
Cairns, Mark A; Ostrum, Robert F; Clement, R Carter
The U.S. Centers for Medicare & Medicaid Services (CMS) has been considering the implementation of a mandatory bundled payment program, the Surgical Hip and Femur Fracture Treatment (SHFFT) model. However, bundled payments without appropriate risk adjustment may be inequitable to providers and may restrict access to care for certain patients. The SHFFT proposal includes adjustment using the Diagnosis-Related Group (DRG) and geographic location. The goal of the current study was to identify and quantify patient factors that could improve risk adjustment for SHFFT bundled payments. We retrospectively reviewed a 5% random sample of Medicare data from 2008 to 2012. A total of 27,898 patients were identified who met SHFFT inclusion criteria (DRG 480, 481, and 482). Reimbursement was determined for each patient over the bundle period (the surgical hospitalization and 90 days of post-discharge care). Multivariable regression was performed to test demographic factors, comorbidities, geographic location, and specific surgical procedures for associations with reimbursement. The average reimbursement was $23,632 ± $17,587. On average, reimbursements for male patients were $1,213 higher than for female patients (p payments; e.g., reimbursement for those ≥85 years of age averaged $2,282 ± $389 less than for those aged 65 to 69 (p reimbursement, but dementia was associated with lower payments, by an average of $2,354 ± $243 (p reimbursement ranging from $22,527 to $24,033. Less common procedures varied by >$20,000 in average reimbursement (p reimbursement (p reimbursed by an average of $10,421 ± $543 more than DRG 482. Payments varied significantly by state (p ≤ 0.01). Risk adjustment incorporating specific comorbidities demonstrated better performance than with use of DRG alone (r = 0.22 versus 0.15). Our results suggest that the proposed SHFFT bundled payment model should use more robust risk-adjustment methods to ensure that providers are reimbursed fairly and that
Saadat, Lily V; Dahlke, Allison R; Rajaram, Ravi; Kreutzer, Lindsey; Love, Remi; Odell, David D; Bilimoria, Karl Y; Yang, Anthony D
The Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial was a national, cluster-randomized, pragmatic, noninferiority trial of 117 general surgery programs, comparing standard ACGME resident duty hour requirements ("Standard Policy") to flexible, less-restrictive policies ("Flexible Policy"). Participating program directors (PDs) were surveyed to assess their perceptions of patient care, resident education, and resident well-being during the study period. A survey was sent to all PDs of the general surgery residency programs participating in the FIRST trial (N = 117 [100% response rate]) in June and July 2015. The survey compared PDs' perceptions of the duty hour requirements in their arm of the FIRST trial during the study period from July 1, 2014 to June 30, 2015. One hundred percent of PDs in the Flexible Policy arm indicated that residents used their additional flexibility in duty hours to complete operations they started or to stabilize a critically ill patient. Compared with the Standard Policy arm, PDs in the Flexible Policy arm perceived a more positive effect of duty hours on the safety of patient care (68.9% vs 0%; p care (98.3% vs 0%; p care (71.8%), continuity of care (94.0%), quality of resident education (83.8%), and resident well-being (55.6%) would be improved with a hypothetical permanent adoption of more flexible duty hours. Program directors involved in the FIRST trial perceived improvements in patient safety, continuity of care, and multiple aspects of resident education and well-being with flexible duty hours. Copyright © 2016 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Lusardi, Annamaria; Mitchell, Olivia S.; Curto, Vilsa
Using a special-purpose module implemented in the Health and Retirement Study, we evaluate financial sophistication in the American population over the age of 50. We combine several financial literacy questions into an overall index to highlight which questions best capture financial sophistication and examine the sensitivity of financial literacy responses to framing effects. Results show that many older respondents are not financially sophisticated: they fail to grasp essential aspects of risk diversification, asset valuation, portfolio choice, and investment fees. Subgroups with notable deficits include women, the least educated, non-Whites, and those over age 75. In view of the fact that retirees increasingly must take on responsibility for their own retirement security, such meager levels of knowledge have potentially serious and negative implications. PMID:28553191
Bodie, Graham D; Collins, William B; Jensen, Jakob D; Davis, Lashara A; Guntzviller, Lisa M; King, Andy J
This article develops a conceptualization and measure of cognitive health sophistication--the complexity of an individual's conceptual knowledge about health. Study 1 provides initial validity evidence for the measure--the Healthy-Unhealthy Other Instrument--by showing its association with other cognitive health constructs indicative of higher health sophistication. Study 2 presents data from a sample of low-income adults to provide evidence that the measure does not depend heavily on health-related vocabulary or ethnicity. Results from both studies suggest that the Healthy-Unhealthy Other Instrument can be used to capture variability in the sophistication or complexity of an individual's health-related schematic structures on the basis of responses to two simple open-ended questions. Methodological advantages of the Healthy-Unhealthy Other Instrument and suggestions for future research are highlighted in the discussion.
Lusardi, Annamaria; Mitchell, Olivia S; Curto, Vilsa
Using a special-purpose module implemented in the Health and Retirement Study, we evaluate financial sophistication in the American population over the age of 50. We combine several financial literacy questions into an overall index to highlight which questions best capture financial sophistication and examine the sensitivity of financial literacy responses to framing effects. Results show that many older respondents are not financially sophisticated: they fail to grasp essential aspects of risk diversification, asset valuation, portfolio choice, and investment fees. Subgroups with notable deficits include women, the least educated, non-Whites, and those over age 75. In view of the fact that retirees increasingly must take on responsibility for their own retirement security, such meager levels of knowledge have potentially serious and negative implications.
Dasenbrock, Hormuzdiyar H; Yan, Sandra C; Smith, Timothy R; Valdes, Pablo A; Gormley, William B; Claus, Elizabeth B; Dunn, Ian F
Although readmission has become a common quality indicator, few national studies have examined this metric in patients undergoing cranial surgery. To utilize the prospective National Surgical Quality Improvement Program 2011-2013 registry to evaluate the predictors of unplanned 30-d readmission and postdischarge mortality after cranial tumor resection. Multivariable logistic regression was applied to screen predictors, which included patient age, sex, tumor location and histology, American Society of Anesthesiologists class, functional status, comorbidities, and complications from the index hospitalization. Of the 9565 patients included, 10.7% (n = 1026) had an unplanned readmission. Independent predictors of unplanned readmission were male sex, infratentorial location, American Society of Anesthesiologists class 3 designation, dependent functional status, a bleeding disorder, and morbid obesity (all P ≤ .03). Readmission was not associated with operative time, length of hospitalization, discharge disposition, or complications from the index admission. The most common reasons for readmission were surgical site infections (17.0%), infectious complications (11.0%), venous thromboembolism (10.0%), and seizures (9.4%). The 30-d mortality rate was 3.2% (n = 367), of which the majority (69.7%, n = 223) occurred postdischarge. Independent predictors of postdischarge mortality were greater age, metastatic histology, dependent functional status, hypertension, discharge to institutional care, and postdischarge neurological or cardiopulmonary complications (all P Readmissions were common after cranial tumor resection and often attributable to new postdischarge complications rather than exacerbations of complications from the initial hospitalization. Moreover, the majority of 30-d deaths occurred after discharge from the index hospitalization. The preponderance of postdischarge mortality and complications requiring readmission highlights the importance of posthospitalization
McCutcheon, Brandon A; Kerezoudis, Panagiotis; Porter, Amanda L; Rinaldo, Lorenzo; Murphy, Meghan; Maloney, Patrick; Shepherd, Daniel; Hirshman, Brian R; Carter, Bob S; Lanzino, Giuseppe; Bydon, Mohamad; Meyer, Fredric
A large national surgical registry was used to establish national benchmarks and associated predictors of major neurologic complications (i.e., coma and stroke) after surgical clipping of unruptured intracranial aneurysms. The American College of Surgeons National Surgical Quality Improvement Program data set between 2007 and 2013 was used for this retrospective cohort analysis. Demographic, comorbidity, and operative characteristics associated with the development of a major neurologic complication (i.e., coma or stroke) were elucidated using a backward selection stepwise logistic regression analysis. This model was subsequently used to fit a predictive score for major neurologic complications. Inclusion criteria were met by 662 patients. Of these patients, 57 (8.61%) developed a major neurologic complication (i.e., coma or stroke) within the 30-day postoperative period. On multivariable analysis, operative time (log odds 0.004 per minute; 95% confidence interval [CI], 0.002-0.007), age (log odds 0.05 per year; 95% CI, 0.02-0.08), history of chronic obstructive pulmonary disease (log odds 1.26; 95% CI, 0.43-2.08), and diabetes (log odds 1.15; 95% CI, 0.38-1.91) were associated with an increased odds of major neurologic complications. When patients were categorized according to quartile of a predictive score generated from the multivariable analysis, rates of major neurologic complications were 1.8%, 4.3%, 6.7%, and 21.2%. Using a large, national multi-institutional cohort, this study established representative national benchmarks and a predictive scoring system for major neurologic complications following operative management of unruptured intracranial aneurysms. The model may assist with risk stratification and tailoring of decision making in surgical candidates. Copyright © 2016 Elsevier Inc. All rights reserved.
Langenfeld, Sean J; Vargo, Daniel J; Schenarts, Paul J
Unprofessional behavior is common among surgical residents and faculty surgeons on Facebook. Usage of social media outlets such as Facebook and Twitter is growing at exponential rates, so it is imperative that surgery program directors (PDs) focus on professionalism within social media, and develop guidelines for their trainees and surgical colleagues. Our study focuses on the surgery PDs current approach to online professionalism within surgical education. An online survey of general surgery PDs was conducted in October 2015 through the Association for Program Directors in Surgery listserv. Baseline PD demographics, usage and approach to popular social media outlets, existing institutional policies, and formal curricula were assessed. A total of 110 PDs responded to the survey (110/259, 42.5% response rate). Social media usage was high among PDs (Facebook 68% and Twitter 40%). PDs frequently viewed the social media profiles of students, residents, and faculty. Overall, 11% of PDs reported lowering the rank or completely removing a residency applicant from the rank order list because of online behavior, and 10% reported formal disciplinary action against a surgical resident because of online behavior. Overall, 68% of respondents agreed that online professionalism is important, and that residents should receive instruction on the safe use of social media. However, most programs did not have formal didactics or known institutional policies in place. Use of social media is high among PDs, and they often view the online behavior of residency applicants, surgical residents, and faculty surgeons. Within surgical education, there needs to be an increased focus on institutional policies and standardized curricula to help educate physicians on social media and online professionalism. Copyright Â© 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
O'Sullivan, K E
Application to the Irish basic surgical training (BST) program in Ireland has decreased progressively over the past 5 years. We hypothesised that this decline was secondary to dissatisfaction with training correlated with reduced operative experience and lack of mentorship among BSTs.
Juan Pablo Sánchez Hernández
Full Text Available Procles, cited by Pausanias (in the imperfect tense about a display in Rome and for an opinion about Pyrrhus of Epirus, probably was not a historian of Hellenistic date, but a contemporary sophist whom Pausanias encountered in person in Rome.
Kesting, Peter; Günzel-Jensen, Franziska
, and Spreadshirt, this article develops a framework that introduces five business model sophistication strategies: (1) uncover additional functions of your product, (2) identify strategic benefits for third parties, (3) take advantage of economies of scope, (4) utilize cross-selling opportunities, and (5) involve...
Full Text Available This longitudinal case study explored Iranian EFL learners’ lexical complexity (LC through the lenses of Dynamic Systems Theory (DST. Fifty independent essays written by five intermediate to advanced female EFL learners in a TOEFL iBT preparation course over six months constituted the corpus of this study. Three Coh-Metrix indices (Graesser, McNamara, Louwerse, & Cai, 2004; McNamara & Graesser, 2012, three Lexical Complexity Analyzer indices (Lu, 2010, 2012; Lu & Ai, 2011, and four Vocabprofile indices (Cobb, 2000 were selected to measure different dimensions of LC. Results of repeated measures analysis of variance (RM ANOVA indicated an improvement with regard to only lexical sophistication. Positive and significant relationships were found between time and mean values in Academic Word List and Beyond-2000 as indicators of lexical sophistication. The remaining seven indices of LC, falling short of significance, tended to flatten over the course of this writing program. Correlation analyses among LC indices indicated that lexical density enjoyed positive correlations with lexical sophistication. However, lexical diversity revealed no significant correlations with both lexical density and lexical sophistication. This study suggests that DST perspective specifies a viable foundation for analyzing lexical complexity
Nugent, Emmeline; Shirilla, Nicole; Hafeez, Adnan; O'Riordain, Diarmuid S; Traynor, Oscar; Harrison, Anthony M; Neary, Paul
The use of simulation to train novice surgeons in laparoscopic skills is becoming increasingly popular. To maximize benefit from simulation, training needs to be delivered and assessed in a structured manner. This study aimed to define performance goals, demonstrate construct validity of the training program, and evaluate whether novice surgeons could reach the preset performance goals. Nine expert laparoscopic surgeons established performance goals for three basic modules of an augmented-reality laparoscopic simulator. The three laparoscopic modules were used by 40 novice surgeons and 40 surgical trainees (postgraduate years [PGYs] 1-4). The performance outcomes were analyzed across the different groups (novice, PGYs 1 and 2, PGYs 3 and 4, expert) to determine construct validity. Then 26 recruited novices trained on the three modules with the aim of reaching the performance goals. The results demonstrated a significant difference in performance between all levels of experience for time (p < 0.001), motion analysis (p < 0.001), and error score (p < 0.001), thus demonstrating construct validity. All 26 novice surgeons significantly improved in performance with repetition for the metrics of time (p < 0.001) and motion analysis (p < 0.001). For two of the modules, the proficiency goals were reached in fewer than 10 trials by 80% of the study participants. Basic skills in laparoscopic surgery can be learned and improved using proficiency-based simulation training. It is possible for novice surgeons to achieve predefined performance goals in a reasonable time frame.
Zhang, Han; Isaac, Andre; Wright, Erin D; Alrajhi, Yaser; Seikaly, Hadi
Otolaryngology-Head and Neck surgery resident physicians (OHNSR) have a high prevalence of burnout, job dissatisfaction and stress as shown within the literature. Formal mentorship programs (FMP) have a proven track record of enhancing professional development and academic success. More importantly FMP have an overall positive impact on residents and assist in improving job satisfaction. The purpose of the study is to determine the effects of a FMP on the well-being of OHNSR. A FMP was established and all OHNSR participation was voluntary. Eight OHNSR participated in the program. Perceived Stress Survey (PSS) and the Maslach Burnout Inventory (MBI) were administered at baseline and then at 3, 6, 9, and 12 month intervals. World Health Quality of Life-Bref Questionnaire (WH-QOL) was administered at baseline and at 12 months. Baseline statistics found a significant burden of stress and burnout with an average PSS of 18.5 with a high MBI of 47.6, 50.6, and 16.5 for the emotional, depersonalization, and personal achievement domains respectively. Quality of life was also found to be low with a WH-QOL score of 71.9. After implementation of the FMP, PSS was reduced to 14.5 at 3 months (p = 0.174) and a statistically significant lower value of 7.9 at 12 months (p = 0.001). Participants were also found to have lower emotional scores (14.9, p values using the WH-QOL was also found to be significantly improved (37.5, P = 0.003) with statistically significant lower scores for the physical health (33.9, p = 0.003), psychological (41.1, p = 0.001), social relationship (46.9, p = 0.019), and environment (53.5, p = 0.012) domains. This is the first study to show that FMP can potentially alleviate high levels of stress and burnout within a surgical residency program and achieve higher levels of personal satisfaction as well as overall quality of life.
Woo, Russell K; Skarsgard, Erik D
Innovation in surgical techniques, technology, and care processes are essential for improving the care and outcomes of surgical patients, including children. The time and cost associated with surgical innovation can be significant, and unless it leads to improvements in outcome at equivalent or lower costs, it adds little or no value from the perspective of the patients, and decreases the overall resources available to our already financially constrained healthcare system. The emergence of a safety and quality mandate in surgery, and the development of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) allow needs-based surgical care innovation which leads to value-based improvement in care. In addition to general and procedure-specific clinical outcomes, surgeons should consider the measurement of quality from the patients' perspective. To this end, the integration of validated Patient Reported Outcome Measures (PROMs) into actionable, benchmarked institutional outcomes reporting has the potential to facilitate quality improvement in process, treatment and technology that optimizes value for our patients and health system. Copyright © 2015 Elsevier Inc. All rights reserved.
Rainer Andergassen; Guido Candela
This paper investigates the effectiveness of development strategies for tourism destinations. We argue that resource investments unambiguously increase tourism revenues and that increasing the degree of tourism sophistication, that is increasing the variety of tourism related goods and services, increases tourism activity and decreases the perceived quality of the destination's resource endowment, leading to an ambiguous effect on tourism revenues. We disentangle these two effects and charact...
Liu, Jason B; Berian, Julia R; Ban, Kristen A; Liu, Yaoming; Cohen, Mark E; Angelos, Peter; Matthews, Jeffrey B; Hoyt, David B; Hall, Bruce L; Ko, Clifford Y
To determine whether concurrently performed operations are associated with an increased risk for adverse events. Concurrent operations occur when a surgeon is simultaneously responsible for critical portions of 2 or more operations. How this practice affects patient outcomes is unknown. Using American College of Surgeons' National Surgical Quality Improvement Program data from 2014 to 2015, operations were considered concurrent if they overlapped by ≥60 minutes or in their entirety. Propensity-score-matched cohorts were constructed to compare death or serious morbidity (DSM), unplanned reoperation, and unplanned readmission in concurrent versus non-concurrent operations. Multilevel hierarchical regression was used to account for the clustered nature of the data while controlling for procedure and case mix. There were 1430 (32.3%) surgeons from 390 (77.7%) hospitals who performed 12,010 (2.3%) concurrent operations. Plastic surgery (n = 393 [13.7%]), otolaryngology (n = 470 [11.2%]), and neurosurgery (n = 2067 [8.4%]) were specialties with the highest proportion of concurrent operations. Spine procedures were the most frequent concurrent procedures overall (n = 2059/12,010 [17.1%]). Unadjusted rates of DSM (9.0% vs 7.1%; P < 0.001), reoperation (3.6% vs 2.7%; P < 0.001), and readmission (6.9% vs 5.1%; P < 0.001) were greater in the concurrent operation cohort versus the non-concurrent. After propensity score matching and risk-adjustment, there was no significant association of concurrence with DSM (odds ratio [OR] 1.08; 95% confidence interval [CI] 0.96-1.21), reoperation (OR 1.16; 95% CI 0.96-1.40), or readmission (OR 1.14; 95% CI 0.99-1.29). In these analyses, concurrent operations were not detected to increase the risk for adverse outcomes. These results do not lessen the need for further studies, continuous self-regulation and proactive disclosure to patients.
Gaies, Michael; Werho, David K; Zhang, Wenying; Donohue, Janet E; Tabbutt, Sarah; Ghanayem, Nancy S; Scheurer, Mark A; Costello, John M; Gaynor, J William; Pasquali, Sara K; Dimick, Justin B; Banerjee, Mousumi; Schwartz, Steven M
Few metrics exist to assess quality of care at pediatric cardiac surgical programs, limiting opportunities for benchmarking and quality improvement. Postoperative duration of mechanical ventilation (POMV) may be an important quality metric because of its association with complications and resource utilization. In this study we modelled case-mix-adjusted POMV duration and explored hospital performance across POMV metrics. This study used the Pediatric Cardiac Critical Care Consortium clinical registry to analyze 4,739 hospitalizations from 15 hospitals (October 2013 to August 2015). All patients admitted to pediatric cardiac intensive care units after an index cardiac operation were included. We fitted a model to predict duration of POMV accounting for patient characteristics. Robust estimates of SEs were obtained using bootstrap resampling. We created performance metrics based on observed-to-expected (O/E) POMV to compare hospitals. Overall, 3,108 patients (65.6%) received POMV; the remainder were extubated intraoperatively. Our model was well calibrated across groups; neonatal age had the largest effect on predicted POMV. These comparisons suggested clinically and statistically important variation in POMV duration across centers with a threefold difference observed in O/E ratios (0.6 to 1.7). We identified 1 hospital with better-than-expected and 3 hospitals with worse-than-expected performance (p < 0.05) based on the O/E ratio. We developed a novel case-mix-adjusted model to predict POMV duration after congenital heart operations. We report variation across hospitals on metrics of O/E duration of POMV that may be suitable for benchmarking quality of care. Identifying high-performing centers and practices that safely limit the duration of POMV could stimulate quality improvement efforts. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
Shin, Jennifer J; Cunningham, Michael J; Emerick, Kevin G; Gray, Stacey T
Surgical competency requires sound clinical judgment, a systematic diagnostic approach, and integration of a wide variety of nontechnical skills. This more complex aspect of clinician development has traditionally been difficult to measure through standard assessment methods. This study was conducted to use the Clinical Practice Instrument (CPI) to measure nontechnical diagnostic and management skills during otolaryngology residency training; to determine whether there is demonstrable change in these skills between residents who are in postgraduate years (PGYs) 2, 4, and 5; and to evaluate whether results vary according to subspecialty topic or method of administration. Prospective study using the CPI, an instrument with previously established internal consistency, reproducibility, interrater reliability, discriminant validity, and responsiveness to change, in an otolaryngology residency training program. The CPI was used to evaluate progression in residents' ability to evaluate, diagnose, and manage case-based clinical scenarios. A total of 248 evaluations were performed in 45 otolaryngology resident trainees at regular intervals. Analysis of variance with nesting and postestimation pairwise comparisons were used to evaluate total and domain scores according to training level, subspecialty topic, and method of administration. Longitudinal residency educational initiative. Assessment with the CPI during PGYs 2, 4, and 5 of residency. Among the 45 otolaryngology residents (248 CPI administrations), there were a mean (SD) of 5 (3) administrations (range, 1-4) during their training. Total scores were significantly different among PGY levels of training, with lower scores seen in the PGY-2 level (44 ) compared with the PGY-4 (64 ) or PGY-5 level (69 ) (P otolaryngology (mean [SD], 72 ) than in subspecialties (range, 55 , P = .003, to 56 , P < .001). Neither administering the examination with an electronic scoring system, rather than a
Pérez Gladish, Blanca María; Arenas Parra, María del Mar; Bilbao Terol, Amelia María; Rodríguez Uria, María Victoria
This study attempts to apply a management science technique to improve the efficiency of Hospital Administration. We aim to design the performance of the surgical services at a Public Hospital that allows the Decision-Maker to plan surgical scheduling over one year in order to reduce waiting lists. Real decision problems usually involve several objectives that have parameters which are often given by the decision maker in an imprecise way. It is possible to handle these kinds of problems ...
Liu, Vincent X; Rosas, Efren; Hwang, Judith; Cain, Eric; Foss-Durant, Anne; Clopp, Molly; Huang, Mengfei; Lee, Derrick C; Mustille, Alex; Kipnis, Patricia; Parodi, Stephen
Novel approaches to perioperative surgical care focus on optimizing nutrition, mobility, and pain management to minimize adverse events after surgical procedures. To evaluate the outcomes of an enhanced recovery after surgery (ERAS) program among 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. A pre-post difference-in-differences study before and after ERAS implementation in the target populations compared with contemporaneous surgical comparator groups (patients undergoing elective gastrointestinal surgery and emergency orthopedic surgery). Implementation began in February and March 2014 and concluded by the end of 2014 at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. A multifaceted ERAS program designed with a particular focus on perioperative pain management, mobility, nutrition, and patient engagement. The primary outcome was hospital length of stay. Secondary outcomes included hospital mortality, home discharge, 30-day readmission rates, and complication rates. The study included a total of 3768 patients undergoing elective colorectal resection (mean [SD] age, 62.7 [14.1] years; 1812 [48.1%] male) and 5002 patients undergoing emergency hip fracture repair (mean [SD] age, 79.5 [11.8] years; 1586 [31.7%] male). Comparator surgical patients included 5556 patients undergoing elective gastrointestinal surgery and 1523 patients undergoing emergency orthopedic surgery. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. The rate ratios for postoperative complications were 0.68 (95% CI, 0.46-0.99; P = .04) for patients
Bohl, Daniel D; Basques, Bryce A; Golinvaux, Nicholas S; Baumgaertner, Michael R; Grauer, Jonathan N
National databases are being used with increasing frequency to conduct orthopaedic research. However, there are important differences in these databases, which could result in different answers to similar questions; this important potential limitation pertaining to database research in orthopaedic surgery has not been adequately explored. The purpose of this study was to explore the interdatabase reliability of two commonly used national databases, the Nationwide Inpatient Sample (NIS) and the National Surgical Quality Improvement Program (NSQIP), in terms of (1) demographics; (2) comorbidities; and (3) adverse events. In addition, using the NSQIP database, we identified (4) adverse events that had a higher prevalence after rather than before discharge, which has important implications for interpretation of studies conducted in the NIS. A retrospective cohort study of patients undergoing operative stabilization of transcervical and intertrochanteric hip fractures during 2009 to 2011 was performed in the NIS and NSQIP. Totals of 122,712 and 5021 patients were included from the NIS and NSQIP, respectively. Age, sex, fracture type, and lengths of stay were compared. Comorbidities common to both databases were compared in terms of more or less than twofold difference between the two databases. Similar comparisons were made for adverse events. Finally, adverse events that had a greater postdischarge prevalence were identified from the NSQIP database. Tests for statistical difference were thought to be of little value given the large sample size and the resulting fact that statistical differences would have been identified even for small, clinically inconsequential differences resulting from the associated high power. Because it is of greater clinical importance to focus on the magnitude of differences, the databases were compared by absolute differences. Demographics and hospital lengths of stay were not different between the two databases. In terms of comorbidities
Full Text Available The American College of Surgeons' National Surgical Quality Improvement Program (NSQIP is the first nationally validated, risk-adjusted, outcomes-based program to measure and compare the quality of surgical care across North America. Participation in this program may provide an opportunity to reduce the incidence of adverse events related to surgery.A systematic review of the literature was performed. MedLine, EMBASE and PubMed were searched for studies relevant to NSQIP. Patient characteristics, intervention, and primary outcome measures were abstracted. The intervention was participation in NSQIP and monitoring of Individual Site Summary Reports with or without implementation of a quality improvement program. The outcomes of interest were change in peri-operative adverse events and mortality represented by pooled risk ratios (pRR and 95% confidence intervals (CI.Eleven articles reporting on 35 health care institutions were included. Nine (82% of the eleven studies implemented a quality improvement program. Minimal improvements in superficial (pRR 0.81; 95% CI 0.72-0.91, deep (pRR 0.82; 95% CI0.64-1.05 and organ space (pRR 1.15; 95% CI 0.96-1.37 infections were observed at centers that did not institute a quality improvement program. However, centers that reported formal interventions for the prevention and treatment of infections observed substantial improvements (superficial pRR 0.55, 95% CI 0.39-0.77; deep pRR 0.61, 95% CI 0.50-0.75, and organ space pRR 0.60, 95% CI 0.50-0.71. Studies evaluating other adverse events noted decreased incidence following NSQIP participation and implementation of a formal quality improvement program.These data suggest that NSQIP is effective in reducing surgical morbidity. Improvement in surgical quality appears to be more marked at centers that implemented a formal quality improvement program directed at the reduction of specific morbidities.
Maynard, Andrew D.; Warheit, David B.; Philbert, Martin A.
It has long been recognized that the physical form of materials can mediate their toxicity—the health impacts of asbestiform materials, industrial aerosols, and ambient particulate matter are prime examples. Yet over the past 20 years, toxicology research has suggested complex and previously unrecognized associations between material physicochemistry at the nanoscale and biological interactions. With the rapid rise of the field of nanotechnology and the design and production of increasingly complex nanoscale materials, it has become ever more important to understand how the physical form and chemical composition of these materials interact synergistically to determine toxicity. As a result, a new field of research has emerged—nanotoxicology. Research within this field is highlighting the importance of material physicochemical properties in how dose is understood, how materials are characterized in a manner that enables quantitative data interpretation and comparison, and how materials move within, interact with, and are transformed by biological systems. Yet many of the substances that are the focus of current nanotoxicology studies are relatively simple materials that are at the vanguard of a new era of complex materials. Over the next 50 years, there will be a need to understand the toxicology of increasingly sophisticated materials that exhibit novel, dynamic and multifaceted functionality. If the toxicology community is to meet the challenge of ensuring the safe use of this new generation of substances, it will need to move beyond “nano” toxicology and toward a new toxicology of sophisticated materials. Here, we present a brief overview of the current state of the science on the toxicology of nanoscale materials and focus on three emerging toxicology-based challenges presented by sophisticated materials that will become increasingly important over the next 50 years: identifying relevant materials for study, physicochemical characterization, and
Full Text Available BackgroundSurgical site infections (SSIs result in significant patient morbidity following immediate tissue expander breast reconstruction (ITEBR. This study determined a single institution's 30-day SSI rate and benchmarked it against that among national institutions participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP.MethodsWomen who underwent ITEBR with/without acellular dermal matrix (ADM were identified using the ACS-NSQIP database between 2005 and 2011. Patient characteristics associated with the 30-day SSI rate were determined, and differences in rates between our institution and the national database were assessed.Results12,163 patients underwent ITEBR, including 263 at our institution. SSIs occurred in 416 (3.4% patients nationwide excluding our institution, with lower rates observed at our institution (1.9%. Nationwide, SSIs were significantly more common in ITEBR patients with ADM (4.5% compared to non-ADM patients (3.2%, P=0.005, and this trend was observed at our institution (2.1% vs. 1.6%, P=1.00. A multivariable analysis of all institutions identified age ≥50 years (odds ratio [OR], 1.4; confidence interval [CI], 1.1-1.7, body mass index ≥30 kg/m2 vs. 4.25 hours (OR, 1.9; CI, 1.5-2.4 as risk factors for SSIs. Our institutional SSI rate was lower than the nationwide rate (OR, 0.4; CI, 0.2-1.1, although this difference was not statistically significant (P=0.07.ConclusionsThe 30-day SSI rate at our institution in patients who underwent ITEBR was lower than the nation. SSIs occurred more frequently in procedures involving ADM both nationally and at our institution.
Sutter, Matthias; Czermak, Simon; Feri, Francesco
Many important decisions require strategic sophistication. We examine experimentally whether teams act more strategically than individuals. We let individuals and teams make choices in simple games, and also elicit first- and second-order beliefs. We find that teams play the Nash equilibrium strategy significantly more often, and their choices are more often a best response to stated first order beliefs. Distributional preferences make equilibrium play less likely. Using a mixture model, the estimated probability to play strategically is 62% for teams, but only 40% for individuals. A model of noisy introspection reveals that teams differ from individuals in higher order beliefs. PMID:24926100
Golo, V.L.; Perelomov, A.M.
Two classes of the two-dimensional Euclidean chiral field theoreties are singled out: 1) the field phi(x) takes the values in the compact Hermitiam symmetric space 2) the field phi(x) takes the values in an orbit of the adjoint representation of the comcompact Lie group. The theories have sophisticated topological and rich analytical structures. They are considered with the help of topological invariants (topological charges). Explicit formulae for the topological charges are indicated, and the lower bound extimate for the action is given
Full Text Available This article compares capital budgeting techniques employed in listed and unlisted companies in Brazil. We surveyed the Chief Financial Officers (CFOs of 398 listed companies and 300 large unlisted companies, and based on 91 respondents, the results suggest that the CFOs of listed companies tend to use less simplistic methods more often, for example: NPV and CAPM, and that CFOs of unlisted companies are less likely to estimate the cost of equity, despite being large companies. These findings indicate that stock exchange listing may require greater sophistication of the capital budgeting process.
Vulliamy, Paul; Junaid, Islam
Peer-mentoring has attracted substantial interest in various healthcare professions, but has not been formally integrated into postgraduate surgical training. This study aimed to assess the feasibility and acceptability of a peer-mentor scheme among junior surgical trainees in the United Kingdom. Trainees entering the first year of core surgical training (CST) in a single postgraduate school of surgery were allocated a mentor in the second year of CST. Allocation was based on location of the initial clinical placement. An anonymised questionnaire regarding the mentorship scheme was sent to all participants in the third month following its introduction. 18 trainees participated in the scheme, of whom 12 (67%) responded to the questionnaire. All respondents had made contact with their allocated mentor or mentee, and no trainees had opted out of the scheme. Areas in which the mentees received guidance included examinations (83%), CV development (67%), and workplace-based assessments (67%). All respondents felt that the mentor scheme was a good addition to CST. Suggestions for improvement of the scheme included introduction of structured meetings and greater engagement with allocated mentors. A pilot peer-mentoring scheme was well received by junior surgical trainees. Consideration should be given to expansion of this scheme and more rigorous assessment of its value.
... millions) (2) change (3) Total $3,625 1% Eye and ocular adnexa 1,496 -3 Digestive system 743 8 Nervous... DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 405...: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality...
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Full Text Available The paper deals with the problems of routing control algorithms of new conception of tram vehicle bogie. The main goal of these research activities is wear reduction of rail wheels and tracks, wear reduction of traction energy losses and increasing of running comfort. The testing experimental tram vehicle with special bogie construction powered by traction battery is utilized for these purposes. This vehicle has a rotary bogie with independent rotating wheels driven by permanent magnets synchronous motors and a solid axle. The wheel forces in bogie are measured by large amounts of the various sensors placed on the testing experimental tram vehicle. Nowadays the designed control algorithms are implemented to the vehicle superset control system. The traction requirements and track characteristics have an effect to these control algorithms. This control including sophisticated routing brings other improvements which is verified and corrected according to individual traction and driving characteristics, and opens new possibilities.
Nehme, Jean; El-Khani, Ussamah; Chow, Andre; Hakky, Sherif; Ahmed, Ahmed R; Purkayastha, Sanjay
To compare multimedia and standard consent, in respect to patient comprehension, anxiety, and satisfaction, for various surgical/interventional procedures. Electronic searches of PubMed, MEDLINE, Ovid, Embase, and Google Scholar were performed. Relevant articles were assessed by 2 independent reviewers. Comparative (randomized and nonrandomized control trials) studies of multimedia and standard consent for a variety of surgical/interventional procedures were included. Studies had to report on at least one of the outcome measures. Studies were reviewed by 2 independent investigators. The first investigator extracted all relevant data, and consensus of each extraction was performed by a second investigator to verify the data. Overall, this review suggests that the use of multimedia as an adjunct to conventional consent appears to improve patient comprehension. Multimedia leads to high patient satisfaction in terms of feasibility, ease of use, and availability of information. There is no conclusive evidence demonstrating a significant reduction in preoperative anxiety.
West, Nicholas P; Sutton, Kate M; Ingeholm, Peter
Recent evidence has demonstrated the importance of dissection in the correct tissue plane for the resection of colon cancer. We have previously shown that meticulous mesocolic plane surgery yields better outcomes and that the addition of central vascular ligation produces an oncologically superio...... specimen compared with standard techniques. We aimed to assess the effect of surgical education on the oncological quality of the resection specimen produced....
Denadai, Rafael; Saad-Hossne, Rogério; Martinhão Souto, Luís Ricardo
Because of ethical and medico-legal aspects involved in the training of cutaneous surgical skills on living patients, human cadavers and living animals, it is necessary the search for alternative and effective forms of training simulation. To propose and describe an alternative methodology for teaching and learning the principles of cutaneous surgery in a medical undergraduate program by using a chicken-skin bench model. One instructor for every four students, teaching materials on cutaneous surgical skills, chicken trunks, wings, or thighs, a rigid platform support, needled threads, needle holders, surgical blades with scalpel handles, rat-tooth tweezers, scissors, and marking pens were necessary for training simulation. A proposal for simulation-based training on incision, suture, biopsy, and on reconstruction techniques using a chicken-skin bench model distributed in several sessions and with increasing levels of difficultywas structured. Both feedback and objective evaluations always directed to individual students were also outlined. The teaching of a methodology for the principles of cutaneous surgery using a chicken-skin bench model versatile, portable, easy to assemble, and inexpensive is an alternative and complementary option to the armamentarium of methods based on other bench models described.
Full Text Available Background: Because of ethical and medico-legal aspects involved in the training of cutaneous surgical skills on living patients, human cadavers and living animals, it is necessary the search for alternative and effective forms of training simulation. Aims: To propose and describe an alternative methodology for teaching and learning the principles of cutaneous surgery in a medical undergraduate program by using a chicken-skin bench model. Materials and Methods: One instructor for every four students, teaching materials on cutaneous surgical skills, chicken trunks, wings, or thighs, a rigid platform support, needled threads, needle holders, surgical blades with scalpel handles, rat-tooth tweezers, scissors, and marking pens were necessary for training simulation. Results: A proposal for simulation-based training on incision, suture, biopsy, and on reconstruction techniques using a chicken-skin bench model distributed in several sessions and with increasing levels of difficultywas structured. Both feedback and objective evaluations always directed to individual students were also outlined. Conclusion: The teaching of a methodology for the principles of cutaneous surgery using a chicken-skin bench model versatile, portable, easy to assemble, and inexpensive is an alternative and complementary option to the armamentarium of methods based on other bench models described.
Senekjian, Lara; Nirula, Raminder
Laparoscopic appendectomy (LA) is increasingly being performed in the United States, despite controversy about differences in infectious complication rates compared with open appendectomy (OA). Subpopulations exist in which infectious complication rates, both surgical site and organ space, differ with respect to LA compared with OA. All appendectomies in the National Surgical Quality Improvement Program database were analyzed with respect to surgical site infection (SSI) and organ space infection (OSI). Multivariate logistic regression analysis identified independent predictors of SSI or OSI. Probabilities of SSI or OSI were determined for subpopulations to identify when LA was superior to OA. From 2005 to 2009, there were 61,830 appendectomies performed (77.5% LA), of which 9,998 (16.2%) were complicated (58.7% LA). The risk of SSI was considerably lower for LA in both noncomplicated and complicated appendicitis. Across all ages, body mass index, renal function, and WBCs, LA was associated with a lower probability of SSI. The risk of OSI was considerably greater for LA in both noncomplicated and complicated appendicitis. In complicated appendicitis, OA was associated with a lower probability of OSI in patients with WBC >12 cells × 10(3)/μL. In noncomplicated appendicitis, OA was associated with a lower probability of OSI in patients with a body mass index OSI, however, SSI is consistently lower in LA patients. Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
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Francke, A.L.; Huijer-Abu Saad, H.; Grypdonck, M.
In a pilot study, a continuing education program on pain assessment and management was implemented and evaluated. Questionnaires were completed by the nurse participants at the beginning, the end, and 2 months after the end of the pilot program. After the pilot program, participants reported having
..., to correct our programming logic in the OPPS data process to apply the line item trim correctly. We... center crosswalk in our programming logic and the packaging status of two drug codes. III. Summary of... dataset used to model the OPPS. In reviewing the program logic used to establish the APC median costs for...
Zhang, Jacques X; Song, Diana; Bedford, Julie; Bucevska, Marija; Courtemanche, Douglas J; Arneja, Jugpal S
Morbidity and mortality conferences have played a traditional role in tracking complications. Recently, the American College of Surgeons National Surgical Quality Improvement Program Pediatrics (ACS NSQIP-P) has gained popularity as a risk-adjusted means of addressing quality assurance. The purpose of this article is to report an analysis of the two methodologies used within pediatric plastic surgery to determine the best way to manage quality. ACS NSQIP-P and morbidity and mortality data were extracted for 2012 and 2013 at a quaternary care institution. Overall complication rates were compared statistically, segregated by type and severity, followed by a subset comparison of ACS NSQIP-P-eligible cases only. Concordance and discordance rates between the two methodologies were determined. One thousand two hundred sixty-one operations were performed in the study period. Only 51.4 percent of cases were ACS NSQIP-P eligible. The overall complication rates of ACS NSQIP-P (6.62 percent) and morbidity and mortality conferences (6.11 percent) were similar (p = 0.662). Comparing for only ACS NSQIP-P-eligible cases also yielded a similar rate (6.62 percent versus 5.71 percent; p = 0.503). Although different complications are tracked, the concordance rate for morbidity and mortality and ACS NSQIP-P was 35.1 percent and 32.5 percent, respectively. The ACS NSQIP-P database is able to accurately track complication rates similarly to morbidity and mortality conferences, although it samples only half of all procedures. Although both systems offer value, limitations exist, such as differences in definitions and purpose. Because of the rigor of the ACS NSQIP-P, we recommend that it be expanded to include currently excluded cases and an extension of the study interval.
The American College of Surgeons/Association of Program Directors in Surgery National Skills Curriculum: adoption rate, challenges and strategies for effective implementation into surgical residency programs.
Korndorffer, James R; Arora, Sonal; Sevdalis, Nick; Paige, John; McClusky, David A; Stefanidis, Dimitris
The American College of Surgeons/Association of Program Directors in Surgery (ACS/APDS) National Skills Curriculum is a 3-phase program targeting technical and nontechnical skills development. Few data exist regarding the adoption of this curriculum by surgical residencies. This study attempted to determine the rate of uptake and identify implementation enablers/barriers. A web-based survey was developed by an international expert panel of surgical educators (5 surgeons and 1 psychologist). After piloting, the survey was sent to all general surgery program directors via email link. Descriptive statistics were used to determine the residency program characteristics and perceptions of the curriculum. Implementation rates for each phase and module were calculated. Adoption barriers were identified quantitatively and qualitatively using free text responses. Standardized qualitative methodology of emergent theme analysis was used to identify strategies for success and details of support required for implementation. Of the 238 program directors approached, 117 (49%) responded to the survey. Twenty-one percent (25/117) were unaware of the ACS/APDS curriculum. Implementation rates for were 36% for phase I, 19% for phase II, and 16% for phase III. The most common modules adopted were the suturing, knot-tying, and chest tube modules of phase I. Over 50% of respondents identified lack of faculty protected time, limited personnel, significant costs, and resident work-hour restrictions as major obstacles to implementation. Strategies for effective uptake included faculty incentives, adequate funding, administrative support, and dedicated time and resources. Despite the availability of a comprehensive curriculum, its diffusion into general surgery residency programs remains low. Obstacles related to successful implementation include personnel, learner, and administrative issues. Addressing these issues may improve the adoption rate of the curriculum. Copyright © 2013 Mosby, Inc
Patil, Nivritti G; Cheng, Stephen W K; Wong, John
Recent high-profile cases have heightened the need for a formal structure to monitor achievement and maintenance of surgical competence. Logbooks, morbidity and mortality meetings, videos and direct observation of operations using a checklist, motion analysis devices, and virtual reality simulators are effective tools for teaching and evaluating surgical skills. As the operating theater is also a place for training, there must be protocols and guidelines, including mandatory standards for supervision, to ensure that patient care is not compromised. Patients appreciate frank communication and honesty from surgeons regarding their expertise and level of competence. To ensure that surgical competence is maintained and keeps pace with technologic advances, professional registration bodies have been promoting programs for recertification. They evaluate performance in practice, professional standing, and commitment to ongoing education.
Ingo, G. M.; Riccucci, C.; Faraldi, F.; Pascucci, M.; Messina, E.; Fierro, G.; Di Carlo, G.
By means of the combined use of X-ray photoelectron spectroscopy (XPS), optical microscopy (OM) and scanning electron microscopy (SEM) coupled with energy dispersive X-ray spectroscopy (EDS) the surface and subsurface chemical and metallurgical features of silver counterfeited Roman Republican coins are investigated to decipher some aspects of the manufacturing methods and to evaluate the technological ability of the Roman metallurgists to produce thin silver coatings. The results demonstrate that over 2000 ago important advances in the technology of thin layer deposition on metal substrates were attained by Romans. The ancient metallurgists produced counterfeited coins by combining sophisticated micro-plating methods and tailored surface chemical modification based on the mercury-silvering process. The results reveal that Romans were able systematically to chemically and metallurgically manipulate alloys at a micro scale to produce adherent precious metal layers with a uniform thickness up to few micrometers. The results converge to reveal that the production of forgeries was aimed firstly to save expensive metals as much as possible allowing profitable large-scale production at a lower cost. The driving forces could have been a lack of precious metals, an unexpected need to circulate coins for trade and/or a combinations of social, political and economic factors that requested a change in money supply. Finally, some information on corrosion products have been achieved useful to select materials and methods for the conservation of these important witnesses of technology and economy.
de Sá, Fábio P; Zina, Juliana; Haddad, Célio F B
Intraspecific communication in frogs plays an important role in the recognition of conspecifics in general and of potential rivals or mates in particular and therefore with relevant consequences for pre-zygotic reproductive isolation. We investigate intraspecific communication in Hylodes japi, an endemic Brazilian torrent frog with territorial males and an elaborate courtship behavior. We describe its repertoire of acoustic signals as well as one of the most complex repertoires of visual displays known in anurans, including five new visual displays. Previously unknown in frogs, we also describe a bimodal inter-sexual communication system where the female stimulates the male to emit a courtship call. As another novelty for frogs, we show that in addition to choosing which limb to signal with, males choose which of their two vocal sacs will be used for visual signaling. We explain how and why this is accomplished. Control of inflation also provides additional evidence that vocal sac movement and color must be important for visual communication, even while producing sound. Through the current knowledge on visual signaling in Neotropical torrent frogs (i.e. hylodids), we discuss and highlight the behavioral diversity in the family Hylodidae. Our findings indicate that communication in species of Hylodes is undoubtedly more sophisticated than we expected and that visual communication in anurans is more widespread than previously thought. This is especially true in tropical regions, most likely due to the higher number of species and phylogenetic groups and/or to ecological factors, such as higher microhabitat diversity.
Fábio P de Sá
Full Text Available Intraspecific communication in frogs plays an important role in the recognition of conspecifics in general and of potential rivals or mates in particular and therefore with relevant consequences for pre-zygotic reproductive isolation. We investigate intraspecific communication in Hylodes japi, an endemic Brazilian torrent frog with territorial males and an elaborate courtship behavior. We describe its repertoire of acoustic signals as well as one of the most complex repertoires of visual displays known in anurans, including five new visual displays. Previously unknown in frogs, we also describe a bimodal inter-sexual communication system where the female stimulates the male to emit a courtship call. As another novelty for frogs, we show that in addition to choosing which limb to signal with, males choose which of their two vocal sacs will be used for visual signaling. We explain how and why this is accomplished. Control of inflation also provides additional evidence that vocal sac movement and color must be important for visual communication, even while producing sound. Through the current knowledge on visual signaling in Neotropical torrent frogs (i.e. hylodids, we discuss and highlight the behavioral diversity in the family Hylodidae. Our findings indicate that communication in species of Hylodes is undoubtedly more sophisticated than we expected and that visual communication in anurans is more widespread than previously thought. This is especially true in tropical regions, most likely due to the higher number of species and phylogenetic groups and/or to ecological factors, such as higher microhabitat diversity.
Patil, R S; Adibi, J; Shoemaker, W C
We developed an artificial intelligence program from a large computerized database of hemodynamic and oxygen transport measurements together with prior studies defining survivors' values, outcome predictors, and a branched-chain decision tree. The artificial intelligence program was then tested on the data of 100 survivors and 100 nonsurvivors not used for the development of the program or other analyses. Using the predictor as a surrogate outcome measure, the therapy recommended by the program improved the predicted outcome 3.16% per therapeutic intervention while the actual therapy given increased outcome 1.86% in surviving patients; the artificial intelligence-recommended therapy improved outcome 7.9% in nonsurvivors, while the actual therapy given increased predicted outcome -0.29% in nonsurvivors (p < .05). There were fewer patients whose predicted outcome decreased after recommended treatment (14%) than after the actual therapy given (37%). Review of therapy recommended by the program did not reveal instances of inappropriate or potentially harmful recommendations.
Roblyer, S.P.; Owzarski, P.C.
The N-Reactor confinement system release dose to the public in a postulated accident is reduced by washing the confinement atmosphere with fog sprays. This allows a low pressure release of confinement atmosphere containing fission products through filters and out an elevated stack. The current accident analysis required revision of the CORRAL code and other codes such as CONTEMPT to properly model the N Reactor confinement into a system of multiple fog-sprayed compartments. In revising these codes, more sophisticated models for the fog sprays and iodine plateout were incorporated to remove some of the conservatism of steam condensing rate, fission product washout and iodine plateout than used in previous studies. The CORRAL code, which was used to describe the transport and deposition of airborne fission products in LWR containment systems for the Rasmussen Study, was revised to describe fog spray removal of molecular iodine (I 2 ) and particulates in multiple compartments for sprays having individual characteristics of on-off times, flow rates, fall heights, and drop sizes in changing containment atmospheres. During postulated accidents, the code determined the fission product removal rates internally rather than from input decontamination factors. A discussion is given of how the calculated plateout and washout rates vary with time throughout the analysis. The results of the accident analyses indicated that more credit could be given to fission product washout and plateout. An important finding was that the release of fission products to the atmosphere and adsorption of fission products on the filters were significantly lower than previous studies had indicated
Liu, Juyuan; Li, Na; Hao, Jinjuan; Li, Yanming; Liu, Anlei; Wu, Yinghong; Cai, Meng
Surgical site infections (SSIs) are the leading cause of hospital-acquired infections and are associated with substantial healthcare costs, with increased morbidity and mortality. To investigate the effects of the antibiotic stewardship program on prevention and control of SSI during clean surgery, we investigated this situation in our institution. We performed a quasi-experimental study to compare the effect before and after the antibiotic stewardship program intervention. During the pre-intervention stage (January 1, 2010 through December 31, 2011), comprehensive surveillance was performed to determine the SSI baseline data. In the second stage (January 1, 2012 through December 31, 2016), an infectious diseases physician and an infection control practitioner identified the surgical patients daily and followed up on the duration of antimicrobial prophylaxis. From January 1, 2010 to December 31, 2016, 41,426 patients underwent clean surgeries in a grade III, class A hospital. The rate of prophylactic antibiotic use in the 41,426 clean surgeries was reduced from 82.9% to 28.0% after the interventions. The rate of antibiotic agents administered within 120 minutes of the first incision increased from 20.8% to 85.1%. The rate at which prophylactic antimicrobial agents were discontinued in the first 24 hours after surgery increased from 22.1% to 60.4%. Appropriate antibiotic selection increased from 37.0% to 93.6%. Prophylactic antibiotic re-dosing increased from 3.8% to 64.8%. The SSI rate decreased from 0.7% to 0.5% (p < 0.05). The pathogen detection rate increased from 16.7% up to 41.8% after intervention. The intensity of antibiotic consumption reduced from 74.9 defined daily doses (DDDs) per 100 bed-days to 34.2 DDDs per 100 bed-days after the interventions. Long-term and continuous antibiotic stewardship programs have important effects on the prevention and control of SSI during clean surgery.
Storey Donald F
Full Text Available Abstract Background Antimicrobial stewardship has been promoted as a key strategy for coping with the problems of antimicrobial resistance and Clostridium difficile. Despite the current call for stewardship in community hospitals, including smaller community hospitals, practical examples of stewardship programs are scarce in the reported literature. The purpose of the current report is to describe the implementation of an antimicrobial stewardship program on the medical-surgical service of a 100-bed community hospital employing a core strategy of post-prescriptive audit with intervention and feedback. Methods For one hour twice weekly, an infectious diseases physician and a clinical pharmacist audited medical records of inpatients receiving systemic antimicrobial therapy and made non-binding, written recommendations that were subsequently scored for implementation. Defined daily doses (DDDs; World Health Organization Center for Drug Statistics Methodology and acquisition costs per admission and per patient-day were calculated monthly for all administered antimicrobial agents. Results The antimicrobial stewardship team (AST made one or more recommendations for 313 of 367 audits during a 16-month intervention period (September 2009 – December 2010. Physicians implemented recommendation(s from each of 234 (75% audits, including from 85 of 115 for which discontinuation of all antimicrobial therapy was recommended. In comparison to an 8-month baseline period (January 2009 – August 2009, there was a 22% decrease in defined daily doses per 100 admissions (P = .006 and a 16% reduction per 1000 patient-days (P = .013. There was a 32% reduction in antimicrobial acquisition cost per admission (P = .013 and a 25% acquisition cost reduction per patient-day (P = .022. Conclusions An effective antimicrobial stewardship program was implemented with limited resources on the medical-surgical service of a 100-bed community hospital.
Karamanos, Efstathios; Osgood, Geoff; Siddiqui, Aamir; Rubinfeld, Ilan
Increasing age has traditionally been associated with impairment in wound healing after operative interventions. This is based mostly on hearsay and anecdotal information. This idea fits with the authors’ understanding of biology in older organisms. This dictum has not been rigorously tested in clinical practice. The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried for all patients undergoing plastic surgery from 2005 to 2010. Variables extracted included basic demographics, comorbidities, previous steroid and tobacco use, wound classification at the end of the surgery, and development of postoperative surgical-site infections. Multivariate analyses were used to investigate the impact of aging in wound dehiscence. A total of 25,967 patients were identified. Overall, the incidence of wound dehiscence was 0.75 percent (n = 196). When patients younger than 30 years were compared to older patient groups, no difference in the probability of developing wound dehiscence was noted. Specifically, the groups of patients aged 61 to 70 years and older than 70 years did not have statistically significant wound healing deficiencies [adjusted OR, 0.63 (95 percent CI, 0.11 to 3.63), adjusted p = 0.609; 2.79 (0.55 to 14.18), adjusted p = 0.217, for 61 to 70 years and older than 70 years, respectively]. Factors independently associated with wound dehiscence included postoperative abscess development, paraplegia, quadriplegia, steroid and tobacco use, deep surgical-site infection development, increasing body mass index, and wound classification at the end of surgery. In patients undergoing plastic surgery, wound dehiscence is a rare complication (0.75 percent). Aging is not associated with an increased incidence of wound dehiscence. Risk, III.
... instruction, including: Microbiology Pathophysiology Pharmacology Anatomy and physiology Medical terminology Curriculum . Course content includes: Advanced surgical anatomy Surgical microbiology Surgical pharmacology Anesthesia methods and agents Bioscience Ethical ...
Morishita, Takashi; Fayad, Sarah M; Goodman, Wayne K; Foote, Kelly D; Chen, Dennis; Peace, David A; Rhoton, Albert L; Okun, Michael S
Deep brain stimulation (DBS) has been established as a safe, effective therapy for movement disorders (Parkinson's disease, essential tremor, etc.), and its application is expanding to the treatment of other intractable neuropsychiatric disorders including depression and obsessive-compulsive disorder (OCD). Several published studies have supported the efficacy of DBS for severely debilitating OCD. However, questions remain regarding the optimal anatomic target and the lack of a bedside programming paradigm for OCD DBS. Management of OCD DBS can be highly variable and is typically guided by each center's individual expertise. In this paper, we review the various approaches to targeting and programming for OCD DBS. We also review the clinical experience for each proposed target and discuss the relevant neuroanatomy. A PubMed review was performed searching for literature on OCD DBS and included all articles published before March 2012. We included all available studies with a clear description of the anatomic targets, programming details, and the outcomes. Six different DBS approaches were identified. High-frequency stimulation with high voltage was applied in most cases, and predictive factors for favorable outcomes were discussed in the literature. DBS remains an experimental treatment for medication refractory OCD. Target selection and programming paradigms are not yet standardized, though an improved understanding of the relationship between the DBS lead and the surrounding neuroanatomic structures will aid in the selection of targets and the approach to programming. We propose to form a registry to track OCD DBS cases for future clinical study design. © 2013 International Neuromodulation Society.
Zakaria, Ahmed S.; Haddad, Richard; Dragomir, Alice; Kassouf, Wassim; Andonian, Sero; Aprikian, Armen G.
Introduction: According to the Royal College objectives of training in urology, urologic surgical procedures are divided as category A, B and C. We wanted to determine the level of proficiency required and achieved by urology training faculty for Royal College accreditation. Methods: We conducted a survey that was sent electronically to all Canadian urology training faculty. Questions focused on demographics (i.e., years of practice, geographic location, subspecialty, access to robotic surgery), operating room contact with residents, opinion on the level of proficiency required from a list of 54 surgical procedures, and whether their most recent graduates attained category A proficiency in these procedures. Results: The response rate was 43.7% (95/217). Among respondents, 92.6% were full timers, 21.1% practiced urology for less than 5 years and 3.2% for more than 30 years. Responses from Quebec and Ontario formed 69.4% (34.7% each). Of the respondents, 37.9% were uro-oncologists and 75.7% reported having access to robotic surgery. Sixty percent of faculty members operate with R5 residents between 2 to 5 days per month. When respondents were asked which categories should be listed as category A, only 8 procedures received 100% agreement. Also, results varied significantly when analyzed by sub-specialty. For example, almost 50% or more of uro-oncologists believed that radical cystectomy, anterior pelvic exenteration and extended pelvic lymphadenectomy should not be category A. The following procedures had significant disagreement suggesting the need for re-classification: glanular hypospadias repair, boari flap, entero-vesical and vesicovaginal fistulae repair. Overall, more than 80% of faculty reported that their recent graduating residents had achieved category A proficiency, in a subset of procedures. However, more than 50% of all faculty either disagreed or were ambivalent that all of their graduating residents were Category A proficient in several procedures
LaGrone, Lacey N; Fuhs, Amy K; Egoavil, Eduardo Huaman; Rodriguez Castro, Manuel J A; Valderrama, Roberto; Isquith-Dicker, Leah N; Herrera-Matta, Jaime; Mock, Charles N
Evidence for the positive impact of quality improvement (QI) programs on morbidity, mortality, patient satisfaction, and cost is strong. Data regarding the status of QI programs in low- and middle-income countries, as well as in-depth examination of barriers and facilitators to their implementation, are limited. This cross-sectional, descriptive study employed a mixed-methods design, including distribution of an anonymous quantitative survey and individual interviews with healthcare providers who participate in the care of the injured at ten large hospitals in Lima, Peru. Key areas identified for improvement in morbidity and mortality (M&M) conferences were the standardization of case selection, incorporation of evidence from the medical literature into case presentation and discussion, case documentation, and the development of a clear plan for case follow-up. The key barriers to QI program implementation were a lack of prioritization of QI, lack of sufficient human and administrative resources, lack of political support, and lack of education on QI practices. A national program that makes QI a required part of all health providers' professional training and responsibilities would effectively address a majority of identified barriers to QI programs in Peru. Specifically, the presence of basic QI elements, such as M&M conferences, should be required at hospitals that train pre-graduate physicians. Alternatively, short of this national-level organization, efforts that capitalize on local examples through apprenticeships between institutions or integration of QI into continuing medical education would be expected to build on the facilitators for QI programs that exist in Peru.
Bauer, Bruce; Williams, Erin; Stratman, Erik J
The public and other medical specialties expect dermatologists who offer cosmetic dermatology services to provide competent care. There are numerous barriers to achieving cosmetic dermatology competency during residency. Many dermatology residents enter the workforce planning to provide cosmetic services. If a training gap exists, this may adversely affect patient safety. To identify resources available for hands-on cosmetic dermatology training in US dermatology residency training programs and to assess program director (PD) attitudes toward cosmetic dermatology training during residency and strategies, including discounted pricing, used by training programs to overcome barriers related to resident-performed cosmetic dermatology procedures. An online survey in academic dermatology practices among PDs of US dermatology residency programs. Frequency of cosmetic dermatology devices and injectables used for dermatology resident hands-on cosmetic dermatology training, categorizing PD attitudes toward cosmetic dermatology training during residency and describing residency-related discounted pricing models. Responses from PDs were received from 53 of 114 (46%) US dermatology residency programs. All but 3 programs (94%) offered hands-on cosmetic dermatology training using botulinum toxin, and 47 of 53 (89%) provided training with hyaluronic acid fillers. Pulsed dye lasers represented the most common laser use experienced by residents (41 of 52 [79%]), followed by Q-switched Nd:YAG (30 of 52 [58%]). Discounted procedures were offered by 32 of 53 (60%) programs, with botulinum toxin (30 of 32 [94%]) and fillers (27 of 32 [84%]) most prevalent and with vascular lasers (17 of 32 [53%]) and hair removal lasers (12 of 32 [38%]) less common. Various discounting methods were used. Only 20 of 53 (38%) PDs believed that cosmetic dermatology should be a necessary aspect of residency training; 14 of 52 (27%) PDs thought that residents should not be required to perform any cosmetic
... consequence of increasing health care costs to the Medicare program and limiting the choices of those patients... with information concerning the illness, injury or condition that brought the patient to the ASC, as.../grievances relating, but not limited to, mistreatment, neglect, verbal, mental, sexual, or physical abuse...
Suction curettage; Surgical abortion; Elective abortion - surgical; Therapeutic abortion - surgical ... Surgical abortion involves dilating the opening to the uterus (cervix) and placing a small suction tube into the uterus. ...
Full Text Available Background: Residency training is the basis of good clinical and surgical practice. Purpose: The aim is to know the demographics, training experience, and perception of young ophthalmologists to improve the present residency programs in India. Setting: Young ophthalmologists trained in India. Methods: A survey was conducted by the Academic and Research Committee of the All India Ophthalmology Society, in 2014–2016 of young ophthalmologists (those trained between 2002 and 2012, with 2–10 years' postresidency experience to gauge teaching of clinical and surgical skills during the postgraduate residency program. Statistical Analysis: Statistical Package for Social Sciences version 16. Results: Of the 1005 respondents, 531 fulfilled inclusion criteria. Average age was 32.6 years (standard deviation [SD] 4. On a scale of 0–10, clinical skills teaching was graded as (mean, SD: Slit lamp examination (7.2, SD 2.8, indirect ophthalmoscopy (6.2, SD 3.3, gonioscopy (5.7, SD 3.4, perimetry (6.2, SD 3.2, optical coherence tomography (4.6, SD 4, and orthoptic evaluation (4.3, SD 3.1. The mean (SD and median of surgeries performed independently was intracapsular cataract extraction 3.0 (14.9, 0; extracapsular cataract extraction 39.9 (53.2, 18; small incision cataract surgery 75.3 (64.4, 55; phacoemulsification 30 (52.6, 1; pterygium excision 31.5 (43.5, 15; dacryocystectomy 20.3 (38.1, 4; dacryocystorhinostomy 11.7 (26.2, 2; chalazion 46.4 (48.3, 30; trabeculectomies 4 (14.9, 0; strabismus correction 1.4 (4.9, 0; laser-assisted in situ Keratomileusis 1.5 (12.2, 0; retinal detachment 1.5 (12.5, 0; vitrectomy 3.0 (17.0, 0; keratoplasty 5.2 (17.8, 0; eyelid surgery 8.6 (18.9, 2 and ocular emergencies 41.7 (52.4, 20. Observed and assisted surgeries were more common. However, the range of grading was 0–10 in all categories. Conclusion: Residency training in India varies considerably from program to program. Standardization is needed to assure all graduates
Eichhorn, G.; Accomazzi, A.; Grant, C. S.; Henneken, E.; Kurtz, M. J.; Murray, S. S.
The ADS provides access to over 940,000 references from astronomy and planetary sciences publications and 1.5 million records from physics publications. It is funded by NASA and provides free access to these references, as well as to 2.4 million scanned pages from the astronomical literature. These include most of the major astronomy and several planetary sciences journals, as well as many historical observatory publications. The references now include the abstracts from all volumes of the Journal of Geophysical Research (JGR) since the beginning of 2002. We get these abstracts on a regular basis. The Kluwer journal Solar Physics has been scanned back to volume 1 and is available through the ADS. We have extracted the reference lists from this and many other journals and included them in the reference and citation database of the ADS. We have recently scanning Earth, Moon and Planets, another Kluwer journal, and will scan other Kluwer journals in the future as well. We plan on extracting references from these journals as well in the near future. The ADS has many sophisticated query features. These allow the user to formulate complex queries. Using results lists to get further information about the selected articles provide the means to quickly find important and relevant articles from the database. Three advanced feedback queries are available from the bottom of the ADS results list (in addition to regular feedback queries already available from the abstract page and from the bottom of the results list): 1. Get reference list for selected articles: This query returns all known references for the selected articles (or for all articles in the first list). The resulting list will be ranked according to how often each article is referred to and will show the most referenced articles in the field of study that created the first list. It presumably shows the most important articles in that field. 2. Get citation list for selected articles: This returns all known articles
Full Text Available Background & Aims: Patient safety is one of the indicators of risk management in clinical governance system. Surgical care is one of the most sophisticated medical care in the hospitals. So it is not surprising that nearly half of the adverse events, 66% were related to surgery. Pre-flight aircraft Inspection model is starting point for designing surgical safety checklist that use for audit procedure. The aim of this study is to evaluate the effect of the use of surgical safety checklist on surgical patients mortality and complications. Materials and Methods: This is a prospective descriptive study. This study was conducted in 2012 in the North West of Iran. The population consisted of patients who had undergoing surgery in α university of medical science`s hospital which have surgical department. In this study, 1125 patients underwent surgery within 3 months were studied. Data collection tool was designed based on WHO model and Surgcical Care and Outcomes Assessment Program(SCOAP. Data analysis was performed using the SPSS-20 statistical software and logistic regression analysis was used to calculate P values for each comparison. Results: No significant differences between patients in the two periods (before and after There was. All complications rate reduced from 11 percent to 4 percent after the intervention by checklist (p<0.001. In the all hospitals mortality rate was decreased from 3.44% to 1.3% (p <0.003. Overall rate of surgical site infection and unplanned return to the operating room was reduced (p<0.001 and p<0.046. Conclusion: Many people every year due to lack of safety in hospitals, lose their lives. Despite the risks, such as leaving surgery sets in patient body and wrong surgery is due to lack of proper safety programs during surgery. By using safety checklist in all hospitals mortality rate and complications was reduced but this reduction was extremely in α3 hospital (from 5.2% to 1.48%.
Schneider, Andrew; Hutcheon, Deborah A; Hale, Allyson; Ewing, Joseph A; Miller, Megan; Scott, John D
Many insurance companies require patient participation in a medically supervised weight management program (WMP) before offering approval for bariatric surgery. Clinical data surrounding benefits of participation are limited. To evaluate the relationship between preoperative insurance-mandated WMP participation and postoperative outcomes in bariatric surgery patients. Regional referral center and teaching hospital. A retrospective review of patients who underwent vertical sleeve gastrectomy or Roux-en-Y gastric bypass between January 2014 and January 2016 was performed. Patients (N = 354) were divided into 2 cohorts and analyzed according to presence (n = 266) or absence (n = 88) of an insurance-mandated WMP requirement. Primary endpoints included rate of follow-up and percent of excess weight loss (%EWL) at postoperative months 1, 3, 6, and 12. All patients, regardless of the insurance-mandated WMP requirement, followed a program-directed preoperative diet. The majority of patients with an insurance-mandated WMP requirement had private insurance (63.9%). Both patient groups experienced a similar proportion of readmissions and reoperations, rate of follow-up, and %EWL at 1, 3, 6, and 12 months (P = NS). Median operative duration and hospital length of stay were also similar between groups. Linear regression analysis revealed no significant improvement in %EWL at 12 months in the yes-WMP group. These data show that patients who participate in an insurance-mandated WMP in addition to completing a program-directed preoperative diet experience no significant benefit to rate of readmission, reoperation, follow-up, or %EWL up to 12 months postoperation. Our findings suggest that undergoing bariatric surgery without completing an insurance-mandated WMP is safe and effective. Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
Dasenbrock, Hormuzdiyar H; Smith, Timothy R; Rudy, Robert F; Gormley, William B; Aziz-Sultan, M Ali; Du, Rose
OBJECTIVE Although reoperation and readmission have been used as quality metrics, there are limited data evaluating the rate of, reasons for, and predictors of reoperation and readmission after microsurgical clipping of unruptured aneurysms. METHODS Adult patients who underwent craniotomy for clipping of an unruptured aneurysm electively were extracted from the prospective National Surgical Quality Improvement Program registry (2011-2014). Multivariable logistic regression and recursive partitioning analysis evaluated the independent predictors of nonroutine hospital discharge, unplanned 30-day reoperation, and readmission. Predictors screened included patient age, sex, comorbidities, American Society of Anesthesiologists (ASA) classification, functional status, aneurysm location, preoperative laboratory values, operative time, and postoperative complications. RESULTS Among the 460 patients evaluated, 4.2% underwent any reoperation at a median of 7 days (interquartile range [IQR] 2-17 days) postoperatively, and 1.1% required a cranial reoperation. The most common reoperation was ventricular shunt placement (23.5%); other reoperations were tracheostomy, craniotomy for hematoma evacuation, and decompressive hemicraniectomy. Independent predictors of any unplanned reoperation were age greater than 51 years and longer operative time (p ≤ 0.04). Readmission occurred in 6.3% of patients at a median of 6 days (IQR 5-13 days) after discharge from the surgical hospitalization; 59.1% of patients were readmitted within 1 week and 86.4% within 2 weeks of discharge. The most common reason for readmission was seizure (26.7%); other causes of readmission included hydrocephalus, cerebrovascular accidents, and headache. Unplanned readmission was independently associated with age greater than 65 years, Class II or III obesity (body mass index > 35 kg/m 2 ), preoperative hyponatremia, and preoperative anemia (p ≤ 0.04). Readmission was not associated with operative time
Hakkarainen, Timo W; Dellinger, E Patchen; Evans, Heather L; Farjah, Farhood; Farrokhi, Ellen; Steele, Scott R; Thirlby, Richard; Flum, David R
Surgical site infections (SSI) are an important source of morbidity and mortality. Chlorhexidine in isopropyl alcohol is effective in preventing central venous-catheter associated infections, but its effectiveness in reducing SSI in clean-contaminated procedures is uncertain. Surgical studies to date have had contradictory results. We aimed to further evaluate the relationship of commonly used antiseptic agents and SSI, and to determine if isopropyl alcohol has a unique effect. We performed a prospective cohort analysis to evaluate the relationship of commonly used skin antiseptic agents and SSI for patients undergoing mostly clean-contaminated surgery from January 2011 through June 2012. Multivariate regression modeling predicted expected rates of SSI. Risk adjusted event rates (RAERs) of SSI were compared across groups using proportionality testing. Among 7,669 patients, the rate of SSI was 4.6%. The RAERs were 0.85 (p = 0.28) for chlorhexidine (CHG), 1.10 (p = 0.06) for chlorhexidine in isopropyl alcohol (CHG+IPA), 0.98 (p = 0.96) for povidone-iodine (PVI), and 0.93 (p = 0.51) for iodine-povacrylex in isopropyl alcohol (IPC+IPA). The RAERs were 0.91 (p = 0.39) for the non-IPA group and 1.10 (p = 0.07) for the IPA group. Among elective colorectal patients, the RAERs were 0.90 (p = 0.48) for CHG, 1.04 (p = 0.67) for CHG+IPA, 1.04 (p = 0.85) for PVI, and 1.00 (p = 0.99) for IPC+IPA. For clean-contaminated surgical cases, this large-scale state cohort study did not demonstrate superiority of any commonly used skin antiseptic agent in reducing the risk of SSI, nor did it find any unique effect of isopropyl alcohol. These results do not support the use of more expensive skin preparation agents. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
Molena, Daniela; Mungo, Benedetto; Stem, Miloslawa; Feinberg, Richard L; Lidor, Anne O
The development of minimally invasive operative techniques and improvement in postoperative care has made surgery a viable option to a greater number of elderly patients. Our objective was to evaluate the outcomes of laparoscopic and open foregut operation in relation to the patient age. Patients who underwent gastric fundoplication, paraesophageal hernia repair, and Heller myotomy were identified via the National Surgical Quality Improvement Program (NSQIP) database (2005-2011). Patient characteristics and outcomes were compared between five age groups (group I: ≤65 years, II: 65-69 years; III: 70-74 years; IV: 75-79 years; and V: ≥80 years). Multivariable logistic regression analysis was used to predict the impact of age and operative approach on the studied outcomes. A total of 19,388 patients were identified. Advanced age was associated with increased rate of 30-day mortality, overall morbidity, serious morbidity, and extended length of stay, regardless of the operative approach. After we adjusted for other variables, advanced age was associated with increased odds of 30-day mortality compared with patients <65 years (III: odds ratio 2.70, 95% confidence interval 1.34-5.44, P = .01; IV: 2.80, 1.35-5.81, P = .01; V: 6.12, 3.41-10.99, P < .001). Surgery for benign foregut disease in elderly patients carries a burden of mortality and morbidity that needs to be acknowledged. Copyright © 2014 Mosby, Inc. All rights reserved.
Alejandra Salcedo Monsalve
Full Text Available This article shows the results of a research in which I decided to analyze the narratives of professors of medical and surgical specialties in a university hospital in the city of Bogota, and interpret their teaching experiences, to learn some elements of their identity and the pedagogical knowledge they have built. A qualitative study was conducted from the hermeneutical historical approach, using life stories. Five teachers participated voluntarily. An analysis of the narratives focused on the meaning and the interpretation of the findings in the light of pedagogical theory was performed. In relation to teacher identity, the specialists became teachers unintentionally as a response to own labor requirements of the job at the university hospital. The construction process of the teachers started from their years of schooling, and pedagogical practice has a strong influence on what they learned from their own teachers. The academic activity is being undertaken by the major motivation vocation, expressions of thanks of their students and satisfaction for achieving the proposed learning objectives. The lack of teacher training creates tension and concern among teachers, which could be prevented with teacher education programs.
Kim, Minkyung; Crossley, Scott A.; Kyle, Kristopher
This study conceptualizes lexical sophistication as a multidimensional phenomenon by reducing numerous lexical features of lexical sophistication into 12 aggregated components (i.e., dimensions) via a principal component analysis approach. These components were then used to predict second language (L2) writing proficiency levels, holistic lexical…
Kalogeropoulos, A.; Albæk, E.; de Vreese, C.H.; van Dalen, A.
In analogy to political sophistication, it is imperative that citizens have a certain level of economic sophistication, especially in times of heated debates about the economy. This study examines the impact of different influences (media, interpersonal communication and personal experiences) on
Blair, Kristine L.
With the recent interest in the fifth century B.C. theories of Protagoras and Gorgias come assumptions about the philosophical affinity of the Greek educator Isocrates to this pair of older sophists. Isocratean education in discourse, with its emphasis on collaborative political discourse, falls within recent definitions of a sophist curriculum.…
Allen, James E.
While Aristotle's philosophical views are more foundational than those of many of the Older Sophists, Aristotle's rhetorical theories inherit and incorporate many of the central tenets ascribed to Sophistic rhetoric, albeit in a more systematic fashion, as represented in the "Rhetoric." However, Aristotle was more than just a rhetorical…
The surgical light is an important tool for surgeons to create and maintain good visibility on the surgical task. Chapter 1 gives background to the field of (surgical) lighting and related terminology. Although the surgical light has been developed strongly since its introduction a long time ago,
Federal Laboratory Consortium — The Surgical Critical Care Initiative (SC2i) is a USU research program established in October 2013 to develop, translate, and validate biology-driven critical care....
U.S. Department of Health & Human Services — The Ambulatory Surgical Center Quality Reporting (ASCQR) Program seeks to make care safer and more efficient through quality reporting. ASCs eligible for this...
Buck, Dominique B.; Ultee, Klaas H J; Zettervall, Sara L.; Soden, Pete A.; Darling, Jeremy; Wyers, Mark; van Herwaarden, Joost A.; Schermerhorn, Marc L.
Objective: We sought to compare current practices in patient selection and 30-day outcomes for transperitoneal and retroperitoneal abdominal aortic aneurysm (AAA) repairs. Methods: All patients undergoing elective transperitoneal or retroperitoneal surgical repair for AAA between January 2011 and
Mull, Hillary J; Borzecki, Ann M; Loveland, Susan; Hickson, Kathleen; Chen, Qi; MacDonald, Sally; Shin, Marlena H; Cevasco, Marisa; Itani, Kamal M F; Rosen, Amy K
The Patient Safety Indicators (PSIs) use administrative data to screen for select adverse events (AEs). In this study, VA Surgical Quality Improvement Program (VASQIP) chart review data were used as the gold standard to measure the criterion validity of 5 surgical PSIs. Independent chart review was also used to determine reasons for PSI errors. The sensitivity, specificity, and positive predictive value of PSI software version 4.1a were calculated among Veterans Health Administration hospitalizations (2003-2007) reviewed by VASQIP (n = 268,771). Nurses re-reviewed a sample of hospitalizations for which PSI and VASQIP AE detection disagreed. Sensitivities ranged from 31% to 68%, specificities from 99.1% to 99.8%, and positive predictive values from 31% to 72%. Reviewers found that coding errors accounted for some PSI-VASQIP disagreement; some disagreement was also the result of differences in AE definitions. These results suggest that the PSIs have moderate criterion validity; however, some surgical PSIs detect different AEs than VASQIP. Future research should explore using both methods to evaluate surgical quality. Published by Elsevier Inc.
Fan, Joe King-Man; Chan, Fion Siu-Yin; Chu, Kent-Man
Surgical smoke is the gaseous by-product formed during surgical procedures. Most surgeons, operating theatre staff and administrators are unaware of its potential health risks. Surgical smoke is produced by various surgical instruments including those used in electrocautery, lasers, ultrasonic scalpels, high speed drills, burrs and saws. The potential risks include carbon monoxide toxicity to the patient undergoing a laparoscopic operation, pulmonary fibrosis induced by non-viable particles, and transmission of infectious diseases like human papilloma virus. Cytotoxicity and mutagenicity are other concerns. Minimisation of the production of surgical smoke and modification of any evacuation systems are possible solutions. In general, a surgical mask can provide more than 90% protection to exposure to surgical smoke; however, in most circumstances it cannot provide air-tight protection to the user. An at least N95 grade or equivalent respirator offers the best protection against surgical smoke, but whether such protection is necessary is currently unknown.
Luker, Kali R; Sullivan, Maura E; Peyre, Sarah E; Sherman, Randy; Grunwald, Tiffany
The aim of this study was to compare the surgical knowledge of residents before and after receiving a cognitive task analysis-based multimedia teaching module. Ten plastic surgery residents were evaluated performing flexor tendon repair on 3 occasions. Traditional learning occurred between the first and second trial and served as the control. A teaching module was introduced as an intervention between the second and third trial using cognitive task analysis to illustrate decision-making skills. All residents showed improvement in their decision-making ability when performing flexor tendon repair after each surgical procedure. The group improved through traditional methods as well as exposure to our talk-aloud protocol (P > .01). After being trained using the cognitive task analysis curriculum the group displayed a statistically significant knowledge expansion (P multimedia surgical curriculum instruction achieved greater command of problem solving and are better equipped to make correct decisions in flexor tendon repair.
Medicare and Medicaid programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; electronic reporting pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; revision to Quality Improvement Organization regulations. Final rule with comment period.
This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2013 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, the ASC Quality Reporting (ASCQR) Program, and the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program. We are continuing the electronic reporting pilot for the Electronic Health Record (EHR) Incentive Program, and revising the various regulations governing Quality Improvement Organizations (QIOs), including the secure transmittal of electronic medical information, beneficiary complaint resolution and notification processes, and technical changes. The technical changes to the QIO regulations reflect CMS' commitment to the general principles of the President's Executive Order on Regulatory Reform, Executive Order 13563 (January 18, 2011).
Targarona Soler, Eduardo Ma; Jover Navalon, Jose Ma; Gutierrez Saiz, Javier; Turrado Rodríguez, Víctor; Parrilla Paricio, Pascual
Residents in our country have achieved a homogenous surgical training by following a structured residency program. This is due to the existence of specific training programs for each specialty. The current program, approved in 2007, has a detailed list of procedures that a surgeon should have performed in order to complete training. The aim of this study is to analyze the applicability of the program with regard to the number of procedures performed during the residency period. A data collection form was designed that included the list of procedures from the program of the specialty; it was sent in April 2014 to all hospitals with accredited residency programs. In September 2014 the forms were analysed, and a general descriptive study was performed; a subanalysis according to the resident's sex and Autonomous region was also performed. The number of procedures performed according to the number of residents in the different centers was also analyzed. The survey was sent to 117 hospitals with accredited programs, which included 190 resident places. A total of 91 hospitals responded (53%). The training offered adapts in general to the specialty program. The total number of procedures performed in the different sub-areas, in laparoscopic and emergency surgery is correct or above the number recommended by the program, with the exception of esophageal-gastric and hepatobiliary surgery. The sub-analysis according to Autonomous region did not show any significant differences in the total number of procedures, however, there were significant differences in endocrine surgery (P=.001) and breast surgery (P=.042). A total of 55% of residents are female, with no significant differences in distribution in Autonomous regions. However, female surgeons operate more than their male counterparts during the residency period (512±226 vs. 625±244; P<.01). The number of residents in the hospital correlates with the number of procedures performed; the residents with more procedures
Full Text Available Musical skills and expertise vary greatly in Western societies. Individuals can differ in their repertoire of musical behaviours as well as in the level of skill they display for any single musical behaviour. The types of musical behaviours we refer to here are broad, ranging from performance on an instrument and listening expertise, to the ability to employ music in functional settings or to communicate about music. In this paper, we first describe the concept of 'musical sophistication' which can be used to describe the multi-faceted nature of musical expertise. Next, we develop a novel measurement instrument, the Goldsmiths Musical Sophistication Index (Gold-MSI to assess self-reported musical skills and behaviours on multiple dimensions in the general population using a large Internet sample (n = 147,636. Thirdly, we report results from several lab studies, demonstrating that the Gold-MSI possesses good psychometric properties, and that self-reported musical sophistication is associated with performance on two listening tasks. Finally, we identify occupation, occupational status, age, gender, and wealth as the main socio-demographic factors associated with musical sophistication. Results are discussed in terms of theoretical accounts of implicit and statistical music learning and with regard to social conditions of sophisticated musical engagement.
Political attitudes can be associated with moral concerns. This research investigated whether people's level of political sophistication moderates this association. Based on the Moral Foundations Theory, this article examined whether political sophistication moderates the extent to which reliance on moral foundations, as categories of moral concerns, predicts judgements about policy positions. With this aim, two studies examined four policy positions shown by previous research to be best predicted by the endorsement of Sanctity, that is, the category of moral concerns focused on the preservation of physical and spiritual purity. The results showed that reliance on Sanctity predicted political sophisticates' judgements, as opposed to those of unsophisticates, on policy positions dealing with equal rights for same-sex and unmarried couples and with euthanasia. Political sophistication also interacted with Fairness endorsement, which includes moral concerns for equal treatment of everybody and reciprocity, in predicting judgements about equal rights for unmarried couples, and interacted with reliance on Authority, which includes moral concerns for obedience and respect for traditional authorities, in predicting opposition to stem cell research. Those findings suggest that, at least for these particular issues, endorsement of moral foundations can be associated with political attitudes more strongly among sophisticates than unsophisticates. © 2015 International Union of Psychological Science.
Full Text Available Theory of Mind (ToM, i.e. the ability to understand others' mental states, endows humans with highly adaptive social skills such as teaching or deceiving. Candidate evolutionary explanations have been proposed for the unique sophistication of human ToM among primates. For example, the Machiavellian intelligence hypothesis states that the increasing complexity of social networks may have induced a demand for sophisticated ToM. This type of scenario ignores neurocognitive constraints that may eventually be crucial limiting factors for ToM evolution. In contradistinction, the cognitive scaffolding hypothesis asserts that a species' opportunity to develop sophisticated ToM is mostly determined by its general cognitive capacity (on which ToM is scaffolded. However, the actual relationships between ToM sophistication and either brain volume (a proxy for general cognitive capacity or social group size (a proxy for social network complexity are unclear. Here, we let 39 individuals sampled from seven non-human primate species (lemurs, macaques, mangabeys, orangutans, gorillas and chimpanzees engage in simple dyadic games against artificial ToM players (via a familiar human caregiver. Using computational analyses of primates' choice sequences, we found that the probability of exhibiting a ToM-compatible learning style is mainly driven by species' brain volume (rather than by social group size. Moreover, primates' social cognitive sophistication culminates in a precursor form of ToM, which still falls short of human fully-developed ToM abilities.
Müllensiefen, Daniel; Gingras, Bruno; Musil, Jason; Stewart, Lauren
Musical skills and expertise vary greatly in Western societies. Individuals can differ in their repertoire of musical behaviours as well as in the level of skill they display for any single musical behaviour. The types of musical behaviours we refer to here are broad, ranging from performance on an instrument and listening expertise, to the ability to employ music in functional settings or to communicate about music. In this paper, we first describe the concept of 'musical sophistication' which can be used to describe the multi-faceted nature of musical expertise. Next, we develop a novel measurement instrument, the Goldsmiths Musical Sophistication Index (Gold-MSI) to assess self-reported musical skills and behaviours on multiple dimensions in the general population using a large Internet sample (n = 147,636). Thirdly, we report results from several lab studies, demonstrating that the Gold-MSI possesses good psychometric properties, and that self-reported musical sophistication is associated with performance on two listening tasks. Finally, we identify occupation, occupational status, age, gender, and wealth as the main socio-demographic factors associated with musical sophistication. Results are discussed in terms of theoretical accounts of implicit and statistical music learning and with regard to social conditions of sophisticated musical engagement.
Chirilă, M; Mureşan, R; Cosgarea, M; Tomescu, E
Adduction bilateral vocal fold immobility syndrome may be due by both recurrent laryngeal nerves paralysis--Gerhardt syndrome--and all intrinsic laryngeal muscles paralysis--Riegel syndrome. Etiology of Gerhardt syndrome is thyroid surgery, intubation's maneuver, trauma, neurological disorders, extrala-ryngeal malignancies. The manifestations of Gerhardt syndrome are inspiratory dyspnea and slightly influenced voicing by paramedian vocal folds paralysis with an important narrowing of the airway at the glottic level. The surgical procedures for enlargement of the glottic space can be classified in many ways and their major characteristics are: changes at the glottic level; surgical approach: open neck or endoscopic, with or without opening of the mucosal lining; the need for tracheostomy; the equipment used. The aim of this review is to expound the variety of interventions through the last century marked by the development of the diagnostic methods, the anesthesia and the surgical armament with sophisticated instruments and technologies.
Erickson, Sarah J.; Montague, Erica Q.; Maclean, Peggy C.; Bancroft, Mary E.; Lowe, Jean R.
Children born very low birth weight (development of self-regulation and effective functional skills, and play serves as an important avenue of early intervention. The current study investigated associations between maternal flexibility and toddler play sophistication in Caucasian, Spanish speaking Hispanic, English speaking Hispanic, and Native American toddlers (18-22 months adjusted age) in a cross-sectional cohort of 73 toddlers born VLBW and their mothers. We found that the association between maternal flexibility and toddler play sophistication differed by ethnicity (F(3,65) = 3.34, p = .02). In particular, Spanish speaking Hispanic dyads evidenced a significant positive association between maternal flexibility and play sophistication of medium effect size. Results for Native Americans were parallel to those of Spanish speaking Hispanic dyads: the relationship between flexibility and play sophistication was positive and of small-medium effect size. Findings indicate that for Caucasians and English speaking Hispanics, flexibility evidenced a non-significant (negative and small effect size) association with toddler play sophistication. Significant follow-up contrasts revealed that the associations for Caucasian and English speaking Hispanic dyads were significantly different from those of the other two ethnic groups. Results remained unchanged after adjusting for the amount of maternal language, an index of maternal engagement and stimulation; and after adjusting for birth weight, gestational age, gender, test age, cognitive ability, as well maternal age, education, and income. Our results provide preliminary evidence that ethnicity and acculturation may mediate the association between maternal interactive behavior such as flexibility and toddler developmental outcomes, as indexed by play sophistication. Addressing these association differences is particularly important in children born VLBW because interventions targeting parent interaction strategies such as
Rombouts, Jeroen V.K.; Stentoft, Lars; Violante, Francesco
innovation for a Laplace innovation assumption improves the pricing in a smaller way. Apart from investigating directly the value of model sophistication in terms of dollar losses, we also use the model condence set approach to statistically infer the set of models that delivers the best pricing performance.......We assess the predictive accuracy of a large number of multivariate volatility models in terms of pricing options on the Dow Jones Industrial Average. We measure the value of model sophistication in terms of dollar losses by considering a set 248 multivariate models that differer...
Hebbelstrup Rye Rasmussen, Stig
This article examines the impact of cognitive ability on ideological voting. We find, using a US sample and a Danish sample, that the effect of cognitive ability rivals the effect of the traditionally strongest predicter of ideological voting political sophistication. Furthermore, the results...... are consistent with the effect of cognitive ability being partly mediated by political sophistication. Much of the effect of cognitive ability remains however and is not explained by differences in education or Openness to experience either. The implications of these results for democratic theory are discussed....
Peter, Johannes; Rosman, Tom; Mayer, Anne-Kathrin; Leichner, Nikolas; Krampen, Günter
Background: Particularly in higher education, not only a view of science as a means of finding absolute truths (absolutism), but also a view of science as generally tentative (multiplicism) can be unsophisticated and obstructive for learning. Most quantitative epistemic belief inventories neglect this and understand epistemic sophistication as…
Full Text Available A strong link has been established between operational excellence and the degree of sophistication of logistics organization, a function of factors such as performance monitoring, investment in Information Technology [IT] and the formalization of logistics organization, as proposed in the Bowersox, Daugherty, Dröge, Germain and Rogers (1992 Leading Edge model. At the same time, shippers have been increasingly outsourcing their logistics activities to third party providers. This paper, based on a survey with large Brazilian shippers, addresses a gap in the literature by investigating the relationship between dimensions of logistics organization sophistication and drivers of logistics outsourcing. To this end, the dimensions behind the logistics sophistication construct were first investigated. Results from factor analysis led to the identification of six dimensions of logistics sophistication. By means of multivariate logistical regression analyses it was possible to relate some of these dimensions, such as the formalization of the logistics organization, to certain drivers of the outsourcing of logistics activities of Brazilian shippers, such as cost savings. These results indicate the possibility of segmenting shippers according to characteristics of their logistics organization, which may be particularly useful to logistics service providers.
Danckert, Bolette; Dinesen, Peter Thisted; Sønderskov, Kim Mannemar
is founded on politically sophisticated individuals having a greater comprehension of news and other mass-mediated sources, which makes them less likely to rely on neighborhood cues as sources of information relevant for political attitudes. Based on a unique panel data set with fine-grained information...
Scott, J. Blake
Claims that teaching ethics is particularly important to technical writing. Outlines a classical, sophistic approach to ethics based on the theories and pedagogies of Protagoras, Gorgias, and Isocrates, which emphasizes the Greek concept of "nomos," internal and external deliberation, and responsible action. Discusses problems and…
This article looks at the work of contemporary Dutch fashion designer Alexander van Slobbe (1959) and examines how, since the 1990s, his fashion practices have consistently and consciously put forward a unique reflection on questions related to materiality, sophisticated archaism, luxury,
This article looks at the work of contemporary Dutch fashion designer Alexander van Slobbe (1959) and examines how, since the 1990s, his fashion practices have consistently and consciously put forward a unique reflection on questions related to materiality, sophisticated archaism, luxury,
Ranasinghe, R.W.M.R.J.B.; Callaghan, D.; Roelvink, D.
The dependency between the accuracy/uncertainty of storm erosion exceedance estimates obtained via a probabilistic model and the level of sophistication of the structural function (storm erosion model) embedded in the probabilistic model is assessed via the application of Callaghan et al.'s (2008)
Strohl, Alexis M; Vitkus, Lauren
The article reviews some commonly used orthodontic treatments as well as new strategies to assist in the correction of malocclusion. Many techniques are used in conjunction with surgical intervention and are a necessary compliment to orthognathic surgery. Basic knowledge of these practices will aid in the surgeon's ability to adequately treat the patient. Many orthodontists and surgeons are eliminating presurgical orthodontics to adopt a strategy of 'surgery first' orthodontics in orthognathic surgery. This has the benefit of immediate improvement in facial aesthetics and shorter treatment times. The advent of virtual surgical planning has helped facilitate the development of this new paradigm by making surgical planning faster and easier. Furthermore, using intraoperative surgical navigation is improving overall precision and outcomes. A variety of surgical and nonsurgical treatments may be employed in the treatment of malocclusion. It is important to be familiar with all options available and tailor the patient's treatment plan accordingly. Surgery-first orthodontics, intraoperative surgical navigation, virtual surgical planning, and 3D printing are evolving new techniques that are producing shorter treatment times and subsequently improving patient satisfaction without sacrificing long-term stability.
Nix, Ralph E; Onofrio, Kathleen; Konoske, Paula J; Galarneau, Mike R; Hill, Martin
.... The primary objective of the study was to provide the Air Force with the ability to validate clinical requirements of the MFST assemblage, with the goal of using NHRC's Estimating Supplies Program (ESP...
Full Text Available The world’s most numerous bird, the domestic chicken, and their wild ancestor, the red junglefowl, have long been used as model species for animal behaviour research. Recently, this research has advanced our understanding of the social behaviour, personality, and cognition of fowl, and demonstrated their sophisticated behaviour and cognitive skills. Here, we overview some of this research, starting with describing research investigating the well-developed senses of fowl, before presenting how socially and cognitively complex they can be. The realisation that domestic chickens, our most abundant production animal, are behaviourally and cognitively sophisticated should encourage an increase in general appraise and fascination towards them. In turn, this should inspire increased use of them as both research and hobby animals, as well as improvements in their unfortunately often poor welfare.
The paper analyses the advantages and disadvantages of the second generation improved technologies and third generation technologies mainly developed in China in terms of safety and economy. The paper also discusses the maturity of the second generation improved technologies and the sophistication of the third generation technologies respectively. Meanwhile, the paper proposes that the advantage and disadvantage of second generation improved technologies and third generation technologies should be carefully taken into consideration and the relationship between the maturity and sophistication should be properly dealt with in the current stage. A two-step strategy shall be taken as a solution to solve the problem of insufficient capacity of nuclear power, trace and develop the third generation technologies, so as to ensure the sound and fast development of nuclear power. (authors)
This text covers the basic theory and computation for a first course in linear programming, including substantial material on mathematical proof techniques and sophisticated computation methods. Includes Appendix on using Excel. 1984 edition.
Paola Boel; Gabriele Camera
The welfare cost of anticipated inflation is quantified in a calibrated model of the U.S. economy that exhibits tractable equilibrium dispersion in wealth and earnings. Inflation does not generate large losses in societal welfare, yet its impact varies noticeably across segments of society depending also on the financial sophistication of the economy. If money is the only asset, then inflation hurts mostly the wealthier and more productive agents, while those poorer and less productive may ev...
Szénási, Lieutenant-Colonel Endre
According to my experiences, the Western world hopelessly fails to understand Russian mentality, or misinterprets it. During my analysis of the Russian way of thinking I devoted special attention to the examination of military mentality. I have connected the issue of the Russian way of thinking to the contemporary imperial policies of Putin’s Russia. I have also attempted to prove the level of sophistication of both. I hope that a better understanding of both the Russian mentality and imperi...
van Dongen, Koen W; Ahlberg, Gunnar; Bonavina, Luigi; Carter, Fiona J; Grantcharov, Teodor P; Hyltander, Anders; Schijven, Marlies P; Stefani, Alessandro; van der Zee, David C; Broeders, Ivo A M J
Virtual reality (VR) simulators have been demonstrated to improve basic psychomotor skills in endoscopic surgery. The exercise configuration settings used for validation in studies published so far are default settings or are based on the personal choice of the tutors. The purpose of this study was to establish consensus on exercise configurations and on a validated training program for a virtual reality simulator, based on the experience of international experts to set criterion levels to construct a proficiency-based training program. A consensus meeting was held with eight European teams, all extensively experienced in using the VR simulator. Construct validity of the training program was tested by 20 experts and 60 novices. The data were analyzed by using the t test for equality of means. Consensus was achieved on training designs, exercise configuration, and examination. Almost all exercises (7/8) showed construct validity. In total, 50 of 94 parameters (53%) showed significant difference. A European, multicenter, validated, training program was constructed according to the general consensus of a large international team with extended experience in virtual reality simulation. Therefore, a proficiency-based training program can be offered to training centers that use this simulator for training in basic psychomotor skills in endoscopic surgery.
Dawson, Caitlin; Aalto, Daniel; Šimko, Juraj; Vainio, Martti; Tervaniemi, Mari
Musical experiences and native language are both known to affect auditory processing. The present work aims to disentangle the influences of native language phonology and musicality on behavioral and subcortical sound feature processing in a population of musically diverse Finnish speakers as well as to investigate the specificity of enhancement from musical training. Finnish speakers are highly sensitive to duration cues since in Finnish, vowel and consonant duration determine word meaning. Using a correlational approach with a set of behavioral sound feature discrimination tasks, brainstem recordings, and a musical sophistication questionnaire, we find no evidence for an association between musical sophistication and more precise duration processing in Finnish speakers either in the auditory brainstem response or in behavioral tasks, but they do show an enhanced pitch discrimination compared to Finnish speakers with less musical experience and show greater duration modulation in a complex task. These results are consistent with a ceiling effect set for certain sound features which corresponds to the phonology of the native language, leaving an opportunity for music experience-based enhancement of sound features not explicitly encoded in the language (such as pitch, which is not explicitly encoded in Finnish). Finally, the pattern of duration modulation in more musically sophisticated Finnish speakers suggests integrated feature processing for greater efficiency in a real world musical situation. These results have implications for research into the specificity of plasticity in the auditory system as well as to the effects of interaction of specific language features with musical experiences. PMID:28450829
Dawson, Caitlin; Aalto, Daniel; Šimko, Juraj; Vainio, Martti; Tervaniemi, Mari
Musical experiences and native language are both known to affect auditory processing. The present work aims to disentangle the influences of native language phonology and musicality on behavioral and subcortical sound feature processing in a population of musically diverse Finnish speakers as well as to investigate the specificity of enhancement from musical training. Finnish speakers are highly sensitive to duration cues since in Finnish, vowel and consonant duration determine word meaning. Using a correlational approach with a set of behavioral sound feature discrimination tasks, brainstem recordings, and a musical sophistication questionnaire, we find no evidence for an association between musical sophistication and more precise duration processing in Finnish speakers either in the auditory brainstem response or in behavioral tasks, but they do show an enhanced pitch discrimination compared to Finnish speakers with less musical experience and show greater duration modulation in a complex task. These results are consistent with a ceiling effect set for certain sound features which corresponds to the phonology of the native language, leaving an opportunity for music experience-based enhancement of sound features not explicitly encoded in the language (such as pitch, which is not explicitly encoded in Finnish). Finally, the pattern of duration modulation in more musically sophisticated Finnish speakers suggests integrated feature processing for greater efficiency in a real world musical situation. These results have implications for research into the specificity of plasticity in the auditory system as well as to the effects of interaction of specific language features with musical experiences.
Chee, Yewlin E; Newman, Lori R; Loewenstein, John I; Kloek, Carolyn E
To design and implement a teaching skills curriculum that addressed the needs of an ophthalmology residency training program, to assess the effect of the curriculum, and to present important lessons learned. A teaching skills curriculum was designed for the Harvard Medical School (HMS) Residency Training Program in Ophthalmology. Results of a needs assessment survey were used to guide curriculum objectives. Overall, 3 teaching workshops were conducted between October 2012 and March 2013 that addressed areas of need, including procedural teaching. A postcurriculum survey was used to assess the effect of the curriculum. Massachusetts Eye and Ear Infirmary, a tertiary care institution in Boston, MA. Overall, 24 residents in the HMS Residency Training Program in Ophthalmology were included. The needs assessment survey demonstrated that although most residents anticipated that teaching would be important in their future career, only one-third had prior formal training in teaching. All residents reported they found the teaching workshops to be either very or extremely useful. All residents reported they would like further training in teaching, with most residents requesting additional training in best procedural teaching practices for future sessions. The pilot year of the resident-as-teacher curriculum for the HMS Residency Training Program in Ophthalmology demonstrated a need for this curriculum and was perceived as beneficial by the residents, who reported increased comfort in their teaching skills after attending the workshops. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Verbeeten, Frank H M
This study examines the impact of uncertainty on the sophistication of capital budgeting practices. While the theoretical applications of sophisticated capital budgeting practices (defined as the use of real option reasoning and/or game theory decision rules) have been well documented, empirical
Crane, Patrick C; Selanders, Louise
To provide a historical perspective in the development of oncology nursing and surgical oncology as critical components of today's health care system. Review of the literature and Web sites of key organizations. The evolution of surgical oncology nursing has traversed a historical journey from that of a niche subspecialty of nursing that had very little scientific underpinning, to a highly sophisticated discipline within a very short time. Nursing continues to contribute its expertise to the encyclopedic knowledge base of surgical oncology and cancer care, which have helped improve the lives of countless patients and families who have had to face the difficulties of this diagnosis. An understanding of the historical context for which a nursing specialty such as surgical oncology nursing evolves is critical to gaining an appreciation for the contributions of nursing. Copyright © 2016 Elsevier Inc. All rights reserved.
Full Text Available This article analyses the three epideictic orations of Isocrates which are in themselves a precious testimony of the quality of intellectual life at the close of the fourth century before Christ. To this period belong also the Socratics who are generally seen as an important link between Socrates and Plato. The author of this article proposes a more productive approach to the study of Antisthenes, Euclid of Megara and other so-called Socratics, revealing them not as independent thinkers but rather as adherents of the sophistic school and also as teachers, thereby, including them among those who took part in the educative activity of their time
Mourier, J; Nonglaton, J M; Syratchev, I V; Tanner, L
CTF3 (CLIC Test Facility 3), currently under construction at CERN, is a test facility designed to demonstrate the key feasibility issues of the CLIC (Compact LInear Collider) two-beam scheme. When completed, this facility will consist of a 150 MeV linac followed by two rings for bunch-interleaving, and a test stand where 30 GHz power will be generated. In this paper, the work that has been carried out on the linac's low power RF system is described. This includes, in particular, a sophisticated phase control system for the RF pulse compressor to produce a flat-top rectangular pulse over 1.4 µs.
Azarmehr, Iman; Stokbro, Kasper; Bell, R. Bryan
Purpose: This systematic review investigates the most common indications, treatments, and outcomes of surgical navigation (SN) published from 2010 to 2015. The evolution of SN and its application in oral and maxillofacial surgery have rapidly developed over recent years, and therapeutic indicatio...
Dankelman, J.; Horeman, T.
The present invention relates to a surgical instrument for minimall-invasive surgery, comprising a handle, a shaft and an actuating part, characterised by a gastight cover surrounding the shaft, wherein the cover is provided with a coupler that has a feed- through opening with a loskable seal,
Gardner, Aimee K; Diesen, Diana L; Hogg, Deborah; Huerta, Sergio
The purpose of this study was to integrate relevant goal-setting theory and to identify if trainees' goal orientations have an impact on the assigned goals-performance relationship. Trainees attended 1 of the 3 goal-training activities (do your best, performance, or learning goals) for knot tying (KT) and camera navigation (CN) during the 3rd-year clerkship rotation. Questionnaires and pretests and/or post-tests were completed. One twenty-seven 3rd-year medical students (age: 25 ± 2.6; 54% women) participated in the training program. Pretraining to post-training performance changes were significant for all groups on both tasks (P goals group (do your best: KTΔ = 2.14, CNΔ = 1.69; performance: KTΔ = 2.49, CNΔ = 2.24; learning: KTΔ = 3.04 CNΔ = 2.76). Correlations between goal orientations and improvement were examined, revealing a unique role of goal orientation for performance improvement. These data indicate that consideration of goal type and trainee goal orientation must be considered during curriculum development to maximize educational value. Copyright © 2016 Elsevier Inc. All rights reserved.
Full Text Available Background: Constructing gene co-expression networks from cancer expression data is important for investigating the genetic mechanisms underlying cancer. However, correlation coefficients or linear regression models are not able to model sophisticated relationships among gene expression profiles. Here, we address the 3-way interaction that 2 genes’ expression levels are clustered in different space locations under the control of a third gene’s expression levels. Results: We present xSyn, a software tool for identifying such 3-way interactions from cancer gene expression data based on an optimization procedure involving the usage of UPGMA (Unweighted Pair Group Method with Arithmetic Mean and synergy. The effectiveness is demonstrated by application to 2 real gene expression data sets. Conclusions: xSyn is a useful tool for decoding the complex relationships among gene expression profiles. xSyn is available at http://www.bdxconsult.com/xSyn.html .
Loyau, Adeline; Blanchet, Simon; van Laere, Pauline; Clobert, Jean; Danchin, Etienne
Semen limitation (lack of semen to fertilize all of a female's eggs) imposes high fitness costs to female partners. Females should therefore avoid mating with semen-limited males. This can be achieved by using public information extracted from watching individual males' previous copulating activities. This adaptive preference should be flexible given that semen limitation is temporary. We first demonstrate that the number of offspring produced by males Drosophila melanogaster gradually decreases over successive copulations. We then show that females avoid mating with males they just watched copulating and that visual public cues are sufficient to elicit this response. Finally, after males were given the time to replenish their sperm reserves, females did not avoid the males they previously saw copulating anymore. These results suggest that female fruit flies may have evolved sophisticated behavioural processes of resistance to semen-limited males, and demonstrate unsuspected adaptive context-dependent mate choice in an invertebrate.
Noack, M.; Seybold, J.; Ruehle, R.
The software environment RSYST was originally used to solve problems of reactor physics. The consideration of advanced scientific simulation requirements and the strict application of modern software design principles led to a system which is perfectly suitable to solve problems in various complex scientific problem domains. Starting with a review of the early days of RSYST, we describe the straight evolution driven by the need of software environment which combines the advantages of a high-performance database system with the capability to integrate sophisticated scientific technical applications. The RSYST architecture is presented and the data modelling capabilities are described. To demonstrate the powerful possibilities and flexibility of the RSYST environment, we describe a wide range of RSYST applications, e.g., mechanical simulations of multibody systems, which are used in biomechanical research, civil engineering and robotics. In addition, a hypermedia system which is used for scientific technical training and documentation is presented. (orig.) [de
Preoperative Hospitalization Is Independently Associated With Increased Risk for Venous Thromboembolism in Patients Undergoing Colorectal Surgery: A National Surgical Quality Improvement Program Database Study.
Greaves, Spencer W; Holubar, Stefan D
An important factor in the pathophysiology of venous thromboembolism is blood stasis, thus, preoperative hospitalization length of stay may be contributory to risk. We assessed preoperative hospital length of stay as a risk factor for venous thromboembolism. We performed a retrospective review of patients who underwent colorectal operations using univariate and multivariable propensity score analyses. This study was conducted at a tertiary referral hospital. Data on patients was obtained from the American College of Surgeons National Surgical Quality Improvement Program 2005-2011 Participant Use Data Files. Short-term (30-day) postoperative venous thromboembolism was measured. Our analysis included 242,670 patients undergoing colorectal surgery (mean age, 60 years; 52.9% women); of these, 72,219 (29.9%) were hospitalized preoperatively. The overall rate of venous thromboembolism was 2.07% (1.4% deep vein thrombosis, 0.5% pulmonary embolism, and 0.2% both). On multivariable analysis, the most predictive independent risk factors for venous thromboembolism were return to the operating room (OR, 1.62 (95% CI, 1.44-1.81); p relationship between preoperative lengths of stay and risk of postoperative venous thromboembolism (p risk factor for venous thromboembolism and its associated increase in mortality after colorectal surgery, whereas laparoscopy is a strong protective variable. Further research into preoperative screening for highest-risk patients is indicated.
Risk factors for unplanned readmission within 30 days after pediatric neurosurgery: a nationwide analysis of 9799 procedures from the American College of Surgeons National Surgical Quality Improvement Program.
Sherrod, Brandon A; Johnston, James M; Rocque, Brandon G
OBJECTIVE Hospital readmission rate is increasingly used as a quality outcome measure after surgery. The purpose of this study was to establish, using a national database, the baseline readmission rates and risk factors for patient readmission after pediatric neurosurgical procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was queried for pediatric patients treated by a neurosurgeon between 2012 and 2013. Procedures were categorized by current procedural terminology (CPT) code. Patient demographics, comorbidities, preoperative laboratory values, operative variables, and postoperative complications were analyzed via univariate and multivariate techniques to find associations with unplanned readmissions within 30 days of the primary procedure. RESULTS A total of 9799 cases met the inclusion criteria, 1098 (11.2%) of which had an unplanned readmission within 30 days. Readmission occurred 14.0 ± 7.7 days postoperatively (mean ± standard deviation). The 4 procedures with the highest unplanned readmission rates were CSF shunt revision (17.3%; CPT codes 62225 and 62230), repair of myelomeningocele > 5 cm in diameter (15.4%), CSF shunt creation (14.1%), and craniectomy for infratentorial tumor excision (13.9%). The lowest unplanned readmission rates were for spine (6.5%), craniotomy for craniosynostosis (2.1%), and skin lesion (1.0%) procedures. On multivariate regression analysis, the odds of readmission were greatest in patients experiencing postoperative surgical site infection (SSI; deep, organ/space, superficial SSI, and wound disruption: OR > 12 and p 10 days (OR 1.411, p = 0.010), oxygen supplementation (OR 1.645, p = 0.010), nutritional support (OR 1.403, p = 0.009), seizure disorder (OR 1.250, p = 0.021), and longer operative time (per hour increase, OR 1.059, p = 0.029). CONCLUSIONS This study may aid in identifying patients at risk for unplanned readmission following pediatric neurosurgery
Olshove, Vincent; Berndsen, Nicole; Sivarajan, Veena; Nawathe, Pooja; Phillips, Alistair
Cardiac surgery on Jehovah's Witnesses (JW) can be challenging, given the desire to avoid blood products. Establishment of a blood conservation program involving the pre-, intra- and post-operative stages for all patients may lead to a minimized need for blood transfusion in all patients. Pre-operatively, all JW patients were treated with high dose erythropoietin 500 IU/kg twice a week. JW patients were compared to matching non-JW patients from the congenital cardiac database, two per JW to serve as control. Blood use, ventilation time, bypass time, pre-operative hematocrit, first in intensive care unit (ICU) and at discharge and 24 hour chest drainage were compared. Pre-operative huddle, operating room huddle and post-operative bedside handoff were done with the congenital cardiac surgeon, perfusionist, anesthesiologist and intensive care team in all patients for goal alignment. Five JW patients (mean weight 24.4 ± 25.0 Kg, range 6.3 - 60 Kg) were compared to 10 non-JW patients (weight 22.0 ± 22.8 Kg, range 6.2 - 67.8 Kg). There was no difference in bypass, cross-clamp, time to extubation (0.8 vs. 2.1 hours), peak inotrope score (2.0 vs. 2.3) or chest drainage. No JW patient received a blood product compared to 40% of non-JW. The pre-operative hematocrit (Hct) was statistically greater for the JW patients (46.1 ± 3.3% vs. 36.3 ± 4.7%, pconservation techniques across the continuum of care allowed bloodless surgery for JW and non-JW patients alike. Blood conservation is a team sport and to make significant strides requires participation and input by all care providers.
Ben-Or, Sharon; Nifong, L Wiley; Chitwood, W Randolph
In July 2000, the da Vinci Surgical System (Intuitive Surgical, Inc) received Food and Drug Administration approval for intracardiac applications, and the first mitral valve repair was done at the East Carolina Heart Institute in May 2000. The system is now approved and used in many surgical specialties. With this disruptive technology and accepted use, surgeons and hospitals are seeking the most efficacious training pathway leading to safe use and responsible credentialing.One of the most important issues related to safe use is assembling the appropriate team of professionals involved with patient care. Moreover, proper patient selection and setting obtainable goals are also important.Creation and maintenance of a successful program are discussed in the article focusing on realistic goals. This begins with a partnership between surgeon leaders, hospital administrators, and industry support. Through this partnership, an appropriate training pathway and clinical pathway for success can be outlined. A timeline can then be created with periods of data analysis and adjustments as necessary. A successful program is attainable by following this pathway and attending to every detail along the journey.
Does Receiving a Blood Transfusion Predict for Length of Stay in Children Undergoing Cranial Vault Remodeling for Craniosynostosis? Outcomes Using the Pediatric National Surgical Quality Improvement Program Dataset.
Markiewicz, Michael R; Alden, Tord; Momin, Mohmed Vasim; Olsson, Alexis B; Jurado, Ray J; Abdullah, Fizan; Miloro, Michael
Recent interventions have aimed at reducing the need for blood transfusions in the perioperative period in patients with craniosynostosis undergoing cranial vault remodeling. However, little is known regarding whether the receipt of a blood transfusion influences the length of hospital stay. The purpose of this study was to assess whether the receipt of a blood transfusion in patients undergoing cranial vault remodeling is associated with an increased length of stay. To address the research purposes, we designed a retrospective cohort study using the 2014 Pediatric National Surgical Quality Improvement Program (NSQIP Peds) dataset. The primary predictor variable was whether patients received a blood transfusion during cranial vault remodeling. The primary outcome variable was length of hospital stay after the operation. The association between the receipt of blood transfusions and length of stay was assessed using the Student t test. The association between other covariates and the outcome variable was assessed using linear regression, analysis of variance, and the Tukey test for post hoc pair-wise comparisons. The sample was composed of 756 patients who underwent cranial vault remodeling: 503 who received blood transfusions and 253 who did not. The primary predictor variable of blood transfusion was associated with an increased length of stay (4.1 days vs 3.0 days, P = .03). Other covariates associated with an increased length of stay included race, American Society of Anesthesiologists status, premature birth, presence of a congenital malformation, and number of sutures involved in craniosynostosis. The receipt of a blood transfusion in the perioperative period in patients with craniosynostosis undergoing cranial vault remodeling was associated with an increased length of stay. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Full Text Available ... and Safety Inspiring Quality Initiative Resources Continuous Quality Improvement ACS Clinical Scholars in Residence AHRQ Safety Program ... Enrollment Webinars ACS NSQIP ACS National Surgical Quality Improvement Program ACS National Surgical Quality Improvement Program About ...
Full Text Available ... Quality and Safety Inspiring Quality Initiative Resources Continuous Quality Improvement ACS Clinical Scholars in Residence AHRQ Safety Program ... ISCR Enrollment Webinars ACS NSQIP ACS National Surgical Quality Improvement Program ACS National Surgical Quality Improvement Program About ...
Stojkoski, Viktor; Utkovski, Zoran; Kocarev, Ljupco
Economic complexity reflects the amount of knowledge that is embedded in the productive structure of an economy. By combining tools from network science and econometrics, a robust and stable relationship between a country's productive structure and its economic growth has been established. Here we report that not only goods but also services are important for predicting the rate at which countries will grow. By adopting a terminology which classifies manufactured goods and delivered services as products, we investigate the influence of services on the country's productive structure. In particular, we provide evidence that complexity indices for services are in general higher than those for goods, which is reflected in a general tendency to rank countries with developed service sector higher than countries with economy centred on manufacturing of goods. By focusing on country dynamics based on experimental data, we investigate the impact of services on the economic complexity of countries measured in the product space (consisting of both goods and services). Importantly, we show that diversification of service exports and its sophistication can provide an additional route for economic growth in both developing and developed countries.
van Veen, S H C M; van Kleef, R C; van de Ven, W P M M; van Vliet, R C J A
This study explores the predictive power of interaction terms between the risk adjusters in the Dutch risk equalization (RE) model of 2014. Due to the sophistication of this RE-model and the complexity of the associations in the dataset (N = ~16.7 million), there are theoretically more than a million interaction terms. We used regression tree modelling, which has been applied rarely within the field of RE, to identify interaction terms that statistically significantly explain variation in observed expenses that is not already explained by the risk adjusters in this RE-model. The interaction terms identified were used as additional risk adjusters in the RE-model. We found evidence that interaction terms can improve the prediction of expenses overall and for specific groups in the population. However, the prediction of expenses for some other selective groups may deteriorate. Thus, interactions can reduce financial incentives for risk selection for some groups but may increase them for others. Furthermore, because regression trees are not robust, additional criteria are needed to decide which interaction terms should be used in practice. These criteria could be the right incentive structure for risk selection and efficiency or the opinion of medical experts. Copyright © 2017 John Wiley & Sons, Ltd.
Kyle, Kristopher; Crossley, Scott; Berger, Cynthia
This study introduces the second release of the Tool for the Automatic Analysis of Lexical Sophistication (TAALES 2.0), a freely available and easy-to-use text analysis tool. TAALES 2.0 is housed on a user's hard drive (allowing for secure data processing) and is available on most operating systems (Windows, Mac, and Linux). TAALES 2.0 adds 316 indices to the original tool. These indices are related to word frequency, word range, n-gram frequency, n-gram range, n-gram strength of association, contextual distinctiveness, word recognition norms, semantic network, and word neighbors. In this study, we validated TAALES 2.0 by investigating whether its indices could be used to model both holistic scores of lexical proficiency in free writes and word choice scores in narrative essays. The results indicated that the TAALES 2.0 indices could be used to explain 58% of the variance in lexical proficiency scores and 32% of the variance in word-choice scores. Newly added TAALES 2.0 indices, including those related to n-gram association strength, word neighborhood, and word recognition norms, featured heavily in these predictor models, suggesting that TAALES 2.0 represents a substantial upgrade.
Alexander, Gregory L; Madsen, Richard W; Miller, Erin L; Wakefield, Douglas S; Wise, Keely K; Alexander, Rachel L
To test for significant differences in information technology sophistication (ITS) in US nursing homes (NH) based on location. We administered a primary survey January 2014 to July 2015 to NH in each US state. The survey was cross-sectional and examined 3 dimensions (IT capabilities, extent of IT use, degree of IT integration) among 3 domains (resident care, clinical support, administrative activities) of ITS. ITS was broken down by NH location. Mean responses were compared across 4 NH categories (Metropolitan, Micropolitan, Small Town, and Rural) for all 9 ITS dimensions and domains. Least square means and Tukey's method were used for multiple comparisons. Methods yielded 815/1,799 surveys (45% response rate). In every health care domain (resident care, clinical support, and administrative activities) statistical differences in facility ITS occurred in larger (metropolitan or micropolitan) and smaller (small town or rural) populated areas. This study represents the most current national assessment of NH IT since 2004. Historically, NH IT has been used solely for administrative activities and much less for resident care and clinical support. However, results are encouraging as ITS in other domains appears to be greater than previously imagined. © 2016 National Rural Health Association.
Akam, Thomas; Costa, Rui; Dayan, Peter
The recently developed 'two-step' behavioural task promises to differentiate model-based from model-free reinforcement learning, while generating neurophysiologically-friendly decision datasets with parametric variation of decision variables. These desirable features have prompted its widespread adoption. Here, we analyse the interactions between a range of different strategies and the structure of transitions and outcomes in order to examine constraints on what can be learned from behavioural performance. The task involves a trade-off between the need for stochasticity, to allow strategies to be discriminated, and a need for determinism, so that it is worth subjects' investment of effort to exploit the contingencies optimally. We show through simulation that under certain conditions model-free strategies can masquerade as being model-based. We first show that seemingly innocuous modifications to the task structure can induce correlations between action values at the start of the trial and the subsequent trial events in such a way that analysis based on comparing successive trials can lead to erroneous conclusions. We confirm the power of a suggested correction to the analysis that can alleviate this problem. We then consider model-free reinforcement learning strategies that exploit correlations between where rewards are obtained and which actions have high expected value. These generate behaviour that appears model-based under these, and also more sophisticated, analyses. Exploiting the full potential of the two-step task as a tool for behavioural neuroscience requires an understanding of these issues.
Akam, Thomas; Costa, Rui; Dayan, Peter
The recently developed ‘two-step’ behavioural task promises to differentiate model-based from model-free reinforcement learning, while generating neurophysiologically-friendly decision datasets with parametric variation of decision variables. These desirable features have prompted its widespread adoption. Here, we analyse the interactions between a range of different strategies and the structure of transitions and outcomes in order to examine constraints on what can be learned from behavioural performance. The task involves a trade-off between the need for stochasticity, to allow strategies to be discriminated, and a need for determinism, so that it is worth subjects’ investment of effort to exploit the contingencies optimally. We show through simulation that under certain conditions model-free strategies can masquerade as being model-based. We first show that seemingly innocuous modifications to the task structure can induce correlations between action values at the start of the trial and the subsequent trial events in such a way that analysis based on comparing successive trials can lead to erroneous conclusions. We confirm the power of a suggested correction to the analysis that can alleviate this problem. We then consider model-free reinforcement learning strategies that exploit correlations between where rewards are obtained and which actions have high expected value. These generate behaviour that appears model-based under these, and also more sophisticated, analyses. Exploiting the full potential of the two-step task as a tool for behavioural neuroscience requires an understanding of these issues. PMID:26657806
Full Text Available The recently developed 'two-step' behavioural task promises to differentiate model-based from model-free reinforcement learning, while generating neurophysiologically-friendly decision datasets with parametric variation of decision variables. These desirable features have prompted its widespread adoption. Here, we analyse the interactions between a range of different strategies and the structure of transitions and outcomes in order to examine constraints on what can be learned from behavioural performance. The task involves a trade-off between the need for stochasticity, to allow strategies to be discriminated, and a need for determinism, so that it is worth subjects' investment of effort to exploit the contingencies optimally. We show through simulation that under certain conditions model-free strategies can masquerade as being model-based. We first show that seemingly innocuous modifications to the task structure can induce correlations between action values at the start of the trial and the subsequent trial events in such a way that analysis based on comparing successive trials can lead to erroneous conclusions. We confirm the power of a suggested correction to the analysis that can alleviate this problem. We then consider model-free reinforcement learning strategies that exploit correlations between where rewards are obtained and which actions have high expected value. These generate behaviour that appears model-based under these, and also more sophisticated, analyses. Exploiting the full potential of the two-step task as a tool for behavioural neuroscience requires an understanding of these issues.
Zhai, Changhai; Wang, Xiaomin; Kong, Jingchang; Li, Shuang; Xie, Lili
The development of a powerful numerical model to simulate the fracture behavior of concrete material has long been one of the dominant research areas in earthquake engineering. A reliable model should be able to adequately represent the discontinuous characteristics of cracks and simulate various failure behaviors under complicated loading conditions. In this paper, a numerical formulation, which incorporates a sophisticated rigid-plastic interface constitutive model coupling cohesion softening, contact, friction and shear dilatation into the XFEM, is proposed to describe various crack behaviors of concrete material. An effective numerical integration scheme for accurately assembling the contribution to the weak form on both sides of the discontinuity is introduced. The effectiveness of the proposed method has been assessed by simulating several well-known experimental tests. It is concluded that the numerical method can successfully capture the crack paths and accurately predict the fracture behavior of concrete structures. The influence of mode-II parameters on the mixed-mode fracture behavior is further investigated to better determine these parameters.
Full Text Available Opportunity identification is the key element of the entrepreneurial process; therefore the issue of developing this skill in students is a crucial task in contemporary European education which has recognized entrepreneurship as one of the lifelong learning key competences. The earlier opportunity identification becomes a habitual way of thinking and behavior across a broad range of contexts, the more likely that entrepreneurial disposition will steadily reside in students. In order to nurture opportunity identification in students for making them able to organize sophisticated businesses in the future, certain demands ought to be put forward as well to the teacher – the person who is to promote these qualities in their students. The paper reflects some findings of a research conducted within the frameworks of a workplace learning project for the teachers of one of Riga secondary schools (Latvia. The main goal of the project was to teach the teachers to identify hidden inner links between apparently unrelated things, phenomena and events within 10th grade study curriculum and connect them together and create new opportunities. The creation and solution of cross-disciplinary tasks were the means for achieving this goal.
Fushing, Hsieh; McAssey, Michael P; Beisner, Brianne; McCowan, Brenda
We develop a three-step computing approach to explore a hierarchical ranking network for a society of captive rhesus macaques. The computed network is sufficiently informative to address the question: Is the ranking network for a rhesus macaque society more like a kingdom or a corporation? Our computations are based on a three-step approach. These steps are devised to deal with the tremendous challenges stemming from the transitivity of dominance as a necessary constraint on the ranking relations among all individual macaques, and the very high sampling heterogeneity in the behavioral conflict data. The first step simultaneously infers the ranking potentials among all network members, which requires accommodation of heterogeneous measurement error inherent in behavioral data. Our second step estimates the social rank for all individuals by minimizing the network-wide errors in the ranking potentials. The third step provides a way to compute confidence bounds for selected empirical features in the social ranking. We apply this approach to two sets of conflict data pertaining to two captive societies of adult rhesus macaques. The resultant ranking network for each society is found to be a sophisticated mixture of both a kingdom and a corporation. Also, for validation purposes, we reanalyze conflict data from twenty longhorn sheep and demonstrate that our three-step approach is capable of correctly computing a ranking network by eliminating all ranking error.
Full Text Available We develop a three-step computing approach to explore a hierarchical ranking network for a society of captive rhesus macaques. The computed network is sufficiently informative to address the question: Is the ranking network for a rhesus macaque society more like a kingdom or a corporation? Our computations are based on a three-step approach. These steps are devised to deal with the tremendous challenges stemming from the transitivity of dominance as a necessary constraint on the ranking relations among all individual macaques, and the very high sampling heterogeneity in the behavioral conflict data. The first step simultaneously infers the ranking potentials among all network members, which requires accommodation of heterogeneous measurement error inherent in behavioral data. Our second step estimates the social rank for all individuals by minimizing the network-wide errors in the ranking potentials. The third step provides a way to compute confidence bounds for selected empirical features in the social ranking. We apply this approach to two sets of conflict data pertaining to two captive societies of adult rhesus macaques. The resultant ranking network for each society is found to be a sophisticated mixture of both a kingdom and a corporation. Also, for validation purposes, we reanalyze conflict data from twenty longhorn sheep and demonstrate that our three-step approach is capable of correctly computing a ranking network by eliminating all ranking error.
Markot, Peter B
...) staffing and medical/surgical services offered under the Prime Vendor (PV) Generation III contract would provide the best supply chain management solution for Walter Reed Army Medical Center (WRAMC...
5G is the upcoming evolution for the current cellular networks that aims at satisfying the future demand for data services. Heterogeneous cloud radio access networks (H-CRANs) are envisioned as a new trend of 5G that exploits the advantages of heterogeneous and cloud radio access networks to enhance spectral and energy efficiency. Remote radio heads (RRHs) are small cells utilized to provide high data rates for users with high quality of service (QoS) requirements, while high power macro base station (BS) is deployed for coverage maintenance and low QoS users service. Inter-tier interference between macro BSs and RRHs and energy efficiency are critical challenges that accompany resource allocation in H-CRANs. Therefore, we propose an efficient resource allocation scheme using online learning, which mitigates interference and maximizes energy efficiency while maintaining QoS requirements for all users. The resource allocation includes resource blocks (RBs) and power. The proposed scheme is implemented using two approaches: centralized, where the resource allocation is processed at a controller integrated with the baseband processing unit and decentralized, where macro BSs cooperate to achieve optimal resource allocation strategy. To foster the performance of such sophisticated scheme with a model free learning, we consider users\\' priority in RB allocation and compact state representation learning methodology to improve the speed of convergence and account for the curse of dimensionality during the learning process. The proposed scheme including both approaches is implemented using software defined radios testbed. The obtained results and simulation results confirm that the proposed resource allocation solution in H-CRANs increases the energy efficiency significantly and maintains users\\' QoS.
Alexander, Gregory L; Pasupathy, Kalyan S; Steege, Linsey M; Strecker, E Bradley; Carley, Kathleen M
The role of nursing home (NH) information technology (IT) in quality improvement has not been clearly established, and its impacts on communication between care givers and patient outcomes in these settings deserve further attention. In this research, we describe a mixed method approach to explore communication strategies used by healthcare providers for resident skin risk in NH with high IT sophistication (ITS). Sample included NH participating in the statewide survey of ITS. We incorporated rigorous observation of 8- and 12-h shifts, and focus groups to identify how NH IT and a range of synchronous and asynchronous tools are used. Social network analysis tools and qualitative analysis were used to analyze data and identify relationships between ITS dimensions and communication interactions between care providers. Two of the nine ITS dimensions (resident care-technological and administrative activities-technological) and total ITS were significantly negatively correlated with number of unique interactions. As more processes in resident care and administrative activities are supported by technology, the lower the number of observed unique interactions. Additionally, four thematic areas emerged from staff focus groups that demonstrate how important IT is to resident care in these facilities including providing resident-centered care, teamwork and collaboration, maintaining safety and quality, and using standardized information resources. Our findings in this study confirm prior research that as technology support (resident care and administrative activities) and overall ITS increases, observed interactions between staff members decrease. Conversations during staff interviews focused on how technology facilitated resident centered care through enhanced information sharing, greater virtual collaboration between team members, and improved care delivery. These results provide evidence for improving the design and implementation of IT in long term care systems to support
Functionalized poly(p-xylylenes) or so-called reactive polymers can be synthesized via chemical vapor deposition (CVD) polymerization. The resulting ultra-thin coatings are pinhole-free and can be conformally deposited to a wide range of substrates and materials. More importantly, the equipped functional groups can served as anchoring sites for tailoring the surface properties, making these reactive coatings a robust platform that can deal with sophisticated challenges faced in biointerfaces. In this work presented herein, surface coatings presenting various functional groups were prepared by CVD process. Such surfaces include aldehyde-functionalized coating to precisely immobilize saccharide molecules onto well-defined areas and alkyne-functionalized coating to click azide-modified molecules via Huisgen 1,3-dipolar cycloaddition reaction. Moreover, CVD copolymerization has been conducted to prepare multifunctional coatings and their specific functions were demonstrated by the immobilization of biotin and NHS-ester molecules. By using a photodefinable coating, polyethylene oxides were immobilized onto a wide range of substrates through photo-immobilization. Spatially controlled protein resistant properties were characterized by selective adsorption of fibrinogen and bovine serum albumin as model systems. Alternatively, surface initiator coatings were used for polymer graftings of polyethylene glycol) methyl ether methacrylate, and the resultant protein- and cell- resistant properties were characterized by adsorption of kinesin motor proteins, fibrinogen, and murine fibroblasts (NIH3T3). Accessibility of reactive coatings within confined microgeometries was systematically studied, and the preparation of homogeneous polymer thin films within the inner surface of microchannels was demonstrated. Moreover, these advanced coatings were applied to develop a dry adhesion process for microfluidic devices. This process provides (i) excellent bonding strength, (ii) extended
Dion, Marc; Kashyap, Satish; Louie, Aloisius
This report describes the essential features of the MS-DOS version of DIDEC-DREO, an interactive program for creating wire grid, surface patch, and cell models of complex structures for electromagnetic interaction analysis. It uses the device-independent graphics library DIGRAF and the graphics kernel system HALO, and can be executed on systems with various graphics devices. Complicated structures can be created by direct alphanumeric keyboard entry, digitization of blueprints, conversion form existing geometric structure files, and merging of simple geometric shapes. A completed DIDEC geometric file may then be converted to the format required for input to a variety of time domain and frequency domain electromagnetic interaction codes. This report gives a detailed description of the program DIDEC-DREO, its installation, and its theoretical background. Each available interactive command is described. The associated program HEDRON which generates simple geometric shapes, and other programs that extract the current amplitude data from electromagnetic interaction code outputs, are also discussed.
Simmerman, Erika; Simmerman, Andrew; Lassiter, Randi; King, Ray; Ham, Ben; Adam, Bao-Ling; Ferdinand, Colville; Holsten, Steven
As operative experience in general surgery decreases and work hour limitations increase there is less exposure of surgical residents to advanced vascular and trauma exposures. Many institutions have demonstrated benefits of cadaver laboratory courses. We have incorporated a multimedia cadaver laboratory course into our general surgery residency didactics curriculum with the objective to demonstrate a benefit of the program as well as the feasibility of incorporation. This is a prospective study at a tertiary care institution including general surgery residents within our residency program. A curriculum was designed, requiring residents to complete multimedia learning modules before both a trauma cadaver laboratory and vascular exposure cadaver laboratory. Outcome measures included self-efficacy/confidence (precourse and postcourse 5-point Likert surveys), knowledge (net performance on precourse and postcourse multiple choice examinations), and resident perception of the curriculum (postcourse 5-point Likert survey). Data were analyzed using ANOVA paired t-tests. For the vascular cadaver laboratory, resident knowledge improved overall from an average of 41.2% to 50.0% of questions correct (p = 0.032) and self-efficacy/confidence improved by 0.59 from 1.52 to 2.11 out of 5 (p = 0.009). Median confidence is 1.37 out of 5 and 2.32 out of 5, before and after course, respectively. Wilcoxon nonparametric test reveals a p = 0.011. Resident's perception of the usefulness of the laboratory evaluation was 3.85 out 5. There were 85.71% agreed that the laboratory is useful and 14.29% were disagree. The Z-score is -0.1579 (means 0.1579 standard deviations a score of 3.85 below the benchmark). The percentile rank is 56.27%. The coefficient of variation is 24.68%. For the trauma cadaver laboratory, resident knowledge improved overall from an average of 55.89% to 66.17% of questions correct (p = 0.001) and self-efficacy/confidence improved by 0.75 from 1.68 out of 5 to 2.43 out of
Davies, Jennifer; Khatib, Manaf; Bello, Fernando
open surgical procedure. Better quality research is needed into the benefits of open surgical simulation, and this would hopefully stimulate further development of simulators with more accurate and objective assessment tools. © 2013 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Regenwetter, Michel; Ho, Moon-Ho R.; Tsetlin, Ilia
This project reconciles historically distinct paradigms at the interface between individual and social choice theory, as well as between rational and behavioral decision theory. The authors combine a utility-maximizing prescriptive rule for sophisticated approval voting with the ignorance prior heuristic from behavioral decision research and two…
This article proposes an analysis of Plato's "Sophist" (230b4--e5) that underlines the bond between the logical and the emotional components of the Socratic "elenchus", with the aim of depicting the social valence of this philosophical practice. The use of emotions characterizing the 'elenctic' method described by Plato is…
Shaikh, Faisal M; Hseino, Hazem; Hill, Arnold D K; Kavanagh, Eamon; Traynor, Oscar
Basic surgical skills are an integral part of surgical training. Simulation-based surgical training offers an opportunity both to trainees and trainers to learn and teach surgical skills outside the operating room in a nonpatient, nonstressed environment. However, widespread adoption of simulation technology especially in medical education is prohibited by its inherent higher cost, limited space, and interruptions to clinical duties. Mobile skills laboratory has been proposed as a means to address some of these limitations. A new program is designed by the Royal College of Surgeons in Ireland (RCSI), in an approach to teach its postgraduate basic surgical trainees the necessary surgical skills, by making the use of mobile innovative simulation technology in their own hospital settings. In this article, authors describe the program and students response to the mobile surgical skills being delivered in the region of their training hospitals and by their own regional consultant trainers.
Full Text Available Vanessa Shifflette,1 Susannah Hambright,2 Joseph Darryl Amos,1 Ernest Dunn,3 Maria Allo4 1Associates in Surgical Acute Care, Methodist Dallas Medical Center, Dallas, TX, USA; 2Methodist Surgical Associates, Methodist Dallas Medical Center, Dallas, TX, USA; 3Graduate Medical Education - General Surgery, Methodist Dallas Medical Center, Dallas, TX, USA; 4Santa Clara Valley Medical Center, San Jose, CA, USA Background: Surgery continues to be an intense, time-consuming residency. Many medical students decide against surgery as a profession due to the long work hours and family strain. The pregnant female surgical resident has an added stress factor compared to her male counterpart. Methods: We distributed an electronic, online 26-question survey to 32 general surgery programs in the southwestern region of the United States. Each program distributed our survey to the female surgical residents who had been pregnant during residency in the last 5 years. Each program was re-contacted 6 weeks after the initial contact. Most questions were in a 5-point Likert scale format. The responses were collected and analyzed using the Survey Monkey website. Results: An unvalidated survey was sent to 32 general surgery programs and 26 programs responded (81%. Each program was asked for the total number of possible responses from female residents that met our criteria (60 female residents. Seven of the programs (27% stated that they have had zero residents pregnant. We had 22 residents respond (37%. Over half of the residents (55% were pregnant during their 2nd or 3rd year of residency, with only 18% pregnant during a research year. Thirty-one percent had a lower American Board of Surgery In-Training Exam (ABSITE score. Ninety percent of the residents were able to take 4 weeks or more for maternity leave. Most of the residents (95% stated that they would do this again during residency given the opportunity, but many of the residents felt that returning back to work
Eliyas, S; Vere, J; Ali, Z; Harris, I
Non-surgical endodontic retreatment is the treatment of choice for endodontically treated teeth with recurrent or residual disease in the majority of cases. In some cases, surgical endodontic treatment is indicated. Successful micro-surgical endodontic treatment depends on the accuracy of diagnosis, appropriate case selection, the quality of the surgical skills, and the application of the most appropriate haemostatic agents and biomaterials. This article describes the armamentarium and technical procedures involved in performing micro-surgical endodontics to a high standard.
Schurink, M.; Hulscher, J. B. F.; Nieuwenhuijs, V. B.; Heineman, E.; Rings, E. H. H. M.
Aim. In 2001, a multidisciplinary intestinal rehabilitation program, prompted by a nationwide collaboration on intestinal failure (Dutch Registry for Intestinal Failure and Intestinal Transplantation), was started for children who have short bowel syndrome (SBS). This study evaluates this program,
Aaron M. French
While eBanking security continues to increase in sophistication to protect against threats, the usability of the eBanking decreases resulting in poor security behaviors by the users. The current research evaluates se curity risks and measures taken for eBanking solutions. A case study is presented describing how increased complexity decreases vulnerabilities online but increases vulnerabilities from internal threats and eBanking users
Harris, Robert D; Parker, Gary
Compact ultrasound (US) was introduced in an austere setting with no other available imaging for an annual mass surgical screening day. Compact US examinations were performed on 25 patients from more than 7000 potential patients, as deemed possibly useful by the screening surgeons. Of the 20 patients with recorded data, compact US was helpful in 14 of 20 as a decision-making tool, obviating computed tomography for preoperative planning. Compact US was helpful in most cases, saving resources (computed tomography), technologist time, and radiation risk in this select population. © 2015 by the American Institute of Ultrasound in Medicine.
Calhoon, John H; Baisden, Clint; Holler, Ben; Hicks, George L; Bove, Ed L; Wright, Cameron D; Merrill, Walter H; Fullerton, Dave A
We sought to define an accurate measure of thoracic surgical education costs. Program directors from six distinct and differently sized and geographically located thoracic surgical training programs used a common template to provide estimates of resident educational costs. These data were reviewed, clarifying questions or discrepancies when noted and using best estimates when exact data were unavailable. Subsequently, a composite of previously published cost-estimation products was used to capture accurate cost data. Data were then compiled and averaged to provide an accurate picture of all costs associated with thoracic surgical education. Before formal accounting was performed, the estimated average for all programs was approximately $250,000 per year per resident. However, when formal evaluations by the six programs were performed, the annual cost of resident education ranged from $330,000 to $667,000 per year per resident. The average cost of $483,000 per year was almost double the initial estimates. Variability was noted by region and size of program. Faculty teaching costs varied from $208,000 to $346,000 per year. Simulation costs ranged from $0 to $80,000 per year. Resident savings to program ranged from $0 to $135,000 per year and averaged $37,000 per year per resident. Thoracic surgical education costs are considerably higher than initial estimates from program directors and probably represent an unappreciated source of financial burden for cardiothoracic surgical educational programs. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
... procedures performed to treat pelvic floor disorders with surgical mesh: Transvaginal mesh to treat POP Transabdominal mesh to treat ... address safety risks Final Order for Reclassification of Surgical Mesh for Transvaginal Pelvic Organ Prolapse Repair Final Order for Effective ...
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Kehlet, Henrik; Wilmore, Douglas W
OBJECTIVE: To evaluate the effect of modifying perioperative care in noncardiac surgical patients on morbidity, mortality, and other outcome measures. BACKGROUND: New approaches in pain control, introduction of techniques that reduce the perioperative stress response, and the more frequent use...... anesthesia in elective operations, and pilot studies of fast track surgical procedures using the multimodality approach. RESULTS: The introduction of newer approaches to perioperative care has reduced both morbidity and mortality in surgical patients. In the future, most elective operations will become day...... surgical procedures or require only 1 to 2 days of postoperative hospitalization. Reorganization of the perioperative team (anesthesiologists, surgeons, nurses, and physical therapists) will be essential to achieve successful fast track surgical programs. CONCLUSIONS: Understanding perioperative...
Full Text Available Aim. Modular mini-robots can be used in novel minimally invasive surgery techniques like natural orifice transluminal endoscopic surgery (NOTES and laparoendoscopic single site (LESS surgery. The control of these miniature assistants is complicated. The aim of this study is the in silico investigation of a remote controlling interface for modular miniature robots which can be used in minimally invasive surgery. Methods. The conceptual controlling system was developed, programmed, and simulated using professional robotics simulation software. Three different modes of control were programmed. The remote controlling surgical interface was virtually designed as a high scale representation of the respective modular mini-robot, therefore a modular controlling system itself. Results. With the proposed modular controlling system the user could easily identify the conformation of the modular mini-robot and adequately modify it as needed. The arrangement of each module was always known. The in silico investigation gave useful information regarding the controlling mode, the adequate speed of rearrangements, and the number of modules needed for efficient working tasks. Conclusions. The proposed conceptual model may promote the research and development of more sophisticated modular controlling systems. Modular surgical interfaces may improve the handling and the dexterity of modular miniature robots during minimally invasive procedures.
Kuo, Calvin C; Robb, William J
The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.
Risk factors for unplanned readmission within 30 days after pediatric neurosurgery: a nationwide analysis of 9799 procedures from the American College of Surgeons National Surgical Quality Improvement Program
Sherrod, Brandon A.; Johnston, James M.; Rocque, Brandon G.
Objective Readmission rate is increasingly used as a quality outcome measure after surgery. The purpose of this study was to establish, using a national database, the baseline readmission rates and risk factors for readmission after pediatric neurosurgical procedures. Methods The American College of Surgeons National Surgical Quality Improvement Program–Pediatric database was queried for pediatric patients treated by a neurosurgeon from 2012 to 2013. Procedures were categorized by current procedural terminology code. Patient demographics, comorbidities, preoperative laboratory values, operative variables, and postoperative complications were analyzed via univariate and multivariate techniques to find associations with unplanned readmission within 30 days of the primary procedure. Results A total of 9799 cases met the inclusion criteria, 1098 (11.2%) of which had an unplanned readmission within 30 days. Readmission occurred 14.0 ± 7.7 days postoperatively (mean ± standard deviation). The 4 procedures with the highest unplanned readmission rates were CSF shunt revision (17.3%), repair of myelomeningocele > 5 cm in diameter (15.4%), CSF shunt creation (14.1%), and craniectomy for infratentorial tumor excision (13.9%). Spine (6.5%), craniotomy for craniosynostosis (2.1%), and skin lesion (1.0%) procedures had the lowest unplanned readmission rates. On multivariate regression analysis, the odds of readmission were greatest in patients experiencing postoperative surgical site infection (SSI; deep, organ/space, superficial SSI and wound disruption: OR > 12 and p readmission risk. Independent patient risk factors for unplanned readmission included Native American race (OR 2.363, p = 0.019), steroid use > 10 days (OR 1.411, p = 0.010), oxygen supplementation (OR 1.645, p = 0.010), nutritional support (OR 1.403, p = 0.009), seizure disorder (OR 1.250, p = 0.021), and longer operative time (per hour increase, OR 1.059, p = 0.014). Conclusions This study may aid in
Jayaraman, Sudha P; Jiang, Yushan; Resch, Stephen; Askari, Reza; Klompas, Michael
Interventions to contain two multi-drug-resistant Acinetobacter (MDRA) outbreaks reduced the incidence of multi-drug-resistant (MDR) organisms, specifically methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and Clostridium difficile in the general surgery intensive care unit (ICU) of our hospital. We therefore conducted a cost-effective analysis of a proactive model infection-control program to reduce transmission of MDR organisms based on the practices used to control the MDRA outbreak. We created a model of a proactive infection control program based on the 2011 MDRA outbreak response. We built a decision analysis model and performed univariable and probabilistic sensitivity analyses to evaluate the cost-effectiveness of the proposed program compared with standard infection control practices to reduce transmission of these MDR organisms. The cost of a proactive infection control program would be $68,509 per year. The incremental cost-effectiveness ratio (ICER) was calculated to be $3,804 per aversion of transmission of MDR organisms in a one-year period compared with standard infection control. On the basis of probabilistic sensitivity analysis, a willingness-to-pay (WTP) threshold of $14,000 per transmission averted would have a 42% probability of being cost-effective, rising to 100% at $22,000 per transmission averted. This analysis gives an estimated ICER for implementing a proactive program to prevent transmission of MDR organisms in the general surgery ICU. To better understand the causal relations between the critical steps in the program and the rate reductions, a randomized study of a package of interventions to prevent healthcare-associated infections should be considered.
Ansorg, J; Hassan, I; Fendrich, V; Polonius, M J; Rothmund, M; Langer, P
One of the reasons for young doctors to leave the clinical work to go abroad or into non-clinical fields is insufficient quality of training under bad circumstances. Aim of the study was to evaluate the surgical training in Germany from the viewpoint of the residents. A questionnaire was prepared by residents and consultants and approved by the German surgical societies (Deutsche Gesellschaft fur Chirurgie und Berufsverband der Deutschen Chirurgen). It was sent to surgical residents between June 2003 and June 2004, published in "Der Chirurg BDC" and distributed among residents taking part in courses conducted by the BDC. It could be answered anonymously by email, mail or online. The questionnaire was sent back by 584 surgical residents (about 30 % of all). 58 % of the residents declared that they finished the training in the intended time (6 years). Rotation-systems as part of a structured residency program existed for 43 %. Standard surgical procedures were discussed or explained before the procedure in only 46 %. 61 % of the residents were not satisfied with the teaching assistance by their clinical teachers in the OR. Only 33 % had regular talks with the Chief about their progress in surgical training. 18 % of residents felt, that the hospital is interested in their progress in training. Indication-conferences took place in 52 % and mortality-conferences in only 20 % of programs. Regular seminars on recent issues took place in 62 %, and 61 % of residents did not get financial support to attend congresses. 36 % of residents had to use their holidays to attend congresses. Surgical training structures are not well established in about 50 % of the training hospitals from where we got answers to our survey. The training potential of daily surgical work is not used appropriately. It is therefore imperative to develop guidelines for surgical training, the use of log-books and rotation-programs.
McCulloch, Peter; Morgan, Lauren; New, Steve; Catchpole, Ken; Roberston, Eleanor; Hadi, Mohammed; Pickering, Sharon; Collins, Gary; Griffin, Damian
Patient safety improvement interventions usually address either work systems or team culture. We do not know which is more effective, or whether combining approaches is beneficial. To compare improvement in surgical team performance after interventions addressing teamwork culture, work systems, or both. Suite of 5 identical controlled before-after intervention studies, with preplanned analysis of pooled data for indirect comparisons of strategies. Operating theatres in 5 UK hospitals performing elective orthopedic, plastic, or vascular surgery PARTICIPANTS:: All operating theatres staff, including surgeons, nurses, anaesthetists, and others INTERVENTIONS:: 4-month safety improvement interventions, using teamwork training (TT), systems redesign and standardization (SOP), Lean quality improvement, SOP + TT combination, or Lean + TT combination. Team technical and nontechnical performance and World Health Organization (WHO) checklist compliance, measured for 3 months before and after intervention using validated scales. Pooled data analysis of before-after change in active and control groups, comparing combined versus single and systems versus teamwork interventions, using 2-way ANOVA. We studied 453 operations, (255 intervention, 198 control). TT improved nontechnical skills and WHO compliance (P teamwork training and systems rationalization are more effective than those adopting either approach alone. This has important implications for safety improvement strategies in hospitals.
Hamidi, Yaser; Moeini, Mahin; Yousefi, Hojatollah
Ostomy patients suffer from many physical and mental problems, which can be solved to a large extent with the help of education and follow-up programs. These follow-ups can be done in person or on the telephone by the nurses, or even, by sending a text message that is an easier way for the patients to adapt to their condition. This study aimed to investigate the effect of an interactive follow-up program on the adjustment of ostomy inpatients after being discharged. This study is a clinical trial, conducted on 64 ostomy patients who were discharged from the surgical wards of the hospital affiliated to Isfahan University of Medical Sciences. Subjects in the experimental group participated in a 6-week follow-up program via text message. The information about the patients were collected by Olbrisch Ostomy Adjustment Scale. The obtained results have suggested that 34.4% of the patients in the experimental group and 28.1% of the patients in the control group were female. Before the intervention, comparing the mean score of ostomy adjustment and its dimensions in the two groups showed no significant difference (P > 0.05). However, a significant difference was observed between the two groups immediately after the intervention (P 0.05). The findings of this study suggested that using SMS can be considered as a proper tool or method for following up the ostomy patients.
Blume, A.; DeJong, D.V.; Maier, M.
We experimentally investigate coordination games in which cognition plays an important role, i.e. where outcomes are affected by the agents level of understanding of the game and the beliefs they form about each others understanding.We ask whether and when repeated exposure permits agents to learn
Wohlrab, Kyle; Jelovsek, J Eric; Myers, Deborah
Today's educational environment has made it more difficult to rely on the Halstedian model of "see one, do one, teach one" in gynecologic surgical training. There is decreased surgical volume, but an increased number of surgical modalities. Fortunately, surgical simulation has evolved to fill the educational void. Whether it is through skill generalization or skill transfer, surgical simulation has shifted learning from the operating room back to the classroom. This article explores the principles of surgical education and ways to introduce simulation as an adjunct to residency training. We review high- and low-fidelity surgical simulators, discuss the progression of surgical skills, and provide options for skills competency assessment. Time and money are major hurdles when designing a simulation curriculum, but low-fidelity models, intradepartmental cost sharing, and utilizing local experts for simulation proctoring can aid in developing a simulation program. Copyright © 2017 Elsevier Inc. All rights reserved.
Hayek, A; Al Bokhaiti, M; Schwarz, M H; Boercsoek, J
With the publication and enforcement of the standard IEC 61508 of safety related systems, recent system architectures have been presented and evaluated. Among a number of techniques and measures to the evaluation of safety integrity level (SIL) for safety-related systems, several measures such as reliability block diagrams and Markov models are used to analyze the probability of failure on demand (PFD) and mean time to failure (MTTF) which conform to IEC 61508. The current paper deals with the quantitative analysis of the novel 1oo4-architecture (one out of four) presented in recent work. Therefore sophisticated calculations for the required parameters are introduced. The provided 1oo4-architecture represents an advanced safety architecture based on on-chip redundancy, which is 3-failure safe. This means that at least one of the four channels have to work correctly in order to trigger the safety function.
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Burgert, O.; Neumuth, T.; Gessat, M.; Jacobs, S.; Lemke, H. U.
The generation, storage, transfer, and representation of image data in radiology are standardized by DICOM. To cover the needs of image guided surgery or computer assisted surgery in general one needs to handle patient information besides image data. A large number of objects must be defined in DICOM to address the needs of surgery. We propose an analysis process based on Surgical Workflows that helps to identify these objects together with use cases and requirements motivating for their specification. As the first result we confirmed the need for the specification of representation and transfer of geometric models. The analysis of Surgical Workflows has shown that geometric models are widely used to represent planned procedure steps, surgical tools, anatomical structures, or prosthesis in the context of surgical planning, image guided surgery, augmented reality, and simulation. By now, the models are stored and transferred in several file formats bare of contextual information. The standardization of data types including contextual information and specifications for handling of geometric models allows a broader usage of such models. This paper explains the specification process leading to Geometry Mesh Service Object Pair classes. This process can be a template for the definition of further DICOM classes.
Ullán, Ana M; Belver, Manuel H; Fernández, Esperanza; Lorente, Felix; Badía, Marta; Fernández, Beatriz
Various nonpharmacological strategies to relieve hospitalized children's pain propose play as a central element. Play is considered an essential resource to improve the negative psychosocial effects of the disease and the hospitalization itself. However, the empirical research of play in health settings has not received much attention. The goal of this study was to determine the effect of a program to promote play in the hospital on postsurgical pain in pediatric patients. The research hypothesis was that children will manifest less pain if they are distracted through play during the postsurgical period. We carried out a randomized parallel trial with two groups, an experimental group and a control group. The control group did not receive any specific treatment, only the standard attention contemplated in the hospital. The parents of the children from the experimental group received instructions to play with their children in the postsurgical period and specific play material with which to play. The results obtained support the research hypothesis. On average, the children from the experimental group scored lower on a pain scale than the children from the control group. This occurred in the three postsurgical measurements of pain. It is concluded that the program to promote play can decrease children's perception of pain. Copyright © 2014 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
In the Netherlands, each year over 1700 patients die from preventable surgical errors. Numerous initiatives to improve surgical practice have had some impact, but problems persist. Despite the introduction of checklists and protocols, patient safety in surgery remains a continuing challenge. This is
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Cabral, Richard A; Eggenberger, Terry; Keller, Kathryn; Gallison, Barry S; Newman, David
To improve surgical team communication, a team at Broward Health Imperial Point Hospital, Ft Lauderdale, Florida, implemented a program for process improvement using a locally adapted World Health Organization Surgical Safety Checklist. This program included a standardized, comprehensive time out and a briefing/debriefing process. Postimplementation responses to the Safety Attitudes Questionnaire revealed a significant increase in the surgical team's perception of communication compared with that reported on the pretest (6% improvement resulting in t79 = -1.72, P improved surgical teamwork behaviors and an enhanced culture of safety in the OR. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.
Naruse, I; Keino, H; Taniguchi, M
Whole-embryo culture systems are useful in the fields of not only embryology but also teratology, toxicology, pharmacology, and physiology. Of the many advantages of whole-embryo culture, we focus here on the surgical manipulation of mammalian embryos. Whole-embryo culture allows us to manipulate mammalian embryos, similarly to fish, amphibian and avian embryos. Many surgical experiments have been performed in mammalian embryos in vitro. Such surgical manipulation alters the destiny of morphogenesis of the embryos and can answer many questions concerning developmental issues. As an example of surgical manipulation using whole-embryo culture systems, one of our experiments is described. Microsurgical electrocauterization of the deep preaxial mesodermal programmed cell death zone (fpp) in the footplate prevented the manifestation of polydactyly in genetic polydactyly mouse embryos (Pdn/Pdn), in which fpp was abolished.
Full Text Available The success of an epilepsy surgery program depends upon the early identification of potential surgical candidates and selecting from them, ideal candidates for surgery, who are destined to have a post-operative seizure-free outcome without any unacceptable neurological deficits. Since epilepsy surgery centers in resource-poor countries will lack the full range of state-of-the-art technologies usually available in resource-rich countries to perform pre-surgical evaluation, cost-effectively utilization of the locally available investigative facilities to select the surgical candidates becomes challenging. In the present era of rapid electronic communications and telemedicine, it has become possible for epilepsy surgery centers to pool their technological and human resources and to partner with centers nationally and internationally in implementing pre-surgical evaluation strategies.
Full Text Available ... Safety Resources About the Patient Education Program The Recovery Room Choosing Wisely Educational Programs Educational Programs Educational ... and practice the skills needed for optimal postoperative recovery. The kit supports the entire surgical team with ...
Full Text Available ... Military Health System Strategic Partnership Military Health System Strategic Partnership About Excelsior Surgical Society ... Programs Quality Programs Overview About Quality Programs ACS Leadership in Quality ACS Leadership in Quality Setting the ...
Vercler, Christian J
The encounter between a patient and her surgeon is unique for several reasons. The surgeon inflicts pain upon a patient for the patient's own good. An operative intervention is irreducibly personal, such that the decisions about and performance of operations are inseparable from the idiosyncrasies of the individual surgeon. Furthermore, there is a chasm of knowledge between the patient and surgeon that is difficult to cross. Hence, training in the discipline of surgery includes the inculcation of certain virtues and practices to safeguard against abuses of this relationship and to make sure that the best interests of the patient are prioritized. The stories in this issue are evidence that in contemporary practice this is not quite enough, as surgeons reflect on instances they felt were ethically challenging. Common themes include the difficulty in communicating surgical uncertainty, patient-surgeon relationships, ethical issues in surgical training, and the impact of the technological imperative on caring for dying patients.
Regenwetter, Michel; Ho, Moon-Ho R; Tsetlin, Ilia
This project reconciles historically distinct paradigms at the interface between individual and social choice theory, as well as between rational and behavioral decision theory. The authors combine a utility-maximizing prescriptive rule for sophisticated approval voting with the ignorance prior heuristic from behavioral decision research and two types of plurality heuristics to model approval voting behavior. When using a sincere plurality heuristic, voters simplify their decision process by voting for their single favorite candidate. When using a strategic plurality heuristic, voters strategically focus their attention on the 2 front-runners and vote for their preferred candidate among these 2. Using a hierarchy of Thurstonian random utility models, the authors implemented these different decision rules and tested them statistically on 7 real world approval voting elections. They cross-validated their key findings via a psychological Internet experiment. Although a substantial number of voters used the plurality heuristic in the real elections, they did so sincerely, not strategically. Moreover, even though Thurstonian models do not force such agreement, the results show, in contrast to common wisdom about social choice rules, that the sincere social orders by Condorcet, Borda, plurality, and approval voting are identical in all 7 elections and in the Internet experiment. PsycINFO Database Record (c) 2007 APA, all rights reserved.
Full Text Available The human pathogens Yersinia pseudotuberculosis and Yersinia enterocolitica cause enterocolitis, while Yersinia pestis is responsible for pneumonic, bubonic, and septicaemic plague. All three share an infection strategy that relies on a virulence factor arsenal to enable them to enter, adhere to, and colonise the host while evading host defences to avoid untimely clearance. Their arsenal includes a number of adhesins that allow the invading pathogens to establish a foothold in the host and to adhere to specific tissues later during infection. When the host innate immune system has been activated, all three pathogens produce a structure analogous to a hypodermic needle. In conjunction with the translocon, which forms a pore in the host membrane, the channel that is formed enables the transfer of six ‘effector’ proteins into the host cell cytoplasm. These proteins mimic host cell proteins but are more efficient than their native counterparts at modifying the host cell cytoskeleton, triggering the host cell suicide response. Such a sophisticated arsenal ensures that yersiniae maintain the upper hand despite the best efforts of the host to counteract the infecting pathogen.
An algorithmic programming approach for back pain symptoms in failed back surgery syndrome using spinal cord stimulation with a multicolumn surgically implanted epidural lead: a multicenter international prospective study.
Rigoard, Philippe; Jacques, Line; Delmotte, Alexandre; Poon, Katherine; Munson, Russell; Monlezun, Olivier; Roulaud, Manuel; Prevost, Audrey; Guetarni, Farid; Bataille, Benoit; Kumar, Krishna
Many studies have demonstrated the efficacy and the medical/economic value of epidural spinal cord stimulation for the treatment of "failed back surgery syndrome" (FBSS). However, the back pain component of FBSS has been recalcitrant. Recent clinical trials have suggested that multicolumn surgically implanted leads combined with enhanced programming capabilities in the newer implantable pulse generators demonstrate the ability to treat the back pain component of FBSS. The objective of our present international multicentre study is to prospectively evaluate these findings in a larger population. We conducted a prospective, nonrandomized, observational study on 76 patients with refractory FBSS, consecutively implanted with multicolumn spinal cord stimulation (SCS) between 2008 and 2011 in three neurosurgical pain management centers (Poitiers, France; Montréal, Canada; and Regina, Canada). The primary objective of this study was to prospectively analyze the effect of multicolumn lead programming on paresthesia coverage for the back pain region in these patients. The secondary objective was to assess the analgesic efficacy of this technique on the global and back pain components. Paresthesia could be induced in the lower extremities in the majority of patients with at least one of the configurations tested. Bilateral low back paresthesia was induced in 53.5% of patients, while unilateral low back paresthesia was induced in 78.9% of patients. Multicolumn configurations were statistically more effective than monocolumn configurations for all anatomic regions studied. At 6 months, 75.4% of patients receiving multicolumn stimulation (n = 57) obtained at least a 30% improvement of the back pain VAS score, while 42.1% of patients obtained at least a 50% improvement of the back pain VAS score. This study confirms the hypothesis that multicolumn SCS should be considered as an important tool in the treatment of radicular and axial pain in FBSS patients. The efficacy of this
Decrease the inflammatory response Vasodilatation leads to better perfusion and ... Must NOT be allowed to come in contact with brain, meninges, eyes or .... project (SCIP): Evolution of National Quality Measure. Surgical. Infection 2008 ...
Agbo, S. P.
Hemorrhoids are common human afflictions known since the dawn of history. Surgical management of this condition has made tremendous progress from complex ligation and excision procedures in the past to simpler techniques that allow the patient to return to normal life within a short period. Newer techniques try to improve on the post-operative complications of older ones. The surgical options for the management of hemorrhoids today are many. Capturing all in a single article may be difficult if not impossible. The aim of this study therefore is to present in a concise form some of the common surgical options in current literature, highlighting some important post operative complications. Current literature is searched using MEDLINE, EMBASE and the Cochrane library. The conclusion is that even though there are many surgical options in the management of hemorrhoids today, most employ the ligature and excision technique with newer ones having reduced post operative pain and bleeding. PMID:22413048
Surgical site infections (SSIs) are a worldwide problem that has ... deep tissue is found on clinical examination, re-opening, histopathological or radiological investigation ..... Esposito S, Immune system and SSI, Journal of Chemotherapy, 2001.
If these therapies fail, and with a thorough multidisciplinary approach involving carefully ... Generally, surgical pain management is divided into neuro- modulative .... 9 suggested. It is important to be sure that the underlying instability or.
Nabavi, A; Schipper, J
Patient safety during operations hinges on the surgeon's skills and abilities. However, surgical training has come under a variety of restrictions. To acquire dexterity with decreasingly "simple" cases, within the legislative time constraints and increasing expectations for surgical results is the future challenge. Are there alternatives to traditional master-apprentice learning? A literature review and analysis of the development, implementation, and evaluation of surgical simulation are presented. Simulation, using a variety of methods, most important physical and virtual (computer-generated) models, provides a safe environment to practice basic and advanced skills without endangering patients. These environments have specific strengths and weaknesses. Simulations can only serve to decrease the slope of learning curves, but cannot be a substitute for the real situation. Thus, they have to be an integral part of a comprehensive training curriculum. Our surgical societies have to take up that challenge to ensure the training of future generations.
Jones, Kory; Lebron, Ricardo A; Mangram, Alicia; Dunn, Ernest
Surgical education has undergone radical changes in the past decade. The introductions of laparoscopic surgery and endovascular techniques have required program directors to alter surgical training. The 6 competencies are now in place. One issue that still needs to be addressed is the business aspect of surgical practice. Often residents complete their training with minimal or no knowledge on coding of charges or basic aspects on how to set up a practice. We present our program, which has been in place over the past 2 years and is designed to teach the residents practice management. The program begins with a series of 10 lectures given monthly beginning in August. Topics include an introduction to types of practices available, negotiating a contract, managed care, and marketing the practice. Both medical and surgical residents attend these conferences. In addition, the surgical residents meet monthly with the business office to discuss billing and coding issues. These are didactic sessions combined with in-house chart reviews of surgical coding. The third phase of the practice management plan has the coding team along with the program director attend the outpatient clinic to review in real time the evaluation and management coding of clinic visits. Resident evaluations were completed for each of the practice management lectures. The responses were recorded on a Likert scale. The scores ranged from 4.1 to 4.8 (average, 4.3). Highest scores were given to lectures concerning negotiating employee agreements, recruiting contracts, malpractice insurance, and risk management. The medical education department has tracked resident coding compliance over the past 2 years. Surgical coding compliance increased from 36% to 88% over a 12-month period. The program director who participated in the educational process increased his accuracy from 50% to 90% over the same time period. When residents finish their surgical training they need to be ready to enter the world of business
Binenbaum, Gil; Volpe, Nicholas J
To describe the prevalence, management, and career outcomes of ophthalmology residents who struggle with surgical competency and to explore related educational issues. Fourteen-question written survey. Fifty-eight program directors at Accreditation Council on Graduate Medical Education-accredited, United States ophthalmology residency programs, representing a total of 2179 resident graduates, between 1991 and 2000. Study participants completed a mailed, anonymous survey whose format combined multiple choice and free comment questions. Number of surgically challenged residents, types of problems identified, types of remediation, final departmental decision at the end of residency, known career outcomes, and residency program use of microsurgical skills laboratories and applicant screening tests. One hundred ninety-nine residents (9% overall; 10% mean per program) were labeled as having trouble mastering surgical skills. All of the programs except 2 had encountered such residents. The most frequently cited problems were poor hand-eye coordination (24%) and poor intraoperative judgment (22%). Most programs were supportive and used educational rather than punitive measures, the most common being extra practice-laboratory time (32%), scheduling cases with the best teaching surgeon (23%), and counseling (21%). Nearly one third (31%) of residents were believed to have overcome their difficulties before graduation. Other residents were encouraged to pursue medical ophthalmology (22%) or to obtain further surgical training through a fellowship (21%) or a supervised practice setting (12%); these residents were granted a departmental statement of satisfactory completion of residency for Board eligibility. Twelve percent were asked to leave residency. Of reported career outcomes, 92% of residents were practicing ophthalmology, 65% as surgical and 27% as medical ophthalmologists. Ninety-eight percent of residency programs had microsurgical practice facilities, 64% had a formal
Rafael Pinilla González
related with a control program. Methods: Intervention study conducted in the surgical services of "Joaquin Albarrán" hospital in the period of May 2008 to December 2010. It included evaluations of quality of prescription and of feedback in the medical assistance team, educational sessions, checking of antimicrobial use policies and consultations with the antibiotic regulatory committee. The monthly antimicrobial consumption rates were registered and expressed as dose prescribed per 1000 patient-days. Results: The most frequently used antibiotics were cephalosporins, metronidazole, ciprofloxacin, penicillin and cotrimoxazole. The high consumption rates of ceftriaxone (94.4 DPD and cefazoline (88. 3 DPD was underlined along with the evident decrease in the consumption of first, third and fourth generation cephalosporins, whereas cefuroxime consumption increased from 23.8 (2008 to 35.7 (2010 DPD. Sodium penicillin (36.0 DPD, amoxicillin (7.2 DPD and amoxicillin plus sulbactam (5.8 DPD represented the most used penicillin. The consumption rate of metronidazole decreased from 312.4 to 75.7 DPD, that of ciprofloxacin from 220.8 to 52.4 DPD, chloramphenicol from 27.9 to 3.5 DDP and cotrimoxazole from 99.4 to 26.6 DDP in the years 2008 and 2010 respectively. Conclusions: It was evident that the control program implemented in the surgical services has brought about changes in the consumption patterns indicating improvement in the quality of prescribing patterns.
de Heer, Brooke
Prior research on rapes reported to law enforcement has identified criminal sophistication and the use of force against the victim as possible unique identifiers to serial rape versus one-time rape. This study sought to contribute to the current literature on reported serial rape by investigating how the level of criminal sophistication of the rapist and use of force used were associated with two important outcomes of rape: victim injury and overall severity of the assault. In addition, it was evaluated whether rapist and victim ethnicity affected these relationships. A nation-wide sample of serial rape cases reported to law enforcement collected by the Federal Bureau of Investigation (FBI) was analyzed (108 rapists, 543 victims). Results indicated that serial rapists typically used a limited amount of force against the victim and displayed a high degree of criminal sophistication. In addition, the more criminally sophisticated the perpetrator was, the more sexual acts he performed on his victim. Finally, rapes between a White rapist and White victim were found to exhibit higher levels of criminal sophistication and were more severe in terms of number and types of sexual acts committed. These findings provide a more in-depth understanding of serial rape that can inform both academics and practitioners in the field about contributors to victim injury and severity of the assault. © The Author(s) 2014.
Heskin, Leonie; Mansour, Ehab; Lane, Brian; Kavanagh, Dara; Dicker, Pat; Ryan, Donncha; Gildea-Byrne, Kate; Pawlikowska, Teresa; Tierney, Sean; Traynor, Oscar
Acquisition of skills early in surgical training represents a significant challenge at present because of training time constraints. The aim of this study was to investigate if an intensive surgical boot camp was effective in transferring skills at the beginning of a surgical training program. New core surgical trainees (n = 58) took part in a 5-day boot camp. There were pretest and posttest assessments of knowledge, technical skills, and confidence levels. The boot camp used simulation and senior surgical faculty to teach a defined range of technical and nontechnical skills. The scores for knowledge (53.8% vs 68.4%, P technical skills (35.9% to 60.6% vs 50.6% to 78.2%, P Skills improvements were still present a year later. The 5-day surgical boot camp proved to be an effective way to rapidly acquire surgical knowledge and skills while increasing the confidence levels of trainees. Copyright © 2015 Elsevier Inc. All rights reserved.
Full Text Available ... Online Guide to Choosing a Surgical Residency Practice Management Workshops Patients and Family Patient Education Patient Education Patients Medical Professionals Skills Programs Find ...
Roy, S. G.; Koons, P. O.; Gerbi, C. C.; Capps, D. K.; Tucker, G. E.; Rogers, Z. A.
Sophisticated numerical tools exist for modeling geomorphic processes and linking them to tectonic and climatic systems, but they are often seen as inaccessible for users with an exploratory level of interest. We have improved the accessibility of landscape evolution models by producing a simple graphics user interface (GUI) that takes advantage of the Channel-Hillslope Integrated Landscape Development (CHILD) model. Model access is flexible: the user can edit values for basic geomorphic, tectonic, and climate parameters, or obtain greater control by defining the spatiotemporal distributions of those parameters. Users can make educated predictions by choosing their own parametric values for the governing equations and interpreting the results immediately through model graphics. This method of modeling allows users to iteratively build their understanding through experimentation. Use of this GUI is intended for inquiry and discovery-based learning activities. We discuss a number of examples of how the GUI can be used at the upper high school, introductory university, and advanced university level. Effective teaching modules initially focus on an inquiry-based example guided by the instructor. As students become familiar with the GUI and the CHILD model, the class can shift to more student-centered exploration and experimentation. To make model interpretations more robust, digital elevation models can be imported and direct comparisons can be made between CHILD model results and natural topography. The GUI is available online through the University of Maine's Earth and Climate Sciences website, through the Community Surface Dynamics Modeling System (CSDMS) model repository, or by contacting the corresponding author.
Kan, Hirohito; Kasai, Harumasa; Arai, Nobuyuki; Kunitomo, Hiroshi; Hirose, Yasujiro; Shibamoto, Yuta
An effective background field removal technique is desired for more accurate quantitative susceptibility mapping (QSM) prior to dipole inversion. The aim of this study was to evaluate the accuracy of regularization enabled sophisticated harmonic artifact reduction for phase data with varying spherical kernel sizes (REV-SHARP) method using a three-dimensional head phantom and human brain data. The proposed REV-SHARP method used the spherical mean value operation and Tikhonov regularization in the deconvolution process, with varying 2-14mm kernel sizes. The kernel sizes were gradually reduced, similar to the SHARP with varying spherical kernel (VSHARP) method. We determined the relative errors and relationships between the true local field and estimated local field in REV-SHARP, VSHARP, projection onto dipole fields (PDF), and regularization enabled SHARP (RESHARP). Human experiment was also conducted using REV-SHARP, VSHARP, PDF, and RESHARP. The relative errors in the numerical phantom study were 0.386, 0.448, 0.838, and 0.452 for REV-SHARP, VSHARP, PDF, and RESHARP. REV-SHARP result exhibited the highest correlation between the true local field and estimated local field. The linear regression slopes were 1.005, 1.124, 0.988, and 0.536 for REV-SHARP, VSHARP, PDF, and RESHARP in regions of interest on the three-dimensional head phantom. In human experiments, no obvious errors due to artifacts were present in REV-SHARP. The proposed REV-SHARP is a new method combined with variable spherical kernel size and Tikhonov regularization. This technique might make it possible to be more accurate backgroud field removal and help to achive better accuracy of QSM. Copyright © 2016 Elsevier Inc. All rights reserved.
A retrospective study of post surgical complications was conducted on records of students' Large Animal Surgical Laboratories in the Faculty of Veterinary Medicine (F.V.M.), Ahmadu Bello University (A.B.U), Zaria from 1989 to 1993. Three hundred and eleven surgical complications were recorded from five surgical ...
The programmer's task is often taken to be the construction of algorithms, expressed in hierarchical structures of procedures: this view underlies the majority of traditional programming languages, such as Fortran. A different view is appropriate to a wide class of problem, perhaps including some problems in High Energy Physics. The programmer's task is regarded as having three main stages: first, an explicit model is constructed of the reality with which the program is concerned; second, this model is elaborated to produce the required program outputs; third, the resulting program is transformed to run efficiently in the execution environment. The first two stages deal in network structures of sequential processes; only the third is concerned with procedure hierarchies. (orig.)
Jackson, M A
The programmer's task is often taken to be the construction of algorithms, expressed in hierarchical structures of procedures: this view underlies the majority of traditional programming languages, such as Fortran. A different view is appropriate to a wide class of problem, perhaps including some problems in High Energy Physics. The programmer's task is regarded as having three main stages: first, an explicit model is constructed of the reality with which the program is concerned; second, thi...
Effects of a tele-prehabilitation program or an in-person prehabilitation program in surgical candidates awaiting total hip or knee arthroplasty: Protocol of a pilot single blind randomized controlled trial.
Doiron-Cadrin, Patrick; Kairy, Dahlia; Vendittoli, Pascal-André; Lowry, Véronique; Poitras, Stéphane; Desmeules, François
The accessibility for total joint arthroplasty often comes up against long wait lists, and may lead to deleterious effects for the awaiting patients. This pilot single blind randomized controlled trial aims to evaluate the impact of a telerehabilitation prehabilitation program before a hip or knee arthroplasty compared to in-person prehabilitation or to usual wait for surgery. Thirty-six patients on a wait list for a total hip or knee arthroplasty will be recruited and randomly assigned to one of three groups. The in-person prehabilitation group (n = 12) will receive a 12-week rehabilitation program (2 sessions/week) including education, exercises of the lower limb and cardiovascular training. Patients in the tele-prehabilitation group (n = 12) will receive the same intervention using a telecommunication software. The control group (n = 12) will be provided with the hospital's usual documentation before surgery. The Lower Extremity Functional Scale (LEFS) will be the primary outcome measure taken at baseline and at 12 weeks. Secondary measures will include self-reported function and quality of life as well as performance tests. A mixed-model, 2-way repeated-measure ANOVA will be used to analyse the effects of the rehabilitation programs. This pilot study is the first to evaluate the feasibility and the impact of a telerehabilitation prehabilitation program for patients awaiting a total joint arthroplasty. The results of this pilot-RCT will set the foundations for further research in the fields of rehabilitation and tele-medicine for patients suffering from lower limb osteoarthritis. ClinicalTrials.gov: NCT02636751.
Cevidanes, Lucia; Tucker, Scott; Styner, Martin; Kim, Hyungmin; Chapuis, Jonas; Reyes, Mauricio; Proffit, William; Turvey, Timothy; Jaskolka, Michael
This paper discusses the development of methods for computer-aided jaw surgery. Computer-aided jaw surgery allows us to incorporate the high level of precision necessary for transferring virtual plans into the operating room. We also present a complete computer-aided surgery (CAS) system developed in close collaboration with surgeons. Surgery planning and simulation include construction of 3D surface models from Cone-beam CT (CBCT), dynamic cephalometry, semi-automatic mirroring, interactive cutting of bone and bony segment repositioning. A virtual setup can be used to manufacture positioning splints for intra-operative guidance. The system provides further intra-operative assistance with the help of a computer display showing jaw positions and 3D positioning guides updated in real-time during the surgical procedure. The CAS system aids in dealing with complex cases with benefits for the patient, with surgical practice, and for orthodontic finishing. Advanced software tools for diagnosis and treatment planning allow preparation of detailed operative plans, osteotomy repositioning, bone reconstructions, surgical resident training and assessing the difficulties of the surgical procedures prior to the surgery. CAS has the potential to make the elaboration of the surgical plan a more flexible process, increase the level of detail and accuracy of the plan, yield higher operative precision and control, and enhance documentation of cases. Supported by NIDCR DE017727, and DE018962 PMID:20816308
Langebæk, Rikke; Eika, Berit; Jensen, Asger Lundorff
The surgical educational environment is potentially stressful and this can negatively affect students' learning. The aim of this study was to investigate whether veterinary students' level of anxiety is higher in a surgical course than in a non-surgical course and if pre-surgical training...... in a Surgical Skills Lab (SSL) has an anxiety reducing effect. Investigations were carried out as a comparative study and a parallel group study. Potential participants were fourth-year veterinary students who attended a surgical course (Basic Surgical Skills) and a non-surgical course (Clinical Examination...... and 28 students from 2010). Our results show that anxiety levels in veterinary students are significantly higher in a surgical course than in a non-surgical course (p...
Pluyter, J.R.; Buzink, S.N.; Rutkowski, A.F.; Jakimowicz, J.J.
Background. Surgeons perform complex tasks while exposed to multiple distracting sources that may increase stress in the operating room (e.g., music, conversation, and unadapted use of sophisticated technologies). This study aimed to examine whether such realistic social and technological distracting conditions may influence surgical performance. Methods. Twelve medical interns performed a laparoscopic cholecystectomy task with the Xitact LC 3.0 virtual reality simulator under distracting con...
P. H. M. Bonai
Full Text Available Nosocomial infection or nosocomial infection (NI is one of the factors that increase the cost of maintaining patients in the health system, even in processes that should safely occur, such as hospital patients and performing simple and routine surgical procedures surgical centers and clinics leading to complications resulting from these infections that prolong hospital stay and promote pain and suffering to the patient, resulting in the defense of the quality of services and influencing negatively the hospitals. Therefore, the aim of this study was to review the factors that result in surgical site infection, with the purpose of better understanding of the subject and the possibility of preventive actions to better treatment outcome of the patient.
Koyama, Masashi; Kurono, Kenji; Iida, Akihiko; Suzuki, Hirochika; Hara, Masaki; Mizutani, Hirokazu; Ohba, Satoru; Mizutani, Masaru; Nakajima, Yoichiro.
The CT, US, and MRI findings of confirmed retained surgical sponges were reviewed. The CT examinations in eight lesions demonstrated round or oval masses with heterogeneous internal structures. The US examinations in 5 lesions demonstrated low echogenic masses with high echogenic internal structures, which suggested retained surgical sponges. MR imagings in three lesions showed slightly high intensity comparable to that of muscles on T1-weighted images and high signal intensity on T2-weighted images, suggesting fluid collections of high protein concentration. (author)
Yerdelen-Damar, Sevda; Elby, Andrew
This study investigates how elite Turkish high school physics students claim to approach learning physics when they are simultaneously (i) engaged in a curriculum that led to significant gains in their epistemological sophistication and (ii) subject to a high-stakes college entrance exam. Students reported taking surface (rote) approaches to…
Tettey, Mark; Tamatey, Martin; Edwin, Frank
Ghana is one of the few low-to-middle-income countries in sub-Saharan Africa able to consistently sustain a cardiothoracic program with locally trained staff for more than two decades. Cardiothoracic surgery practice in Ghana started in 1964 but faltered from a combination of political and the economic problems. In 1989, Dr. Kwabena Frimpong-Boateng, a Ghanaian cardiothoracic surgeon trained in Hannover, rekindled interest in cardiothoracic surgery and in establishing a National Cardiothoracic Centre. His vision and leadership has brought cardiothoracic surgery practice in Ghana to its current high level. As a result, the medical landscape of what is achievable locally in both pediatric and adult patients has changed substantially: outbound medical travel that used to be common among Ghanaian cardiovascular patients has been reduced drastically. Ghana's National Cardiothoracic Center (NCTC), the only tertiary center in the country for cardiothoracic surgical pathology manages all such patients that were previously referred abroad. The NCTC has become a medical/surgical hub in the West African sub-region providing service, training, and research opportunities to neighboring countries. The Centre is accredited by the West African College of Surgeons as a center of excellence for training specialists in cardiothoracic surgery. Expectedly, practicing cardiothoracic surgery in such a resource-poor setting has peculiar challenges. This review focuses on the history, practice, successes, and challenges of cardiovascular and thoracic surgery in Ghana.
Levi-Mazloum, Niels Donald; Prag, Jørgen Brorson; Jensen, J S
Mycoplasma hominis and Ureaplasma urealyticum are common inhabitants of the human genital tract. Evidence for an aetiological role in pyelonephritis, pelvic inflammatory disease, post-abortion and post-partum fever has been presented. There are sporadic reports of Mycoplasma causing serious...... extragenital infection such as septicemia, septic arthritis, neonatal meningitis and encephalitis. We review 38 cases of surgical infections with Mycoplasma....
Heckmann, A; Leclère, F M; Vogt, P M; Steiert, A
Nowadays surgical intervention is an essential part of the treatment of idiopathic gynecomastia. Choosing the right method is crucial and is based on the current status in the clinical and histological evaluation. Before finalizing the process of choosing a specific method a prior interdisciplinary evaluation of the patient is necessary to ascertain clear indications for a surgical intervention. Liposuction is one of the methods which have become popular in recent years. The advantages are the possible combination with traditional techniques, such as subcutaneous mastectomy or periareolar mastopexy. The main indication is for gynecomastia stage IIa/b and is justifiable due to the reduction in surgical complications and scarring. Furthermore this technique provides an excellent aesthetical outcome for the patient. A total of 162 patients suffering from gynecomastia stages I-III (according to Simon) were surgically treated between 2000 and 2010 and these cases were retrospectively evaluated. The results showed a decline in the use of a T-shaped incision in combination with subcutaneous mastectomy with periareolar tightening compared to an increase in the use of subcutaneous mastectomy in combination with liposuction. The excised tissue should always be sent for histological examination to make sure no malignant cells were present.
Full Text Available Surgical manifestations of filariasis as seen in 150 cases over a period of three years in the department of Surgery, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha are reviewed. The genital manifestations are more common than the elephantiasis in this endemic zone.
Culwick, Caroline; Devine, Chris; Coombs, Catherine
Effective handovers are vital to patient safety and continuity of care, and this is recognised by several national bodies including the GMC. The existing model at Great Western Hospital (GWH) involved three general surgical teams and a urology team placing their printed patient lists, complete with weekend jobs, in a folder for the on-call team to collect at the weekend. We recognised a need to reduce time searching for patients, jobs and reviews, and to streamline weekend ward rounds. A unified weekend list ordering all surgical patients by ward and bed number was introduced. Discrepancies in the layout of each team's weekday list necessitated the design of a new weekday list to match the weekend list to facilitate the easy transfer of information between the two lists. A colour coding system was also used to highlight specific jobs. Prior to this improvement project only 7.1% of those polled were satisfied with the existing system, after a series of interventions satisfaction increased to 85.7%. The significant increase in overall satisfaction with surgical handover following the introduction of the unified weekend list is promising. Locating patients and identifying jobs is easier and weekend ward rounds can conducted in a more logical and timely fashion. It has also helped facilitate the transition to consultant ward rounds of all surgical inpatients at the weekends with promising feedback from a recent consultants meeting.
Ben Ameur, Hazem; Affes, Nejmeddine; Rejab, Haitham; Abid, Bassem; Boujelbene, Salah; Mzali, Rafik; Beyrouti, Mohamed Issam
The colostomy may be terminal or lateral, temporary or permanent. It may have psychological, medical or surgical complications. reporting the incidence of surgical complications of colostomies, their therapeutic management and trying to identify risk factors for their occurrence. A retrospective study for a period of 5 years in general surgery department, Habib Bourguiba hospital, Sfax, including all patients operated with confection of a colostomy. Were then studied patients reoperated for stoma complication. Among the 268 patients who have had a colostomy, 19 patients (7%) developed surgical stoma complications. They had a mean age of 59 years, a sex ratio of 5.3 and a 1-ASA score in 42% of cases. It was a prolapse in 9 cases (reconfection of the colostomy: 6 cases, restoration of digestive continuity: 3 cases), a necrosis in 5 cases (reconfection of the colostomy), a plicature in 2 cases (reconfection of the colostomy) a peristomal abscess in 2 cases (reconfection of the colostomy: 1 case, restoration of digestive continuity: 1 case) and a strangulated parastomal hernia in 1 case (herniorrhaphy). The elective incision and the perineal disease were risk factors for the occurrence of prolapse stomial. Surgical complications of colostomies remain a rare event. Prolapse is the most common complication, and it is mainly related to elective approach. Reoperation is often required especially in cases of early complications, with usually uneventful postoperative course.
outcomes could help residency programs and policy makers in structuring more efficient training. Keywords: surgical education, fatigue, simulator, sleep deprivation, duty hours
Watanabe, Gou; Ishikawa, Norihiro
The da Vinci surgical system was developed by Intuitive Surgical Inc. in the United States as an endoscopic surgical device to assist remote control surgeries. In 1998, the Da Vinci system was first used for cardiothoracic procedures. Currently a combination of robot-assisted internal thoracic artery harvest together with coronary artery bypass grafting (CABG) through a mini-incision (ThoraCAB) or totally endoscopic procedures including anastomoses under robotic assistance (TECAB) are being conducted for the treatment of coronary artery diseases. With the recent advances in catheter interventions, hybrid procedures combining catheter intervention with ThoraCAB or TECAB are anticipated in the future.On the other hand, with the decrease in number of coronary artery bypass surgeries, the share of valvular surgeries is expected to increase in the future. Among them, mitral valvuloplasty for mitral regurgitation is anticipated to be conducted mainly by low-invasive procedures, represented by minimally invasive cardiac surgery( MICS) and robot-assisted surgery. Apart from the intrinsic good surgical view, robotic-assisted systems offer additional advantages of the availability of an amplified view and the easy to observe the mitral valve in the physiological position. Thus, robotic surgical surgeries that make complicated procedures easier are expected to accomplish further developments in the future. Furthermore, while the number of surgeries for atrial septal defects has decreased dramatically following the widespread use of Amplatzer septal occluder, robotic surgery may become a good indication for cases in which the Amplatzer device is not indicated. In Japan, clinical trial of the da Vinci robotic system for heart surgeries has been completed. Statutory approval of the da Vinci system for mitral regurgitation and atrial septal defects is anticipated in the next few years.
Surgical laboratory in pregraduate students in medicine is beneficial and improves learning processes in cognitive aspects and skills acquisition. It is also an early initiation into scientific research. The laboratory is the introductory pathway into basic concepts of medical science (meaningful learning). It is also where students gain knowledge in procedures and abilities to obtain professional skills, an interactive teacher-student process. Medicine works rapidly to change from an art to a science. This fact compromises all schools and medical faculties to analyze their actual lesson plans. Simulators give students confidence and ability and save time, money and resources, eliminating at the same time the ethical factor of using live animals and the fear of patient safety. Multimedia programs may give a cognitive context evolving logically with an explanation based on written and visual animation followed by a clinical problem and its demonstration in a simulator, all before applying knowledge to the patient.
Full Text Available ... Quality Standard Optimal Resources for Surgical Quality and Safety Inspiring Quality Initiative Resources Continuous Quality Improvement ACS Clinical Scholars in Residence AHRQ Safety Program for ISCR AHRQ Safety Program for ISCR ...
Full Text Available ... SESAP Sampler SRGS Resources in Surgical Education ACS Fundamentals of Surgery Curriculum Mastery in General Surgery Program ... Communications to the Profession Advocacy Advocacy Overview Quality Payment Program QPP Resource Center QPP Resource Center 2018 ...
Full Text Available ... About Quality Programs ACS Leadership in Quality ACS Leadership in Quality Setting the Quality Standard Optimal Resources for Surgical Quality and Safety Inspiring Quality Initiative Resources Continuous Quality Improvement ACS Clinical Scholars in Residence AHRQ Safety Program ...
Full Text Available ... You Want to Be a Surgeon Resident Resources Teaching Resources Online Guide to Choosing a Surgical Residency ... Research Findings Quality Program Initiatives Communications to the Profession Advocacy Advocacy Overview Quality Payment Program QPP Resource ...
Bermudez, Luis; Trost, Kristen; Ayala, Ruben
Background. Humanitarian surgical organizations consider both quantity of patients receiving care and quality of the care provided as a measure of success. However, organizational efficacy is often judged by the percent of resources spent towards direct intervention/surgery, which may discourage investment in an outcomes monitoring system. Operation Smile's established Global Standards of Care mandate minimum patient followup and quality of care. Purpose. To determine whether investment of resources in an outcomes monitoring system is necessary and effectively measures success. Methods. This paper analyzes the quantity and completeness of data collected over the past four years and compares it against changes in personnel and resources assigned to the program. Operation Smile began investing in multiple resources to obtain the missing data necessary to potentially implement a global Surgical Outcomes Auditing System. Existing personnel resources were restructured to focus on postoperative program implementation, data acquisition and compilation, and training materials used to educate local foundation and international employees. Results. An increase in the number of postoperative forms and amount of data being submitted to headquarters occurred. Conclusions. Humanitarian surgical organizations would benefit from investment in a surgical outcomes monitoring system in order to demonstrate success and to ameliorate quality of care. PMID:23401763
... organized for general surgeons undertaking paediatric surgical emergencies. More paediatric surgeons should be trained and more paediatric surgical units should established in the country. Key Words: Paediatric Abdominal Surgical Emergencies; Paediatric Surgeons, General Surgeons. Journal of College of Medicine ...
. The planned visits were advertised locally and in the national media. Screening of the patients was done first by the local medical teams and later by the visiting surgical teams. The surgical teams were comprised of the following personnel:.
Culwick, Caroline; Devine, Chris; Coombs, Catherine
Effective handovers are vital to patient safety and continuity of care, and this is recognised by several national bodies including the GMC. The existing model at Great Western Hospital (GWH) involved three general surgical teams and a urology team placing their printed patient lists, complete with weekend jobs, in a folder for the on-call team to collect at the weekend. We recognised a need to reduce time searching for patients, jobs and reviews, and to streamline weekend ward rounds. A unif...
Many topics in surgical skills education have been implemented without a solid scientific basis. For that reason we have tried to find this scientific basis. We have focused on training and evaluation of minimally invasive surgical skills in a training setting and in practice in the operating room. This thesis has led to an enlarged insight in the organization of surgical skills training during residency training of surgical medical specialists.
Leraas, Harold J; Cox, Morgan L; Bendersky, Victoria A; Sprinkle, Shanna S; Gilmore, Brian F; Gunasingha, Rathnayaka M; Tracy, Elisabeth T; Sudan, Ranjan
Surgical skills training varies greatly between institutions and is often left to students to approach independently. Although many studies have examined single interventions of skills training, no data currently exists about the implementation of surgical skills assessment as a component of the medical student surgical curriculum. We created a technical skills competition and evaluated its effect on student surgical skill development. Second-year medical students enrolled in the surgery clerkship voluntarily participated in a surgical skills competition consisting of knot tying, laparoscopic peg transfer, and laparoscopic pattern cut. Winning students were awarded dinner with the chair of surgery and a resident of their choice. Individual event times and combined times were recorded and compared for students who completed without disqualification. Disqualification included compromising cutting pattern, dropping a peg out of the field of vision, and incorrect knot tying technique. Timed performance was compared for 2 subsequent academic years using Mann-Whitney U test. Overall, 175 students competed and 71 students met qualification criteria. When compared by academic year, 2015 to 2016 students (n = 34) performed better than 2014 to 2015 students (n = 37) in pattern cut (133s vs 167s, p = 0.040), peg transfer (66s vs 101s, p skills competition improves student technical performance. Further research is needed regarding long-term benefits of surgical competitions for medical students. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Sadideen, Hazim; Alvand, Abtin; Saadeddin, Munir; Kneebone, Roger
The concept of surgical expertise and the processes involved in its development are topical, and there is a constant drive to identify reliable measures of expert performance in surgery. This review explores the notion of whether surgical experts are "born" or "made", with reference to educational theory and pertinent literature. Peer-reviewed publications, books, and online resources on surgical education, expertise and training were reviewed. Important themes and aspects of expertise acquisition were identified in order to better understand the concept of a surgical expert. The definition of surgical expertise and several important aspects of its development are highlighted. Innate talent plays an important role, but is insufficient on its own to produce a surgical expert. Multiple theories that explore motor skill acquisition and memory are relevant, and Ericsson's theory of the development of competence followed by deliberate self-practice has been especially influential. Psychomotor and non-technical skills are necessary for progression in the current climate in light of our training curricula; surgical experts are adaptive experts who excel in these. The literature suggests that surgical expertise is reached through practice; surgical experts are made, not born. A deeper understanding of the nature of expert performance and its development will ensure that surgical education training programmes are of the highest possible quality. Surgical educators should aim to develop an expertise-based approach, with expert performance as the benchmark. Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Full Text Available The presented work is an alternative to established measurement systems in surgical navigation. The system is based on camera based tracking of QR code markers. The application uses a single video camera, integrated in a surgical lamp, that captures the QR markers attached to surgical instruments and to the patient.
The Nigerian Journal of Surgical Research is a publication of the Surgical Research Society with main office in Zaria, Nigeria. Zaria is home to Ahmadu Bello University (ABU), a premier university in Nigeria. The aim of The Nigerian Journal of Surgical Research is to cover developments and advances in the broad field of ...
Hanly, Eric J; Miller, Brian E; Kumar, Rajesh; Hasser, Christopher J; Coste-Maniere, Eve; Talamini, Mark A; Aurora, Alexander A; Schenkman, Noah S; Marohn, Michael R
One of the most significant limitations of surgical robots has been their inability to allow multiple surgeons and surgeons-in-training to engage in collaborative control of robotic surgical instruments. We report the initial experience with a novel two-headed da Vinci surgical robot that has two collaborative modes: the "swap" mode allows two surgeons to simultaneously operate and actively swap control of the robot's four arms, and the "nudge" mode allows them to share control of two of the robot's arms. The utility of the mentoring console operating in its two collaborative modes was evaluated through a combination of dry laboratory exercises and animal laboratory surgery. The results from surgeon-resident collaborative performance of complex three-handed surgical tasks were compared to results from single-surgeon and single-resident performance. Statistical significance was determined using Student's t-test. Collaborative surgeon-resident swap control reduced the time to completion of complex three-handed surgical tasks by 25% compared to single-surgeon operation of a four-armed da Vinci (P nudge mode was particularly useful for guiding a resident's hands during crucially precise steps of an operation (such as proper placement of stitches). The da Vinci mentoring console greatly facilitates surgeon collaboration during robotic surgery and improves the performance of complex surgical tasks. The mentoring console has the potential to improve resident participation in surgical robotics cases, enhance resident education in surgical training programs engaged in surgical robotics, and improve patient safety during robotic surgery.
Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Short Inpatient Hospital Stays; Transition for Certain Medicare-Dependent, Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System; Provider Administrative Appeals and Judicial Review. Final rule with comment period; final rule.
This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2016 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program. Further, this document includes certain finalized policies relating to the hospital inpatient prospective payment system: Changes to the 2-midnight rule under the short inpatient hospital stay policy; and a payment transition for hospitals that lost their status as a Medicare-dependent, small rural hospital (MDH) because they are no longer in a rural area due to the implementation of the new Office of Management and Budget delineations in FY 2015 and have not reclassified from urban to rural before January 1, 2016. In addition, this document contains a final rule that finalizes certain 2015 proposals, and addresses public comments received, relating to the changes in the Medicare regulations governing provider administrative appeals and judicial review relating to appropriate claims in provider cost reports.
on a moveable pedestal) demonstrated during the program visit to CMU.......................................................45 APPENDIX LIST OF... bridge inspection, and tank inspection. The CMU research group has constructed a variety of highly articulated snake robots, which can exploit their...visit to CMU. The locomoting or free crawling snake (on the left) is observed climbing a pole. The surgical type snake on a moveable pedestal (on the
Datta, Néha; MacQueen, Ian T; Schroeder, Alexander D; Wilson, Jessica J; Espinoza, Juan C; Wagner, Justin P; Filipi, Charles J; Chen, David C
In underserved communities around the world, inguinal hernias represent a significant burden of surgically-treatable disease. With traditional models of international surgical assistance limited to mission trips, a standardized framework to strengthen local healthcare systems is lacking. We established a surgical education model using web-based tools and wearable technology to allow for long-term proctoring and assessment in a resource-poor setting. This is a feasibility study examining wearable technology and web-based performance rating tools for long-term proctoring in an international setting. Using the Lichtenstein inguinal hernia repair as the index surgical procedure, local surgeons in Paraguay and Brazil were trained in person by visiting international expert trainers using a formal, standardized teaching protocol. Surgeries were captured in real-time using Google Glass and transmitted wirelessly to an online video stream, permitting real-time observation and proctoring by mentoring surgeon experts in remote locations around the world. A system for ongoing remote evaluation and support by experienced surgeons was established using the Lichtenstein-specific Operative Performance Rating Scale. Data were collected from 4 sequential training operations for surgeons trained in both Paraguay and Brazil. With continuous internet connectivity, live streaming of the surgeries was successful. The Operative Performance Rating Scale was immediately used after each operation. Both surgeons demonstrated proficiency at the completion of the fourth case. A sustainable model for surgical training and proctoring to empower local surgeons in resource-poor locations and "train trainers" is feasible with wearable technology and web-based communication. Capacity building by maximizing use of local resources and expertise offers a long-term solution to reducing the global burden of surgically-treatable disease. Copyright © 2015 Association of Program Directors in Surgery
Nestel, Debra; Harlim, Jennifer; Bryant, Melanie; Rampersad, Rajay; Hunter-Smith, David; Spychal, Bob
The landscape of surgical training is changing. The anticipated increase in the numbers of surgical trainees and the shift to competency-based surgical training places pressures on an already stretched health service. With these pressures in mind, we explored trainers' and trainees' experiences of surgical training in a less traditional rotation, an outer metropolitan hospital. We considered practice-based learning theories to make meaning of surgical training in this setting, in particular Actor-network theory. We adopted a qualitative approach and purposively sampled surgical trainers and trainees to participate in individual interviews and focus groups respectively. Transcripts were made and thematically analysed. Institutional human research ethics approval was obtained. Four surgical trainers and fourteen trainees participated. Almost without exception, participants' report training needs to be well met. Emergent inter-related themes were: learning as social activity; learning and programmatic factors; learning and physical infrastructure; and, learning and organizational structure. This outer metropolitan hospital is suited to the provision of surgical training with the current rotational system for trainees. The setting offers experiences that enable consolidation of learning providing a rich and varied overall surgical training program. Although relational elements of learning were paramount they occurred within a complex environment. Actor-network theory was used to give meaning to emergent themes acknowledging that actors (both people and objects) and their interactions combine to influence training quality, shifting the focus of responsibility for learning away from individuals to the complex interactions in which they work and learn.
Quérat, C; Germain, N; Dumollard, J-M; Estour, B; Peoc'h, M; Prades, J-M
Hyperthyroidism includes several clinical and histopathological situations. Surgery is commonly indicated after failure of medical treatment. The aim of this study was to analyze the indications and complications of surgery as well as endocrine results. Patients operated on for hyperthyroidism between 2004 and 2012 were included in a retrospective study. Total thyroidectomy was performed for Graves' disease, toxic multinodular goiter and amiodarone-associated thyrotoxicosis; patients with toxic nodule underwent hemithyroidectomy. Pathologic analysis assessed surgical specimens; postoperative complications and resolution of hyperthyroidism were noted. Two hundred patients from 15 to 83 years old were included. One hundred and eighty-eight underwent primary surgery and 12 were re-operated for recurrent goiter (6 with subtotal thyroidectomy for multinodular goiter 25 years previously; 6 with hemithyroidectomy for solitary nodule 15 years previously). Eighty-two patients suffered from toxic multinodular goiter, 78 from Graves' disease, 35 from solitary toxic nodules and 5 from amiodarone-associated thyrotoxicosis. Fourteen papillary carcinomas (including 11 papillary microcarcinomas) and 34 healthy parathyroid glands (17%) were identified in the pathological specimens. Postoperative complications comprised 4% permanent recurrent laryngeal nerve palsy (1 year follow-up), 9% hematoma requiring surgical revision, and 3% definitive hypocalcemia. Normalization of thyroid hormone levels was observed in 198 patients. Two recurrences occurred due to incomplete resection (1 case of Graves' disease and 1 intrathoracic toxic goiter that occurred respectively 18 and 5 months after resection). Postoperative complications were more frequent in multinodular goiter (23%) than in Graves' disease (13%) (ns: P>0.05). Surgical management of hyperthyroidism enables good endocrinal control if surgery is complete. Patients need to be fully informed of all possible postoperative complications
Merino, M L; Gómez de Liaño, P; Merino, P; Franco, G
We report 3 cases with a vertical incomitance in upgaze, narrowing of palpebral fissure, and pseudo-overaction of both inferior oblique muscles. Surgery consisted of an elevation of both lateral rectus muscles with an asymmetrical weakening. A satisfactory result was achieved in 2 cases, whereas a Lambda syndrome appeared in the other case. The surgical technique of upper-insertion with a recession of both lateral rectus muscles improved vertical incomitance in 2 of the 3 patients; however, a residual deviation remains in the majority of cases. Copyright © 2011 Sociedad Española de Oftalmología. Published by Elsevier Espana. All rights reserved.
Târcoveanu, E; Lupaşcu, C; Vasilescu, A; Moldovanu, R; Ichim, Mihaela; Georgescu, St; Niculescu, D; Dănilă, N; Dimofte, G; Anton, Raluca; Crumpei, Felicia; Florea, Niculina; Ungureanu, Cristina
Gynecomastia describes a benign increase of the mammary gland in men. When medical treatment fails, the surgical procedure is the treatment of choice. There are two main surgical procedures: subdermal mastectomy and liposuction. To evaluate the results after surgical treatment (mastectomy) performed in a general surgery unit. We performed a retrospective study; all the patients operated for gynecomastia were reviewed. The clinical, imaging, biological, intraoperative and histological data were included into a MS Access database and statistical analyzed. From 1990-2007, 114 patients were admitted in the First Surgical Clinic Iaşi for gynecomastia. Only 12.6% from the patients were with bilateral gynecomastia. The mean age was 40.54 +/- 1.83 years old (range 12-84). Mean body mass was 26.72 +/- 0.46 kg/m2 (range 18.5-41), and about 20% from the patients had a BMI of over 30 kg/m2. We also noted that 46.5% were smokers. Simon classification was used for preoperative staging: 2.6% from the cases (N = 3) were included in stage I, 16.7% (N = 19) in stage IIa, 50% (N = 57) in stage IIb and 30.7% in stage III. The patients included in stages IIa and I are younger then the patients included in stage III (p = 0.024). Mastodynia was noted in 46 cases (40.4%). Ultrasound exam was performed in all the cases, and the larger diameter of the nodule measured was 3.75 +/- 0.18 cm (range 0.5-9.7). Only three cases were preoperatively treated with tamoxifen. Most of the cases were operated using general anesthesia (53.5%). Mastectomy was performed by peri-areolar (70.2%), elliptical (28.9%) or radial (0.9%) incisions. The subdermal mastectomy using peri-areolar approach was performed especially for the cases included in stages I, IIa and IIb--p gynecomastia in 6 cases; the other cases presented dilated ducts. We also noted intraductal papillary hyperplasia in 87 cases and chronic inflammation in 35 cases. The histological exam also revealed intraductal papilloma--9 cases, fibro
Hale, Diane F; Sexton, Justin C; Benavides, Linda C; Benavides, Jerry M; Lundy, Jonathan B
The deployment of surgical assets has been driven by mission demands throughout years of military operations in Iraq and Afghanistan. The transition to the highly expeditious Golden Hour Offset Surgical Transport Team (GHOST- T) now offers highly mobile surgical assets in nontraditional operating rooms; the content of the surgical instrument sets has also transformed to accommodate this change. The 102nd Forward Surgical Team (FST) was attached to Special Operations assigned to southern Afghanistan from June 2015 to March 2016. The focus was to decrease overall size and weight of FST instrument sets without decreasing surgical capability of the GHOST-T. Each instrument set was evaluated and modified to include essential instruments to perform damage control surgery. The overall number of main instrument sets was decreased from eight to four; simplified augmentation sets have been added, which expand the capabilities of any main set. The overall size was decreased by 40% and overall weight decreased by 58%. The cardiothoracic, thoracotomy, and emergency thoracotomy trays were condensed to thoracic set. The orthopedic and amputation sets were replaced with an augmentation set of a prepackaged orthopedic external fixator set). An augmentation set to the major or minor basic sets, specifically for vascular injuries, was created. Through the reorganization of conventional FST surgical instrument sets to maintain damage control capabilities and mobility, the 102nd GHOST-T reduced surgical equipment volume and weight, providing a lesson learned for future surgical teams operating in austere environments. 2017.
Bonnar, Paul E; Senthinathan, Arrani; Nakamachi, Yoshiko; Backstein, David J; Steinberg, Marilyn; Morris, Andrew M
Abstract Background Surgical site infections are common causes of healthcare-associated infections. Using surgical antimicrobial prophylaxis (SAP) is a complex process that can reduce these rates if performed correctly. While antimicrobial stewardship programs have developed guidelines for SAP, there has been less focus on understanding and modifying the behavioral and contextual factors required to optimize prophylaxis use. We performed chart reviews and workflow analyses to develop interven...
Rogers, Mary E; Creed, Peter A; Searle, Judy
To identify the reasons why interns would not choose a surgical career. This qualitative study used semi-structured telephone interviews to explore the future career choices of 41 junior doctors (14 men, 27 women). Doctors were asked to identify specialties they would not take up, and state why this was the case. Thirty (73.2%) of the 41 interns nominated surgery as a specialty they would not choose. Themes relating to reasons for not wanting to pursue a surgical career included the lifestyle associated with surgery (66.7%), the culture within the surgical work environment (53.3%), the lack of interest in performing surgical work (36.7%), and the training requirements associated with surgery (33.3%). Both sexes had similar reasons for not wanting to choose a surgical career; but additionally, women referred to the male domination of surgery, and the difficulty and inflexibility of the training program as deterrents. Efforts are needed to promote interest in surgery as a career especially for women, to improve the surgical work environment so that medical students and junior doctors have exposure to positive role models and surgical placements, and to provide a more flexible approach to surgical training.
An estimated 550 to 650 surgical fires occur annually in the United States. Surgical fires may have severe consequences, including burns, disfigurement, long-term medical care, or death. This article introduces a potential certification program for the prevention of surgical fires. A pilot study was conducted with a convenience sample of 10 anesthesia providers who participated in the education module. The overall objective was to educate surgical team members and to prepare them to become certified in surgical fire prevention. On completion of the education module, participants completed the 50-question certification examination. The mean pretest score was 66%; none of the participants had enough correct responses (85%) to be considered competent in surgical fire prevention. The mean post- test score was 92.80%, with all participants answering at least 85% of questions correct. A paired-samples t test showed a statistically significant increase in knowledge: t (df = 9) = 11.40; P = .001. Results of the pilot study indicate that this course can remediate gaps in knowledge of surgical fire prevention for providers. Their poor performance on the pretest suggests that many providers may not receive sufficient instruction in surgical fire prevention.
Lehmann, K S; Gröne, J; Lauscher, J C; Ritz, J-P; Holmer, C; Pohlen, U; Buhr, H-J
Training and simulation are gaining importance in surgical education. Today, virtual reality surgery simulators provide sophisticated laparoscopic training scenarios and offer detailed assessment methods. This also makes simulators interesting for the application in surgical skills courses. The aim of the current study was to assess the suitability of a virtual surgery simulator for training and assessment in an established surgical training course. The study was conducted during the annual "Practical Course for Visceral Surgery" (Warnemuende, Germany). 36 of 108 course participants were assigned at random for the study. Training was conducted in 15 sessions over 5 days with 4 identical virtual surgery simulators (LapSim) and 2 standardised training tasks. The simulator measured 16 individual parameters and calculated 2 scores. Questionnaires were used to assess the test persons' laparoscopic experience, their training situation and the acceptance of the simulator training. Data were analysed with non-parametric tests. A subgroup analysis for laparoscopic experience was conducted in order to assess the simulator's construct validity and assessment capabilities. Median age was 32 (27 - 41) years; median professional experience was 3 (1 - 11) years. Typical laparoscopic learning curves with initial significant improvements and a subsequent plateau phase were measured over 5 days. The individual training sessions exhibited a rhythmic variability in the training results. A shorter night's sleep led to a marked drop in performance. The participants' different experience levels could clearly be discriminated ( ≤ 20 vs. > 20 laparoscopic operations; p ≤ 0.001). The questionnaire showed that the majority of the participants had limited training opportunities in their hospitals. The simulator training was very well accepted. However, the participants severely misjudged the real costs of the simulators that were used. The learning curve on the
Full Text Available This paper investigates selected short- and mid-term effects in trade in goods between the Visegrad countries (V4: the Czech Republic, Hungary, Poland and the Slovak Republic and the Republic of Korea under the framework of the Free Trade Agreement between the European Union and the Republic of Korea. This Agreement is described in the “Trade for All” (2015: 9 strategy as the most ambitious trade deal ever implemented by the EU. The primary purpose of our analysis is to identify, compare, and evaluate the evolution of the technological sophistication of bilateral exports and imports. Another dimension of the paper concentrates on the developments within intra-industry trade. Moreover, these objectives are approached taking into account the context of the South Korean direct investment inflow to the V4. The evaluation of technological sophistication is based on UNCTAD’s methodology, while the intensity of intra-industry trade is measured by the GL-index and identification of its subcategories (horizontal and vertical trade. The analysis covers the timespan 2001–2015. The novelty of the paper lies in the fact that the study of South Korean-V4 trade relations has not so far been carried out from this perspective. Thus this paper investigates interesting phenomena identified in the trade between the Republic of Korea (ROK and V4 economies. The main findings imply an impact of South Korean direct investments on trade. This is represented by the trade deficit of the V4 with ROK and the structure of bilateral trade in terms of its technological sophistication. South Korean investments might also have had positive consequences for the evolution of IIT, particularly in the machinery sector. The political interpretation indicates that they may strengthen common threats associated with the middle-income trap, particularly the technological gap and the emphasis placed on lower costs of production.
Are, C; Berman, R S; Wyld, L; Cummings, C; Lecoq, C; Audisio, R A
The significant global variations in surgical oncology training paradigms can have a detrimental effect on tackling the rising global cancer burden. While some variations in training are essential to account for the differences in types of cancer and biology, the fundamental principles of providing care to a cancer patient remain the same. The development of a global curriculum in surgical oncology with incorporated essential standards could be very useful in building an adequately trained surgical oncology workforce, which in turn could help in tackling the rising global cancer burden. The leaders of the Society of Surgical Oncology and European Society of Surgical Oncology convened a global curriculum committee to develop a global curriculum in surgical oncology. A global curriculum in surgical oncology was developed to incorporate the required domains considered to be essential in training a surgical oncologist. The curriculum was constructed in a modular fashion to permit flexibility to suit the needs of the different regions of the world. Similarly, recognizing the various sociocultural, financial and cultural influences across the world, the proposed curriculum is aspirational and not mandatory in intent. A global curriculum was developed which may be considered as a foundational scaffolding for training surgical oncologists worldwide. It is envisioned that this initial global curriculum will provide a flexible and modular scaffolding that can be tailored by individual countries or regions to train surgical oncologists in a way that is appropriate for practice in their local environment. Copyright © 2016 Society of Surgical Oncology, European Society of Surgical Oncology. Published by Elsevier Ltd.. All rights reserved.
Raghunath, S K; Nagaraja, H; Srivatsa, N
Inguinal lymphadenectomy remains the standard of care for metastatic nodal disease in cases of penile, urethral, vulval and vaginal cancers. Outcomes, including cure rates and overall and progression-free survivals, have progressively improved in these diseases with extending criteria to offer inguinal lymph node dissection for patients 'at-risk' for metastasis or loco-regional recurrence. Hence, despite declining incidence of advanced stages of these cancers, many patients will still need to undergo lymphadenectomy for optimal oncological outcomes. Inguinal node dissection is a morbid procedure with operative morbidity noted in almost two third of the patients. Video endoscopic inguinal lymphadenectomy (VEIL) was described and currently practiced with proven equivalent oncological outcomes. We describe our technique of VEIL using laparoscopic and robotic access as well as various new surgical strategies.
Full Text Available Surgical treatment of craniopharyngiomas is challenging and despite advancements it continues to pose a challenge. Proponents of subtotal resection in conjunction with radiotherapy argue that this less aggressive approach can yield appropriate results with the lower morbidity. On the contrary, other argument is that gross total resection is superior. Though surgical management of craniopharyngioma is challenging due to its location and important surrounding neurovascular structures, optimal surgical results can be expected following radical surgical excision. Radical excision of craniopharyngiomas is associated with excellent long-term recurrence free survival. Radiation induced long-term complications can be altogether avoided by excising these tumors completely.
Basti, Z.; Mayer, A.
Stoma construction is among standard surgical skills and is performed for many indications. Every stoma means huge impact on quality of life for patients even with great improvement in surgical technique and ostomy devices. All patients are very sensitive to complication of stoma and the most frequent complication is parastomal hernia. Incidence reported in literature is very high and unacceptable, it is 30-70%. Surgical approach is very demanding on technical equipment and experiences of surgeon. Authors focus on each surgical approach for treating this complication weather it´s using mesh or laparoscopic or open approach. (author)
... of Legislation and Public Policy (OLPP) Office of Science Policy, Reporting, and Program Analysis (OSPRA) Division of Extramural Research (DER) Extramural Scientific Branches Grants Management Branch (GMB) Office of Committee Management ( ...
Reactive systems are systems that maintain an ongoing interaction with their environment, activated by receiving input events from the environment and producing output events in response. Modern programming languages designed to program such systems use a paradigm based on the notions of instants and activations. We describe a library for Standard ML that provides basic primitives for programming reactive systems. The library is a low-level system upon which more sophisticated reactive behavi...
Rangel, Erika L; Smink, Douglas S; Castillo-Angeles, Manuel; Kwakye, Gifty; Changala, Marguerite; Haider, Adil H; Doherty, Gerard M
Although family priorities influence specialty selection and resident attrition, few studies describe resident perspectives on pregnancy during surgical training. To directly assess the resident experience of childbearing during training. A self-administered 74-question survey was electronically distributed in January 2017 to members of the Association of Women Surgeons, to members of the Association of Program Directors in Surgery listserv, and through targeted social media platforms. Surgeons who had 1 or more pregnancies during an Accreditation Council for Graduate Medical Education-accredited US general surgery residency program and completed training in 2007 or later were included. Important themes were identified using focus groups of surgeons who had undergone pregnancy during training in the past 7 years. Additional topics were identified through MEDLINE searches performed from January 2000 to July 2016 combining the keywords pregnancy, resident, attrition, and parenting in any specialty. Descriptive data on perceptions of work schedule during pregnancy, maternity leave policies, lactation and childcare support, and career satisfaction after childbirth. This study included 347 female surgeons (mean [SD] age, 30.5 [2.7] years) with 452 pregnancies. A total of 297 women (85.6%) worked an unmodified schedule until birth, and 220 (63.6%) were concerned that their work schedule adversely affected their health or the health of their unborn child. Residency program maternity leave policies were reported by 121 participants (34.9%). A total of 251 women (78.4%) received maternity leave of 6 weeks or less, and 250 (72.0%) perceived the duration of leave to be inadequate. The American Board of Surgery leave policy was cited as a major barrier to the desired length of leave by 268 of 326 respondents (82.2%). Breastfeeding was important to 329 (95.6%), but 200 (58.1%) stopped earlier than they wished because of poor access to lactation facilities and challenges leaving
The ANNALS of AFRICAN SURGERY. January 2016 Volume 13 Issue 1 1. EDITORIAL. Access to Specialized Surgical Care. Saidi H. University of Nairobi. Correspondence to: Prof Hassan Saidi, P.O Box 30196-00100, Nairobi. Email: email@example.com. Ann Afr Surg. 2016;13(1):1-2. The narrative of surgical disease in ...
'To sleep: perchance to dream', is the frequent mantra of the surgical resident. However, unlike. Hamlet, there is no ensuing speculation as to what dreams may come as there are seldom any!! Surgical residency has been both vilified and immortalized, but the fact remains that it is one of the most challenging, provocative ...
Van Goethem, Bart
In this thesis some recent technological developments in human surgery are evaluated for their potential use in veterinary medicine by introducing them as surgical innovations for canine gonadectomy. Barbed sutures achieve wound apposition without surgical knot tying and thus avoid knot-associated
Many topics in surgical skills education have been implemented without a solid scientific basis. For that reason we have tried to find this scientific basis. We have focused on training and evaluation of minimally invasive surgical skills in a training setting and in practice in the operating room.
Full Text Available Surgical treatment of gynecomastia could present unique challenges for the plastic surgeon. Achieving a good balance between effectiveness of the selected approach and the satisfactory aesthetic outcome often is a difficult endeavor. Optimal surgical treatment involves a combination of liposuction and direct excision. In the present study the charts of 11 patients treated with suction-assisted liposuction and direct surgical excision were retrospectively reviewed; a special emphasis is placed on the surgical technique. The mean follow-up period of the patients was 11.6 months. No infection, hematoma, nipple-areola complex necrosis and nipple retraction was encountered in this series. The combined surgical treatment of gynecomastia has shown to be a reliable technique in both small and moderate breast enlargement including those with skin excess.
Johnson, Paul J; Schmidt, David E; Duvvuri, Umamaheswar
The number of robot-assisted surgeries performed with the da Vinci surgical system has increased significantly over the past decade. The articulating movements of the robotic surgical grasper are controlled by grip controls at the master console. The user interface has been implicated as one contributing factor in surgical grasping errors. The goal of our study was to characterize and evaluate the user interface of the da Vinci surgical system in controlling surgical graspers. An angular manipulator with force sensors was used to increment the grip control angle as grasper output angles were measured. Input force at the grip control was simultaneously measured throughout the range of motion. Pressure film was used to assess the maximum grasping force achievable with the endoscopic grasping tool. The da Vinci robot's grip control angular input has a nonproportional relationship with the grasper instrument output. The grip control mechanism presents an intrinsic resistant force to the surgeon's fingertips and provides no haptic feedback. The da Vinci Maryland graspers are capable of applying up to 5.1 MPa of local pressure. The angular and force input at the grip control of the da Vinci robot's surgical graspers is nonproportional to the grasper instrument's output. Understanding the true relationship of the grip control input to grasper instrument output may help surgeons understand how to better control the surgical graspers and promote fewer grasping errors. Copyright © 2014 Elsevier Inc. All rights reserved.
Bonrath, Esther M; Dedy, Nicolas J; Gordon, Lauren E; Grantcharov, Teodor P
The aim of the study was to determine whether individualized coaching improved surgical technical skill in the operating room to a higher degree than current residency training. Clinical training in the operating room is a valuable opportunity for surgeons to acquire skill and knowledge; however, it often remains underutilized. Coaching has been successfully used in various industries to enhance performance, but its role in surgery has been insufficiently investigated. This randomized controlled trial was conducted at one surgical training program. Trainees undergoing a minimally invasive surgery rotation were randomized to either conventional training (CT) or comprehensive surgical coaching (CSC). CT included ward and operating room duties, and regular departmental teaching sessions. CSC comprised performance analysis, debriefing, feedback, and behavior modeling. Primary outcome measures were technical performance as measured on global and procedure-specific rating scales, and surgical safety parameters, measured by error count. Operative performance was assessed by blinded video analysis of the first and last cases recorded by the participants during their rotation. Twenty residents were randomized and 18 completed the study. At posttraining the CSC group (n = 9) scored significantly higher on a procedure-specific skill scale compared with the CT group (n = 9) [median, 3.90 (interquartile range, 3.68-4.30) vs 3.60 (2.98-3.70), P = 0.017], and made fewer technical errors [10 (7-13) vs 18 (13-21), P = 0.003]. Significant within-group improvements for all skill metrics were only noted in the CSC group. Comprehensive surgical coaching enhances surgical training and results in skill acquisition superior to conventional training.
Deretić Irina J.
Full Text Available In this paper, the author attempts to elucidate validity of Plato's criticism of Parmenides' simplified monistic ontology, as well as his concept of non-being. In contrast to Parmenides, Plato introduces a more complex ontology of the megista gene and redefines Parmenides' concept of non-being as something absolutely different from being. According to Plato, not all things are in the same sense, i. e. they have the different ontological status. Additionally, he redefines Parmenides' concept of absolute non-being as 'difference' or 'otherness.' .
The control systems at Sellafield fuel handling plant are described. The requirements called for built-in diagnostic features as well as the ability to handle a large sequencing application. Speed was also important; responses better than 50ms were required. The control systems are used to automate operations within each of the three main process caves - two Magnox fuel decanners and an advanced gas-cooled reactor fuel dismantler. The fuel route within the fuel handling plant is illustrated and described. ASPIC (Automated Sequence Package for Industrial Control) which was developed as a controller for the plant processes is described. (U.K.)
Lee, Andrew G.; Greenlee, Emily; Oetting, Thomas A.; Beaver, Hilary A.; Johnson, A. Tim; Boldt, H. Culver; Abramoff, Michael; Olson, Richard; Carter, Keith
The Accreditation Council for Graduate Medical Education has mandated that all residency training programs teach and assess 6 general competencies.1 A.G. Lee and K.D. Carter, Managing the new mandate in resident education: A blueprint for translating a national mandate into local compliance,
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IND computer program introduces Bayesian and Markov/maximum-likelihood (MML) methods and more-sophisticated methods of searching in growing trees. Produces more-accurate class-probability estimates important in applications like diagnosis. Provides range of features and styles with convenience for casual user, fine-tuning for advanced user or for those interested in research. Consists of four basic kinds of routines: data-manipulation, tree-generation, tree-testing, and tree-display. Written in C language.
Van Esbroeck, Alexander; Rubinfeld, Ilan; Hall, Bruce; Syed, Zeeshan
To investigate the use of machine learning to empirically determine the risk of individual surgical procedures and to improve surgical models with this information. American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data from 2005 to 2009 were used to train support vector machine (SVM) classifiers to learn the relationship between textual constructs in current procedural terminology (CPT) descriptions and mortality, morbidity, Clavien 4 complications, and surgical-site infections (SSI) within 30 days of surgery. The procedural risk scores produced by the SVM classifiers were validated on data from 2010 in univariate and multivariate analyses. The procedural risk scores produced by the SVM classifiers achieved moderate-to-high levels of discrimination in univariate analyses (area under receiver operating characteristic curve: 0.871 for mortality, 0.789 for morbidity, 0.791 for SSI, 0.845 for Clavien 4 complications). Addition of these scores also substantially improved multivariate models comprising patient factors and previously proposed correlates of procedural risk (net reclassification improvement and integrated discrimination improvement: 0.54 and 0.001 for mortality, 0.46 and 0.011 for morbidity, 0.68 and 0.022 for SSI, 0.44 and 0.001 for Clavien 4 complications; P risk for individual procedures. This information can be measured in an entirely data-driven manner and substantially improves multifactorial models to predict postoperative complications. Copyright © 2014 Elsevier Inc. All rights reserved.
Neal, C P; Dennison, A R; Garcea, G
Chronic pancreatitis (CP) is an inflammatory disease of the pancreas which causes chronic pain, as well as exocrine and endocrine failure in the majority of patients, together producing social and domestic upheaval and a very poor quality of life. At least half of patients will require surgical intervention at some stage in their disease, primarily for the treatment of persistent pain. Available data have now confirmed that surgical intervention may produce superior results to conservative and endoscopic treatment. Comprehensive individual patient assessment is crucial to optimal surgical management, however, in order to determine which morphological disease variant (large duct disease, distal stricture with focal disease, expanded head or small duct/minimal change disease) is present in the individual patient, as a wide and differing range of surgical approaches are possible depending upon the specific abnormality within the gland. This review comprehensively assesses the evidence for these differing approaches to surgical intervention in chronic pancreatitis. Surgical drainage procedures should be limited to a small number of patients with a dilated duct and no pancreatic head mass. Similarly, a small population presenting with a focal stricture and tail only disease may be successfully treated by distal pancreatectomy. Long-term results of both of these procedure types are poor, however. More impressive results have been yielded for the surgical treatment of the expanded head, for which a range of surgical options now exist. Evidence from level I studies and a recent meta-analysis suggests that duodenum-preserving resections offer benefits compared to pancreaticoduodenectomy, though the results of the ongoing, multicentre ChroPac trial are awaited to confirm this. Further data are also needed to determine which of the duodenum-preserving procedures provides optimal results. In relation to small duct/minimal change disease total pancreatectomy represents the only
During the Great War, the French surgeon Alexis Carrel, in collaboration with the English chemist Henry Dakin, devised an antiseptic treatment for infected wounds. This paper focuses on Carrel's attempt to standardise knowledge of infected wounds and their treatment, and looks closely at the vision of surgical skill he espoused and its difference from those associated with the doctrines of scientific management. Examining contemporary claims that the Carrel-Dakin method increased rather than diminished demands on surgical work, this paper further shows how debates about antiseptic wound treatment opened up a critical space for considering the nature of skill as a vital dynamic in surgical innovation and practice.
Tsai, Thomas C; Orav, E John; Jha, Ashish K
The relationship between patient satisfaction and surgical quality is unclear for US hospitals. Using national data, we examined if hospitals with high patient satisfaction have lower levels of performance on accepted measures of the quality and efficiency of surgical care. Federal policymakers have made patient satisfaction a core measure for the way hospitals are evaluated and paid through the value-based purchasing program. There is broad concern that performance on patient satisfaction may have little or even a negative correlation with the quality of surgical care, leading to potential trade-offs in efforts to improve patient experience with other surgical quality measures. We used the Hospital Consumer Assessment of Healthcare Providers and Systems survey data from 2010 and 2011 to assess performance on patient experience. We used national Medicare data on 6 common surgical procedures to calculate measures of surgical efficiency and quality: risk-adjusted length of stay, process score, risk-adjusted mortality rate, risk-adjusted readmission rate, and a composite z score across all 4 metrics. Multivariate models adjusting for hospital characteristics were used to assess the independent relationships between patient satisfaction and measures of surgical efficiency and quality. Of the 2953 US hospitals that perform one of these 6 procedures, the median patient satisfaction score was 69.5% (interquartile range, 63%-75.5%). Length of stay was shorter in hospitals with the highest levels of patient satisfaction (7.1 days vs 7.7 days, P patient satisfaction had the higher process of care performance (96.5 vs 95.5, P patient satisfaction also had a higher composite score for quality across all measures (P patient satisfaction provided more efficient care and were associated with higher surgical quality. Our findings suggest there need not be a trade-off between good quality of care for surgical patients and ensuring a positive patient experience.
Jensen, Rune Dall; Seyer-Hansen, Mikkel; Christensen, Mette Krogh
Dream Team is an extracurricular pregraduate surgical talent development project founded in 2009 at Aarhus University Hospital, Denmark. It aims to identify and develop laparoscopic surgical talents during medical school. Dream Team contains two parts: 1) a weeklong boot camp where app. 10 % of 8th...... the mentorship the students will be in operation room at least once a week and participate as much as their skills allow. Dream Team differs from similar pregraduate programs as it selects the most talented students, but does the boot camp select the best and does the mentorship program provide optimal learning......? A PhD project aims to critically analyze and develop Dream Team. The PhD project is based on theories about deliberate practice and social learning. In addition, we compare surgical talent development with talent development in elite sport in order to inspire, refine and develop Dream Team...
Objective: To review factors influencing the choice of anaesthesia for ophthalmic surgical procedures. ... as risk associated with general anaesthesia (8) they are more .... Wilson ME, Pandey SK, Thakur J. Paediatric cataract blindness in the ...
Mar 23, 2017 ... aDepartamet of Pediatric Surgery, Hospital Teresa Herrera, Complejo Hospitalario. Universitario de A ... Advances in anesthesia, neonatal intensive, surgical, and cardiac care have ... First, these patients are at risk of airway ...
surgical procedure). Arterial cannulation ... Acute retinal necrosis syndrome after epidural corticos- teroid injections ... prevented, or respond to early recognition and treatment. ..... drugs should only be administered if there are no alternatives.
Soler, Luc; Marescaux, Jacques
Technological innovations of the twentieth century have provided medicine and surgery with new tools for education and therapy definition. Thus, by combining Medical Imaging and Virtual Reality, patient-specific applications providing preoperative surgical simulation have become possible.
Lu, Kim C; Hunt, Steven R
Although medical management can control symptoms in a recurring incurable disease, such as Crohn's disease, surgical management is reserved for disease complications or those problems refractory to medical management. In this article, we cover general principles for the surgical management of Crohn's disease, ranging from skin tags, abscesses, fistulae, and stenoses to small bowel and extraintestinal disease. Copyright © 2013 Elsevier Inc. All rights reserved.
Van Goethem, Bart
In this thesis some recent technological developments in human surgery are evaluated for their potential use in veterinary medicine by introducing them as surgical innovations for canine gonadectomy. Barbed sutures achieve wound apposition without surgical knot tying and thus avoid knot-associated negative consequences (lengthy placement, impaired wound healing around bulky knots, and the effect of unsightly knots on cosmetics). A study in 9 dogs found that celiotomy closure was easily achiev...
Siew Kheong Lum
Conclusion: Quality of training can be improved by changing to a curriculum and competency based model, utilization of continuous assessment methods, reducing service requirements and better compensation for trainers. Southeast Asia has the potential to provide centres of excellence for surgical training. Surgical educators in SEA will find useful information in this paper to improve their programs which will hopefully evolve into a common core curriculum and enable cross border exchange of surgical trainees in SEA for broader exposure.
incisors were more proclined. One of the goals of pre - surgical orthodontic treatment is decompensation of the occlusion and movement of teeth into...purpose of this study is to analyze pre - surgical orthodontic incisor decompensation attained in a group of orthognathic surgery patients treated in...the Tri-Service Orthodontic Residency Program. B. Specific Hypothesis Pre - surgical orthodontic treatment does not achieve full decompensation of
Forgione, Antonello; Guraya, Salman Y
Historically, operating room (OR) has always been considered as a stand-alone trusted platform for surgical education and training. However, concerns about financial constraints, quality control, and patient safety have urged the surgical educators to develop more cost-effective, surgical educational platforms that can be employed outside the OR. Furthermore, trained surgeons need to regularly update their surgical skills to keep abreast with the emerging surgical technologies. This research aimed to explore the value of currently available modern surgical tools that can be used outside the OR and also elaborates the existing laparoscopic surgical training programs in world-class centers across the globe with a view to formulate a blended and unified structured surgical training program. Several data sources were searched using MeSH terms "Laparoscopic surgery" and "Surgical training" and "Surgical curriculum" and "fundamentals of endoscopic surgery" and "fundamentals of laparoscopic surgery" and "Telementoring" and "Box trainer." The eligibility criteria used in data extraction searched for original and review articles and by excluding the editorial articles, short communications, conference proceedings, personal view, and commentaries. Data synthesis and data analysis were done by reviewing the initially retrieved 211 articles. Irrelevant and duplicate and redundant articles were excluded from the study. Finally, 12 articles were selected for this systematic review. Data results showed that a myriad of cutting-edge technical innovations have provided modern surgical training tools such as the simulation-based mechanical and virtual reality simulators, animal and cadaveric labs, telementoring, telerobotic-assisted surgery, and video games. Surgical simulators allow the trainees to acquire surgical skills in a tension-free environment without supervision or time constraints. The existing world-renowned surgical training centers employ various clusters of training
Elective Stoma Reversal Has a Higher Incidence of Postoperative Clostridium Difficile Infection Compared With Elective Colectomy: An Analysis Using the American College of Surgeons National Surgical Quality Improvement Program and Targeted Colectomy Databases.
Skancke, Matthew; Vaziri, Khashayar; Umapathi, Bindu; Amdur, Richard; Radomski, Michal; Obias, Vincent
Clostridium difficile infection is caused by the proliferation of a gram-positive anaerobic bacteria after medical or surgical intervention and can result in toxic complications, emergent surgery, and death. This analysis evaluates the incidence of C difficile infection in elective restoration of intestinal continuity compared with elective colon resection. This was a retrospective database review of the 2015 American College of Surgeons National Surgical Quality Improvement Project and targeted colectomy database. The intervention cohort was defined as the primary Current Procedural Terminology codes for ileostomy/colostomy reversal (44227, 44620, 44625, and 44626) and International Classification of Diseases codes for ileostomy/colostomy status (VV44.2, VV44.3, VV55.2, VV55.3, Z93.2, Z93.3, Z43.3, and Z43.2). A total of 2235 patients underwent elective stoma reversal compared with 10403 patients who underwent elective colon resection. Multivariate regression modeling of the impact of stoma reversal on postoperative C difficile infection risk was used as the study intervention. The incidence of C difficile infection in the 30 days after surgery was measured. The incidence of C difficile infection in the 30-day postoperative period was significantly higher (3.04% vs 1.25%; p difficile infection incidence in the 30-day postoperative period. The study was limited because it was a retrospective database review with observational bias. Patients who undergo elective stoma reversal have a higher incidence of postoperative C difficile infection compared with patients who undergo an elective colectomy. Given the impact of postoperative C difficile infection, a heightened sense of suspicion should be given to symptomatic patients after stoma reversal. See at Video Abstract at http://links.lww.com/DCR/A553.
Roberts, Kurt E; Bell, Robert L; Duffy, Andrew J
Surgical training is changing: one hundred years of tradition is being challenged by legal and ethical concerns for patient safety, work hours restrictions, the cost of operating room time, and complications. Surgical simulation and skills training offers an opportunity to teach and practice advanced skills outside of the operating room environment before attempting them on living patients. Simulation training can be as straight forward as using real instruments and video equipment to manipulate simulated “tissue” in a box trainer. More advanced, virtual reality simulators are now available and ready for widespread use. Early systems have demonstrated their effectiveness and discriminative ability. Newer systems enable the development of comprehensive curricula and full procedural simulations. The Accreditation Council of Graduate Medical Education’s (ACGME) has mandated the development of novel methods of training and evaluation. Surgical organizations are calling for methods to ensure the maintenance of skills, advance surgical training, and to credential surgeons as technically competent. Simulators in their current form have been demonstrated to improve the operating room performance of surgical residents. Development of standardized training curricula remains an urgent and important agenda, particularly for minimal invasive surgery. An innovative and progressive approach, borrowing experiences from the field of aviation, can provide the foundation for the next century of surgical training, ensuring the quality of the product. As the technology develops, the way we practice will continue to evolve, to the benefit of physicians and patients. PMID:16718842
Han, So-Eun; Ryoo, Suk-Tae; Lim, So Young; Pyon, Jai-Kyung; Bang, Sa-Ik; Oh, Kap-Sung; Mun, Goo-Hyun
The current trend in minimally invasive surgery is to make a small surgical incision. However, the excessive tensile stress applied by the retractors to the skin surrounding the incision often results in a long wound healing time and extensive scarring. To minimize these types of wound problems, the authors evaluated a simple and cost-effective method to minimize surgical incision scars based on the use of a latex surgical glove. The tunnel-shaped part of a powder-free latex surgical glove was applied to the incision and the dissection plane. It was fixed to the full layer of the dissection plane with sutures. The glove on the skin surface then was sealed with Ioban (3 M Health Care, St. Paul, MN, USA) to prevent movement. The operation proceeded as usual, with the retractor running through the tunnel of the latex glove. It was possible to complete the operation without any disturbance of the visual field by the surgical glove, and the glove was neither torn nor separated by the retractors. The retractors caused traction and friction during the operation, but the extent of damage to the postoperative skin incision margin was remarkably less than when the operation was performed without a glove. This simple and cost-effective method is based on the use of a latex surgical glove to protect the surgical skin incision site and improve the appearance of the postoperative scar. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Full Text Available Abstract Background The aim of this study was to confirm recent results from a previous study focussing on the development of a method to measure the bacterial translocation through puncture holes in surgical gloves under real surgical conditions. Methods An established method was applied to detect bacterial migration from the operating site through the punctured glove. Biogel™ double-gloving surgical gloves were used during visceral surgeries over a 6-month period. A modified Gaschen-bag method was used to retrieve organisms from the inner glove, and thus-obtained bacteria were compared with micro-organisms detected by an intra-operative swab. Results In 20 consecutive procedures, 194 gloves (98 outer gloves, 96 inner gloves were examined. The rate of micro-perforations of the outer surgical glove was 10% with a median wearing time of 100 minutes (range: 20-175 minutes. Perforations occurred in 81% on the non-dominant hand, with the index finger most frequently (25% punctured. In six cases, bacterial migration could be demonstrated microbiologically. In 5% (5/98 of outer gloves and in 1% (1/96 of the inner gloves, bacterial migration through micro-perforations was observed. For gloves with detected micro-perforations (n = 10 outer layers, the calculated migration was 50% (n = 5. The minimum wearing time was 62 minutes, with a calculated median wearing time of 71 minutes. Conclusions This study confirms previous results that bacterial migration through unnoticed micro-perforations in surgical gloves does occur under real practical surgical conditions. Undetected perforation of surgical gloves occurs frequently. Bacterial migration from the patient through micro-perforations on the hand of surgeons was confirmed, limiting the protective barrier function of gloves if worn over longer periods.
Ajao, Oluwole Gbolagunte; Alao, Adekola
In 1904, William Halsted introduced the present model of surgical residency program which has been adopted worldwide. In some developing countries, where surgical residency training programs are new, some colleges have introduced innovations to the Halsted's original concept of surgical residency training. These include 1) primary examination, 2) rural surgical posting, and 3) submission of dissertation for final certification. Our information was gathered from the publications on West African College of Surgeons' (WACS) curriculum of the medical schools, faculty papers of medical schools, and findings from committees of medical schools. Verbal information was also gathered via interviews from members of the WACS. Additionally, our personal experience as members and examiners of the college are included herein. We then noted the differences between surgical residency training programs in the developed countries and that of developing countries. The innovations introduced into the residency training programs in the developing countries are mainly due to the emphasis placed on paper qualifications and degrees instead of performance. We conclude that the innovations introduced into surgical residency training programs in developing countries are the result of the misconception of what surgical residency training programs entail. Published by Elsevier Inc.
Gan, Qi; Shao, Pengfei; Wang, Dong; Ye, Jian; Zhang, Zeshu; Wang, Xinrui; Xu, Ronald
Near infrared (NIR) fluorescence imaging technique can provide precise and real-time information about tumor location during a cancer resection surgery. However, many intraoperative fluorescence imaging systems are based on wearable devices or stand-alone displays, leading to distraction of the surgeons and suboptimal outcome. To overcome these limitations, we design a projective fluorescence imaging system for surgical navigation. The system consists of a LED excitation light source, a monochromatic CCD camera, a host computer, a mini projector and a CMOS camera. A software program is written by C++ to call OpenCV functions for calibrating and correcting fluorescence images captured by the CCD camera upon excitation illumination of the LED source. The images are projected back to the surgical field by the mini projector. Imaging performance of this projective navigation system is characterized in a tumor simulating phantom. Image-guided surgical resection is demonstrated in an ex-vivo chicken tissue model. In all the experiments, the projected images by the projector match well with the locations of fluorescence emission. Our experimental results indicate that the proposed projective navigation system can be a powerful tool for pre-operative surgical planning, intraoperative surgical guidance, and postoperative assessment of surgical outcome. We have integrated the optoelectronic elements into a compact and miniaturized system in preparation for further clinical validation.
Full Text Available Craniopharyngiomas are biologically benign lesions (WHO Grade 1 of the sellar and suprasellar region, associated with a serious morbidity. About 50% of these tumors become clinically apparent during childhood. Clinical symptoms include headaches, chiasm syndrome, hydrocephalus, pituitary insufficiencies, and obesity. Growth arrest is a typical symptom in children. The treatment of craniopharyngiomas includes surgery as well as radiotherapy. The goal of surgery varies according to the tumor location and extension and may range from complete resection to biopsy. Surgical complications are well known and cause constant evaluation of surgical strategies. Diencephalic obesity is related to surgical manipulation of hypothalamic tissue. Therefore, a classification system for craniopharyngiomas based on preoperative MRI is suggested by the authors, which may help assess the surgical risk. Recurrences are frequent in craniopharyngiomas, even after complete or gross-total resection. Radiotherapy is therefore recommended to patients with incomplete resections. However, the ideal time for radiotherapy after surgery is under discussion.The treatment of craniopharyngiomas requires an interdisciplinary and multimodal approach. Each patient should receive an individually tailored treatment. Surgically, different approaches as well as different degrees of resection can be considered, depending on tumor location and tumor extension.
Lee, Jae Hyun; Lim, Soo Yeon; Lee, Jang Hyun; Ahn, Hee Chang
Localized scleroderma is characterized by a thickening of the skin from excessive collagen deposits. It is not a fatal disease, but quality of life can be adversely affected due to changes in skin appearance, joint contractures, and, rarely, serious deformities of the face and extremities. We present six cases of localized scleroderma in face from our surgical practice. We reviewed six localized scleroderma cases that were initially treated with medication and then received follow-up surgery between April 2003 and February 2015. Six patients had facial lesions. These cases presented with linear dermal sclerosis on the forehead, oval subcutaneous and dermal depression in the cheek. En coup de sabre (n=4), and oval-shaped lesion of the face (n=2) were successfully treated. Surgical methods included resection with or without Z-plasty (n=3), fat graft (n=1), dermofat graft (n=1), and adipofascial free flap (n=1). Deformities of the affected parts were surgically corrected without reoccurrence. We retrospectively reviewed six cases of localized scleroderma that were successfully treated with surgery. And we propose an algorithm for selecting the best surgical approach for individual localized scleroderma cases. Although our cases were limited in number and long-term follow-up will be necessary, we suggest that surgical management should be considered as an option for treating scleroderma patients.
Cevidanes, Lucia H C; Tucker, Scott; Styner, Martin; Kim, Hyungmin; Chapuis, Jonas; Reyes, Mauricio; Proffit, William; Turvey, Timothy; Jaskolka, Michael
In this article, we discuss the development of methods for computer-aided jaw surgery, which allows us to incorporate the high level of precision necessary for transferring virtual plans into the operating room. We also present a complete computer-aided surgery system developed in close collaboration with surgeons. Surgery planning and simulation include construction of 3-dimensional surface models from cone-beam computed tomography, dynamic cephalometry, semiautomatic mirroring, interactive cutting of bone, and bony segment repositioning. A virtual setup can be used to manufacture positioning splints for intraoperative guidance. The system provides further intraoperative assistance with a computer display showing jaw positions and 3-dimensional positioning guides updated in real time during the surgical procedure. The computer-aided surgery system aids in dealing with complex cases with benefits for the patient, with surgical practice, and for orthodontic finishing. Advanced software tools for diagnosis and treatment planning allow preparation of detailed operative plans, osteotomy repositioning, bone reconstructions, surgical resident training, and assessing the difficulties of the surgical procedures before the surgery. Computer-aided surgery can make the elaboration of the surgical plan a more flexible process, increase the level of detail and accuracy of the plan, yield higher operative precision and control, and enhance documentation of cases. 2010 American Association of Orthodontists. Published by Mosby, Inc. All rights reserved.
Lee, David Y; Flaherty, Devin C; Lau, Briana J; Deutsch, Gary B; Kirchoff, Daniel D; Huynh, Kelly T; Lee, Ji-Hey; Faries, Mark B; Bilchik, Anton J
With the first qualifying examination administered September 15, 2014, complex general surgical oncology (CGSO) is now a board-certified specialty. We aimed to assess the attitudes and perceptions of current and future surgical oncology fellows regarding the recently instituted Accreditation Council for Graduate Medical Education (ACGME) accreditation. A 29-question anonymous survey was distributed to fellows in surgical oncology fellowship programs and applicants interviewing at our fellowship program. There were 110 responses (79 fellows and 31 candidates). The response rate for the first- and second-year fellows was 66 %. Ninety-percent of the respondents were aware that completing an ACGME-accredited fellowship leads to board eligibility in CGSO. However, the majority (80 %) of the respondents stated that their decision to specialize in surgical oncology was not influenced by the ACGME accreditation. The fellows in training were concerned about the cost of the exam (90 %) and expressed anxiety in preparing for another board exam (83 %). However, the majority of the respondents believed that CGSO board certification will be helpful (79 %) in obtaining their future career goals. Interestingly, candidate fellows appeared more focused on a career in general complex surgical oncology (p = 0.004), highlighting the impact that fellowship training may have on organ-specific subspecialization. The majority of the surveyed surgical oncology fellows and candidates believe that obtaining board certification in CGSO is important and will help them pursue their career goals. However, the decision to specialize in surgical oncology does not appear to be motivated by ACGME accreditation or the new board certification.
Cho, Vincent; Chan, Alpha
The influence of electronic word of mouth (eWOM) has been heavily investigated in relation to online ratings. However, only a few studies examined the content of eWOM. From the perspective of the consideration sets model, consumers formulate an awareness set, a consideration set and a choice set before making a purchase. We argue that the formulation of these sets is influenced by eWOM based on its volume, valance and content relating to product attributes such as value for money, product sophistication and experiential feeling. In this study, the content of posts relating to Shure professional earphones in the online forum Mingo (www.mingo-hmw.com/forum) was captured and annotated. During the data collection period, Mingo was the sole online forum relating to professional earphones. Without much interference from other online forums, the circumstances of this study closely approximate a laboratory setting. In addition, we collected the actual sales, marketing costs, fault rates and number of retail stores selling the Shure professional earphones for 126 weeks. Our findings show that the weekly volume of posts, their relative number of positive (negative) comments, especially regarding value for money and sound quality, and those posts from the earlier week impinged strongly on weekly sales of Shure products. From the regression models, the explained variance in sales jumps from 0.236 to 0.732 due to the influence of eWOM.
Mathematical models of gas dispersion have evolved drastically since the 1930's. For a long time, the most widely used approach was the so-called Gaussian model as described in practical terms by Turner or box models which have shown relative merits. In the field of heavy gas dispersion, the use of such approaches appeared somewhat limited and therefore new models have been proposed. Some of these new generation models were making use of the latest progress in turbulence modelling as derived from laboratory work as well as numerical advances. The advent of faster and larger computers made possible the development of three dimensional codes that were computing both flow field and gas dispersion taking into account details of the ground obstacles, heat exchange and possibly phase changes as well. The description of these new types of models makes them appear as a considerable improvement over the simpler approaches. However, recent comparisons between many of these have led to the conclusion that the scatter between predictions attained with sophisticated models was just as large as with other ones. It seems therefore, that current researchers might have fallen into the trap of confusing mathematical precision with accuracy. It is therefore felt necessary to enlighten this question by an investigation which, rather than comparing individual models, would analyse the key features of both approaches and put in evidence their relative merits and degree of realism when being really applied
Pillarisetti, S G
Since it is believed that "a picture is worth a thousand words," incorporation of computer-generated line art was used as a adjunct to gross description in surgical pathology reporting in selected cases. The lack of an integrated software program was overcome by using commercially available graphic and word processing software. A library of drawings was developed over the last few years. Most time-consuming is the development of templates and the graphic library. With some effort it is possible to integrate graphics of high quality into surgical pathology reports.
of postoperative pulmonary function and less hypoxemia with endoscopic operation. The slight modification of surgical stress responses by endoscopic surgery is in contrast to the common, though not universal, demonstration of less pain, shorter hospital stay, and less morbidity after endoscopic surgery...... operations where differences are more likely to be found. The clinical consequences of these findings in relation to all over surgical outcome remain to be defined, but effective pain treatment, stress reduction by other techniques, and provision of an active rehabilitation program with early mobilization...
Full Text Available Chronic pancreatitis is a progressive inflammatory disease resulting in permanent structural damage of the pancreas. It is mainly characterized by recurring epigastric pain and pancreatic insufficiency. In addition, progression of the disease might lead to additional complications, such as pseudocyst formation or development of pancreatic cancer. The medical and surgical treatment of chronic pancreatitis has changed significantly in the past decades. With regard to surgical management, pancreatic head resection has been shown to be a mainstay in the treatment of severe chronic pancreatitis because the pancreatic head mass is known to trigger the chronic inflammatory process. Over the years, organ-preserving procedures, such as the duodenum-preserving pancreatic head resection and the pylorus-preserving Whipple, have become the surgical standard and have led to major improvements in pain relief, preservation of pancreatic function, and quality of life of patients.
Sade, Robert M; Kavarana, Minoo N
Ethical behavior has always been deeply ingrained in surgical culture, but ethical deliberation has only recently become an important component of cardiac surgical practice. In our earlier review, we covered a range of issues including several related to informed consent, conflict of interest, professional self-regulation and innovation, among many others. This update covers several topics of interest to cardiac surgeons and cardiologists, focusing on controversial issues specific to the practice of cardiothoracic surgery: informed consent, relations with hospitals and euthanasia and physician-assisted suicide. The future holds much uncertainty for cardiac surgical practice, research and culture, and we provide an update on ethical issues to serve as a platform for envisioning what is to come.
Rutkow, I M; Imbembo, A L; Zuidema, G D
The application and interviewing procedure for surgical house officership is an important process to both the medical student and the clinical department. Up-to-date, informative, and honest appraisals of the training programs under evaluation must be obtained. A survey was undertaken to compare and contrast students' and surgical department members' perceptions of nationwide surgical residency application procedures. It is concluded from this sampling that the majority of medical students applying to university-sponsored surgical training programs and the training institutions themselves generally are satisfied with the present application and interviewing experience. Certain areas in need of reform were elucidated, and the following recommendations are offered to aid in the development of a more effective process: (1) if possible, the descriptive information brochure should be updated on a yearly basis and must be comprehensive in scope; (2) when "en masse" interviewing is conducted, it should be held on a number of dates during the year, not just one, and a limited time for "walk-in" interviews should be allowed; (3) an opportunity should be available for the spouse or fiance'(e) to accompany the applicant; (4) an interviewer should prepare for an interview by having read the applicant's file beforehand; and (5) the interviewing schedule should be arranged so that the applicant is able to meet either the department chairperson and/or program director.
M.J. Koudstaal (Maarten)
textabstractThe scope of this thesis is to shed more light, from a number of perspectives, on surgically assisted rapid maxillary expansion (SARME). The primary questions this thesis set out to answer were; ‘is there a difference in stability between bone-borne and tooth-borne distraction?’ and ‘can
Langebæk, Rikke; Eika, Berit; Pedersen, Lene Tanggaard
A surgical educational environment is potentially stressful and can negatively affect students' learning. The aim of the present study was to investigate the emotions experienced by veterinary students in relation to their first encounter with live-animal surgery and to identify possible sources...... of positive and negative emotions, respectively. During a Basic Surgical Skills course, 155 veterinary fourth-year students completed a survey. Of these, 26 students additionally participated in individual semi-structured interviews. The results of the study show that students often experienced a combination...
Schiavon, S.; Trenaghi, P.; Nardini, S.; Pagan, V.
A review was made of the chest X-ray features of 120 patients who underwent surgical treatment for mediastinal non-vascular pathologies over the past 12 years in the Mestre Hospital. A method of analysis is proposed which takes into account not only the differences between the immediate post-operative period and the follow-up, but also the anatomotopographic partition and the surgical practice. Normal and pathological patterns for both of the above periods are described. The ''dimness'' of the arial tracheogram is emphasized as a usefull and early sign of mediastinal recurrence
van Melle, Joost P; Wolff, Djoeke; Hörer, Jürgen
by the European Congenital Heart Surgeons Association among 22 member centres. Outcome of surgery to address failing Fontan was collected in 225 patients among which were patients with Fontan takedown (n=38; 17%), Fontan conversion (n=137; 61%) or HTX (n=50; 22%). RESULTS: The most prevalent indication...... for failing Fontan surgery was arrhythmia (43.6%), but indications differed across the surgical groups (p...OBJECTIVE: The objective of this European multicenter study was to report surgical outcomes of Fontan takedown, Fontan conversion and heart transplantation (HTX) for failing Fontan patients in terms of all-cause mortality and (re-)HTX. METHODS: A retrospective international study was conducted...
Clifton, Matthew S; Wulkan, Mark L
Pediatric surgical training in the United States remained basically unchanged from the model developed by Ladd and Gross in the 1930s until recently. Standardized curriculum and novel evaluation methods are now being implemented. Pediatric Surgical education is currently undergoing a transition to competency-based evaluation and promotion. Unfortunately, there is little data on the efficacy of these changes. This presents an opportunity for further study of how we conduct training, and how we evaluate and promote our trainees. Copyright © 2015 Elsevier Inc. All rights reserved.
Peshkepija, Andi N; Basson, Marc D; Davis, Alan T; Ali, Muhammad; Haan, Pam S; Gupta, Rama N; Hardaway, John C; Nebeker, Cody A; McLeod, Michael K; Osmer, Robert L; Anderson, Cheryl I
We studied prevalence and predictors of meaningful self-reflection among surgical residents and with prompting/structured interventions, sought to improve/sustain resident skills. Residents from six programs recorded 1032 narrative self-reflective comments (120 residents), using a web-based platform. If residents identified something learned or to be improved, self-reflection was deemed meaningful. Independent variables PGY level, resident/surgeon gender, study site/Phase1: July2014-August2015 vs. Phase2: September2015-September2016) were analyzed. Meaningful self-reflection was documented in 40.6% (419/1032) of entries. PGY5's meaningfully self-reflected less than PGY1-4's, 26.1% vs. 49.6% (p = 0.002). In multivariate analysis, resident narratives during Phase 2 were 4.7 times more likely to engage in meaningful self-reflection compared to Phase1 entries (p self-reflection, compared to Phase1. Surgical residents uncommonly practice meaningful self-reflection, even when prompted, and PGY5/chief residents reflect less than more junior residents. Substantial/sustained improvements in resident self-reflection can occur with both training and interventions. Copyright © 2017 Elsevier Inc. All rights reserved.
Pluchino, F; Broggi, G; Fornari, M; Franzini, A; Solero, C L; Allegranza, A
During a period of 10 years (1977-1986) 40 cases of tumour of the pineal region have been treated at the Istituto Neurologico "C. Besta"-of Milan. Out of these 40 cases, 27 (67.5%) were in the paediatric (10-15 years) or juvenile (15-20 years) age at the time of operation. Since 1983 a specific diagnostic and therapeutic protocol has been adopted and thereafter direct surgical removal of the tumour was performed only when the neuroradiological investigations were highly suggestive of a benign extrinsic lesion. Sixteen cases in this series underwent direct surgical removal; in the remaining 24 cases stereotactic biopsy of the tumour was performed in the first instance. On the basis of the histological diagnosis obtained by this procedure surgical excision of the tumour (9 cases) or radiotherapy (15 cases) was then performed. 25 cases underwent surgical removal of the lesion. In all the cases the infratentorial supracerebellar approach as introduced by Krause and then modified by Stein was adopted. On analysis of the data of this series it was observed that in 25% of the cases completely benign resectable tumours were found; in 25% of the cases astrocytoma (grade I-II) which could be treated at least by partial removal were present; in 30% of the cases radiosensitive lesions were encountered. In the remaining 20% of the cases highly malignant tumours were found which should be treated only by radiotherapy and/or chemotherapy.
Leersum, N.J. van; Snijders, H.S.; Henneman, D.; Kolfschoten, N.E.; Gooiker, G.A.; Berge, M.G. Ten; Eddes, E.H.; Wouters, M.W.; Tollenaar, R.A.E.M.; Bemelman, W.A.; Dam, R.M. van; Elferink, M.A.; Karsten, T.M.; Krieken, J.H. van; Lemmens, V.E.; Rutten, H.J.; Manusama, E.R.; Velde, C.J. van de; Meijerink, W.J.H.J.; Wiggers, T.; Harst, E. van der; Dekker, J.W.T.; Boerma, D.
INTRODUCTION: In 2009, the nationwide Dutch Surgical Colorectal Audit (DSCA) was initiated by the Association of Surgeons of the Netherlands (ASN) to monitor, evaluate and improve colorectal cancer care. The DSCA is currently widely used as a blueprint for the initiation of other audits, coordinated
Lipszyc, E; Pfister, C; Liard, A; Mitrofanoff, P
The buried penis is a rare congenital entity, whose treatment is surgical. There are few publications concerning this matter. The authors report on their experience in 10 cases (1990-1995). In this abnormality, the tip of the glans does not project from the pubic or scrotal skin. It is due to: 1) an excessive development of the penile fascia which retracts the penis; 2) insufficient attachment of the penile skin at the base of the penis; 3) often excessive prepubic fat worsens the appearance of the abnormality but does not by itself totally explain it; 4) a tight phimosis is often present. Surgical treatment is necessary because this aspect tends to persist even after puberty. One cannot indeed count on the development at the age of puberty, neither on the diminution of the fat, nor on the simple cure of the phimosis. One must above all ban circumcision which causes the risk of eliminating the skin necessary for reconstruction. The surgical procedure will comprise: 1) a longitudinal dorsal incision extended circumferentially; 2) resection of the thickened fascia penis; 3) anchoring of the deep face of the dermis to the proximal part of the fascia penis at the base of the penis. This surgical procedure has always brought a significant improvement to the appearance of the penis.
The work presented in this thesis first addresses the magnitude of the clinical problem of surgically treated tubal pregnancy in The Netherlands. Next, we studied the adherence to recommendations from the Dutch guideline on diagnosis and management of ectopic pregnancy. A systematic review and
van Leersum, N. J.; Snijders, H. S.; Henneman, D.; Kolfschoten, N. E.; Gooiker, G. A.; ten Berge, M. G.; Eddes, E. H.; Wouters, M. W. J. M.; Tollenaar, R. A. E. M.; Bemelman, W. A.; van Dam, R. M.; Elferink, M. A.; Karsten, Th M.; van Krieken, J. H. J. M.; Lemmens, V. E. P. P.; Rutten, H. J. T.; Manusama, E. R.; van de Velde, C. J. H.; Meijerink, W. J. H. J.; Wiggers, Th; van der Harst, E.; Dekker, J. W. T.; Boerma, D.
In 2009, the nationwide Dutch Surgical Colorectal Audit (DSCA) was initiated by the Association of Surgeons of the Netherlands (ASN) to monitor, evaluate and improve colorectal cancer care. The DSCA is currently widely used as a blueprint for the initiation of other audits, coordinated by the Dutch
Alp, E.; Bijl, D.; Bleichrodt, R.P.; Hansson, B.M.; Voss, A.
Gaseous byproducts produced during electrocautery, laser surgery or the use of ultrasonic scalpels are usually referred to as 'surgical smoke'. This smoke, produced with or without a heating process, contains bio-aerosols with viable and non-viable cellular material that subsequently poses a risk of
Borel-Rinkes, Inne H. M.; Gouma, Dirk J.; Hamming, Jaap F.
Surgical training in the Netherlands has traditionally been characterized by learning on the job under the classic master-trainee doctrine. Over the past decades, it has become regionally organized with intensive structural training courses, and a peer-based quality control system. Recently, the
Lee, Sung Ryul; Koo, Bum Hwan; Byun, Geon Young; Lee, Seung Geun; Kim, Myoung Jin; Hong, Soo Kyung; Kim, Su Yeon; Lee, Yu Jin
The Internet is used worldwide, but its effect on hospital selection of minor surgical disease has not hitherto been thoroughly studied. To investigate the effect of the Internet dissemination on hospital selection of minor surgical disease and information affecting selection, we conducted a survey of patients who underwent laparoscopic surgery from January 2016 to April 2017. We analyzed the questionnaire responses of 1916 patients. Over 80% of patients in all groups selected the hospital based on Internet information. Among patients aged over 60 years, 65.1% selected the hospital based on Internet information. With regard to hospital selection factors, the highest number of responses was for sophisticated surgical treatment (93.1%). The second highest was for a simplified medical care system (33.0%); third was a comprehensive nursing care system (18.1%). Among responses about surgical treatment, the most were obtained for short operation time and fewer hospitalization days (81.5%). Copyright © 2018 John Wiley & Sons, Ltd.
Hedley-Whyte, John; Milamed, Debra R
The planning for surgery in war was revisited in 1937 when Ian Fraser was elected a member of the Surgical Travellers. At their 1938 Surgical Travellers meeting in Vienna, Ian and Eleanor Fraser were evicted from their hotel room by the Nazis. The 1939 meeting in Belfast discussed the organization of surgery and the conduct of Emergency Medical Service Hospitals in the United Kingdom; the vast majority were to be under civilian government and military control. From 1943 lengthy and informative organizational meetings were held at least monthly under the chairmanship of Sir Alexander Hood, KBE, Head of the RAMC. Surgical Consultants, now Major Generals, Brigadiers or Full Colonels in the British and U.S. Armies stationed in the UK, prepared for the invasion of Europe. The allocation of medical, surgical, nursing and auxiliary responsibilities was delineated. Liaison with the RAF and US Army Air Force was close as it was with the proposed leaders, Ulstermen Brooke and Montgomery. Montgomery chose Arthur Porritt as Surgeon in Chief to Supreme Headquarters Allied Expeditionary Force (SHAEF), and Eisenhower, General Albert W. Kenner. Just after D-Day, Porritt met Ian Fraser, who had waded in on Arromanches Beach. The triage and evacuation plans for Allied casualties had been controversial, particularly as regards Landing Ship Tanks (LSTs). The dispute with the Hood-selected surgeons on one side, against medical and surgical deployment of LSTs, and Admiral Ernest King and Winston Churchill on the other, favouring LST use for surgery and evacuation. King and Churchill were correct but total Allied air superiority allowed wide use of many of the Allies' Dakotas; 10,000 DC-3s were eventually in service. Supported by forty Allied combat planes to each Luftwaffe, the dispute about Landing Ship Tank use in about a fortnight became moot. The multifaceted role of the Princess Royal in the Emergency Medical Services of the United Kingdom and her close liaison with the Consultant
Ota, D; Loftin, B; Saito, T; Lea, R; Keller, J
Virtual reality (VR) is an emerging technology that can teach surgeons new procedures and can determine their level of competence before they operate on patients. Also VR allows the trainee to return to the same procedure or task several times later as a refresher course. Laparoscopic surgery is a new operative technique which requires the surgeon to observe the operation on a video-monitor and requires the acquisition of new skills. VR simulation could duplicate the operative field and thereby enhance training and reduce the need for expensive animal training models. Our preliminary experience has shown that we have the technology to model tissues and laparoscopic instruments and to develop in real time a VR learning environment for surgeons. Another basic need is to measure competence. Surgical training is an apprenticeship requiring close supervision and 5-7 years of training. Technical competence is judged by the mentor and has always been subjective. If VR surgical simulators are to play an important role in the future, quantitative measurement of competence would have to be part of the system. Because surgical competence is "vague" and is characterized by such terms as "too long, too short" or "too close, too far," it is possible that the principles of fuzzy logic could be used to measure competence in a VR surgical simulator. Because a surgical procedure consists of a series of tasks and each task is a series of steps, we will plan to create two important tasks in a VR simulator and validate their use. These tasks consist of laparoscopic knot tying and laparoscopic suturing. Our hypothesis is that VR in combination with fuzzy logic can educate surgeons and determine when they are competent to perform these procedures on patients.
Kotsis, Sandra V; Chung, Kevin C
The traditional method of teaching in surgery is known as "see one, do one, teach one." However, many have argued that this method is no longer applicable, mainly because of concerns for patient safety. The purpose of this article is to show that the basis of the traditional teaching method is still valid in surgical training if it is combined with various adult learning principles. The authors reviewed literature regarding the history of the formation of the surgical residency program, adult learning principles, mentoring, and medical simulation. The authors provide examples for how these learning techniques can be incorporated into a surgical resident training program. The surgical residency program created by Dr. William Halsted remained virtually unchanged until recently with reductions in resident work hours and changes to a competency-based training system. Such changes have reduced the teaching time between attending physicians and residents. Learning principles such as experience, observation, thinking, and action and deliberate practice can be used to train residents. Mentoring is also an important aspect in teaching surgical technique. The authors review the different types of simulators-standardized patients, virtual reality applications, and high-fidelity mannequin simulators-and the advantages and disadvantages of using them. The traditional teaching method of "see one, do one, teach one" in surgical residency programs is simple but still applicable. It needs to evolve with current changes in the medical system to adequately train surgical residents and also provide patients with safe, evidence-based care.
Kolontarev, K B; Govorov, A V; Rasner, P I; Sheptunov, S A; Prilepskaya, E A; Maltsev, E G; Pushkar, D Yu
Since the first use of robotic surgical system in 2000, the robot-assisted technology has gained wide popularity throughout the world. Robot-assisted surgical training is a complex issue that requires significant efforts from students and teacher. During the last two decades, simulation-based training had received active development due to wide-spread occurrence and popularization of laparoscopic and robot-assisted surgical techniques. We performed a systematic review to identify the currently available simulators for robot-assisted surgery. We searched the Medline and Pubmed, English sources of literature data, using the following key words and phrases: "robotics", "robotic surgery", "computer assisted surgery", "simulation", "computer simulation", "virtual reality", "surgical training", and "surgical education". There were identified 565 publications, which meet the key words and phrases; 19 publications were selected for the final analysis. It was established that simulation-based training is the most promising teaching tool that can be used in the training of the next generation robotic surgeons. Today the use of simulators to train surgeons is validated. Price of devices is an obvious barrier for inclusion in the program for training of robotic surgeons, but the lack of this tool will result in a sharp increase in the duration of specialists training.
Ovaere, Sander; Zimmerman, David D E; Brady, Richard R
Surgeon engagement with social media is growing rapidly. Innovative applications in diverse fields of health care are increasingly available. The aim of this review is to explore the current and future applications of social media in surgical training. In addition, risks and barriers of social media engagement are analyzed, and recommendations for professional social media use amongst trainers and trainees are suggested. The published, peer-reviewed literature on social media in medicine, surgery and surgical training was reviewed. MESH terms including "social media", "education", "surgical training" and "web applications" were used. Different social media surgical applications are already widely available but limited in use in the trainee's curriculum. E-learning modalities, podcasts, live surgery platforms and microblogs are used for teaching purposes. Social media enables global research collaboratives and can play a role in patient recruitment for clinical trials. The growing importance of networking is emphasized by the increased use of LinkedIn, Facebook, Sermo and other networking platforms. Risks of social media use, such as lack of peer review and the lack of source confirmation, must be considered. Governing surgeon's and trainee's associations should consider adopting and sharing their guidelines for standards of social media use. Surgical training is changing rapidly and as such, social media presents tremendous opportunities for teaching, training, research and networking. Awareness must be raised on the risks of social media use. Copyright © 2018 Association of Program Directors in Surgery. All rights reserved.
Matthews, Alexander H; Abdelrahman, Tarig; Powell, Arfon G M T; Lewis, Wyn G
Bibliometric analysis highlights the key topics and publications, which have shaped surgical education. Here, the 100 most cited articles in the arena of surgical education were analyzed. Thomson Reuters Web of Science was interrogated using the keyword search terms "surgery" and ("learning" or "skills" or "competence" or "assessment" or "training" or "procedure-based assessments" or "performance" or "technical skills" or "curriculum" or "education" or "mentoring"] to identify all English language full articles, and the 100 most cited articles were analyzed by topic, journal, author, year, institution, and country of origin. A total of 403,733 eligible articles were returned and the median citation number was 164 (range: 107-1018). The most cited article (by Seymour, Yale University School of Medicine, Annals of Surgery, 1018 citations) focused on the use of virtual reality surgical simulation training. Annals of Surgery published the highest number of articles and received the most citations (n = 16, 3715 citations). The countries with the greatest number of publications were the USA (n = 45), Canada (n = 19), and the UK (n = 18). The commonest topics included simulation (n = 45) and assessment of clinical competence (n = 40). Surgical skill acquisition and assessment was the area of focus of 85% of the most cited contemporary articles, and this study provides the most cited references, serving as a guide as to what makes a citable published work in the field of surgical education. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Cardenas-Camarena, Lazaro; Dorado, Carlos; Guerrero, Maria Teresa; Nava, Rosa
Aesthetic breast area improvements for gynecomastia and gender dysphoria patients who seek a more masculine appearance have increased recently. We present our clinical experience in breast masculinization and a classification for these patients. From July 2003 to May 2014, 68 patients seeking a more masculine thorax underwent surgery. They were divided into five groups depending on three factors: excess fatty tissue, breast tissue, and skin. A specific surgical treatment was assigned according to each group. The surgical treatments included thoracic liposuction, subcutaneous mastectomy, periareolar skin resection in one or two stages, and mastectomy with a nipple areola complex graft. The evaluation was performed 6 months after surgery to determine the degree of satisfaction and presence of complications. Surgery was performed on a total of 68 patients, 45 male and 22 female, with ages ranging from 18 to 49 years, and an average age of 33 years. Liposuction alone was performed on five patients; subcutaneous mastectomy was performed on eight patients; subcutaneous mastectomy combined with liposuction was performed on 27 patients; periareolar skin resection was performed on 11 patients; and mastectomy with NAC free grafts was performed on 16 patients. The surgical procedure satisfied 94% of the patients, with very few complications. All patients who wish to obtain a masculine breast shape should be treated with only one objective regardless patient's gender: to obtain a masculine thorax. We recommend a simple mammary gland classification for determining the best surgical treatment for these patients LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Carl van Walraven
Full Text Available Surgical site infections (SSI are an important cause of peri-surgical morbidity with risks that vary extensively between patients and surgeries. Quantifying SSI risk would help identify candidates most likely to benefit from interventions to decrease the risk of SSI.We randomly divided all surgeries recorded in the National Surgical Quality Improvement Program from 2010 into a derivation and validation population. We used multivariate logistic regression to determine the independent association of patient and surgical covariates with the risk of any SSI (including superficial, deep, and organ space SSI within 30 days of surgery. To capture factors particular to specific surgeries, we developed a surgical risk score specific to all surgeries having a common first 3 numbers of their CPT code.Derivation (n = 181 894 and validation (n = 181 146 patients were similar for all demographics, past medical history, and surgical factors. Overall SSI risk was 3.9%. The SSI Risk Score (SSIRS found that risk increased with patient factors (smoking, increased body mass index, certain comorbidities (peripheral vascular disease, metastatic cancer, chronic steroid use, recent sepsis, and operative characteristics (surgical urgency; increased ASA class; longer operation duration; infected wounds; general anaesthesia; performance of more than one procedure; and CPT score. In the validation population, the SSIRS had good discrimination (c-statistic 0.800, 95% CI 0.795-0.805 and calibration.SSIRS can be calculated using patient and surgery information to estimate individual risk of SSI for a broad range of surgery types.
Hinze, R.; Jeuring, J.T.; Löh, A.
The last decade has seen a number of approaches to generic programming: PolyP, Functorial ML, `Scrap Your Boilerplate', Generic Haskell, `Generics for the Masses', etc. The approaches vary in sophistication and target audience: some propose full-blown pro- gramming languages, some suggest
Hinze, R.; Jeuring, J.T.; Löh, A.
The last decade has seen a number of approaches to data- type-generic programming: PolyP, Functorial ML, `Scrap Your Boiler- plate', Generic Haskell, `Generics for the Masses', etc. The approaches vary in sophistication and target audience: some propose full-blown pro- gramming languages, some
Bal, H.E.; Steiner, J.G.; Tanenbaum, A.S.
When distributed systems first appeared, they were programmed in traditional sequential languages, usually with the addition of a few library procedures for sending and receiving messages. As distributed applications became more commonplace and more sophisticated, this ad hoc approach became less
Oyo-Ita, Angela; Chinnock, Paul; Ikpeme, Ikpeme A
Injury to the abdomen can be blunt or penetrating. Abdominal injury can damage internal organs such as the liver, spleen, kidneys, intestine, and large blood vessels. There are controversies about the best approach to manage abdominal injuries. To assess the effects of surgical and non-surgical interventions in the management of abdominal trauma in a haemodynamically stable and non-peritonitic abdomen. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), EMBASE Classic+EMBASE (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), CINAHL Plus (EBSCO), and clinical trials registers, and screened reference lists. We ran the most recent search on 17 September 2015. Randomised controlled trials of surgical interventions and non-surgical interventions involving people with abdominal injury who were haemodynamically stable with no signs of peritonitis. The abdominal injury could be blunt or penetrating. Two review authors independently applied the selection criteria. Data were extracted by two authors using a standard data extraction form, and are reported narratively. Two studies are included, which involved a total of 114 people with penetrating abdominal injuries. Both studies are at moderate risk of bias because the randomisation methods are not fully described, and the original study protocols are no longer available. The studies were undertaken in Finland between 1992 and 2002, by the same two researchers.In one study, 51 people were randomised to surgery or an observation protocol. None of the participants in the study died. Seven people had complications: 5 (18.5%) in the surgical group and 2 (8.3%) in the observation group; the difference was not statistically significant (P = 0.42; Fischer's exact). Among the 27 people who had surgery, 6 (22.2%) surgeries were negative laparotomies, and 15 (55.6%) were non
Besselink, MG; de Bruijn, MT; Rutten, JP; Boermeester, MA; Hofker, HS; Gooszen, HG
Background: This study evaluated the various surgical strategies for treatment of (suspected) infected necrotizing pancreatitis (INP) and patient referrals for this condition in the Netherlands. Methods: This retrospective study included all 106 consecutive patients who had surgical treatment for
Rosenberg, Jacob; Herring, W Joseph; Blobner, Manfred
INTRODUCTION: Sustained deep neuromuscular blockade (NMB) during laparoscopic surgery may facilitate optimal surgical conditions. This exploratory study assessed whether deep NMB improves surgical conditions and, in doing so, allows use of lower insufflation pressures during laparoscopic cholecys...
Gallagher, Anthony G; Ritter, E Matt; Champion, Howard; Higgins, Gerald; Fried, Marvin P; Moses, Gerald; Smith, C Daniel; Satava, Richard M
To inform surgeons about the practical issues to be considered for successful integration of virtual reality simulation into a surgical training program. The learning and practice of minimally invasive surgery (MIS) makes unique demands on surgical training programs. A decade ago Satava proposed virtual reality (VR) surgical simulation as a solution for this problem. Only recently have robust scientific studies supported that vision A review of the surgical education, human-factor, and psychology literature to identify important factors which will impinge on the successful integration of VR training into a surgical training program. VR is more likely to be successful if it is systematically integrated into a well-thought-out education and training program which objectively assesses technical skills improvement proximate to the learning experience. Validated performance metrics should be relevant to the surgical task being trained but in general will require trainees to reach an objectively determined proficiency criterion, based on tightly defined metrics and perform at this level consistently. VR training is more likely to be successful if the training schedule takes place on an interval basis rather than massed into a short period of extensive practice. High-fidelity VR simulations will confer the greatest skills transfer to the in vivo surgical situation, but less expensive VR trainers will also lead to considerably improved skills generalizations. VR for improved performance of MIS is now a reality. However, VR is only a training tool that must be thoughtfully introduced into a surgical training curriculum for it to successfully improve surgical technical skills.
Sepehri, Mitra; Jørgensen, Bo
With a continuing increase in the number of tattoos performed worldwide, the need to treat tattoo complications is growing. Earlier treatments of chronic inflammatory tattoo reactions were dominated by a medical approach, or with no active intervention. In this chapter, we will address modern surgical approaches applied to situations when medical treatment is inefficient and lasers are not applicable. Dermatome shaving is positioned as first-line treatment of allergic tattoo reactions and also indicated in a number of other tattoo reactions, supplemented with excision in selected cases. The methods allow fundamental treatment with removal of the culprit pigment from the dermis. The different instruments, surgical methods, and treatment schedules are reviewed, and a guide to surgeons is presented. Postoperative treatments and the long-term outcomes are described in detail. An algorithm on specialist treatment and follow-up of tattoo reactions, which can be practiced in other countries, is presented. © 2017 S. Karger AG, Basel.
This new edition presents information and knowledge on the field of biomedical devices and surgical tools. The authors look at the interactions between nanotechnology, nanomaterials, design, modeling, and tools for surgical and dental applications, as well as how nanostructured surfaces can be created for the purposes of improving cell adhesion between medical devices and the human body. Each original chapter is revised in this second edition and describes developments in coatings for heart valves, stents, hip and knee joints, cardiovascular devices, orthodontic applications, and regenerative materials such as bone substitutes. There are also 8 new chapters that address: Microvascular anastomoses Inhaler devices used for pulmonary delivery of medical aerosols Surface modification of interference screws Biomechanics of the mandible (a detailed case study) Safety and medical devices The synthesis of nanostructured material Delivery of anticancer molecules using carbon nanotubes Nano and micro coatings for medic...
Portie Felix, Antonio; Navarro Sanchez, Gustavo; Hernandez Solar, Abel; Grass Baldoquin, Jorge Alberto; Domloge Fernandez, Joana
The obesity is the chronic non-communicable disease with a higher rate of growth in past 20 years. It is a risk factor for type 2 diabetes mellitus, high blood pressure, cardiovascular and respiratory affections, infertility, sexual and functional impotence, metabolic syndrome, load joint disorders and some types of cancer (breast, colon, prostate). The metabolic bariatric surgery is the surgical treatment more effective for the morbid obesity at long -and medium- term and not the pharmacologic treatment and the isolated diets. The aim of present historical review of the international literature on the evolution of surgical techniques of the bariatric surgery (malabsorption techniques, gastric restrictive techniques and mixed techniques), is to make available to those interested in this subject, a valuable therapeutic tool to be rationally used. (author)
Kimura, F T; Pavia Noble, A; Soriano Padilla, F; Soto Miranda, A; Medellín Rodríguez, A
This study presents a statistical review of corrective surgery for cleft palate, based on cases treated at the maxillo-facial surgery units of the Pediatrics Hospital of the Centro Médico Nacional and at Centro Médico La Raza of the National Institute of Social Security of Mexico, over a five-year period. Interdisciplinary management as performed at the Cleft-Palate Clinic, in an integrated approach involving specialists in maxillo-facial surgery, maxillar orthopedics, genetics, social work and mental hygiene, pursuing to reestablish the stomatological and psychological functions of children afflicted by cleft palate, is amply described. The frequency and classification of the various techniques practiced in that service are described, as well as surgical statistics for 188 patients, which include a total of 256 palate surgeries performed from March 1984 to March 1989, applying three different techniques and proposing a combination of them in a single surgical time, in order to avoid complementary surgery.
Zamora-Valdes, Daniel; Taner, Timucin; Nagorney, David M.
Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. In select patients, surgical treatment in the form of either resection or transplantation offers a curative option. The aims of this review are to (1) review the current American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines on the surgical management of HCC and (2) review the proposed changes to these guidelines and analyze the strength of evidence underlying these proposals. Three authors identified the most relevant publications in the literature on liver resection and transplantation for HCC and analyzed the strength of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification. In the United States, the liver allocation system provides priority for liver transplantation to patients with HCC within the Milan criteria. Current evidence suggests that liver transplantation may also be indicated in certain patient groups beyond Milan criteria, such as pediatric patients with large tumor burden or adult patients who are successfully downstaged. Patients with no underlying liver disease may also benefit from liver transplantation if the HCC is unresectable. In patients with no or minimal (compensated) liver disease and solitary HCC ≥2 cm, liver resection is warranted. If liver transplantation is not available or contraindicated, liver resection can be offered to patients with multinodular HCC, provided that the underlying liver disease is not decompensated. Many patients may benefit from surgical strategies adapted to local resources and policies (hepatitis B prevalence, organ availability, etc). Although current low-quality evidence shows better overall survival with aggressive surgical strategies, this approach is limited to select patients. Larger and well-designed prospective studies are needed to better define the benefits and limits of such approach. PMID:28975836
Sloth, Christoffer; Wisniewski, Rafael
a controller for motion compensation in beating-heart surgery, and prove that it is safe, i.e., the surgical tool is kept within an allowable distance and orientation of the heart. We solve the problem by simultaneously finding a control law and a barrier function. The motion compensation system is simulated...... from several initial conditions to demonstrate that the designed control system is safe for every admissible initial condition....
Kitka, M.; Masek, M.
Fractures of the ribs is the most common thoracic injury after blunt trauma. Chest wall instability (flail chest) is a common occurrence in the presence of multiple ribs fracture. Unilateral or bilateral fractures more ribs anteriorly or posteriorly will produce enough instability that paradoxical respiratory motion results in hypoventilation of an unacceptable degree. Open approach and surgical stabilisation of the chest preserved pulmonary function, improved pain control, minimized posttraumatic deformities and shorter back to work time. (author)
Loose, D A
Among vascular malformations, the predominantly venous malformations represent the majority of cases. They form a clinical entity and therefore need clear concepts concerning diagnosis and treatment. This paper presents an overview of contemporary classification as well as tactics and techniques of treatment. According to the Hamburg Classification, predominantly venous malformations are categorized into truncular and extratruncular forms, with truncular forms distinguished as obstructions and dilations, and extratruncular forms as limited or infiltrating. The tactics of treatment represent surgical and non-surgical methods or combined techniques. Surgical approaches utilize different tactics and techniques that are adopted based on the pathologic form and type of the malformation: (I) operation to reduce the haemodynamic activity of the malformation; (II) operation to eliminate the malformation; and (III) reconstructive operation. As for (I), a type of a tactic is the operation to derive the venous flow. In (II), the total or partial removal of the venous malformation is demonstrated subdivided into three different techniques. In this way, the infiltrating as well as the limited forms can be treated. An additional technique is dedicated to the treatment of a marginal vein. Approach (III) involves the treatment of venous aneurysms, where a variety of techniques have been successful. Long-term follow-up demonstrates positive results in 91% of the cases. Congenital predominantly venous malformations should be treated according to the principles developed during the past decades in vascular surgery, interventional treatment and multidisciplinary treatment. The days of predominantly conservative treatment should be relegated to the past. Special skills and experiences are necessary to carry out appropriate surgical strategy, and the required operative techniques should be dictated by the location and type of malformation and associated findings.
McKinley, Stephen Alan
A new era of robotic surgery is poised to begin when critical patents held by Intuitive Surgical (IS) expire in 2016. IS market dominance for decades has led to an effective monopoly that will be challenged by several commercial enterprises working on next generation general robotic surgery systems. Robotic surgery has the potential to alleviate the skill-gap between experienced and inexperienced surgeons through the automation of sub-tasks within surgicalprocedures.The primary objective of...
Maruyama, Izumi; Sato, Gohei; Okaue, Toyotake; Isobe, Yoshinari; Ohtsu, Akira; Sugimoto, Yuzo (Kansai Electric Power Co., Inc., Osaka (Japan))
Severe radiation proctitis was surgically treated in 8 cases. Colostomy was performed in 2 cases, total resection of the rectum in 2 and proctectomy with colostomy in 4. Perineal abscess developed in the 2 cases with total resection of the rectum. Rather than completely resection of the lesion, a procedure leaving no dead space i.e. proctectomy with colostomy, is desirable for radiation proctitis. Complete preoperative examination of the condition of the underlying disease and possible urinary tract complications is important.
O Connor, Paul
BACKGROUND: Surgical checklists has been shown to improve patient safety and teamwork in the operating theatre. However, despite the known benefits of the use of checklists in surgery, in some cases the practical implementation has been found to be less than universal. A questionnaire methodology was used to quantitatively evaluate the attitudes of theatre staff towards a modified version of the World Health Organisation (WHO) surgical checklist with relation to: beliefs about levels of compliance and support, impact on patient safety and teamwork, and barriers to the use of the checklist. METHODS: Using the theory of planned behaviour as a framework, 14 semi-structured interviews were conducted with theatre personnel regarding their attitudes towards, and levels of compliance with, a checklist. Based upon the interviews, a 27-item questionnaire was developed and distribute to all theatre personnel in an Irish hospital. RESULTS: Responses were obtained from 107 theatre staff (42.6% response rate). Particularly for nurses, the overall attitudes towards the effect of the checklist on safety and teamworking were positive. However, there was a lack of rigour with which the checklist was being applied. Nurses were significantly more sensitive to the barriers to the use of the checklist than anaesthetists or surgeons. Moreover, anaesthetists were not as positively disposed to the surgical checklist as surgeons and nurse. This finding was attributed to the tendency for the checklist to be completed during a period of high workload for the anaesthetists, resulting in a lack of engagement with the process. CONCLUSION: In order to improve the rigour with which the surgical checklist is applied, there is a need for: the involvement of all members of the theatre team in the checklist process, demonstrated support for the checklist from senior personnel, on-going education and training, and barriers to the implementation of the checklist to be addressed.
Vigano, A N; Minzioni, G; Graffigna, A; Paganini, F; Salerno, J A
The article deals with the modern approaches to the treatment of supraventricular tachycardia . The authors analyse the results of operations in ectopic atrial tachycardias, the Wolff-Parkinson-White syndrome, modal re-entry tachycardias, and atrial fibrillation . The last-named is of most interest because the authors possess experience in a new operation for isolation of the internodal tracts. In all conditions the authors obtained convincing evidence on the efficacy of modern surgical treatment in supraventricular tachycardias.
Berg, David A; Milner, Richard E; Fisher, Carol A; Goldberg, Amy J; Dempsey, Daniel T; Grewal, Harsh
Recent studies comparing inexpensive low-fidelity box trainers to expensive computer-based virtual reality systems demonstrate similar acquisition of surgical skills and transferability to the clinical setting. With new mandates emerging that all surgical residency programs have access to a surgical skills laboratory, we describe our cost-effective approach to teaching basic and advanced open and laparoscopic skills utilizing inexpensive bench models, box trainers, and animate models. Open models (basic skills, bowel anastomosis, vascular anastomosis, trauma skills) and laparoscopic models (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, advanced in vivo skills) are constructed using a combination of materials found in our surgical research laboratories, retail stores, or donated by industry. Expired surgical materials are obtained from our hospital operating room and animal organs from food-processing plants. In vivo models are performed in an approved research facility. Operation, maintenance, and administration of the surgical skills laboratory are coordinated by a salaried manager, and instruction is the responsibility of all surgical faculty from our institution. Overall, the cost analyses of our initial startup costs and operational expenditures over a 3-year period revealed a progressive decrease in yearly cost per resident (2002-2003, $1,151; 2003-2004, $1,049; and 2004-2005, $982). Our approach to surgical skills education can serve as a template for any surgery program with limited financial resources.
Lee, Marcel H; Ingvertsen, Britt T; Kirpensteijn, Jolle; Jensen, Asger L; Kristensen, Annemarie T
To compare gravimetric and colorimetric methods of quantifying surgical blood loss, and to determine if there is a correlation between preoperative hemostatic tests (buccal mucosa bleeding time [BMBT] and intraoperative blood loss). Prospective clinical study. Dogs (n=15) admitted for cutaneous tumor excision, orthopedic procedure, or exploratory laparotomy. Intraoperative blood loss was quantified by measuring irrigation fluid and weighing surgical sponges used for blood and fluid collection during surgery. Results of gravimetric measurements were then correlated to blood loss quantified using spectrophotometric analysis of hemoglobin (Hb) content. Hemostatic variables including BMBT were measured before surgery and compared with the calculated amount of blood loss. Blood loss quantified by gravimetric measurement showed a significant correlation with colorimetric determination of Hb content in surgical sponges and collected irrigation fluid (r=0.93, P<.0001). BMBT correlated weakly but significantly with intraoperative blood loss (r=0.56, P<.05). Quantifying intraoperative blood loss using spectrophotometric Hb analysis accurately assessed the amount of blood loss; however, it is a time-consuming procedure, primarily applicable as a research tool. Gravimetric evaluation of intraoperative blood loss was found to be an accurate method, which can be recommended for use in a clinical setting. Estimation of blood loss using a gravimetric method is accurate and applicable in the clinical setting and provides surgeons with a simple and objective tool to evaluate intraoperative blood loss.
Andriole, Dorothy A; Jeffe, Donna B; Schechtman, Kenneth B
We sought to determine the extent to which recent increases in levels of gender and racial diversity in the overall resident-physician workforce were evident among core-surgical specialty resident workforces. Chi-square tests for trend assessed the importance of changes from 1996 to 2004 in proportions of women and African Americans in the surgery-resident workforce. Surgery-resident trends were compared with overall resident workforce trends using two-tailed t-tests to compare regression slopes that quantified rates of change over time. Chi-square tests assessed differences between proportions of women and African Americans in the current overall board-certified workforce and their proportions in the surgery board-certified workforce. From 1996 to 2004, proportions of women increased in all seven surgical specialties studied. Compared with the overall trend toward increasing proportions of women in the resident workforce, the trend in one surgical specialty was larger (obstetrics/gynecology, p 0.05), and two were smaller (each p 0.05). Proportions of African Americans decreased in three specialties (each p workforce, except obstetrics/gynecology, remained lower than in the overall board-certified workforce (each p workforces have persisted since 1996 and will likely perpetuate ongoing surgery board-certified workforce disparities.
Haritoglou, C; Wolf, A
The detachment of the neurosensory retina from the underlying retinal pigment epithelium can be related to breaks of the retina allowing vitreous fluid to gain access to the subretinal space, to exudative changes of the choroid such as tumours or inflammatory diseases or to excessive tractional forces exerted by interactions of the collagenous vitreous and the retina. Tractional retinal detachment is usually treated by vitrectomy and exudative detachment can be addressed by treatment of the underlying condition in many cases. In rhegmatogenous retinal detachment two different surgical procedures, vitrectomy and scleral buckling, can be applied for functional and anatomic rehabilitation of our patients. The choice of the surgical procedure is not really standardised and often depends on the experience of the surgeon and other more ocular factors including lens status, the number of retinal breaks, the extent of the detachment and the amount of preexisting PVR. Using both techniques, anatomic success rates of over 90 % can be achieved. Especially in young phakic patients scleral buckling offers the true advantage to prevent the progression of cataract formation requiring cataract extraction and intraocular lens implantation. Therefore, scleral buckling should be considered in selected cases as an alternative surgical option in spite of the very important technical refinements in modern vitrectomy techniques. Georg Thieme Verlag KG Stuttgart · New York.
Full Text Available Abstract Background Electrocautery, laser tissue ablation, and ultrasonic scalpel tissue dissection all generate a 'surgical smoke' containing ultrafine ( Methods To measure the amount of generated particulates in 'surgical smoke' during different surgical procedures and to quantify the particle number concentration for operation room personnel a condensation particle counter (CPC, model 3007, TSI Inc. was applied. Results Electro-cauterization and argon plasma tissue coagulation induced the production of very high number concentration (> 100000 cm-3 of particles in the diameter range of 10 nm to 1 μm. The peak concentration was confined to the immediate local surrounding of the production side. In the presence of a very efficient air conditioning system the increment and decrement of ultrafine particle occurrence was a matter of seconds, with accumulation of lower particle number concentrations in the operation room for only a few minutes. Conclusion Our investigation showed a short term very high exposure to ultrafine particles for surgeons and close assisting operating personnel – alternating with longer periods of low exposure.
Full Text Available Objective. Over the past decade, multiple factors have changed the pattern of neonatal surgical emergencies. An increase in prenatal screenings and the development of neonatal tertiary care centres have changed the clinical approach to these kids. Materials and methods. Between 1995 to 2011 were retrospectively reviewed 34 patients with diagnosis of uncommon rare neonatal surgical emergencies at our institute. We analyzed: sex, gestational age, weight at birth, primary pathology, prenatal diagnosis, associated anomalies, age and weight at surgery, clinical presentation, start of oral feeding and hospitalization. The follow-up was performed at 6,12, 24 and 36 months. Results. There were 21 male and 13 female. The gestational age ranged between 28 and 36 weeks. The weight at birth ranged between 700 and 1400 grams. Oral feeding was started between 4th and 10th postoperative day. The average hospitalization was about 70.47 days. To date, all patients have finished the followup. They are healthy. Conclusion. The outcome of the patients with uncommon surgical emergencies is different based on the etiology. Overall survival is generally good but is influenced by the associated anomalies.
Sakaguchi, Masahiro; Katsumi, Masaharu; Ishimoto, Kiwao; Yamamoto, Shinji; Yukawa, Hirofumi; Koh, Kenzo; Yamaguchi, Kazuya; Ohta, Masataka; Hayashido, Motonori
Radiotherapy for malignant tumors is effective and established. However, there are many complications in radiotherapy. A typical complication is radiation enterocolitis. It is difficult to treat severe histological damage to the irradiated tissues. This paper reports our experience with 26 patients with radiation enterocolitis for whom surgical treatment was given during a period of 16 years in our surgical department. The most frequent original disease requiring irradiation was cancer of the cervix uteri (15 cases) which was followed by cancer of the urinary bladder (7 cases). All of these patients had received external 60 Co irradiation. The ileum was the most frequent site of the lesion, followed by the rectum, sigmoid and descending colon. The period between the end of irradiation and the onset of enterocolitis ranged from 2 months to 10 years, with an average of 28 months. The main symptoms were intestinal obstruction in the ileum, and melena and fistula in the rectum and sigmoid colon. Intestinal resection was performed in 10 patients, a bypass operation in 4, and colostomy in 12. As to types of intestinal suture in these cases, Gambee's single layer method was thought useful from our experience. Colostomy as surgical management of melena and fistula did not yield satisfactory results. (author)
Evgeniou, Evgenios; Loizou, Peter
The reduction in time for training at the workplace has created a challenge for the traditional apprenticeship model of training. Simulation offers the opportunity for repeated practice in a safe and controlled environment, focusing on trainees and tailored to their needs. Recent technological advances have led to the development of various simulators, which have already been introduced in surgical training. The complexity and fidelity of the available simulators vary, therefore depending on our recourses we should select the appropriate simulator for the task or skill we want to teach. Educational theory informs us about the importance of context in professional learning. Simulation should therefore recreate the clinical environment and its complexity. Contemporary approaches to simulation have introduced novel ideas for teaching teamwork, communication skills and professionalism. In order for simulation-based training to be successful, simulators have to be validated appropriately and integrated in a training curriculum. Within a surgical curriculum, trainees should have protected time for simulation-based training, under appropriate supervision. Simulation-based surgical education should allow the appropriate practice of technical skills without ignoring the clinical context and must strike an adequate balance between the simulation environment and simulators. © 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.
Full Text Available The photokeratoscope has increased the understanding of the aspheric nature of the cornea as well as a better understanding of normal corneal topography. This has significantly affected the development of newer and more predictable models of surgical astigmatic correction. Relaxing incisions effectively flatten the steeper meridian an equivalent amount as they steepen the flatter meridian. The net change in spherical equivalent is, therefore, negligible. Poor predictability is the major limitation of relaxing incisions. Wedge resection can correct large degrees of postkeratoplasty astigmatism, Resection of 0.10 mm of tissue results in approximately 2 diopters of astigmatic correction. Prolonged postoperative rehabilitation and induced irregular astigmatism are limitations of the procedure. Transverse incisions flatten the steeper meridian an equivalent amount as they steepen the flatter meridian. Semiradial incisions result in two times the amount of flattening in the meridian of the incision compared to the meridian 90 degrees away. Combination of transverse incisions with semiradial incisions describes the trapezoidal astigmatic keratotomy. This procedure may correct from 5.5 to 11.0 diopters dependent upon the age of the patient. The use of the surgical keratometer is helpful in assessing a proper endpoint during surgical correction of astigmatism.
Ivanov, P A; Grishin, A V
Results of surgical treatment of 61 patients with injuries of the duodenum are analyzed. The causes of injuries were stab-incised wounds in 24 patients, missile wound -- in 7, closed abdominal trauma -- in 26, trauma of the duodenum during endoscopic papillosphincterotomy -- in 4. All the patients underwent surgery. Complications were seen in 32 (52.5%) patients, 21 patients died, lethality was 34.4%. Within the first 24 hours since the trauma 7 patients died due to severe combined trauma, blood loss, 54 patients survived acute period of trauma, including 28 patients after open trauma, 26 -- after closed and 4 -- after trauma of the duodenum during endoscopic papillosphincterotomy. Diagnostic and surgical policies are discussed. Results of treatment depending on kind and time of surgery are regarded. It is demonstrated that purulent complications due to retroperitoneal phlegmona, traumatic pancreatitis, pneumonia are the causes of significant number of unfavorable outcomes. Therefore, it is important to adequately incise and drainage infected parts of retroperitoneal fat tissue with two-lumen drainages. Decompression through duodenal tube is the effective procedure for prophylaxis of suture insufficiency and traumatic pancreatitis. Suppression of pancreatic and duodenal secretion with octreotid improves significantly surgical treatment results.
Parekh, Dilip; Natarajan, Sathima
Advances over the past decade have indicated that a complex interplay between environmental factors, genetic predisposition, alcohol abuse, and smoking lead towards the development of chronic pancreatitis. Chronic pancreatitis is a complex disorder that causes significant and chronic incapacity in patients and a substantial burden on the society. Major advances have been made in the etiology and pathogenesis of this disease and the role of genetic predisposition is increasingly coming to the fore. Advances in noninvasive diagnostic modalities now allow for better diagnosis of chronic pancreatitis at an early stage of the disease. The impact of these advances on surgical treatment is beginning to emerge, for example, patients with certain genetic predispositions may be better treated with total pancreatectomy versus lesser procedures. Considerable controversy remains with respect to the surgical management of chronic pancreatitis. Modern understanding of the neurobiology of pain in chronic pancreatitis suggests that a window of opportunity exists for effective treatment of the intractable pain after which central sensitization can lead to an irreversible pain syndrome in patients with chronic pancreatitis. Effective surgical procedures exist for chronic pancreatitis; however, the timing of surgery is unclear. For optimal treatment of patients with chronic pancreatitis, close collaboration between a multidisciplinary team including gastroenterologists, surgeons, and pain management physicians is needed.
Schwartz, Marshall Z
The discussions on health care reform over the past two years have focused on cost containment while trying to maintain quality of care. Focusing on just cost and quality unfortunately does not address other very important factors that impact on our health care delivery system. Availability of a well-trained workforce, maintaining the sophisticated medical/surgical education system, and ultimately access to quality care by the public are critical to maintaining and enhancing our health care delivery system. Unfortunately, all five of these components are under at risk. Thus, we have evolving the ultimate perfect storm affecting our health care delivery system. Although not ideal and given the uniqueness of our population and their expectations, our current delivery system is excellent compared to other countries. However, the cost of our current system is rising at an alarming rate. Currently, health care consumes 17% of our gross domestic product. If our system is not revised this will continue to rise and by 2025 it will consume 48%. The dilemma, given the current state of our overall economy and rising debt, is how to address this major problem. Unfortunately, the Affordable Care Act, which is now law, does not address most of the issues and the cost was initially grossly under estimated. Furthermore, the law does not address the issues of workforce, maintaining our medical education system or ultimately, access. A major revision of our system will be necessary to truly create a system that protects and enhances all five of the components of our health care delivery system. To effectively accomplish this will require addressing those issues that lead to wasteful spending and diversion of our health care dollars to profit instead of care. Improved and efficient delivery systems that reduce complications, reduction of duplication of tertiary and quaternary programs or services within the same markets (i.e. regionalization of care), health insurance reform, and
Bonavina, Luigi; Mozzi, Enrico; Peracchia, Alberto
The use of virtual reality simulation is currently being proposed within programs of postgraduate surgical education. The simple tasks that make up an operative procedure can be repeatedly performed until satisfactory execution is achieved, and the errors can be corrected by means of objective assessment. The aim of this study was to evaluate the applicability and the results of structured practice with the LapSim laparoscopic simulator used by undergraduate medical students. A significant reduction in operative time and errors was noted in several tasks (navigation, clipping, etc.). Although the transfer of technical skills to the operating room environment remains to be demonstrated, our research shows that this type of teaching is applicable to undergraduate medical students and in future may become a useful tool for selecting individuals for surgical residency programs.
Verwilghen, Denis; Singh, Ameet
A diverse array of pathogen-related, patient-related, and caretaker-related issues influence risk and prevention of surgical site infections (SSIs). The entire surgical team involved in health care settings in which surgical procedures are performed play a pivotal role in the prevention of SSIs. ...
The aim of Journal of Surgical Technique and Case Report is to advance surgical knowledge and practice by promoting the reporting of innovative and reproducible surgical techniques ... Anterior palatal island advancement flap for bone graft coverage: technical note · EMAIL FREE FULL TEXT EMAIL FREE FULL TEXT
Chu, Kathryn M; Ford, Nathan P; Trelles, Miguel
Somalia is one of the most political unstable countries in the world. Ongoing insecurity has forced an inconsistent medical response by the international community, with little data collection. This paper describes the "remote" model of surgical care by Medecins Sans Frontieres, in Guri-El, Somalia. The challenges of providing the necessary prerequisites for safe surgery are discussed as well as the successes and limitations of task shifting in this resource-limited context. In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. The objectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and non-violent trauma. At the start of the program, expatriate surgeons and anesthesiologists established safe surgical practices and performed surgical procedures. After January 2008, expatriates were evacuated due to insecurity and surgical care has been provided by local Somalian doctors and nurses with periodic supervisory visits from expatriate staff. Between October 2006 and December 2009, 2086 operations were performed on 1602 patients. The majority (1049, 65%) were male and the median age was 22 (interquartile range, 17-30). 1460 (70%) of interventions were emergent. Trauma accounted for 76% (1585) of all surgical pathology; gunshot wounds accounted for 89% (584) of violent injuries. Operative mortality (0.5% of all surgical interventions) was not higher when Somalian staff provided care compared to when expatriate surgeons and anesthesiologists. The delivery of surgical care in any conflict-settings is difficult, but in situations where international support is limited, the challenges are more extreme. In this model, task shifting, or the provision of services by less trained cadres, was utilized and peri-operative mortality remained low demonstrating that safe surgical practices can be accomplished even without the presence of fully trained surgeon and anesthesiologists. If security improves
Redden, Mark D; Chin, Tze Yang; van Driel, Mieke L
Empyema refers to pus in the pleural space, commonly due to adjacent pneumonia, chest wall injury, or a complication of thoracic surgery. A range of therapeutic options are available for its management, ranging from percutaneous aspiration and intercostal drainage to video-assisted thoracoscopic surgery (VATS) or thoracotomy drainage. Intrapleural fibrinolytics may also be administered following intercostal drain insertion to facilitate pleural drainage. There is currently a lack of consensus regarding optimal treatment. To assess the effectiveness and safety of surgical versus non-surgical treatments for complicated parapneumonic effusion or pleural empyema. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 9), MEDLINE (Ebscohost) (1946 to July week 3 2013, July 2015 to October 2016) and MEDLINE (Ovid) (1 May 2013 to July week 1 2015), Embase (2010 to October 2016), CINAHL (1981 to October 2016) and LILACS (1982 to October 2016) on 20 October 2016. We searched ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for ongoing studies (December 2016). Randomised controlled trials that compared a surgical with a non-surgical method of management for all age groups with pleural empyema. Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach. We included eight randomised controlled trials with a total of 391 participants. Six trials focused on children and two on adults. Trials compared tube thoracostomy drainage (non-surgical), with or without intrapleural fibrinolytics, to either VATS or thoracotomy (surgical) for the management of pleural empyema. Assessment of risk of bias for the included studies was generally unclear for selection and blinding but low for attrition and reporting bias. Data analyses compared
Slocum, Terry A.; Yoder, Stephen C.
Outlines reasons why computer programming should be taught to geographers. These include experience using macro (scripting) languages and sophisticated visualization software, and developing a deeper understanding of general hardware and software capabilities. Discusses the distinct advantages and few disadvantages of the programming language…
Newcomb, Anna B; Trickey, Amber W; Porrey, Melissa; Wright, Jeffrey; Piscitani, Franco; Graling, Paula; Dort, Jonathan
The Accreditation Council for Graduate Medical Education milestones provide a framework of specific interpersonal and communication skills that surgical trainees should aim to master. However, training and assessment of resident nontechnical skills remains challenging. We aimed to develop and implement a curriculum incorporating interactive learning principles such as group discussion and simulation-based scenarios to formalize instruction in patient-centered communication skills, and to identify best practices when building such a program. The curriculum is presented in quarterly modules over a 2-year cycle. Using our surgical simulation center for the training, we focused on proven strategies for interacting with patients and other providers. We trained and used former patients as standardized participants (SPs) in communication scenarios. Surgical simulation center in a 900-bed tertiary care hospital. Program learners were general surgery residents (postgraduate year 1-5). Trauma Survivors Network volunteers served as SPs in simulation scenarios. We identified several important lessons: (1) designing and implementing a new curriculum is a challenging process with multiple barriers and complexities; (2) several readily available facilitators can ease the implementation process; (3) with the right approach, learners, faculty, and colleagues are enthusiastic and engaged participants; (4) learners increasingly agree that communication skills can be improved with practice and appreciate the curriculum value; (5) patient SPs can be valuable members of the team; and importantly (6) the culture of patient-physician communication appears to shift with the implementation of such a curriculum. Our approach using Trauma Survivors Network volunteers as SPs could be reproduced in other institutions with similar programs. Faculty enthusiasm and support is strong, and learner participation is active. Continued focus on patient and family communication skills would enhance
Chen, Xiaodong Phoenix; Sullivan, Amy M; Alseidi, Adnan; Kwakye, Gifty; Smink, Douglas S
Providing resident autonomy in the operating room (OR) is one of the major challenges for surgical educators today. The purpose of this study was to explore what approaches expert surgical teachers use to assess residents' readiness for autonomy in the OR. We particularly focused on the assessments that experts make prior to conducting the surgical time-out. We conducted semistructured in-depth interviews with expert surgical teachers from March 2016 to September 2016. Purposeful sampling and snowball sampling were applied to identify and recruit expert surgical teachers from general surgery residency programs across the United States to represent a range of clinical subspecialties. All interviews were audio-recorded, deidentified, and transcribed. We applied the Framework Method of content analysis, discussed and reached final consensus on the themes. We interviewed 15 expert teachers from 9 institutions. The majority (13/15) were Program or Associate Program Directors; 47% (7/15) primarily performed complex surgical operations (e.g., endocrine surgery). Five themes regarding how expert surgical teachers determine residents' readiness for OR autonomy before the surgical time-out emerged. These included 3 domains of evidence elicited about the resident (resident characteristics, medical knowledge, and beyond the current OR case), 1 variable relating to attending characteristics, and 1 variable composed of contextual factors. Experts obtained one or more examples of evidence, and adjusted residents' initial autonomy using factors from the attending variable and the context variable. Expert surgical teachers' assessments of residents' readiness for OR autonomy included 5 key components. Better understanding these inputs can contribute to both faculty and resident development, enabling increased resident autonomy and preparation for independent practice. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Cannon, Jamie A; Altom, Laura K; Deierhoi, Rhiannon J; Morris, Melanie; Richman, Joshua S; Vick, Catherine C; Itani, Kamal M F; Hawn, Mary T
Surgical site infection is a major cause of morbidity after colorectal resections. Despite evidence that preoperative oral antibiotics with mechanical bowel preparation reduce surgical site infection rates, the use of oral antibiotics is decreasing. Currently, the administration of oral antibiotics is controversial and considered ineffective without mechanical bowel preparation. The aim of this study is to examine the use of mechanical bowel preparation and oral antibiotics and their relationship to surgical site infection rates in a colorectal Surgical Care Improvement Project cohort. This retrospective study used Veterans Affairs Surgical Quality Improvement Program preoperative risk and surgical site infection outcome data linked to Veterans Affairs Surgical Care Improvement Project and Pharmacy Benefits Management data. Univariate and multivariable models were performed to identify factors associated with surgical site infection within 30 days of surgery. This study was conducted in 112 Veterans Affairs hospitals. Included were 9940 patients who underwent elective colorectal resections from 2005 to 2009. The primary outcome measured was the incidence of surgical site infection. Patients receiving oral antibiotics had significantly lower surgical site infection rates. Those receiving no bowel preparation had similar surgical site infection rates to those who had mechanical bowel preparation only (18.1% vs 20%). Those receiving oral antibiotics alone had an surgical site infection rate of 8.3%, and those receiving oral antibiotics plus mechanical bowel preparation had a rate of 9.2%. In adjusted analysis, the use of oral antibiotics alone was associated with a 67% decrease in surgical site infection occurrence (OR=0.33, 95% CI 0.21-0.50). Oral antibiotics plus mechanical bowel preparation was associated with a 57% decrease in surgical site infection occurrence (OR=0.43, 95% CI 0.34-0.55). Timely administration of parenteral antibiotics (Surgical Care Improvement
Chiva, Luis M; Mínguez, Jose; Querleu, Denis; Cibula, David; du Bois, Andreas
The aim of this study was to understand the current situation of surgical education and training in Europe among members of the European Society of Gynecological Oncology (ESGO) and its impact on the daily surgical practice of those that have completed an accredited fellowship in gynecologic oncology. A questionnaire addressing topics of interest in surgical training was designed and sent to ESGO members with surgical experience in gynecologic oncology. The survey was completely confidentially and could be completed in less than 5 minutes. Responses from 349 members from 42 European countries were obtained, which was 38% of the potential target population. The respondents were divided into 2 groups depending on whether they had undergone an official accreditation process. Two thirds of respondents said they had received a good surgical education. However, accredited gynecologists felt that global surgical training was significantly better. Surgical self-confidence among accredited specialists was significantly higher regarding most surgical oncological procedures than it was among their peers without such accreditation. However, the rate of self-assurance in ultraradical operations, and bowel and urinary reconstruction was quite low in both groups. There was a general request for standardizing surgical education across the ESGO area. Respondents demanded further training in laparoscopy, ultraradical procedures, bowel and urinary reconstruction, and postoperative management of complications. Furthermore, they requested the creation of fellowship programs in places where they are not now accredited and the promotion of rotations and exchange in centers of excellence. Finally, respondents want supporting training in disadvantaged countries of the ESGO area. Specialists in gynecologic oncology that have obtained a formal accreditation received a significantly better surgical education than those that have not. The ESGO responders recognize that their society should
Erdman, Mary Kate; Bonaroti, Alisha; Provenzano, Gina; Appelbaum, Rachel; Browne, Marybeth
To evaluate trends of emotional intelligence (EI) in surgical education and to compare the incorporation of EI in surgical education to other fields of graduate medical education. A MEDLINE search was performed for publications containing both "surgery" and "emotional intelligence" with at least one term present in the title. Articles were included if the authors deemed EI in surgical education to be a significant focus. A separate series of MEDLINE searches were performed with the phrase "emotional intelligence" in any field and either "surg*," "internal medicine," "pediatric," "neurology," "obstetric," "gynecology," "OBGYN," "emergency," or "psychiat*" in the title. Articles were included if they discussed resident education as the primary subject. Next, a qualitative analysis of the articles was performed, with important themes from each article noted. Lehigh Valley Health Network in Allentown, PA. Eight articles addressed surgical resident education and satisfied inclusion criteria with 0, 1, and 7 articles published between 2001 and 2005, 2005 and 2010, and 2010 and 2015, respectively. The comparative data for articles on EI and resident education showed the following : 8 in surgery, 2 in internal medicine, 2 in pediatrics, 0 in neurology, 0 in OBGYN, 1 in emergency medicine, and 3 in psychiatry. Integration of EI principles is a growing trend within surgical education. A prominent theme is quantitative assessment of EI in residents and residency applicants. Further study is warranted on the integration process of EI in surgical education and its effect on patient outcomes and long-term job satisfaction. Copyright © 2017 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Andris, Deborah A
In the United States, obesity has reached epidemic proportions. Serious medical complications, impaired quality of life, and premature mortality are all associated with obesity. Medical conditions such as type 2 diabetes mellitus, hypertension, hyperlipidemia, or sleep apnea can improve or be cured with weight loss. Medical treatment programs focused on diet, behavior modification, and/or pharmacologic intervention have met with limited long-term success. Although surgical treatments for obesity have become popular in recent years, they should only be used as a last resort for weight loss. Not all patients can be considered appropriate candidates for surgery; therefore, guidelines based on criteria from the National Institutes of Health should be used preoperatively to help identify suitable persons. Most individuals who opt for weight-loss surgery have usually struggled for many years with losing weight and keeping it off, but surgery alone will not ensure successful weight loss. Patient education is imperative for long-term success. Moreover, any such educational regimen should include information on diet, vitamin and mineral supplementation, and lifestyle changes, as well as expected weight-loss results and improvements in comorbid conditions. Patients must be willing to commit to a long-term follow-up program intended to promote successful weight loss and weight maintenance and to prevent metabolic and nutritional complications.
Hinchcliff, Emily; Green, Isabel; Destephano, Christopher; Cox, Mary; Smink, Douglas; Kumar, Amanika; Hokenstad, Erik; Bengtson, Joan; Cohen, Sarah
To determine if visuospatial perception (VSP) testing is correlated to simulated or intraoperative surgical performance as rated by the American College of Graduate Medical Education (ACGME) milestones. Classification II-2 SETTING: Two academic training institutions PARTICIPANTS: 41 residents, including 19 Brigham and Women's Hospital and 22 Mayo Clinic residents from three different specialties (OBGYN, general surgery, urology). Participants underwent three different tests: visuospatial perception testing (VSP), Fundamentals of Laparoscopic Surgery (FLS®) peg transfer, and DaVinci robotic simulation peg transfer. Surgical grading from the ACGME milestones tool was obtained for each participant. Demographic and subject background information was also collected including specialty, year of training, prior experience with simulated skills, and surgical interest. Standard statistical analysis using Student's t test were performed, and correlations were determined using adjusted linear regression models. In univariate analysis, BWH and Mayo training programs differed in both times and overall scores for both FLS® peg transfer and DaVinci robotic simulation peg transfer (p<0.05 for all). Additionally, type of residency training impacted time and overall score on robotic peg transfer. Familiarity with tasks correlated with higher score and faster task completion (p= 0.05 for all except VSP score). There was no difference in VSP scores by program, specialty, or year of training. In adjusted linear regression modeling, VSP testing was correlated only to robotic peg transfer skills (average time p=0.006, overall score p=0.001). Milestones did not correlate to either VSP or surgical simulation testing. VSP score was correlated with robotic simulation skills but not with FLS skills or ACGME milestones. This suggests that the ability of VSP score to predict competence differs between tasks. Therefore, further investigation is required into aptitude testing, especially prior
de Ruijter, V; Halvax, P; Dallemagne, B; Swanström, L; Marescaux, J; Perretta, S
Technological innovation in surgical science and healthcare is vital and calls for close collaboration between engineering and surgery. To meet this objective, BEST was designed as a free sustainable innovative teaching method for young professionals, combining surgery, engineering, and business in a multidisciplinary, high-quality, low-cost, and learning-by-doing philosophy. This paper reviews the initial outcomes of the program and discusses lessons learned and future directions of this innovative educational method. BEST educational method is delivered in two parts: the first component consisting of live streaming or pre-recorded online lectures, with an interdisciplinary profile focused on surgery, engineering, and business. The second component is an annual 5-day on-site course, organized at IRCAD-IHU, France. The program includes workshops in engineering, entrepreneurship team projects, and in-depth hands-on experience in laparoscopy, robotic surgery, interventional radiology, and flexible endoscopy with special emphasis on the interdisciplinary aspect of the training. A panel of surgeons, engineers, well-established entrepreneurs, and scientists assessed the team projects for potential patent application. From November 2011 till September 2013, 803 individual and institutional users from 79 different countries attended the online course. In total, 134 young professionals from 32 different countries applied to the onsite course. Sixty participants were selected each year for the onsite course. In addition, five participants were selected for a web-based team. Thirteen provisional patents were filed for the most promising projects. BEST proved to be a global talent incubator connecting students to high-quality education despite institutional and economical boundaries. Viable and innovative ideas arose from this revolutionary approach which is likely to spin-off significant technology transfer and lead the way for future interdisciplinary hybrid surgical
Rocos, B; Donaldson, L J
Surgical fires are a rare but serious preventable safety risk in modern hospitals. Data from the US show that up to 650 surgical fires occur each year, with up to 5% causing death or serious harm. This study used the National Reporting and Learning Service (NRLS) database at the National Patient Safety Agency to explore whether spirit-based surgical skin preparation fluid contributes to the cause of surgical fires. The NRLS database was interrogated for all incidents of surgical fires reported between 1 March 2004 and 1 March 2011. Each report was scrutinised manually to discover the cause of the fire. Thirteen surgical fires were reported during the study period. Of these, 11 were found to be directly related to spirit-based surgical skin preparation or preparation soaked swabs and drapes. Despite manufacturer's instructions and warnings, surgical fires continue to occur. Guidance published in the UK and US states that spirit-based skin preparation solutions should continue to be used but sets out some precautions. It may be that fire risk should be included in pre-surgical World Health Organization checklists or in the surgical training curriculum. Surgical staff should be aware of the risk that spirit-based skin preparation fluids pose and should take action to minimise the chance of fire occurring.
Satava, R M
For nearly a decade, advanced computer technologies have created extraordinary educational tools using three-dimensional (3D) visualization and virtual reality. Pioneering efforts in surgical simulation with these tools have resulted in a first generation of simulators for surgical technical skills. Accomplishments include simulations with 3D models of anatomy for practice of surgical tasks, initial assessment of student performance in technical skills, and awareness by professional societies of potential in surgical education and certification. However, enormous challenges remain, which include improvement of technical fidelity, standardization of accurate metrics for performance evaluation, integration of simulators into a robust educational curriculum, stringent evaluation of simulators for effectiveness and value added to surgical training, determination of simulation application to certification of surgical technical skills, and a business model to implement and disseminate simulation successfully throughout the medical education community. This review looks at the historical progress of surgical simulators, their accomplishments, and the challenges that remain.
Effective acquisition of a skill requires practise. Therefore it is of great importance to provide veterinary students with opportunities to practice their surgical skills before carrying out surgical procedures on live patients. Some veterinary schools let students perform entire surgical...... procedures on research animals, in order to learn the basic skills along the way. From an ethical point of view it is questionable however to use live research animals for the sole purpose of practising surgery, and also, research animals are very costly. It is therefore necessary to identify alternative...... teaching methods for veterinary surgical training. At the Department of Small Animal Clinical Sciences, Faculty of Life Sciences, a number of low fidelity, stuffed toy animal dummies was developed for the Surgical Skills Lab in order to teach 4th year students the basic surgical skills. In the Surgical...
Suh, I H; Siu, K-C; Mukherjee, M; Monk, E; Oleynikov, D; Stergiou, N
The purpose of this study was to investigate consistency of performance of robot-assisted surgical tasks in a virtual reality environment. Eight subjects performed two surgical tasks, bimanual carrying and needle passing, with both the da Vinci surgical robot and a virtual reality equivalent environment. Nonlinear analysis was utilized to evaluate consistency of performance by calculating the regularity and the amount of divergence in the movement trajectories of the surgical instrument tips. Our results revealed that movement patterns for both training tasks were statistically similar between the two environments. Consistency of performance as measured by nonlinear analysis could be an appropriate methodology to evaluate the complexity of the training tasks between actual and virtual environments and assist in developing better surgical training programs.
Dydykin, Sergey; Kapitonova, Marina
Traditional department-based surgical interest groups in Russian medical schools are useful tools for student-based selection of specialty training. They also form a nucleus for initiating research activities among undergraduate students. In Russia, the Departments of Topographical Anatomy and Operative Surgery play an important role in initiating student-led research and providing learners with advanced, practical surgical skills. In tandem with department-led activities, student surgical interest groups prepare learners through surgical competitions, known as "Surgical Olympiads," which have been conducted in many Russian centers on a regular basis since 1988. Surgical Olympiads stimulate student interest in the development of surgical skills before graduation and encourage students to choose surgery as their postgraduate specialty. Many of the participants in these surgical Olympiads have become highly qualified specialists in general surgery, orthopedic surgery, neurosurgery, urology, gynecology, and emergency medicine. The present article emphasizes the role of student interest groups and surgical Olympiads in clinical anatomical and surgical undergraduate training in Russia. © 2015 American Association of Anatomists.
Full Text Available Introduction: Spasmodic torticollis (ST is a neuromuscular disorder characterized by uncontrolled clonic and intermittently tonic spasm of the neck muscles. Objective: This retrospective study was done to study clinical picture and to evaluate the surgical results of different surgical procedures in 11 patients who had spasmodic torticollis. Methods: The male to female ratio was 1–2 (4 males and 7 females and their ages ranged from 18 to 65 years. The X-ray of the cervical spine was performed before the operation to exclude cervical disorders that can cause symptoms similar to spasmodic torticollis. MRI of the head and neck was performed in all patients, without finding significant brain lesions. Electromyography of the cervical muscles was performed preoperatively and postoperatively. All cases underwent surgery in the form of variable combinations of ventral rhizotomy of C1, C2+ selective peripheral denervation of neck muscles involved according to the type of torticollis. Mean postoperative follow up period was 24 months. Results: There was no operative mortality. As regards the morbidity, one patient had deficiency of shoulder elevation that was transient and improved after 3 months; one patient had wound infection that responded well to antibiotics after culture and sensitivity. Postoperative dysphagia was found in two cases that improved in one of them after two months. At the last follow up examination period, excellent results were obtained in 55% of patients, good results in 18% of patients, fair results in 18% of patients, and poor results in 9% of cases. Conclusion: There is no standard surgical procedure for treatment of ST; this is adapted to each patient according to type of torticollis. Better results were obtained in simple torticollis (excellent results in 100%, than in complex type (excellent and good results in 33.3%. Keywords: Focal dystonia, Spasmodic torticollis, Anterior rhizotomy, Selective denervation
Buchfelder, Michael; Schlaffer, Sven-Martin
Surgical extraction of as much tumour mass as possible is considered the first step of treatment in acromegaly in many centers. In this article the potential benefits, disadvantages and limitations of operative acromegaly treatment are reviewed. Pertinent literature was selected to provide a review covering current indications, techniques and results of operations for acromegaly. The rapid reduction of tumour volume is an asset of surgery. To date, in almost all patients, minimally invasive, transsphenoidal microscopic or endoscopic approaches are employed. Whether a curative approach is feasible or a debulking procedure is planned, can be anticipated on the basis of preoperative magnetic resonance imaging. The radicality of adenoma resection essentially depends on localization, size and invasive character of the tumour. The normalization rates of growth hormone and IGF-1 secretion, respectively, depend on tumour-related factors such as size, extension, the presence or absence of invasion and the magnitude of IGF-1 and growth hormone oversecretion. However, also surgeon-related factors such as experience and patient load of the centers have been shown to strongly affect surgical results and the rate of complications. As compared to most medical treatments, surgery is relatively cheap since the costs occur only once and not repeatedly. There are several new technical gadgets which aid in the surgical procedure: navigation and variants of intraoperative imaging. For the mentioned reasons, current algorithms of acromegaly management suggest an initial operation, unless the patients are unfit for surgery, refuse an operation or only an unsatisfactory resection is anticipated. A few suggestions are made when a re-operation could be considered.
Full Text Available Chronic low back pain attributed to lumbar disc degeneration poses a serious challenge to physicians. Surgery may be indicated in selected cases following failure of appropriate conservative treatment. For decades, the only surgical option has been spinal fusion, but its results have been inconsistent. Some prospective trials show superiority over usual conservative measures while others fail to demonstrate its advantages. In an effort to improve results of fusion and to decrease the incidence of adjacent segment degeneration, total disc replacement techniques have been introduced and studied extensively. Short-term results have shown superiority over some fusion techniques. Mid-term results however tend to show that this approach yields results equivalent to those of spinal fusion. Nucleus replacement has gained some popularity initially, but evidence on its efficacy is scarce. Dynamic stabilisation, a technique involving less rigid implants than in spinal fusion and performed without the need for bone grafting, represents another surgical option. Evidence again is lacking on its superiority over other surgical strategies and conservative measures. Insertion of interspinous devices posteriorly, aiming at redistributing loads and relieving pain, has been used as an adjunct to disc removal surgery for disc herniation. To date however, there is no clear evidence on their efficacy. Minimally invasive intradiscal thermocoagulation techniques have also been tried, but evidence of their effectiveness is questioned. Surgery using novel biological solutions may be the future of discogenic pain treatment. Collaboration between clinicians and basic scientists in this multidisciplinary field will undoubtedly shape the future of treating symptomatic disc degeneration.
societies regardle~s of their level of sophistication as benefi- cial to the health of both the mother and child. Many taboos for its ,protection exist. With the introduction of Western concepts and mass media commercial advertising this harmo- nious con$ensus 011 .the importance of breast feeding has been somewhat eroded.
Ryberg, Jesper; Petersen, Thomas Søbirk
the only means by which these offenders are likely to be released from prison, it is reasonable—and close to the heart of modern medical ethics—to consider whether the offer involves some kind of coercion. However, despite McMillan's seemingly careful consideration of this question, it appears to us......John McMillan's detailed ethical analysis concerning the use of surgical castration of sex offenders in the Czech Republic and Germany is mainly devoted to considerations of coercion.1 This is not surprising. When castration is offered as an option to offenders and, at the same time, constitutes...
Mateus Domingues Miachon
Full Text Available We performed a systematic review of the literature on the surgical treatment of cleft lip, emphasizing the prevalence, complications associated with the treatment and the points of disagreement between authors. We conducted a literature cross-sectional search that analyzed publications in books, articles and on the databases SciELO - Scientific Electronic Library Online, PubMed, of the National Center for Biotechnology Information. We conclude that: 1 the severity of the cleft will indicate the technique presenting more advantages; 2 the different approaches indicate that there is no consensus on the optimal technique; and 3 the surgeon experience contributes to choosing the best option.
Maruyama, Izumi; Sato, Gohei; Okaue, Toyotake; Isobe, Yoshinari; Ohtsu, Akira; Sugimoto, Yuzo
Severe radiation proctitis was surgically treated in 8 cases. Colostomy was performed in 2 cases, total resection of the rectum in 2 and proctectomy with colostomy in 4. Perineal abscess developed in the 2 cases with total resection of the rectum. Rather than completely resection of the lesion, a procedure leaving no dead space i.e. proctectomy with colostomy, is desirable for radiation proctitis. Complete preoperative examination of the condition of the underlying disease and possible urinary tract complications is important. (Chiba, N.)
Full Text Available ′Packages′ are in fashion today for most surgical procedures in various corporate hospitals and this has included laparoscopic procedures too. A package system enables the hospitals to get cost settlements done more easily. Also, it is more convenient for the patients who are aware upfront of the charges. The principal disadvantages seems to be for the surgeon, who may face displeasure of the patient, hospital or insurance agencies apart from forfeiting his personal charges if (a he is a novice in laparoscopic surgery and takes extra time to complete a procedure, (b unforeseen problems occur during surgery, or (c new pathologies are discovered on exploration.
Narins, David J; Narins, Rhoda S
There has been considerable interest in using non-ablative methods to rejuvenate the skin. The ThermaCool TC (Thermage Inc.) is a radiofrequency (RF) device that has been introduced to induce tightening of the address the problem of skin via a uniform volumetric heating into the deep dermis tightening, resulting in a 'non-surgical facelift'. Radiofrequency produces a uniform volumetric heating into the deep dermis. Twenty treatment areas in 17 patients were treated to evaluate the efficacy and safety of RF treatment to the brow and jowls. The technique was found to produce gradual tightening in most patients, and there were no adverse effects.
A feature of modern advanced computing is the functional approach to programming. In this book, the authors present an introduction to the mathematics which underline functional programming, emphasizing the understanding of definition and specification--a prerequisite of good programming and problem solving with a computer. The book is self-contained, requiring a low level of mathematical sophistication and may be used as an introduction to the mathematics of programming.Provides an introduction to the functional approach to programming**Emphasizes the problem to be solved, not the pro
Swain, JaBaris D; Matousek, Alexi C; Scott, John W; Cooper, Zara; Smink, Douglas S; Bolman, Ralph Morton; Finlayson, Samuel R G; Zinner, Michael J; Riviello, Robert
Academic global surgery is a nascent field focused on improving surgical care in resource-poor settings through a broad-based scholarship agenda. Although there is increasing momentum to expand training opportunities in low-resource settings among academic surgical programs, most focus solely on establishing short-term elective rotations rather than fostering research or career development. Given the complex nature of surgical care delivery and programmatic capacity building in the resource-poor settings, many challenges remain before global surgery is accepted as an academic discipline and an established career path. Brigham and Women's Hospital has established a specialized global surgery track within the general surgery residency program to develop academic leaders in this growing area of need and opportunity. Here we describe our experience with the design and development of the program followed by practical applications and lessons learned from our early experiences. Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2013 rates; hospitals' resident caps for graduate medical education payment purposes; quality reporting requirements for specific providers and for ambulatory surgical centers. final rule.
We are revising the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems. Some of the changes implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively known as the Affordable Care Act) and other legislation. These changes will be applicable to discharges occurring on or after October 1, 2012, unless otherwise specified in this final rule. We also are updating the rate-of-increase limits for certain hospitals excluded from the IPPS that are paid on a reasonable cost basis subject to these limits. The updated rate-of-increase limits will be effective for cost reporting periods beginning on or after October 1, 2012. We are updating the payment policies and the annual payment rates for the Medicare prospective payment system (PPS) for inpatient hospital services provided by long-term care hospitals (LTCHs) and implementing certain statutory changes made by the Affordable Care Act. Generally, these changes will be applicable to discharges occurring on or after October 1, 2012, unless otherwise specified in this final rule. In addition, we are implementing changes relating to determining a hospital's full-time equivalent (FTE) resident cap for the purpose of graduate medical education (GME) and indirect medical education (IME) payments. We are establishing new requirements or revised requirements for quality reporting by specific providers (acute care hospitals, PPS-exempt cancer hospitals, LTCHs, and inpatient psychiatric facilities (IPFs)) that are participating in Medicare. We also are establishing new administrative, data completeness, and extraordinary circumstance waivers or extension requests requirements, as well as a reconsideration process, for quality reporting by ambulatory surgical centers
Schaverien, Mark V
The predictive relationship between candidate selection criteria for surgical training programs and future performance during and at the completion of training has been investigated for several surgical specialties, however there is no interspecialty agreement regarding which selection criteria should be used. Better understanding the predictive reliability between factors at selection and future performance may help to optimize the process and lead to greater standardization of the surgical selection process. PubMed and Ovid MEDLINE databases were searched. Over 560 potentially relevant publications were identified using the search strategy and screened using the Cochrane Collaboration Data Extraction and Assessment Template. 57 studies met the inclusion criteria. Several selection criteria used in the traditional selection demonstrated inconsistent correlation with subsequent performance during and at the end of surgical training. The following selection criteria, however, demonstrated good predictive relationships with subsequent resident performance: USMLE examination scores, Letters of Recommendation (LOR) including the Medical Student Performance Evaluation (MSPE), academic performance during clinical clerkships, the interview process, displaying excellence in extracurricular activities, and the use of unadjusted rank lists. This systematic review supports that the current selection process needs to be further evaluated and improved. Multicenter studies using standardized outcome measures of success are now required to improve the reliability of the selection process to select the best trainees. Published by Elsevier Inc.
Methods: Contact was first initiated between the heads of department at the two institutions and communications was almost entirely through e-mail. A Memorandum of Understanding ... taking part in the exchange programs. Keywords: Surgical training, North-South divide, academic exchange programs, Tanzania, Germany ...
Tice, Tonya; Elliott, Jessica; Gandy, Zielda; Wilkerson, Tammy
As the world economy continues to evolve, businesses and industries must adopt new practices and processes in order to survive. Quality and cost control, work teams and participatory management, and an infusion of technology are transforming the way people work and do business. Employees are now expected to read, write, and communicate…
Werner, Jens; Uhl, Waldemar; Büchler, Markus W.
Patients with predicted severe necrotizing pancreatitis as diagnosed by C-reactive protein (>150 mg/L) and/or contrast-enhanced computed tomography should be managed in the intensive care unit. Prophylactic broad-spectrum antibiotics reduce infection rates and survival in severe necrotizing pancreatitis. Endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy is a causative therapy for gallstone pancreatitis with impacted stones, biliary sepsis, or obstructive jaundice. Fine needle aspiration for bacteriology should be performed to differentiate between sterile and infected pancreatic necrosis in patients with sepsis syndrome. Infected pancreatic necrosis in patients with clinical signs and symptoms of sepsis is an indication for surgery. Patients with sterile pancreatic necrosis should be managed conservatively. Surgery in patients with sterile necrosis may be indicated in cases of persistent necrotizing pancreatitis and in the rare cases of "fulminant acute pancreatitis." Early surgery, within 14 days after onset of the disease, is not recommended in patients with necrotizing pancreatitis. The surgical approach should be organ-preserving (debridement/necrosectomy) and combined with a postoperative management concept that maximizes postoperative evacuation of retroperitoneal debris and exudate. Minimally invasive surgical procedures have to be regarded as an experimental approach and should be restricted to controlled trials. Cholecystectomy should be performed to avoid recurrence of gallstone-associated acute pancreatitis.
All participants must provide a valid consent to surgical clinical trials. A valid consent requires patient capacity, adequate disclosure of information, and voluntariness. Capacity is the ability to understand information relevant to making a decision and to appreciate the reasonably foreseeable consequences of a decision or lack of decision. To protect vulnerable persons, an incapable person should not be enrolled in most clinical trials. The only exception is if the study can only be conducted on incapable persons. If the willing research participant is incapable, consent must be obtained from others through a process called substitute (or proxy) consent. Disclosure refers to the provision of relevant information to the patient and its comprehension by the patient. Most surgical trials carry more than minimal risks, so the requirement for careful disclosure of these risks to potential participants is generally stringent. Voluntariness refers to the freedom of a person to make a treatment decision. In specific circumstances related to emergency research, the requirement for consent may be waived. Waiver can be justified only if the delay required to obtain consent would prevent the research from occurring and only after prior consultation with from the "community" of potential research participants.
Full Text Available Surgical infections are mostly polymicrobial, involving both aerobes and anaerobes. One hundred seventeen cases comprised of abscesses (n=51, secondary peritonitis (n=25, necrotizing fascitis (n=22 and wounds with devitalized tissues (n=19 were studied. The number of microorganisms isolated per lesion was highest in secondary peritonitis (2.32. The aerobe/ anaerobe ratio was 0.81 in secondary peritonitis and 1.8 in necrotizing fascitis. Most secondary peritonitis (80%, necrotizing fascitis (75% and wounds with devitalized tissues (66.7% were polymicrobial. Common microorganisms isolated in our study were E. coli, Staphylococcus aureus, Klebsiella spp., Pseudomonas aeruginosa, Bacteroides fragilis and Peptostreptococcus spp. The most effective antibiotics for S. aureus were clindamycin (79.1% and cefuroxime (70.8%. For Gram-negatives (Klebsiella spp., E. coli and Proteus spp., the most effective antibiotics were cefotaxime, ceftizoxime, amikacin and ciprofloxacin. Pseudomonas aeruginosa was maximally sensitive to amikacin (35.2% and ciprofloxacin (35.2%. The greatest degree of multidrug resistance to all the drugs was found in P. aeruginosa (52.9%, followed by Klebsiella spp. (33.3%, Proteus spp. (33.3%, E. coli (22.2%, and S. aureus (12.5%. All the anaerobes that we isolated were 100% sensitive to metronidazole and chloramphenicol, followed by clindamycin (95% to 100%. Apart from antibiotic therapy, non-antimicrobial methods, such as hyperbaric oxygen therapy and debridement also play an important role in the treatment of surgical infections.
Esposito, Ciro; Esposito, Giovanni
Radiologic evaluation of an infant or child suspected of having a surgical disease can be a complex problem. With this volume, the editors have created a book focused on pediatric imaging written by pediatricians, pediatric surgeons and pediatric radiologists. This book is a collection of over 200 case reports. The concept is a case study approach: The reader is given radiologic images (plain radiography, computed tomography, magnetic resonance imaging, ultrasonography, etc.) and the clinical history of the patient. On the basis of this information, the reader is asked to identify a diagnostic and therapeutic strategy. Each case is complemented by information on the disease affecting the patient and the management of the case shown, including therapy and follow-up. This educational text is targeted at all medical professionals faced with a variety of diagnostic and therapeutic problems affecting infants and children. (orig.)
Esposito, Ciro [Federico II Univ. of Naples (Italy). Chair of Pediatric Surgery; Esposito, Giovanni (eds.) [Federico II Univ. of Naples (Italy). School of Medicine
Radiologic evaluation of an infant or child suspected of having a surgical disease can be a complex problem. With this volume, the editors have created a book focused on pediatric imaging written by pediatricians, pediatric surgeons and pediatric radiologists. This book is a collection of over 200 case reports. The concept is a case study approach: The reader is given radiologic images (plain radiography, computed tomography, magnetic resonance imaging, ultrasonography, etc.) and the clinical history of the patient. On the basis of this information, the reader is asked to identify a diagnostic and therapeutic strategy. Each case is complemented by information on the disease affecting the patient and the management of the case shown, including therapy and follow-up. This educational text is targeted at all medical professionals faced with a variety of diagnostic and therapeutic problems affecting infants and children. (orig.)
Bordeianou, Liliana; Cauley, Christy E; Antonelli, Donna; Bird, Sarah; Rattner, David; Hutter, Matthew; Mahmood, Sadiqa; Schnipper, Deborah; Rubin, Marc; Bleday, Ronald; Kenney, Pardon; Berger, David
Two systems measure surgical site infection rates following colorectal surgeries: the American College of Surgeons National Surgical Quality Improvement Program and the Centers for Disease Control and Prevention National Healthcare Safety Network. The Centers for Medicare & Medicaid Services pay-for-performance initiatives use National Healthcare Safety Network data for hospital comparisons. This study aimed to compare database concordance. This is a multi-institution cohort study of systemwide Colorectal Surgery Collaborative. The National Surgical Quality Improvement Program requires rigorous, standardized data capture techniques; National Healthcare Safety Network allows 5 data capture techniques. Standardized surgical site infection rates were compared between databases. The Cohen κ-coefficient was calculated. This study was conducted at Boston-area hospitals. National Healthcare Safety Network or National Surgical Quality Improvement Program patients undergoing colorectal surgery were included. Standardized surgical site infection rates were the primary outcomes of interest. Thirty-day surgical site infection rates of 3547 (National Surgical Quality Improvement Program) vs 5179 (National Healthcare Safety Network) colorectal procedures (2012-2014). Discrepancies appeared: National Surgical Quality Improvement Program database of hospital 1 (N = 1480 patients) routinely found surgical site infection rates of approximately 10%, routinely deemed rate "exemplary" or "as expected" (100%). National Healthcare Safety Network data from the same hospital and time period (N = 1881) revealed a similar overall surgical site infection rate (10%), but standardized rates were deemed "worse than national average" 80% of the time. Overall, hospitals using less rigorous capture methods had improved surgical site infection rates for National Healthcare Safety Network compared with standardized National Surgical Quality Improvement Program reports. The correlation coefficient
Full Text Available Background: Historically, operating room (OR has always been considered as a stand-alone trusted platform for surgical education and training.However, concerns about financial constraints, quality control, and patient safety have urged the surgical educators to develop more cost-effective, surgical educational platforms that can be employed outside the OR. Furthermore, trained surgeons need to regularly update their surgical skills to keep abreast with the emerging surgical technologies. This research aimed to explore the value of currently available modern surgical tools that can be used outside the OR and also elaborates the existing laparoscopic surgical training programs in world-class centers across the globe with a view to formulate a blended and unified structured surgical training program. Materials and Methods: Several data sources were searched using MeSH terms “Laparoscopic surgery” and “Surgical training” and “Surgical curriculum” and “fundamentals of endoscopic surgery” and “fundamentals of laparoscopic surgery” and “Telementoring” and “Box trainer.” The eligibility criteria used in data extraction searched for original and review articles and by excluding the editorial articles, short communications, conference proceedings, personal view, and commentaries. Data synthesis and data analysis were done by reviewing the initially retrieved 211 articles. Irrelevant and duplicate and redundant articles were excluded from the study. Results: Finally, 12 articles were selected for this systematic review. Data results showed that a myriad of cutting-edge technical innovations have provided modern surgical training tools such as the simulation-based mechanical and virtual reality simulators, animal and cadaveric labs, telementoring, telerobotic-assisted surgery, and video games. Surgical simulators allow the trainees to acquire surgical skills in a tension-free environment without supervision or time constraints
Fleming, Matthew; King, Caroline; Rajeev, Sindhya; Baruwal, Ashma; Schwarz, Dan; Schwarz, Ryan; Khadka, Nirajan; Pande, Sami; Khanal, Sumesh; Acharya, Bibhav; Benton, Adia; Rogers, Selwyn O; Panizales, Maria; Gyorki, David; McGee, Heather; Shaye, David; Maru, Duncan
Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework. We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.
Del-Moral-Luque, J A; Checa-García, A; López-Hualda, Á; Villar-Del-Campo, M C; Martínez-Martín, J; Moreno-Coronas, F J; Montejo-Sancho, J; Rodríguez-Caravaca, G
Antibiotic prophylaxis is the most suitable tool for preventing surgical wound infection. This study evaluated adequacy of antibiotic prophylaxis in surgery for knee arthroplasty and its effect on surgical site infection. Prospective cohort study. We assessed the degree of adequacy of antibiotic prophylaxis, the causes of non-adequacy, and the effect of non-adequacy on surgical site infection. Incidence of surgical site infection was studied after a maximum incubation period of a year. To assess the effect of prophylaxis non-adequacy on surgical site infection we used the relative risk adjusted with the aid of a logistic regression model. The study covered a total of 1749 patients. Antibiotic prophylaxis was indicated in all patients and administered in 99.8% of cases, with an overall protocol adequacy of 77.6%. The principal cause of non-compliance was the duration of prescription of the antibiotics (46.5%). Cumulative incidence of surgical site infection was 1.43%. No relationship was found between prophylaxis adequacy and surgical infection (RR=1.15; 95% CI: .31-2.99) (P>.05). Surveillance and infection control programs enable risk factors of infection and improvement measures to be assessed. Monitoring infection rates enables us to reduce their incidence. Adequacy of antibiotic prophylaxis was high but could be improved. We did not find a relationship between prophylaxis adequacy and surgical site infection rate. Copyright © 2017 SECOT. Publicado por Elsevier España, S.L.U. All rights reserved.
Dexter, Franklin; Epstein, Richard H; Thenuwara, Kokila; Lubarsky, David A
Multiple previous studies have shown that having a large diversity of procedures has a substantial impact on quality management of hospital surgical suites. At hospitals with substantial diversity, unless sophisticated statistical methods suitable for rare events are used, anesthesiologists working in surgical suites will have inaccurate predictions of surgical blood usage, case durations, cost accounting and price transparency, times remaining in late running cases, and use of intraoperative equipment. What is unknown is whether large diversity is a feature of only a few very unique set of hospitals nationwide (eg, the largest hospitals in each state or province). The 2013 United States Nationwide Readmissions Database was used to study heterogeneity among 1981 hospitals in their diversities of physiologically complex surgical procedures (ie, the procedure codes). The diversity of surgical procedures performed at each hospital was quantified using a summary measure, the number of different physiologically complex surgical procedures commonly performed at the hospital (ie, 1/Herfindahl). A total of 53.9% of all hospitals commonly performed 3-fold larger diversity (ie, >30 commonly performed physiologically complex procedures). Larger hospitals had greater diversity than the small- and medium-sized hospitals (P 30 procedures (lower 99% CL, 71.9% of hospitals). However, there was considerable variability among the large teaching hospitals in their diversity (interquartile range of the numbers of commonly performed physiologically complex procedures = 19.3; lower 99% CL, 12.8 procedures). The diversity of procedures represents a substantive differentiator among hospitals. Thus, the usefulness of statistical methods for operating room management should be expected to be heterogeneous among hospitals. Our results also show that "large teaching hospital" alone is an insufficient description for accurate prediction of the extent to which a hospital sustains the
Finding an academic program that caters to children's literature is hard. Many people consider children's literature no more sophisticated than its audience--an arena for those who cannot hack it either as writers or as teachers of adult literature. This author, however, found a new program--a "low residency program"--at Hamline…
Nelson H. Morgon
Full Text Available In this paper, the use of both simple and sophisticated models in the study of electronic transitions was explored for a set of molecular systems: C2H4, C4H4, C4H6, C6H6, C6H8, "C8", C60, and [H2NCHCH(CHCHkCHNH2]+, where k = 0 to 4. The simple model of the free particle (1D, 2D, and 3D boxes, rings or spherical surfaces, considering the boundary conditions, was found to yield similar results to the sophisticated theoretical methods such as EOM-CCSD/6-311++G** or TD(NStates=5,Root=1-M06-2X/6-311++G**.
Danforth, Rachel M; Pitt, Henry A; Flanagan, Mindy E; Brewster, Benjamin D; Brand, Elizabeth W; Frankel, Richard M
Inpatient satisfaction is a key element of hospital pay-for-performance programs. Communication and pain management are known to influence results, but additional factors may affect satisfaction scores. We tested the hypothesis that patient factors and outcome parameters not considered previously are clinically important drivers of inpatient satisfaction. Medical records were reviewed for 1,340 surgical patients who returned nationally standardized inpatient satisfaction questionnaires. These patients were managed by 41 surgeons in seven specialties at two academic medical centers. Thirty-two parameters based on the patient, surgeon, outcomes, and survey were measured. Univariate and multivariable analyses were performed. Inpatients rated their overall experience favorably 75.7% of the time. Less-satisfied patients were more likely to be female, younger, less ill, taking outpatient narcotics, and admitted via the emergency department (all P expectations of patients with cancer, and postoperative complications are important and clinically relevant drivers of surgical inpatient satisfaction. Programs to manage expectations of cancer patient expectations and decrease postoperative morbidity should improve surgical inpatient satisfaction. Further efforts to risk-adjust patient satisfaction scores should be undertaken. Copyright © 2014 Mosby, Inc. All rights reserved.
Li, Xinli; Nylander, William; Smith, Tracy; Han, Soonhee; Gunnar, William
Surgical site infection (SSI) complicates approximately 2% of surgeries in the Veterans Affairs (VA) hospitals. Surgical site infections are responsible for increased morbidity, length of hospital stay, cost, and mortality. Surgical site infection can be minimized by modifying risk factors. In this study, we identified risk factors and developed accurate predictive surgical specialty-specific SSI risk prediction models for the Veterans Health Administration (VHA) surgery population. In a retrospective observation study, surgical patients who underwent surgery from October 2013 to September 2016 from 136 VA hospitals were included. The Veteran Affairs Surgical Quality Improvement Program (VASQIP) database was used for the pre-operative demographic and clinical characteristics, intra-operative characteristics, and 30-day post-operative outcomes. The study population represents 11 surgical specialties: neurosurgery, urology, podiatry, otolaryngology, general, orthopedic, plastic, thoracic, vascular, cardiac coronary artery bypass graft (CABG), and cardiac valve/other surgery. Multivariable logistic regression models were developed for the 30-day post-operative SSIs. Among 354,528 surgical procedures, 6,538 (1.8%) had SSIs within 30 days. Surgical site infection rates varied among surgical specialty (0.7%-3.0%). Surgical site infection rates were higher in emergency procedures, procedures with long operative duration, greater complexity, and higher relative value units. Other factors associated with increased SSI risk were high level of American Society of Anesthesiologists (ASA) classification (level 4 and 5), dyspnea, open wound/infection, wound classification, ascites, bleeding disorder, chemotherapy, smoking, history of severe chronic obstructive pulmonary disease (COPD), radiotherapy, steroid use for chronic conditions, and weight loss. Each surgical specialty had a distinct combination of risk factors. Accurate SSI risk-predictive surgery specialty
A Sophisticated Architecture Is Indeed Necessary for the Implementation of Health in All Policies but not Enough Comment on "Understanding the Role of Public Administration in Implementing Action on the Social Determinants of Health and Health Inequities".
In this commentary, I argue that beyond a sophisticated supportive architecture to facilitate implementation of actions on the social determinants of health (SDOH) and health inequities, the Health in All Policies (HiAP) project faces two main barriers: lack of awareness within policy networks on the social determinants of population health, and a tendency of health actors to neglect investing in other sectors' complex problems. © 2016 by Kerman University of Medical Sciences.
Glenn, Ian C; Abdulhai, Sophia; Lamoshi, Abdulraouf; Ponsky, Todd A
When discussing new trends in pediatric surgery, the tendency is to focus on novel surgical technology and techniques. However, it is equally important to examine how the practicing surgeon stays abreast in an ever-changing field. This article serves as a brief guide to the future of surgical education for the attending surgeon. Broadly, advances in surgical education consist of new methods of filtration and delivery of knowledge.
Sutherland, Michael J
Most residents in training today are in focused on their training, and the thoughts of changing the structure of residencies and fellowships is something that they are ambivalent about or have never heard anything about. The small minority who are vocal on these issues represent an activist group supporting change. This group is very vocal and raises many of the excellent questions we have examined. In discussion with residents, some feel that shortened training will help with the financial issues facing residents. However, many people today add additional years to their training with research years or "super" fellowships. The residents demonstrate that they want to get the skill sets that they desire despite the added length of training. This is unlikely to change even if the minimum number of years of training changes with the evolution of tracked training programs. Medical students, in the Resident and Associate Society of the American College of Surgeons survey, did not indicate that shortened training would have an affect on decision to pursue or not pursue a surgical career. If the focus of these changes is to encourage medical students to pursue a residency in surgical specialties, we may need to look at other options to increase medical student interest. Medical students indicated that lifestyle issues, types of clinical problems, stress-related concerns, and interactions with the surgical faculty were far more important in their decision to enter a surgical specialty than work hours or duration of training. If we are to make a difference in the quality and quantity of applicants for surgical residencies, then changes in the structure of residencies do not seem to be the most effective way to accomplish this. We should possibly focus more on faculty and medical student interaction and the development of positive role models for medical students to see surgeons with attractive practices that minimize some of the traditionally perceived negative stereotypes
Moche, Jason A; Palmer, Orville
The proper evaluation of the patient with nasal obstruction relies on a comprehensive history and physical examination. Once the site of obstruction is accurately identified, the patient may benefit from a trial of medical management. At times however, the definitive treatment of nasal obstruction relies on surgical management. Recognizing the nasal septum, nasal valve, and turbinates as possible sites of obstruction and addressing them accordingly can dramatically improve a patient's nasal breathing. Conservative resection of septal cartilage, submucous reduction of the inferior turbinate, and structural grafting of the nasal valve when appropriate will provide the optimal improvement in nasal airflow and allow for the most stable results. Copyright © 2012. Published by Elsevier Inc.
Lee, Suk Hwan
Enterocutaneous (EC) fistula is an abnormal connection between the gastrointestinal (GI) tract and skin. The majority of EC fistulas result from surgery. About one third of fistulas close spontaneously with medical treatment and radiologic interventions. Surgical treatment should be reserved for use after sufficient time has passed from the previous laparotomy to allow lysis of the fibrous adhesion using full nutritional and medical treatment and until a complete understanding of the anatomy of the fistula has been achieved. The successful management of GI fistula requires a multi-disciplinary team approach including a gastroenterologist, interventional radiologist, enterostomal therapist, dietician, social worker and surgeons. With this coordinated approach, EC fistula can be controlled with acceptable morbidity and mortality.
Tanaka, Tsuguo; Naito, Kazuyo; Noomi, Shinppachiro; Kurioka, Hideaki; Yamagishi, Hisakazu (Kyoto Prefectural Univ. of Medicine (Japan))
Radiation injury to the digestive tract was surgically treated in 22 cases. Six of them died shortly after surgery. Major symptoms were ileus or perforative peritonitis in 20 of the 22 cases, and surgery was performed for ileal lesion in 18 cases, indicating the significance of lesions in the small intestine. Seven patients underwent resection of the injured portion of the intestinal tract and anastomotic reconstruction in one stage, but 3 of them died from rupture of sutures. It was highly probable that anastomosis was made using an injured portion of the intestine. Intraoperative judgement of intestinal injury is made by palpation and inspection. If judgement is difficult, an artificial anus should be constructed first, and anastomotic reconstruction should be done in the 2nd stage. Since delayed injury of this disease is an ischemic change due to vascular obliteration, conservative therapy never leads to complete recovery, but active resection and anastomosis seem to produce a satisfactory result.
Tanaka, Tsuguo; Naito, Kazuyo; Noomi, Shinppachiro; Kurioka, Hideaki; Yamagishi, Hisakazu
Radiation injury to the digestive tract was surgically treated in 22 cases. Six of them died shortly after surgery. Major symptoms were ileus or perforative peritonitis in 20 of the 22 cases, and surgery was performed for ileal lesion in 18 cases, indicating the significance of lesions in the small intestine. Seven patients underwent resection of the injured portion of the intestinal tract and anastomotic reconstruction in one stage, but 3 of them died from rupture of sutures. It was highly probable that anastomosis was made using an injured portion of the intestine. Intraoperative judgement of intestinal injury is made by palpation and inspection. If judgement is difficult, an artificial anus should be constructed first, and anastomotic reconstruction should be done in the 2nd stage. Since delayed injury of this disease is an ischemic change due to vascular obliteration, conservative therapy never leads to complete recovery, but active resection and anastomosis seem to produce a satisfactory result. (Chiba, N.)
Lange, T; Indelicato, D J; Rosen, J M
Virtual reality in surgery and, more specifically, in surgical training, faces a number of challenges in the future. These challenges are building realistic models of the human body, creating interface tools to view, hear, touch, feel, and manipulate these human body models, and integrating virtual reality systems into medical education and treatment. A final system would encompass simulators specifically for surgery, performance machines, telemedicine, and telesurgery. Each of these areas will need significant improvement for virtual reality to impact medicine successfully in the next century. This article gives an overview of, and the challenges faced by, current systems in the fast-changing field of virtual reality technology, and provides a set of specific milestones for a truly realistic virtual human body.
Evans, Charity H; Schenarts, Kimberly D
Training competent and professional surgeons efficiently and effectively requires innovation and modernization of educational methods. Today's medical learner is quite adept at using multiple platforms to gain information, providing surgical educators with numerous innovative avenues to promote learning. With the growth of technology, and the restriction of work hours in surgical education, there has been an increase in use of simulation, including virtual reality, robotics, telemedicine, and gaming. The use of simulation has shifted the learning of basic surgical skills to the laboratory, reserving limited time in the operating room for the acquisition of complex surgical skills". Copyright © 2016 Elsevier Inc. All rights reserved.
Full Text Available Background: The effectiveness of care for patients with leukoplakia depends on how timely and accurately the disease was diagnosed and also by the subsequent choice of the optimal method of treatment. In recent decades, surgery is increasingly using methods that are alternative to standard surgical methods. Purpose: to justify, develop and evaluate treatment algorithm of verrucous and erosive-ulcerative forms of oral leukoplakia with a SIN2 histological structure. Materials and Methods: to achieve this goal, a comprehensive clinical and laboratory examination of 155 patients with oral leukoplakia was performed, which appealed to the Department of Therapeutic Dentistry of the Bogomolets National Medical University in the period from 2011 to 2015. All patients underwent clinical and laboratory tests. Results: after removal of the affected area of the mucosa by radiation of an erbium laser, wound healing under fibrinous plaque was observed at 7.0 ± 0.5 days. When excision of the mucous membrane with a scalpel, the healing took place under the iodinine swab through the granulation phase for 14.0 ± 1.5 days. In patients after the operation of excision of the area of verrucous or erosive-ulcerative oral mucosa leukoplakia with laser radiation without antimicrobial and anti-inflammatory therapy on the third day, in 95% of cases there is no pain syndrome and collateral edema in the postoperative area. After traditional treatment, despite the use of antibiotics and non-steroidal anti-inflammatory drugs, 56% of patients complained of pain, and 62% had collateral edema. Conclusions: the use of ErrYAG laser laser radiation in the surgical treatment of patients with verrucous and erosive-ulcerative forms of leukoplakia promotes acceleration of healing processes of a postoperative wound twice as fast as in the control group. The use of laser technology reduces the risk of inflammatory purulent complications and helps to prevent the recurrence of the
Bongiovanni, Tasce; Yeo, Heather; Sosa, Julie A; Yoo, Peter S; Long, Theodore; Rosenthal, Marjorie; Berg, David; Curry, Leslie; Nunez-Smith, Marcella
High rates of attrition from general surgery residency may threaten the surgical workforce. We sought to gain further insight regarding resident motivations for leaving general surgery residency. We conducted in-depth interviews to generate rich narrative data that explored individual experiences. An interdisciplinary team used the constant comparative method to analyze the data. Four themes characterized experiences of our 19 interviewees who left their residency program. Participants (1) felt an informal contract was breached when clinical duties were prioritized over education, (2) characterized a culture in which there was no safe space to share personal and programmatic concerns, (3) expressed a scarcity of role models who demonstrated better work-life balance, and (4) reported negative interactions with authority resulting in a profound loss of commitment. As general surgery graduate education continues to evolve, our findings may inform interventions and policies regarding programmatic changes to boost retention in surgical residency. Copyright © 2015 Elsevier Inc. All rights reserved.
Lynch, Jeremy; Aughwane, Paul; Hammond, Toby M
Surgical training is rapidly evolving because of reduced training hours and the reduction of training opportunities due to patient safety concerns. There is a popular conception that video game usage might be linked to improved operating ability especially those techniques involving endoscopic modalities. If true this might suggest future directions for training. A search was made of the MEDLINE databases for the MeSH term, "Video Games," combined with the terms "Surgical Procedures, Operative," "Endoscopy," "Robotics," "Education," "Learning," "Simulators," "Computer Simulation," "Psychomotor Performance," and "Surgery, Computer-Assisted,"encompassing all journal articles before November 2009. References of articles were searched for further studies. Twelve relevant journal articles were discovered. Video game usage has been studied in relationship to laparoscopic, gastrointestinal endoscopic, endovascular, and robotic surgery. Video game users acquire endoscopic but not robotic techniques quicker, and training on video games appears to improve performance. Copyright (c) 2010 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.
Mamut, Adiel E; Afshar, Kourosh; Mickelson, Jennifer J; Macneily, Andrew E
The application of minimally invasive surgery (MIS) has become increasingly common in urology training programs and clinical practice. Our objective was to review surgical case data from all 12 Canadian residency programs to identify trends in resident exposure to MIS and open procedures. Every year, beginning in 2003, an average of 41 postgraduate year 3 to 5 residents reported surgical case data to a secure internet relational database. Data were anonymized and extracted for the period 2003 to 2009 by measuring a set of 11 predefined index cases that could be performed in both an open and MIS fashion. 16,687 index cases were recorded by a total of 198 residents. As a proportion, there was a significant increase in MIS from 12% in 2003 to 2004 to 32% in 2008 to 2009 (P=0.01). A significant decrease in the proportion of index cases performed with an open approach was also observed from 88% in 2003 to 2004 to 68% in 2008 to 2009 (P=0.01). The majority of these shifts were secondary to the increased application of MIS for nephrectomies of all type (29%-45%), nephroureterectomy (27%-76%), adrenalectomy (15%-71%), and pyeloplasty (17%-54%) (Pfashion during the study period. MIS constitutes an increasingly significant component of surgical volume in Canadian urology residencies with a reciprocal decrease in exposure to open surgery. These trends necessitate ongoing evaluation to maintain the integrity of postgraduate urologic training.
Full Text Available ... in Residence Clinical Trials Methods Course Health Services Research Methods Course Surgeon Specific Registry Trauma Education Trauma Education Trauma Education Advanced Surgical Skills for Exposure in Trauma Advanced Trauma Life Support ... Quality Program Initiatives Communications to the Profession ...
Full Text Available ... ASE Medical Student Core Curriculum ACS/ASE Medical Student Simulation-Based Surgical Skills Curriculum Cancer Education Cancer Education Cancer Education Cancer Programs Conference: Learn. Interact. Transform. CoC Events Quality Education Quality Education Quality Education ...
Full Text Available ... The Ostomy Home Skills Kit supports patients with educational and simulation materials to learn and practice the skills needed for optimal postoperative recovery. The kit supports the entire surgical team with quality, comprehensive education. The standardized interactive program has been ...
Luthringer, Tyler; Aleksic, Ilija; Caire, Arthur; Albala, David M
Advancements in the robotic surgical technology have revolutionized the standard of care for many surgical procedures. The purpose of this review is to evaluate the important considerations in developing a new robotics program at a given healthcare institution. Patients' interest in robotic-assisted surgery has and continues to grow because of improved outcomes and decreased periods of hospitalization. Resulting market forces have created a solid foundation for the implementation of robotic surgery into surgical practice. Given proper surgeon experience and an efficient system, robotic-assisted procedures have been cost comparable to open surgical alternatives. Surgeon training and experience is closely linked to the efficiency of a new robotics program. Formally trained robotic surgeons have better patient outcomes and shorter operative times. Training in robotics has shown no negative impact on patient outcomes or mentor learning curves. Individual economic factors of local healthcare settings must be evaluated when planning for a new robotics program. The high cost of the robotic surgical platform is best offset with a large surgical volume. A mature, experienced surgeon is integral to the success of a new robotics program.
Grados Pomarino, Sixto; Estrada, Andrew Alejandro; Maetahara Rubio, Denis Miguel; Guzmán Vera, Yanina Sara; Tello Barbarán, Javier
The gingival recession treatment can be made surgical1y with a high predictability of success due to the great advance during the last ones of the mucogingival surgical techniques. The use of connective grafts in coverage of recessions has obtained high rates of success reason why these procedures are common within the modern periodontal surgical practice. Knowing that all patients do not accept the surgical treatment, many investigators have come studying the possibility of treating non-surg...
This thesis deals with visualizing anatomical data for medical education and surgical planning purposes. To this end, we have developed a detailed virtual atlas, the Virtual Surgical Pelvis (VSP),which unifies surgically relevant knowledge on pelvic anatomy. We provide methods to share the knowledge
Shackelford, Stacy; Garofalo, Evan; Shalin, Valerie; Pugh, Kristy; Chen, Hegang; Pasley, Jason; Sarani, Babak; Henry, Sharon; Bowyer, Mark; Mackenzie, Colin F
Maintaining trauma-specific surgical skills is an ongoing challenge for surgical training programs. An objective assessment of surgical skills is needed. We hypothesized that a validated surgical performance assessment tool could detect differences following a training intervention. We developed surgical performance assessment metrics based on discussion with expert trauma surgeons, video review of 10 experts and 10 novice surgeons performing three vascular exposure procedures and lower extremity fasciotomy on cadavers, and validated the metrics with interrater reliability testing by five reviewers blinded to level of expertise and a consensus conference. We tested these performance metrics in 12 surgical residents (Year 3-7) before and 2 weeks after vascular exposure skills training in the Advanced Surgical Skills for Exposure in Trauma (ASSET) course. Performance was assessed in three areas as follows: knowledge (anatomic, management), procedure steps, and technical skills. Time to completion of procedures was recorded, and these metrics were combined into a single performance score, the Trauma Readiness Index (TRI). Wilcoxon matched-pairs signed-ranks test compared pretraining/posttraining effects. Mean time to complete procedures decreased by 4.3 minutes (from 13.4 minutes to 9.1 minutes). The performance component most improved by the 1-day skills training was procedure steps, completion of which increased by 21%. Technical skill scores improved by 12%. Overall knowledge improved by 3%, with 18% improvement in anatomic knowledge. TRI increased significantly from 50% to 64% with ASSET training. Interrater reliability of the surgical performance assessment metrics was validated with single intraclass correlation coefficient of 0.7 to 0.98. A trauma-relevant surgical performance assessment detected improvements in specific procedure steps and anatomic knowledge taught during a 1-day course, quantified by the TRI. ASSET training reduced time to complete vascular
Full Text Available Abstract Background The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities. In this paper we report on surgical interventions carried out by Médecins sans Frontières in Masisi, North Kivu, Democratic Republic of Congo to contribute to the scarce evidence base on surgical needs in conflict. Methods We analysed data on all surgical interventions done at Masisi district hospital between September 2007 and December 2009. Types of interventions are described, and logistic regression used to model associations with violence-related injury. Results 2869 operations were performed on 2441 patients. Obstetric emergencies accounted for over half (675, 57% of all surgical pathology and infections for another quarter (160, 14%. Trauma-related injuries accounted for only one quarter (681, 24% of all interventions; among these, 363 (13% were violence-related. Male gender (adjusted odds ratio (AOR = 20.0, p Conclusions In this study, most surgical interventions were unrelated to violent trauma and rather reflected the general surgical needs of a low-income tropical country. Programs in conflict zones in low-income countries need to be prepared to treat both the war-wounded and non-trauma related life-threatening surgical needs of the general population. Given the limited surgical workforce in these areas, training of local staff and task shifting is recommended to support broad availability of essential surgical care. Further studies into the surgical needs of the population are warranted, including population-based surveys, to improve program planning and resource allocation and the effectiveness of the humanitarian response.
Chu, Kathryn; Havet, Philippe; Ford, Nathan; Trelles, Miguel
The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities. In this paper we report on surgical interventions carried out by Médecins sans Frontières in Masisi, North Kivu, Democratic Republic of Congo to contribute to the scarce evidence base on surgical needs in conflict. We analysed data on all surgical interventions done at Masisi district hospital between September 2007 and December 2009. Types of interventions are described, and logistic regression used to model associations with violence-related injury. 2869 operations were performed on 2441 patients. Obstetric emergencies accounted for over half (675, 57%) of all surgical pathology and infections for another quarter (160, 14%). Trauma-related injuries accounted for only one quarter (681, 24%) of all interventions; among these, 363 (13%) were violence-related. Male gender (adjusted odds ratio (AOR) = 20.0, p violence-related injury. Immediate peri-operative mortality was 0.2%. In this study, most surgical interventions were unrelated to violent trauma and rather reflected the general surgical needs of a low-income tropical country. Programs in conflict zones in low-income countries need to be prepared to treat both the war-wounded and non-trauma related life-threatening surgical needs of the general population. Given the limited surgical workforce in these areas, training of local staff and task shifting is recommended to support broad availability of essential surgical care. Further studies into the surgical needs of the population are warranted, including population-based surveys, to improve program planning and resource allocation and the effectiveness of the humanitarian response.
Stefanie M. Croghan
Full Text Available Background: While an explosion in technological sophistication has revolutionized surgery within the operating theatre, delivery of surgical ward-based care has seen little innovation. Use of telepresence allowing off-site clinicians communicate with patients has been largely restricted to outpatient settings or use of complex, expensive, static devices. We designed a prospective study to ascertain feasibility and face validity of a remotely controlled mobile audiovisual drone (LUCY to access inpatients. This device is, uniquely, lightweight, freely mobile and emulates ‘human’ interaction by swiveling and adjusting height to patients’ eye-level. Methods: Robot-assisted ward rounds(RASWR were conducted over 3 months. A remotely located consultant surgeon communicated with patients/bedside teams via encrypted audiovisual telepresence robot (DoubleRoboticstm, California USA. Likert-scale satisfaction questionnaires, incorporating free-text sections for mixed-methods data collection, were disseminated to patient and staff volunteers following RASWRs. The same cohort completed a linked questionnaire following conventional (gold-standard rounds, acting as control group. Data were paired, and non-parametric analysis performed. Results: RASWRs are feasible (>90% completed without technical difficulty. The RASWR(n=52 observations demonstrated face validity with strong correlations (r>0.7; Spearman, p-value <0.05 between robotic and conventional ward rounds among patients and staff on core themes, including dignity/confidentiality/communication/satisfaction with management plan. Patients (96.08%, n=25 agreed RASWR were a satisfactory alternative when consultant physical presence was not possible. There was acceptance of nursing/NCHD cohort (100% (n=11 willing to regularly partake in RASWR. Conclusion: RASWRs receive high levels of patient and staff acceptance, and offer a valid alternative to conventional ward rounds
Croghan, Stefanie M; Carroll, Paul; Reade, Sarah; Gillis, Amy E; Ridgway, Paul F
While an explosion in technological sophistication has revolutionized surgery within the operating theatre, delivery of surgical ward-based care has seen little innovation. Use of telepresence allowing off-site clinicians communicate with patients has been largely restricted to outpatient settings or use of complex, expensive, static devices. We designed a prospective study to ascertain feasibility and face validity of a remotely controlled mobile audiovisual drone (LUCY) to access inpatients. This device is, uniquely, lightweight, freely mobile and emulates 'human' interaction by swiveling and adjusting height to patients' eye-level. METHODS: Robot-assisted ward rounds(RASWR) were conducted over 3 months. A remotely located consultant surgeon communicated with patients/bedside teams via encrypted audiovisual telepresence robot (DoubleRoboticstm, California USA). Likert-scale satisfaction questionnaires, incorporating free-text sections for mixed-methods data collection, were disseminated to patient and staff volunteers following RASWRs. The same cohort completed a linked questionnaire following conventional (gold-standard) rounds, acting as control group. Data were paired, and non-parametric analysis performed. RESULTS: RASWRs are feasible (>90% completed without technical difficulty). The RASWR(n=52 observations) demonstrated face validity with strong correlations (r>0.7; Spearman, p-value <0.05) between robotic and conventional ward rounds among patients and staff on core themes, including dignity/confidentiality/communication/satisfaction with management plan. Patients (96.08%, n=25) agreed RASWR were a satisfactory alternative when consultant physical presence was not possible. There was acceptance of nursing/NCHD cohort (100% (n=11) willing to regularly partake in RASWR). CONCLUSION: RASWRs receive high levels of patient and staff acceptance, and offer a valid alternative to conventional ward rounds when a consultant cannot be
Small, D.E.; McDonald, M.J.
With a goal of producing faster, safer, and cheaper technologies for nuclear waste cleanup, Sandia is actively developing and extending intelligent systems technologies. Graphical Programming is a key technology for robotic waste cleanup that Sandia is developing for this goal. This paper describes Sancho, Sandia most advanced Graphical Programming supervisory software. Sancho, now operational on several robot systems, incorporates all of Sandia's recent advances in supervisory control. Sancho, developed to rapidly apply Graphical Programming on a diverse set of robot systems, uses a general set of tools to implement task and operational behavior. Sancho can be rapidly reconfigured for new tasks and operations without modifying the supervisory code. Other innovations include task-based interfaces, event-based sequencing, and sophisticated GUI design. These innovations have resulted in robot control programs and approaches that are easier and safer to use than teleoperation, off-line programming, or full automation
Kim, Roger H; Gilbert, Timothy
The learning style preferences of general surgery residents have been previously reported; there is evidence that residents who prefer read/write learning styles perform better on the American Board of Surgery In-Training Examination (ABSITE). However, little is known regarding the learning style preferences of applicants to general surgery residency and their impact on educational outcomes. In this study, the preferred learning styles of surgical residency applicants were determined. We hypothesized that applicant rank data are associated with specific learning style preferences. The Fleming VARK learning styles inventory was offered to all general surgery residency applicants that were interviewed at a university hospital-based program. The VARK model categorizes learners as visual (V), aural (A), read/write (R), kinesthetic (K), or multimodal (MM). Responses on the inventory were scored to determine the preferred learning style for each applicant. Applicant data, including United States Medical Licensing Examination (USMLE) scores, class rank, interview score, and overall final applicant ranking, were examined for association with preferred learning styles. Sixty-seven applicants were interviewed. Five applicants were excluded due to not completing the VARK inventory or having incomplete applicant data. The remaining 62 applicants (92%) were included for analysis. Most applicants (57%) had a multimodal preference. Sixty-nine percent of all applicants had some degree of preference for kinesthetic learning. There were statistically significant differences between applicants of different learning styles in terms of USMLE step 1 scores (P = 0.001) and USMLE step 2 clinical knowledge scores (P = 0.01), but not for class ranks (P = 0.27), interview scores (P = 0.20), or final ranks (P = 0.14). Multiple comparison analysis demonstrated that applicants with aural preferences had higher USMLE 1 scores (233.2) than those with kinesthetic (211.8, P = 0.005) or multimodal
Under a long-standing collaboration with the John A. Hartford Foundation (JAHF), the Atlantic Philanthropies (AP), and specialty societies in 10 targeted specialties, the American Geriatrics Society (AGS) has been working to improve quality of care provided to older adults by surgical and related medical specialists. To support and nurture future academic leaders, the Geriatrics-for-Specialists Initiative (GSI) established the Dennis W. Jahnigen Career Development Scholar Award (JCDA) program in 2002, with AP joining JAHF as a core funder of the awards in 2003. Commencing in 2011, the National Institute on Aging (NIA) launched the Grants for Early Medical/Surgical Specialists' Transition to Aging Research (GEMSSTAR) program, using an RO3 mechanism. Recipients of the JCDA and the GEMSSTAR are provided with 2 years of research support and networking opportunities with other scholars; 79 JCDA and 26 surgical and related medical specialty GEMSSTAR scholars have been funded through these award mechanisms, with AGS, JAHF, and surgical and related medical specialty societies providing matching support for 20 of the GEMSSTAR scholars for leadership development programs. One of the primary criteria for judging the overall success of the program was eventual transition of the award to a federally funded program, which was achieved when NIA launched the GEMSSTAR program in 2011. © 2017, Copyright the Author Journal compilation © 2017, The American Geriatrics Society.
Xu, Lang; Liu, Qian
This paper discusses a real-time simulation method of inextensible surgical thread based on the Cosserat rod theory using position-based dynamics (PBD). The method realizes stable twining and knotting of surgical thread while including inextensibility, bending, twisting and coupling effects. The Cosserat rod theory is used to model the nonlinear elastic behavior of surgical thread. The surgical thread model is solved with PBD to achieve a real-time, extremely stable simulation. Due to the one-dimensional linear structure of surgical thread, the direct solution of the distance constraint based on tridiagonal matrix algorithm is used to enhance stretching resistance in every constraint projection iteration. In addition, continuous collision detection and collision response guarantee a large time step and high performance. Furthermore, friction is integrated into the constraint projection process to stabilize the twining of multiple threads and complex contact situations. Through comparisons with existing methods, the surgical thread maintains constant length under large deformation after applying the direct distance constraint in our method. The twining and knotting of multiple threads correspond to stable solutions to contact and friction forces. A surgical suture scene is also modeled to demonstrate the practicality and simplicity of our method. Our method achieves stable and fast simulation of inextensible surgical thread. Benefiting from the unified particle framework, the rigid body, elastic rod, and soft body can be simultaneously simulated. The method is appropriate for applications in virtual surgery that require multiple dynamic bodies.
Optimisation of surgical care means weighing the risk of treatment related morbidity against the patients’ potential benefits of a surgical intervention. The first part of this thesis focusses on the anaemic patient undergoing colorectal surgery. Hypothesizing that a more profound haemoglobin
Objective Communication between the surgeon and the patient is a core clinical skill. The ability to communicate with patients and their family members is very important in the optimum care of the surgical patient. Few studies have assessed communication between surgical trainees and their patients in sub-Saharan Africa.
Acute abdomen in pregnancy is a disease with a low incidence. The purpose of this work was therefore to create a review of current recommended practice in diagnostics and surgical solution. I also mention surgically relevant physiological and pathological changes specific to pregnancy, differential diagnostics of acute abdomen in pregnancy and impact of the disease and its treatment on the fetus. (author)
Chandru P Sundaram
Conclusions : A review of the evolution of topical hemostatic agents highlights opportunities for potential novel research. Fibrin sealants may have the most opportunity for advancement, and understanding the history of these products is useful. With the drive in urology for minimally invasive surgical techniques, adaptation of topical hemostatic agents to this surgical approach would be valuable and offers an opportunity for novel contributions.
Li, Chun-Chang; Fu, Ju-Peng; Chang, Shun-Cheng; Chen, Tim-Mo; Chen, Shyi-Gen
Gynecomastia is defined as the benign enlargement of the male breast. Multiple surgical options have been used to improve outcomes. The aim of this study was to analyze the surgical approaches to the treatment of gynecomastia and their outcomes over a 10-year period. All patients undergoing surgical correction of gynecomastia in our department between 2000 and 2010 were included for retrospective evaluation. The data were analyzed for etiology, stage of gynecomastia, surgical technique, complications, risk factors, and revision rate. The surgical result was evaluated with self-assessment questionnaires. A total of 41 patients with 75 operations were included. Techniques included subcutaneous mastectomy alone or with additional ultrasound-assisted liposuction (UAL) and isolated UAL. The surgical revision rate for all patients was 4.8%. The skin-sparing procedure gave good surgical results in grade IIb and grade III gynecomastia with low revision and complication rates. The self-assessment report revealed a good level of overall satisfaction and improvement in self-confidence (average scores 9.4 and 9.2, respectively, on a 10-point scale). The treatment of gynecomastia requires an individualized approach. Subcutaneous mastectomy combined with UAL could be used as the first choice for surgical treatment of grade II and III gynecomastia.
with surgical site infection at Muhimbili Orthopedic Institute. ... Determination of the relationship between outcome and exposure variables ... determined by more than 2 hours length of surgical procedure (AOR= 1.4; 95%CI 1.14-6.69; ... hospital, those with metastatic fractures, back, spine were not included as they fall under.
Piyush HEDA; Babita RAGHUWANSHI; Amit PRAKASH; Kishore SONAWANE
Orthognathic surgery is a surgical procedure largely practiced throughout the world for the correction of various maxillofacial deformities. The procedure for correcting a particular deformity will be done after proper evaluation, which includes cephalometric, dental model analysis and photographs. The patient undergoes pre-surgical orthodontic correction for dental compensation, after which surgery is planned. During the last few decades, the profession has witnessed ...
Chmarra, M. K.; Grimbergen, C. A.; Dankelman, J.
Minimally invasive surgery (e.g. laparoscopy) requires special surgical skills, which should be objectively assessed. Several studies have shown that motion analysis is a valuable assessment tool of basic surgical skills in laparoscopy. However, to use motion analysis as the assessment tool, it is
Surgical site infection among patients undergone orthopaedic surgery at Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania. ... of surgical site infection at Muhimbili Orthopedic Institute was high. This was associated with more than 2 hours length of surgery, lack of prophylaxis use, and pre-operative hospital stay.
Dvojnykh, V.P.; Palagin, E.K.
The results of treatment of 23 patients with acute surgical sepsis were analysed. It was shown that the X-ray examination must be obligatory in surveillance of patients with purulent foci. Two roentgenological variants are possible in surgical sepsis: central and perepheric. X-ray examinations of chest organs should be conducted every 2-3 day
Rhodes, R S; Wile, M Z; Persons, M L; Shuck, J M
The program summary of the American Board of Surgery In-Service Training Exam (ABSITE) can be used to quantitate cognitive learning during a surgical residency and to identify areas of curricular weakness in a residency program. Knowledge on each question is categorized as high (known) or low (unknown) depending on the percentage of residents who answered correctly. Knowledge of Level 1 (entry) residents is then compared with Level 5 (exit) residents. Each ABSITE question can thus be categorized on entry versus exit as known-known, unknown-unknown, unknown-known, and known-unknown. Only about half of unknown knowledge on entry appears to become known on exit. Very little knowledge known on entry becomes unknown on exit. Weaknesses in specific subject areas can be readily identified by ranking questions according to the number of exiting residents who answer incorrectly. Use of this technique to quantitate cognitive learning in a residency program may allow objective assessment of changes in curriculum.