Working group 6: The role of technology to enhance clinical and educational efficiency.
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Cardiology↗
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Construct validity testing of a laparoscopic surgical simulator.
BACKGROUND: We present initial data on the construct, content, and face validity of the LAPMentor (Simbionix), virtual reality laparoscopic surgical simulator. STUDY DESIGN: Medical students (MS), residents and fellows (R/F), and experienced laparoscopic surgeons (ES), with < 30 laparoscopic cases per year (ES<30) and those with > 30 laparoscopic cases per year (ES>30), were tested on 9 basic skill tasks (SK) including manipulation of 0-degree and 30-degree cameras (SK1, SK2), eye-hand coordination (SK3), clipping (SK4), grasping and clipping (SK5), two-handed maneuvers (SK6), cutting (SK7), fulguration (SK8), and object-translocation (SK9). RESULTS: Mean MS (n=23), R/F (n=24), ES<30 (n=26), and ES>30 (n=30) ages were 26 years (range 21 to 32 years), 31 years (range 27 to 39 years), 49 years (range 31 to 70 years) and 47 years (range 34 to 69 years), respectively. In the lower level skill tasks (SK3, SK4, SK5, and SK6) the ES>30, ES<30, and R/F had similar scores, but were all substantially better than the MS scores. In the higher level skill tasks (SK7, SK8, and SK9), the ES>30 scores tended to be better than the R/F and ES<30, which were similar, and these, in turn, were markedly better than the MS. The ES>30 had notably higher SK8 scores than the R/F and ES<30, who had similar scores, and these had notably better scores than the MS. CONCLUSIONS: The noncamera skills (SK3 to 9) of the LAPMentor surgical simulator can distinguish between laparoscopically naive and ES. SK8 showed the highest level of construct validity, by accurately differentiating among the MS, R/F, ES<30 and ES>30.
Adult↗
The value of virtual reality-simulator training in the development of laparoscopic surgical skills.
OBJECTIVE: To determine the effectiveness of virtual reality (VR) training in improving the surgical skills of medical students and gynecologic trainees. DESIGN: A prospective observational study to assess the changes observed in objectively measured surgical performance after VR training. SETTING AND POPULATION: University teaching hospital and the laboratories of the University of Western Australia. PARTICIPANTS: Fifteen 5th-year medical students, six junior-doctor trainees (years 1-3), and eight senior trainees (years 4-6). INTERVENTIONS: Standard gynecologic procedures before and after VR training were undertaken on sheep. The procedures were video-recorded and edited to blind the scorer as to identity and seniority of the operator. The procedures were scored using a combination of operative time and penalties for surgical errors. The surgical scores were correlated with the VR scores. MEASUREMENTS AND MAIN RESULTS: Operative skills were assessed using a combination score compiled from scores obtained while undertaking salpingectomy, salpingotomy, and tubal clipping. Virtual reality scores were also a combination score derived from summation of various computer-calculated measures of time and accuracy in undertaking two standardized exercises. RESULTS: The baseline VR scores were significantly related to the overall pre-training scores (salpingectomy p = .032). A better initial VR score was also predictive of better surgical performance. The initial VR score was also predictive of improvement observed between baseline and post-training (p = .004). CONCLUSION: Virtual reality training is of value in improving surgical skills in the clinical environment. It appears to be of most value in the earliest stages of training. These data suggest that serious consideration should be given to incorporating VR training into the training program of obstetricians and gynecologists at an early stage.
Adult↗
Multicenter construct validity for southwestern laparoscopic videotrainer stations.
BACKGROUND: The "Southwestern" videotrainer stations have demonstrated concurrent validity (transferability to the operating room). The purpose of this study was to evaluate the Southwestern stations for construct validity (the ability to discriminate between subjects at different levels of experience). MATERIALS AND METHODS: From two surgical training programs, Institutional Review Board approved protocol data were collected from 142 subjects, including novice (medical students and R1, n = 66), intermediate (R2-R4, n = 67), and advanced (R5 and expert surgeons, n = 9) groups. All participants performed three repetitions on each of five stations. Completion time was scored for each task. Laparoscopic experience was determined from residency case log databases and from expert surgeon personal case logs. Results for the three groups were compared using one-way ANOVA, including relevant pair-wise comparisons. Correlations between number of laparoscopic cases performed and task scores were determined by Pearson's and Spearman's rho-correlation coefficients. RESULTS: The mean number of laparoscopic cases performed prior to completing the five tasks was 0 for novices, 9 for intermediates, and 431 for the advanced group. Significant differences (P < 0.001) were noted between groups for all five tasks and composite score. Task scores and composite scores significantly correlated with laparoscopic experience (P < 0.01). CONCLUSION: These data suggest that differences in laparoscopic ability are detected by performance on the videotrainer; thus, construct validity is demonstrated. Moreover, scores accurately reflect laparoscopic experience. Further validation may allow such simulators to be used for testing and credentialing purposes.
Adult↗
Self-assessment in simulation-based surgical skills training.
BACKGROUND: Simulation-based training provides minimal feedback and relies heavily on self-assessment. Research has shown medical trainees are poor self-assessors. The purpose of this study was to examine trainees' ability to self-assess technical skills using a simulation-trainer. METHODS: Twenty-one medical students performed 10 repetitions of a simulated task. After each repetition they estimated their time and errors made. These were compared with the simulator data. RESULTS: Task time (P < 0.0001) and errors made (P < 0.0001) improved with repetition. Both self-assessment curves reflected their actual performance curves (P < 0.0001). Self-assessment of time did not improve in accuracy (P = 0.26) but error estimation did (P = 0.01) when compared with actual performance. CONCLUSIONS: Novices demonstrated improved skill acquisition using simulation. Their estimates of performance and accuracy of error estimation improved with repetition. Clearly, practice enhances technical skill self-assessment. These results support the notion of self-directed skills training and could have significant implications for residency training programs.
Clinical Competence↗
Operative outcomes of minimally invasive saphenous vein harvest.
BACKGROUND: The longest incision used in surgery is the standard incision for harvesting the greater saphenous vein for arterial grafting. This long incision is associated with significant pain and morbidity. We present a comparative study between two relatively less invasive techniques: the standard bridge technique (BT) and the endoscopic saphenous vein harvest (ESVH). PATIENTS AND METHODS: This is a prospective, nonrandomized, case-matched study of contemporaneous minimally invasive saphenous vein harvest in patients undergoing multiple vessel coronary artery bypass grafting (CABG). Data points include operative time, total wound length, length of vein harvested, intraoperative complications, conversions to open, injury to the graft, postoperative complications and hospital length of stay. Follow-up continued for 8 weeks postdischarge. RESULTS: Within a 10-month period (July 1996 to May 1997), 60 saphenous vein harvests were performed, with 29 by BT and 31 by ESVH. Patient demographics were well matched, except for a larger number of patients with peripheral vascular disease in the ESVH group. ESVH only required 2.3 incisions versus 5 for the BT (P = 0.000001), whereas ESVH produced on average longer veins of 53.9 cm versus 47.7 cm for BT (P = 0.05). Harvest times were comparable in the two groups. However, mean vein preparation times, incision closure times, and total vein operative times for the BT were, respectively, 18.5 minutes, 35.1 minutes, and 94 minutes versus significantly less times of 11.3 minutes (P = 0.009), 10.6 minutes (P = 0.000001), and 73 minutes (P = 0.0001), respectively, for ESVH. The early, minor wound complication rate was 32% for the ESVH group versus 3% for the BT group (P = 0.0048). However, excluding small wound hematomas, the wound complication rate in the ESVH group fell to 13%. Graft quality was acceptable in both groups. CONCLUSIONS: ESVH was demonstrated to be a useful procedure to harvest saphenous veins for CABG surgery. The ESVH technique allowed the harvesting of a longer vein, via shorter and fewer incisions and in less time. However, for maximum operating room efficiency with the new technology, staff education is essential. There was a greater incidence of minor wound complications in the ESVH group; however, the majority of these ESVH complications were small wound hematomas, which did not occur as surgeon experience with the technique increased.
Aged↗
Towards a learning organization: the introduction of a client-centered team-based organization in administrative surveying work.
Within administrative surveying work in Sweden, a transition to a client-centered team-based organization was made during 1998. The aim of this study was to describe the employees' perceptions and expectations of job and organizational practices when working as a generalist in a client-centered team-based organization; job and organizational practices and well-being and effectiveness measures were examined when introducing a team-based organization. Interventions such as courses in how to cope with the role of a generalist, how to increase service to clients, education in technology, law and economics, as well as computer information support, were ongoing at the time of the study. The Team Work Profile and QPS Nordic questionnaires were used. All the surveyors in five regions in Sweden participated, in total 640 surveyors. The transition to a client-centered team-based organization was expected to improve job control and job content but at the same time lead to impairments in job climate and group cohesion. Distress was associated with negative future expectations of the organization. High job control and group cohesion were the central contributors towards growth in personal competence and social effectiveness of teamwork. Both internal and external client-related activities of team and organization were in focus during the transition.
Cooperative Behavior↗
Computer generated slides: a need to curb our enthusiasm.
The popular use of computer generated slides for presentations during plastic surgery scientific meetings has opened a fresh chapter in audiovisual techniques. Although the profusion of colours seen during presentations is a visual treat, the information imparted by these slides leaves much to be desired and raises the question of whether such attractive and apparently professionally made slides are visual aids during such presentations. Presentation slides are displayed for a very short time (10-15 seconds) as compared to slides displayed during a lecture and therefore these presentation slides should have the ability to impart their information very quickly. We conducted a study wherein 36 slides, each having a different colour combination, were displayed to a class of third year medical students who were asked to judge the efficacy of each slide. The attractiveness, clarity and recall of each slide was graded by every student and, with the information obtained, the most effective format and colour combinations to be used while making slides for presentations were established. We conclude that the best format for slides is a plain dark coloured background (blue, purple or green) and a separate, contrasting plain dark coloured title text background (red, green or purple), with white letters for the text and yellow letters for the title.
Audiovisual Aids↗
Interactive multimedia patient simulations in dental and continuing dental education.
Transfer of knowledge from the basic biopsychosocial sciences to patient care is a major task for dental students during their education. Computer-based interactive patient simulations can help students affect this transfer because simulations allow students to develop and practice problem solving and decision-making skills interactively within the context of patient problems. A program for authoring computer-based interactive simulations is described. Patient simulations can effectively integrate basic science relevance, preparation for clinical problem solving, teaching new clinical content and several other necessary elements into curriculum infrastructure. Case simulations also can contribute to evolving educational standards set out by accrediting bodies.
Accreditation↗
Autism and pervasive developmental disorders.
Autism and pervasive developmental disorder, not otherwise specified represent a complex developmental disability in which clinical signs include language delay, social unrelatedness, and unusual or restricted interests. Gradually a better understanding of these disorders as being neurologically-based developmental disorders with multiple etiologies has replaced the idea of emotional disturbance. Although pervasive developmental disorders are rare, the potentially devastating effects make early recognition by pediatricians imperative. Yet, despite promising treatment advances in education, communication technology, behavior treatments, and pharmacology, the prognosis for these disorders remains guarded.
Autistic Disorder↗
The composting potential of different organic solid wastes: experience from the island of Crete.
For the past 20 years, the National Foundation for Agricultural Research in Crete and the School of Agricultural Technology of the Technological and Educational Institute of Crete have been involved in a number of research and development activities, related to the production and evaluation of compost derived from a variety of local solid, mainly agricultural organic wastes. Materials such as olive press cake, olive tree leaves (OTL) and branches, vine branches (VB), pressed grape skins (PGS), pig manure (PM), sewage sludge and the organic fraction of municipal solid waste (OFMSW) have been evaluated for their behaviour during composting, their compatibility in mixtures and the quality of the end product. The quality evaluation included both a detailed physiochemical (pH, electrical conductivity (EC), nutrients concentration, heavy metal concentration, etc.) and biological analyses (pathogenic microorganisms). It also included an agronomic evaluation, in which composts were used either as a soil amendment or as a component for substrates in open air or covered (greenhouse) cultivation mainly of local vegetables (tomatoes, cucumbers, etc.). All materials were composted successfully, especially when mixed. The end products contained large amounts of organic matter, usually combined with an increased EC value. Pressed grape skins should be considered as the ideal raw material, producing a high quality compost, with the lowest EC value (1.57 mS cm(-1)) and the largest organic matter concentration (84.50%), compared to all other materials. When any of the produced compost was used in a ratio of 30% by volume (v/v), it increased plant growth, whereas in larger volumes, it presented phytotoxic behaviour, inhibiting both root and shoot development.
Agriculture↗
Survey of methods of teaching and learning in undergraduate pharmacology within UK higher education.
Many of the pharmacology teachers surveyed in a questionnaire on pharmacology teaching and learning are aware of nontraditional teaching and learning methods and believe they are both appropriate to the discipline and effective in producing learning gain in the students. The reasons that nontraditional teaching methods are not used extensively include a shortage of staff time together with a perception that nontraditional teaching methods are staff-time intensive, a lack of effective motivation and reward of staff by their institutions for implementing nontraditional teaching methods and a shortage of the appropriate facilities and resources required. The questionnaire and its results are discussed in this article.
Adult↗
Group practice--trend for the future.
Group practices in various forms and combinations appear to set the trend for small animal practice management. By pooling their financial resources, energies, and talents, veterinarians can share the burden of increasing overhead costs and enjoy the benefits of specialization, new technologies, continuing education, consultations and referrals, peer review, applied research and publication, and fringe benefits such as paid vacation and sick leave, profit sharing, and pension. Group practices preserve ownership continuity at fair market value and afford opportunities for the utilization of expert business consultants. There are prerequisites to establishing a successful group practice: An adequate personal income base, a sufficient pet population, and business associates with compatible practice philosophy. Special considerations must be given to the social, economic, and psychological forces at work in a group practice environment. Professional and personal interactions can make or break a group practice. The group concept, MIP treatment of clients and their pets, and personalized appointments are important features which must be emphasized. The law of supply and demand and the law of diminishing returns must be kept in focus at all times. In tandem, they dictate the fortunes of all business enterprises and group practices can be particularly vulnerable to them. Long-term business commitment is a condition of group practice ownership and may pose a conflict with other interests. A predetermined buy-sell agreement and deferred compensation plan may provide the answer in case of dissolution, termination, or early retirement. A system of animal and material transport and transfer of business transactions and medical records must be set up between satellite clinics and the base hospital. A hospital-owned-and-operated shuttle service appears to offer the greatest flexibility and convenience. Cost-effectiveness of a shuttle service depends on the volume of referral cases generated for the base hospital. Computers may provide the answer to rapid and reliable transfer of data between satellite clinics and central or base hospitals in the near future. New approaches to small animal medicine and practice management must be explored and adopted. Prepaid pet medical insurance seems to be the answer to rapidly growing sophistication and escalating cost of small animal patient care. Human and companion animal interactions have been given a fresh impetus by veterinary educators, clinical psychologists, psychiatrists, humane societies, organizations for the mentally and physically handicapped, gerontologic centers, and others.(ABSTRACT TRUNCATED AT 400 WORDS)
Animals↗
Staying on the cutting edge and avoiding the bleeding edge.
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Computers↗
Feasibility of obtaining pulmonary venous flow velocity in cardiac patients using transthoracic pulsed wave Doppler technique.
The purpose of this study was to determine, in an adult population, the percentage of patients in whom high quality pulmonary venous flow velocity recordings can be obtained using current transthoracic pulsed wave Doppler techniques. Pulmonary venous and mitral flow velocity variables obtained with a pulsed wave Doppler method were used for the indirect assessment of left ventricular (LV) diastolic function and LV filling pressures. The general clinical use of these methods, however, remains uncertain because the transthoracic success rate of obtaining all components of pulmonary venous flow velocity has been variable, and sometimes reported to be as low as 30% to 60%. Mitral and pulmonary venous flow velocity variables were obtained using pulsed wave Doppler signals in 200 consecutive adult patients (mean age 68.2 +/- 11.4 years) in normal sinus rhythm who were referred for echocardiographic study. Six cardiac sonographers and five ultrasound systems were used. The success rate for obtaining pulmonary venous systolic and diastolic flow velocity was 95%, reverse flow velocity at atrial contraction was 90%, and the duration of reverse flow at atrial contraction was 89%. In the 5% to 11% of patients in whom pulmonary flow velocities could not be adequately recorded, the most common reasons were depth limitations of the pulsed wave Doppler machine, marked cardiac enlargement, or left atrial wall motion artifact. The success rate also was influenced by the ultrasound equipment used, individual variation among sonographers, and even the type (impaired, pseudonormal, restricted) of associated mitral filling pattern. Given current machine technology, sonographer education, and daily practice, high quality, complete recordings of pulmonary venous flow velocity can be obtained in approximately 90% of adult patients using the precordial transthoracic Doppler technique. These results suggest that using these variables as an aid for evaluating LV diastolic function and filling pressures may have broader clinical applicability than previously appreciated.
Adult↗
Multicultural media portrayals and the changing demographic landscape: the psychosocial impact of television representations on the adolescent of color.
The developmental stage of adolescence can be a challenging period with the need for the young person to negotiate certain early psychosocial and physiologic developmental tasks. The developmental tasks that are common to most adolescents can include some unique social, economic, and educational experiences for minority youth because of the sociocultural construction of American society. This article explores some of the theories, concepts, and creative issues related to the psychosocial impact on adolescents of color and multicultural portrayals that appear on television and in other emerging media.
Adolescent↗
The challenge of the evolving media environment.
As media become more powerful and prominent, questions about their positive and negative effects on children and youth will increase. Although the body of quality research about media and youth is growing, there are some significant gaps. Three important areas for future research are identified: physiological research, differential effects research, and media education outcomes research.
Adolescent↗
Improved flight following through continuous quality improvement.
INTRODUCTION: Flight following is a key component of an air medical transport service's safety program. National standards require conscientious adherence to flight following. EastCare monitored its compliance with internal flight-following requirements for three years. SETTING: EastCare is a single-helicopter, hospital-based air medical transport service located in a rural region of the southeastern United States. It has a full-time staff of flight nurses, pilots and communications specialists. METHODS: A continuous quality improvement (CQI) process was initiated to delineate specific areas requiring improvement. These areas were discussed at the air medical service's monthly CQI meetings. RESULTS: In 1989, the communications specialists achieved flight following intervals of < or = 15 minutes in 98% of attempts. In 1990 and 1991, the frequency of flight-following intervals of < or = 15 minutes were 98.8% and 99.6%, respectively. The CQI process pointed out educational requirements, technological problems and other areas for improvement. CONCLUSION: The use of a structured CQI process for this service directly contributed to consistently strong compliance in the frequency of flight following.
Air Ambulances↗