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Simpson AN, Baxter NN, Sorvari A, Boury H, Shore EM, Bogler T, Campbell D, Gagliardi AR. Strategies to support maternal and early childhood wellness: insight from parent and provider qualitative interviews during the COVID-19 pandemic. BMJ Open 2024; 14:e079479. [PMID: 38272559 PMCID: PMC10824034 DOI: 10.1136/bmjopen-2023-079479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/12/2024] [Indexed: 01/27/2024] Open
Abstract
OBJECTIVES The COVID-19 pandemic resulted in rapid changes to the delivery of maternal and newborn care. Our aim was to gain an understanding from parents and healthcare professionals (HCPs) of how the pandemic and associated public health restrictions impacted the peripartum and postpartum experience, as well as longer-term health and well-being of families. DESIGN Qualitative study through focus groups. SETTING Ontario, Canada. PARTICIPANTS HCPs and parents who had a child born during the COVID-19 pandemic. INTERVENTIONS Semistructured interview guide, with questions focused on how the pandemic impacted their care/their ability to provide care, and strategies to improve care and support now or in future situations with similar healthcare restrictions. OUTCOME MEASURES Thematic analysis was used to describe participant experiences and recommendations. RESULTS We included 11 HCPs and 15 parents in 6 focus groups. Participants described their experiences as 'traumatic', with difficulties in accessing prenatal and postpartum services, and feelings of distress and isolation. They also noted delays in speech and development in children born during the pandemic. Key recommendations included the provision of partner accompaniment throughout the course of care, expansion of available services for young families (particularly postpartum), and special considerations for marginalised groups, including access to technology for virtual care or the option of in-person visits. CONCLUSIONS Our findings may inform the development of healthcare system and organisational policies to ensure the provision of maternal and newborn care in the event of future public health emergencies. Of primary importance to the participants was the accommodation of antenatal, intrapartum and postpartum partner accompaniment, and the provision of postpartum services.
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Affiliation(s)
- Andrea N Simpson
- Department of Obstetrics & Gynaecology, University of Toronto, Toronto, Ontario, Canada
- St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
| | - Nancy N Baxter
- The University of Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Anne Sorvari
- St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
| | - Himani Boury
- Toronto General Hospital, Toronto, Ontario, Canada
| | - Eliane M Shore
- Department of Obstetrics & Gynaecology, University of Toronto, Toronto, Ontario, Canada
- St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
| | - Tali Bogler
- St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, University of Toronto, Toronto, ON, Canada
| | - Douglas Campbell
- St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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Khan H, McCaffrey C, Gagnon LH, Hui D, Sobel M, Shore EM. Letter: Evaluating the Impact of a Teaching Video on Medical Students' Knowledge of Induction of Labour: A Pilot Project in Undergraduate Obstetrics Education. J Obstet Gynaecol Can 2023; 45:102156. [PMID: 37230225 DOI: 10.1016/j.jogc.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/03/2023] [Accepted: 05/08/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Haniya Khan
- Department Obstetrics and Gynecology, University of Toronto, Toronto, ON
| | - Carmen McCaffrey
- Department Obstetrics and Gynecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, ON
| | - Louise-Helene Gagnon
- Department Obstetrics and Gynecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Dini Hui
- Department Obstetrics and Gynecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
| | - Mara Sobel
- Department Obstetrics and Gynecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | - Eliane M Shore
- Department Obstetrics and Gynecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, ON.
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Sansregret A, Garber A, Freire-Lizama T, Monton L, Mueller V, Papalia N, Ruiter PJA, Shore EM, Suri M. Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology. J Obstet Gynaecol Can 2023; 45:214-226.e1. [PMID: 37055148 DOI: 10.1016/j.jogc.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
OBJECTIVE To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates. TARGET POPULATION Providers working to improve health care for Canadian women and their families; patients and their families. OUTCOMES Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition. BENEFITS, HARMS, AND COSTS This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time. EVIDENCE Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords "simulation" and "simulator." The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All health care professionals working to improve Canadian women's health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs. RECOMMENDATIONS
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Sansregret A, Garber A, Freire-Lizama T, Monton L, Mueller V, Papalia N, Ruiter PJA, Shore EM, Suri M. Déclaration de consensus n o 434 : Simulation en obstétrique et gynécologie. J Obstet Gynaecol Can 2023; 45:227-240.e1. [PMID: 37055149 DOI: 10.1016/j.jogc.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
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Louridas M, Iancu AM, Grantcharov T, Steele D, Ahmed N, Shore EM. Modeling Technical Skills Learning Curves of Incoming Surgical Trainees. J Surg Educ 2023; 80:51-61. [PMID: 36115788 DOI: 10.1016/j.jsurg.2022.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/17/2022] [Accepted: 08/20/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Not all trainees reach technical competency even after completing surgical training. While assessment of technical skill is not part of the residency interview process, identifying under-performers early on may help identify opportunities for individualized, targeted training. The objectives of this study were to (1) create predictive learning curve (LC) models for each of 3 basic laparoscopic tasks to identify performers versus underperformers and (2) evaluate the use of LCs to identify underperformers during selection into surgical training. DESIGN Predictive LC models were created for laparoscopic pattern cutting (PC), peg transfer (PT) and intra-corporeal knots (IC) over 40 repetitions by 65 novice trainees in 2014. Trainees were categorized as performers and underperformers. Receiver operator characteristic analysis determined the minimum number of repetitions required to predict individual LCs, which were then used to determine the proportion of underperformers. SETTING Technical performance was assessed onsite at the Canadian Residence Matching Service (CaRMS) interviews, after interview completion (January 2015). PARTICIPANTS Applicants to general surgery (GS) and gynecology (OBGYN) participated in a skills assessment during. RESULTS The PC, PT and IC tasks required a minimum of 8, 10, and 5 repetitions respectively, to predict overall performance. Predictive values for each task had excellent sensitivity and specificity: 1.00, 1.00 (PC); 1.00, 1.00 (PT); and 0.94, 1.00 (IC). Eighty applicants completed 8 PC repetitions; 16% were identified as underperformers. CONCLUSIONS Individual LCs for three different laparoscopic tasks can be predicted with excellent sensitivity and specificity based on 10 repetitions or less. This information can be used to identify trainees who may have difficulty with laparoscopic technical skills early on.
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Affiliation(s)
- Marisa Louridas
- Department of Surgery, University of Toronto, Toronto, Ontario,Canada
| | - Ana-Maria Iancu
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Teodor Grantcharov
- Department of Surgery, University of Toronto, Toronto, Ontario,Canada; International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Donna Steele
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Najma Ahmed
- Department of Surgery, University of Toronto, Toronto, Ontario,Canada; Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Eliane M Shore
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada.
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Gordon L, Reed C, Sorensen JL, Schulthess P, Strandbygaard J, Mcloone M, Grantcharov T, Shore EM. Perceptions of safety culture and recording in the operating room: understanding barriers to video data capture. Surg Endosc 2022; 36:3789-3797. [PMID: 34608519 DOI: 10.1007/s00464-021-08695-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 08/23/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Recording in the operating room is an important tool to help surgical teams improve their performance. This is becoming more feasible using the Operating Room Black Box, a comprehensive data capture platform. Operating room (OR) staff, however, may voice reasonable concerns as recording initiatives are implemented. The objective of this study was to assess pre-implementation attitudes of OR staff toward operative recording and explore the relationship of these attitudes to the themes of (1) safety culture, (2) impostor syndrome, and (3) privacy concerns. METHODS This cross-sectional survey study measured staff members' beliefs and opinions of operative recording and used three previously validated tools (safety attitudes questionnaire, clance impostor phenomenon scale, and dispositional privacy concern) to assess personal and professional factors. Concepts were correlated using Pearson's correlation coefficient. RESULTS Forty-three staff members participated in this study, with a response rate of 45% (n = 43/96, 20/22 nurses, 9/11 gynecologists, 14/63 anesthesiologists). Opinions of operative data capture were generally positive (5-point Likert scale, mean = 3.81, SD = 0.91). Nurses tended to have more favorable opinions of the OR Black Box as compared to gynecologists and anesthesiologists, though this did not reach statistical significance (4.15 vs. 3.67 vs 3.43, p = 0.06). Impostor syndrome characteristics correlated with concerns about litigation related to recording (r = - 0.32, p = 0.04). CONCLUSION There are personal and professional attributes of the OR team that impact perceptions of the OR Black Box and implications around privacy and litigation. Addressing these concerns may facilitate successful implementation of the OR Black Box and improve team communication and patient safety in the OR.
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Affiliation(s)
- Lauren Gordon
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 61 Queen St East, 5th Floor, Toronto, ON, M5C 2T2, Canada
- Department of Vascular Surgery, University of Toronto, Toronto, Canada
| | - Cheyanne Reed
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jette Led Sorensen
- Department of Obstetrics and Gynaecology, Juliane Marie Centre for Children, Women and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pansy Schulthess
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 61 Queen St East, 5th Floor, Toronto, ON, M5C 2T2, Canada
- Department of Perioperative Services, St. Michael's Hospital, Toronto, Canada
| | - Jeanett Strandbygaard
- Department of Obstetrics and Gynaecology, Juliane Marie Centre for Children, Women and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Mary Mcloone
- Department of Anaesthesia, St. Michael's Hospital, Toronto, Canada
| | - Teodor Grantcharov
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 61 Queen St East, 5th Floor, Toronto, ON, M5C 2T2, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Eliane M Shore
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 61 Queen St East, 5th Floor, Toronto, ON, M5C 2T2, Canada.
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada.
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Canada.
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Miazga E, Shore EM. Trial of labour after caesarean delivery. CMAJ 2022; 194:E13. [PMID: 35012947 PMCID: PMC8800470 DOI: 10.1503/cmaj.211686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Elizabeth Miazga
- Department of Obstetrics and Gynecology, Unity Health - St. Michael's Hospital; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ont.
| | - Eliane M Shore
- Department of Obstetrics and Gynecology, Unity Health - St. Michael's Hospital; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ont
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Miazga E, Benlolo S, Shore EM, McCaffrey C, Simpson A, Robertson D, Kives SL, Nensi A. It's in the Bag! a Review of Laparoscopic Specimen Retrieval. J Minim Invasive Gynecol 2021. [DOI: 10.1016/j.jmig.2021.09.507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bogler T, Hussain-Shamsy N, Schuler A, Pirmohamed J, Shore EM, Wijayasinghe S, Dennis CL, Vigod SN, Barker LC. Key concerns among pregnant individuals during the pandemic: Online cross-sectional survey. Can Fam Physician 2021; 67:e257-e268. [PMID: 34521722 DOI: 10.46747/cfp.6709e257] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine common sources of concern among pregnant individuals during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN A cross-sectional, open, online electronic survey from May 9, 2020, to June 14, 2020. SETTING Electronic survey open internationally and advertised through Canadian-based social media platforms. PARTICIPANTS Eligible participants understood English and had been pregnant during the COVID-19 pandemic (ie, were pregnant at the time of survey completion or had delivered an infant on or after March 11, 2020). MAIN OUTCOME MEASURES Potential sources of concern related to the pandemic, calculated as the proportion of participants who endorsed each concern among those for whom the concern was relevant. Differences in the proportion of individuals endorsing each concern were compared by parity using modified Poisson regression. Frequency of concerns was examined in terms of level of distress, as per the Kessler Psychological Distress Scale (K6), using multivariable linear regression. RESULTS Out of 1477 participants, 87.3% were Canadian. Top concerns included the following: hospital policies related to support persons during labour (80.9%), not being able to introduce the baby to family and friends (80.1%), and developing COVID-19 while pregnant (79.2%). Primiparous participants were more likely than multiparous participants to be concerned about accessing in-person prenatal classes (51.5% vs 13.3%; relative risk = 3.88; 95% CI 2.02 to 4.98) and cancellation of hospital tours (35.0% vs 5.6%, relative risk = 6.26; 95% CI 4.25 to 9.20), among other concerns. The mean (SD) K6 score was 6.7 (3.8) within the moderate to high distress range. Number of concerns reported was associated with K6 score in both primiparous (β = 0.24; 95% CI 0.20 to 0.29; P < .0001) and multiparous (β = 0.30; 95% CI 0.24 to 0.36; P < .0001) individuals. CONCLUSION Pregnant individuals have unique concerns during the COVID-19 pandemic and the findings indicate the importance of targeted support strategies to meet the particular needs of both primiparous and multiparous pregnant individuals.
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Affiliation(s)
- Tali Bogler
- Family physician and Chair of Family Medicine Obstetrics at St Michael's Hospital (SMH) Academic Family Health Team in Toronto, Ont, Investigator at the Li Ka Shing Knowledge Institute at SMH, and Assistant Professor in the Department o Family and Community Medicine at the University of Toronto (UofT)
| | - Neesha Hussain-Shamsy
- PhD Candidate in Health Services Research at the Institute for Health Policy, Management and Evaluation (IHPME) at UofT
| | - Andrée Schuler
- Research Associate in the Department of Family and Community Medicine at UofT and MAP Centre for Urban Health Solutions at SMH
| | - Jenna Pirmohamed
- Knowledge Broker at the Innovation Office in the Centre for Aging + Brain Health Innovation at Baycrest Health Sciences in Toronto
| | - Eliane M Shore
- Obstetrician and gynecologist at SMH, Investigator at th Li Ka Shing Knowledge Institute, and Assistant Professor in the Department of Obstetrics and Gynaecology at UofT
| | - Sheila Wijayasinghe
- Family physician at SMH, Medical Director of primary care outreach at Women's College Hospital (WCH) in Toronto, and Lecturer at UofT
| | - Cindy-Lee Dennis
- Professor in the Lawrence S. Bloomberg Faculty of Nursing and in the Department of Psychiatry in the Faculty of Medicine at UofT
| | - Simone N Vigod
- Professor in the Department of Psychiatry and the IHPME at UofT, and is Chief of the Department of Psychiatry and the Shirley A. Brown Memorial Chair in Women's Mental Health Research at WCH
| | - Lucy C Barker
- PhD student at the IHPM at UofT, a fellow at Women's College Research Institute and in the Department of Psychiatry at UofT, and a psychiatrist at WCH
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Miazga E, Reed C, Tunde-Byass M, Cipolla A, Shapiro J, Shore EM. Corrigendum to 'Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle' [Journal of Obstetrics and Gynaecology Canada 42 (2020) 1111-1115]. J Obstet Gynaecol Can 2021; 43:1120. [PMID: 34481584 DOI: 10.1016/j.jogc.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Elizabeth Miazga
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.
| | - Cheyanne Reed
- Faculty of Medicine, University of Toronto, Toronto, ON
| | - Modupe Tunde-Byass
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, North York General Hospital, North York, ON
| | - Amanda Cipolla
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, Trillium Health Partners, Mississauga, ON
| | - Jodi Shapiro
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynecology, Mount Sinai Hospital, Toronto, ON
| | - Eliane M Shore
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, ON
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Nensi A, Palter V, Reed C, Schulthess P, Mcloone M, Grantcharov T, Shore EM. Utilizing the Operating Room Black Box to Characterize Intraoperative Delays, Distractions, and Threats in the Gynecology Operating Room: A Pilot Study. Cureus 2021; 13:e16218. [PMID: 34367818 PMCID: PMC8341265 DOI: 10.7759/cureus.16218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Operating Room Black Box (ORBB) technology can be used to capture information during surgery for analysis and potential identification of root causes that jeopardize safety and efficiency. In this study, our objective was to identify and characterize procedural steps, intraoperative distractions, errors, and threats, as well as the non-technical skills of the team during a common minimally invasive gynecologic procedure. Methodology This was a cross-sectional pilot study of 25 patients undergoing total laparoscopic hysterectomy between May 2019 and February 2020 at a Canadian tertiary care academic hospital. Video, audio, and patient physiologic data from all procedures were obtained through a multichannel synchronized recording device (ORBB). Trained analysts reviewed and coded the recordings. Results The median total case time was 165 minutes (interquartile range [IQR]: 160-178 minutes) with the shortest step being cystoscopy and the longest being vaginal cuff closure. Time pressure and device absence or malfunction occurred in 48% of the cases, and a median of 262 (IQR: 228-304) auditory distractions were noted per case. There was a median of 3 (IQR: 2-4) safety threats identified per case and at least one error was identified in 11/25 cases (44%). Only two adverse events were noted among all 25 cases. Observed non-technical skills were mainly positive, and observations were the highest for situational awareness and leadership among the surgical team and communication and teamwork among the nursing/scrub technician and anesthesia teams. Conclusions This study is a novel application of the ORBB in the gynecology operating room to capture information regarding procedure times, intraoperative distractions, errors, and non-technical skills of the team. Frequent intraoperative cognitive and auditory distractions were noted. Although adverse events were rare, safety threats were identified. Ongoing and future research from our group will aim to identify key areas for organizational, technological, and team improvement to minimize inefficiencies and optimize patient safety in the operating room.
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Affiliation(s)
- Alysha Nensi
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, CAN
| | - Vanessa Palter
- Department of Surgery, St. Michael's Hospital, Toronto, CAN
| | - Cheyanne Reed
- Obstetrics and Gynecology, University of Toronto, Toronto, CAN
| | | | - Mary Mcloone
- Department of Anesthesia, St. Michael's Hospital, Toronto, CAN
| | | | - Eliane M Shore
- Obstetrics and Gynecology, University of Toronto, Toronto, CAN.,Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, CAN
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Benlolo S, Hanlon J, Shirreff L, Lefebvre G, Husslein H, Shore EM. Predictive variables for postoperative opioid requirements following hysterectomy. Journal of Obstetrics and Gynaecology Canada 2021. [DOI: 10.1016/j.jogc.2021.02.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Miazga E, Reed C, Olsthoorn A, Fan I, Zhao E, Shapiro J, Cipolla A, Tunde-Byass M, Shore EM. Decreasing caesarean delivery rates using a trial of labour after caesarean delivery (TOLAC) bundle: a multisite quality improvement initiative. Journal of Obstetrics and Gynaecology Canada 2021. [DOI: 10.1016/j.jogc.2021.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Miazga E, Benlolo S, Shore EM, McCaffrey C, Simpson A, Robertson D, Kives S, Nensi A. It's in the bag! A review of laparoscopic specimen retrieval. Journal of Obstetrics and Gynaecology Canada 2021. [DOI: 10.1016/j.jogc.2021.02.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Simulation’s benefits in medical education are well established. However, its use for pandemic preparedness in obstetrics is lacking. Management of obstetrical patients with suspected COVID-19 infection is a complex task with safety considerations for mother, fetus and healthcare workers. Implementation of new workflow algorithms to ensure safety is critical but is challenging to implement in real-time. We sought to improve pandemic preparedness by designing and deploying a high-fidelity simulation exercise involving the admission of a labouring obstetrical patient with suspected COVID-19 into a labour room, urgent transfer to the operating room and neonatal resuscitation. The creation of the simulation scenario was a multi-disciplinary effort with input from a focus group of key clinical stakeholders from within and outside of our centre to ensure clinical validity. Simulations were performed on the clinical unit during regular work hours so workflow could be observed in real-time with access to the equipment and personnel in which this clinical scenario would occur. We completed a total of 11 simulation sessions involving 42 participants. Feedback, obtained from debrief sessions and anonymous surveys, was categorized based on the human factors framework, and used as part of an iterative process to adapt, revise and improve the simulation scenario. The result of this iterative process was the creation of validated departmental infection control protocols that continue to be implemented through the second wave of the COVID-19 pandemic.
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Affiliation(s)
- Samantha Benlolo
- Obstetrics and Gynaecology, St. Michael's Hospital, Unity Health Toronto, Toronto, CAN
| | - Alysha Nensi
- Obstetrics and Gynaecology, St. Michael's Hospital, Unity Health Toronto, Toronto, CAN
| | | | - Caroline Assouad
- Obstetrics and Gynaecology, St. Michael's Hospital, Unity Health Toronto, Toronto, CAN
| | - Taryn S Taylor
- Obstetrics and Gynaecology, London Health Sciences Centre, Schulich School of Medicine and Dentistry, London, CAN
| | - Eliane M Shore
- Obstetrics and Gynaecology, St. Michael Hospital, Unity Health Toronto, Toronto, CAN
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Norris S, Papillon-Smith J, Gagnon LH, Jacobson M, Sobel M, Shore EM. Effect of a Surgical Teaching Video on Resident Performance of a Laparoscopic Salpingo-oophorectomy: A Randomized Controlled Trial. J Minim Invasive Gynecol 2020; 27:1545-1551. [DOI: 10.1016/j.jmig.2020.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
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Miazga E, Reed C, Tunde-Byass M, Cipolla A, Shapiro J, Shore EM. Decreasing Cesarean Delivery Rates Using a Trial of Labour After Cesarean (TOLAC) Bundle. Journal of Obstetrics and Gynaecology Canada 2020; 42:1111-1115. [DOI: 10.1016/j.jogc.2020.02.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 01/26/2023]
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Palter VN, Simpson AN, Yeung G, Lee JY, Grantcharov TP, Shore EM. Operating Room Utilization: A Retrospective Analysis of Perioperative Delays. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Vanessa N. Palter
- Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- This article was presented at the second annual CANSAGES (Canadian Society for Advanced Gynecologic Endoscopic Surgery) Conference, Montreal Quebec, September 16, 2017
| | - Andrea N. Simpson
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada
- This article was presented at the second annual CANSAGES (Canadian Society for Advanced Gynecologic Endoscopic Surgery) Conference, Montreal Quebec, September 16, 2017
| | - Grace Yeung
- The Scarborough Hospital, Toronto, Ontario, Canada
- This article was presented at the second annual CANSAGES (Canadian Society for Advanced Gynecologic Endoscopic Surgery) Conference, Montreal Quebec, September 16, 2017
| | - Jason Y. Lee
- Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- This article was presented at the second annual CANSAGES (Canadian Society for Advanced Gynecologic Endoscopic Surgery) Conference, Montreal Quebec, September 16, 2017
| | - Teodor P. Grantcharov
- Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- This article was presented at the second annual CANSAGES (Canadian Society for Advanced Gynecologic Endoscopic Surgery) Conference, Montreal Quebec, September 16, 2017
| | - Eliane M. Shore
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Ontario, Canada
- This article was presented at the second annual CANSAGES (Canadian Society for Advanced Gynecologic Endoscopic Surgery) Conference, Montreal Quebec, September 16, 2017
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Bao J, Shore EM, Simpson AN, Hare GM, Sholzberg M, Robertson D. Delphi Approach for the Design of an Intraoperative Blood Conservation Pathway for Open Myomectomy. Journal of Obstetrics and Gynaecology Canada 2020; 42:31-37. [DOI: 10.1016/j.jogc.2019.04.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 04/22/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
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Reed C, Gordon L, Sorensen JL, Schulthess P, Grantcharov TP, McLoone M, Shore EM. Perceptions of Operating Room Recording Among Surgical Staff. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Norris S, Papillon-Smith J, Gagnon LH, Jacobson M, Sobel M, Shore EM. 1928 Effect Of a Surgical Teaching Video on Resident Performance of a Laparoscopic Salpingo-Oophorectomy – A Randomized Controlled Trial. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jain L, Robertson D, Shore EM. “OVER THE RAINBOW”: A SIMPLIFIED METHOD FOR INTRACORPOREAL KNOT TYING. Journal of Obstetrics and Gynaecology Canada 2019. [DOI: 10.1016/j.jogc.2019.02.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Shirreff L, Husslein H, Lefebvre GG, Shore EM. Introduction of Physician-Nurse Bedside Rounding and Ward Task List to Improve Quality of Care in Gynaecology: Prospective, Single-Blinded, Pre- and Post-Intervention Study. J Obstet Gynaecol Can 2019; 41:1108-1114. [PMID: 30686607 DOI: 10.1016/j.jogc.2018.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/23/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study sought to determine whether physician-nurse bedside rounds and ward task list improve quality of care as measured by patient satisfaction, earlier discharge, and reduced trainee interruptions. METHODS This prospective, single-blind, pre- and post-intervention study included patients admitted to the gynaecology ward at St. Michael's Hospital in Toronto, Ontario, involving a 6-week baseline, 6-week intervention, and 2-week second baseline phase. During the intervention phase, a chief resident and charge nurse rounded at the bedside simultaneously daily. Nurses recorded non-urgent issues on a ward task list. Patients completed a subset of the National Research Corporation Picker satisfaction questionnaire, discharge times were noted, and residents recorded pages (Canadian Task Force Classification II-2). RESULTS There were 89, 104, and 30 admissions during baseline care, intervention, and second baseline phases, respectively. Mean discharge time in the intervention phase was significantly earlier than baseline (11:18 am ± 1 hour 59 minutes vs. 12:37 pm ± 2 hours 37 minutes, P < 0.001), with early discharges doubling (69% vs. 36%, P < 0.001). Discharge times returned to baseline after the intervention (12:36 pm ± 2 hours 39 minutes). Intervention phase patients appreciated bedside care plans (86 of 94 patients, 92%), with improved National Research Corporation Picker responses, which diminished post-intervention. Paging interruptions were lower during the intervention phase compared with the baseline phase (1.0 ± 1.1 vs. 3.4 ± 2.1, P < 0.001), with non-urgent pages decreasing most (0.5 ± 0.8 vs. 3.0 ± 2.0, P < 0.001). CONCLUSION Combining physician-nurse bedside rounds and ward task list reduces trainee interruptions, positively affects patient satisfaction, and promotes early discharge. Following these initiatives, discharge time, patient satisfaction, and resident paging interruptions returned to baseline.
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Affiliation(s)
- Lindsay Shirreff
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON.
| | - Heinrich Husslein
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Guylaine G Lefebvre
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON
| | - Eliane M Shore
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, ON
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Goulam-Houssein S, Husslein H, Shore EM, Lefebvre G, Vlachou PA. Bilateral Massive Ovarian Edema Due to Chronic Torsion Treated with Conservative Laparoscopic Approach. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2018.0023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Heinrich Husslein
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Canada
| | - Eliane M. Shore
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Canada
| | - Guylaine Lefebvre
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, Canada
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Leung M, Murji A, Allaire C, Singh SS, Thiel J, Tulandi T, Shore EM. Factors influencing the difficulty of laparoscopic myomectomy: the development of a surgical rating tool. Eur J Obstet Gynecol Reprod Biol 2018; 231:230-234. [PMID: 30439651 DOI: 10.1016/j.ejogrb.2018.10.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 10/22/2018] [Accepted: 10/24/2018] [Indexed: 12/12/2022]
Abstract
Objective To obtain expert consensus on the patient and fibroid characteristics that affect the complexity of laparoscopic myomectomy (LM) and to use these factors to create a grading tool for objective evaluation of LM procedures. Study design Modified Delphi Methodology Study (Canadian Task Force III). Setting included a series of online surveys via SurveyMonkey (SurveyMonkey Inc., San Mateo, California, USA). Participants were Canadian minimally invasive gynecologic surgeons (MIGS) who perform LM. A list consisting of patient, uterine and procedural characteristics was disseminated to Canadian MIGS. Opportunity to include additional factors was provided. Consensus was predefined as Cronbach's α of ≥0.80. A second Delphi survey was then done to assign weight value for each item in the grading tool. Results Twenty-seven surgeons from across Canada participated. Most (23/27, 85%) were MIGS fellowship trained, and performed more than 6 LM per year (18/27, 66.7%). Consensus was achieved in the first round of the survey (Cronbach's α = 0.93). Sixteen of 27 factors met the criteria for inclusion (>80% respondents agreed or strongly agreed) and were included in the final rating tool. Factors that met the criteria for inclusion were grouped as patient factors (including body mass index), uterine factors (including number of fibroids, size of largest fibroid), and surgical factors (including ease of developing the cleavage plane). Conclusions Using the Delphi methodology to obtain expert consensus on the factors influencing the difficulty of LM, we have developed an objective grading tool to evaluate the degree of technical complexity of LM.
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Affiliation(s)
- Marian Leung
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Ally Murji
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Catherine Allaire
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sukhbir S Singh
- Department of Obstetrics, Gynaecology, and Newborn Care, University of Ottawa, Ottawa, Ontario, Canada
| | - John Thiel
- Department of Obstetrics and Gynaecology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Togas Tulandi
- Department of Obstetrics and Gynaecology, McGill University, Montreal, Quebec, Canada
| | - Eliane M Shore
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, Division of Gynaecologic Surgery and Pelvic Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.
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Yousuf AA, Frecker H, Satkunaratnam A, Shore EM. Implementation and validation of a retroperitoneal dissection curriculum. Am J Obstet Gynecol 2018; 219:395.e1-395.e11. [PMID: 30278879 DOI: 10.1016/j.ajog.2018.06.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/18/2018] [Accepted: 06/26/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Competency-based education requires educators to use simulation training for the purposes of education and assessment of resident trainees. Research demonstrates that improvement in surgical skills acquired in a simulated environment is transferrable to the operative environment. Laparoscopic retroperitoneal dissection, opening the retroperitoneal space and identifying the ureter, is a fundamental skill for gynecologists. Integrating simulation models into a formal and comprehensive curriculum for teaching ureterolysis could translate to increased surgical competency. OBJECTIVE Our goal was to validate a comprehensive curriculum for laparoscopic retroperitoneal dissection for the purpose of identification of the ureter by evaluating intraoperative performance. STUDY DESIGN A comprehensive curriculum, encompassing didactic and technical skills components and using a previously developed pelvic model, was designed to teach laparoscopic ureterolysis. Novice surgeons (postgraduate years 3-5) were recruited. Participants completed precurriculum and postcurriculum multiple-choice questionnaires to evaluate a didactic component. Preperformance and postperformance on the model was video-recorded. As part of the technical component, participants received constructive feedback from expert surgeons on how to perform laparoscopic retroperitoneal dissection using the simulation model. Participants were then video-recorded performing laparoscopic retroperitoneal dissection in the operating room within 3 months of the curriculum. All videos were blindly assessed by an expert using the Objective Structured Assessment of Technical Skills tool. At the conclusion of the study, participants completed a course evaluation. RESULTS Thirty novice gynecologic surgeons were recruited. High baseline knowledge of ureteric anatomy and injury (multiple-choice question score median and interquartile range) still significantly increased from 7 (5-7.25) precurriculum to 8 (7-9) postcurriculum (P < .001). The median (interquartile range) technical Objective Structured Assessment of Technical Skills score increased significantly from 24.5 (23-28.25) precurriculum to 30 (29.75-32) postcurriculum (P < .001). Video-recordings were completed for 23 participants performing laparoscopic retroperitoneal dissection in the operating room. Intraoperative Objective Structured Assessment of Technical Skills scores (median of 29 [interquartile range 27-32]) correlated with postcurriculum Objective Structured Assessment of Technical Skills scores on the model (r = 0.53, P = .01). The ureter was identified intraoperatively by 91% (n = 21/23) of participants. The majority of residents (81%, n = 21/26) were more comfortable completing a supervised retroperitoneal dissection as a result of participating in the curriculum. Residents believed that this model would be useful to enhance skills acquisition prior to performing the skill in the operating room (65%, n = 17/26). CONCLUSION A comprehensive retroperitoneal dissection curriculum showed improvement in cognitive knowledge and technical skills, which also translated to competent performance in the operating room. In addition to the objective measures, residents believed that their skills acquisition was improved following course completion.
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Affiliation(s)
- Aisha A Yousuf
- Department of Obstetrics and Gynecology, Sidra Medical and Research Center, Doha, Qatar
| | - Helena Frecker
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Michael Garron Hospital, Toronto, Ontario, Canada
| | - Abheha Satkunaratnam
- Division of Gynecologic Surgery and Pelvic Medicine, Department of Obstetrics and Gynecology, St Michael's Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Eliane M Shore
- Division of Gynecologic Surgery and Pelvic Medicine, Department of Obstetrics and Gynecology, St Michael's Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada.
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Lichtman AS, Parker W, Goff B, Mehra N, Shore EM, Lefebvre G, Chiang A, Lenihan J, Schreuder HW. A Randomized Multicenter Study Assessing the Educational Impact of a Computerized Interactive Hysterectomy Trainer on Gynecology Residents. J Minim Invasive Gynecol 2018; 25:1035-1043. [DOI: 10.1016/j.jmig.2018.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 01/23/2018] [Accepted: 01/25/2018] [Indexed: 11/16/2022]
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Smith MK, Martin R, Robblee J, Shore EM. A Case of Epidural Lipomatosis in Pregnancy: Management during Labour and Caesarean Section. J Obstet Gynaecol Can 2018; 40:1182-1185. [PMID: 30007801 DOI: 10.1016/j.jogc.2018.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 04/09/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spinal epidural lipomatosis (SEL) is a rare condition of adipose tissue accumulation in the epidural space. As a result of excess adipose tissue, neuraxial anaesthesia has been reported to behave unpredictably in patients with this condition. CASE A 36-year-old woman had worsening postural headaches during pregnancy. MRI revealed SEL involving the thecal sac between L3/L4 and L5/S1. She had induction of labour but ultimately required a CS for delivery. Her anaesthesia was managed with an epidural inserted at L3/4. She developed a high block with relative sacral sparing. CONCLUSION Although neuraxial anaesthesia was thought to be contraindicated in patients with SEL, it can be done safely. Care must be taken to provide slow epidural titration to avoid high sensory block in patients with this condition.
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Affiliation(s)
| | - Rachel Martin
- Department of Anaesthesia, St. Michael's Hospital, Toronto, ON; Department of Anaesthesia, University of Toronto, Toronto, ON
| | - Jennifer Robblee
- Department of Neurology, Toronto Western Hospital, Toronto, ON; Department of Neurology, University of Toronto, Toronto, ON
| | - Eliane M Shore
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, ON; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON.
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Affiliation(s)
- Eliane M. Shore
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | | | - Mark H. Yudin
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
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Husslein H, Frecker H, Shore EM, Lefebvre G, Latta E, Montanari E, Satkunaratnam A. Comparing two Uterine Manipulators During Total Laparoscopic Hysterectomy: A Randomized Controlled Trial. J Minim Invasive Gynecol 2017; 24:764-771. [PMID: 28279757 DOI: 10.1016/j.jmig.2017.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 02/22/2017] [Accepted: 02/27/2017] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE To compare 2 different types of uterine manipulators (i.e., tight fitting vs loose fitting) used for total laparoscopic hysterectomy (TLH). DESIGN A randomized controlled trial. The primary end points were time for colpotomy, time from skin incision to detachment of the uterus, and histologic assessment of thermal damage to the vagina (Canadian Task Force classification I). SETTING A university teaching hospital. PATIENTS All consecutive women scheduled for TLH from May 2014 to December 2015. Patients were excluded if pregnancy or malignancy was suspected or uterine size exceeded 20 weeks' gestation. INTERVENTIONS Patients were randomized to undergo TLH with 1 of the following uterine manipulators: (1) Colpo-Probe Vaginal Fornix Delineator (Cooper Surgical, Inc, Trumbull, CT) or (2) Hohl manipulator (KARL STORZ AG, Tuttlingen, Germany). MEASUREMENTS AND MAIN RESULTS A total of 91 patients, 49 in the Hohl manipulator group and 42 in the Colpo-Probe group, were included in the final analysis. There was no difference in patient characteristics, uterine weight, or estimated blood loss. The median time for insertion of the manipulator (2 minutes [interquartile range (IQR), 2-5 minutes] vs 6 minutes [IQR, 5-7], p < .001), the median time from skin incision to detachment of the uterus (55 minutes [IQR, 41-70] vs 65 minutes [IQR, 58-79], p = .004), and the median time for colpotomy (7 minutes [IQR, 5-10] vs 12 [IQR, 8-17], p < .001) were shorter with the Hohl manipulator. Thermal damage to the vagina varied greatly and ranged from 32 μm to 5232 μm but was not significantly different between groups (median maximum thermal damage = 1043 μm [IQR, 682-1934] vs 1522 μm [IQR, 884-2144], p = .211). CONCLUSION Use of the Hohl manipulator results in a shorter operative time from skin incision to detachment of the uterus during TLH. Although the colpotomy time is shorter using the Hohl manipulator, this did not translate to less thermal damage to the vaginal cuff. Further studies comparing uterine manipulators are warranted to find the optimal instrument for ease of surgery and decreased thermal spread.
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Affiliation(s)
- Heinrich Husslein
- Department of Obstetrics and Gynecology, Vienna General Hospital, Medical University of Vienna, Austria.
| | - Helena Frecker
- Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eliane M Shore
- Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Guylaine Lefebvre
- Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eleanor Latta
- Department of Laboratory Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eliana Montanari
- Department of Obstetrics and Gynecology, Vienna General Hospital, Medical University of Vienna, Austria
| | - Abheha Satkunaratnam
- Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Lichtman AS, Goff B, Parker W, Mehra N, Shore EM, Lefebvre G, Chiang A, Lenihan J, Schreuder HWR. Improving Cognitive Surgical Knowledge in Ob/Gyn Residents Using an Interactive Computer-Based Laparoscopic Hysterectomy Trainer. J Minim Invasive Gynecol 2016. [DOI: 10.1016/j.jmig.2016.08.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Yousuf AA, Satkunaratnam A, Frecker H, Shore EM. The Development of a Retroperitoneal Dissection Model. J Minim Invasive Gynecol 2016. [DOI: 10.1016/j.jmig.2016.08.593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Shore EM, Grantcharov TP, Husslein H, Shirreff L, Dedy NJ, McDermott CD, Lefebvre GG. Validating a standardized laparoscopy curriculum for gynecology residents: a randomized controlled trial. Am J Obstet Gynecol 2016; 215:204.e1-204.e11. [PMID: 27131588 DOI: 10.1016/j.ajog.2016.04.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 04/18/2016] [Accepted: 04/20/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Residency programs struggle with integrating simulation training into curricula, despite evidence that simulation leads to improved operating room performance and patient outcomes. Currently, there is no standardized laparoscopic training program available for gynecology residents. OBJECTIVE The purpose of this study was to develop and validate a comprehensive ex vivo training curriculum for gynecologic laparoscopy. STUDY DESIGN In a prospective, single-blinded randomized controlled trial (Canadian Task Force Classification I) postgraduate year 1 and 2 gynecology residents were allocated randomly to receive either conventional residency training or an evidence-based laparoscopy curriculum. The 7-week curriculum consisted of cognitive didactic and interactive sessions, low-fidelity box trainer and high-fidelity virtual reality simulator technical skills, and high-fidelity team simulation. The primary outcome measure was the technical procedure score at laparoscopic salpingectomy with the use of the objective structured assessment of laparoscopic salpingectomy tool. Secondary outcome measures related to performance in multiple-choice questions and technical performance at box trainer and virtual reality simulator tasks. A sample size of 10 residents per group was planned (n = 20). Results are reported as medians (interquartile ranges), and data were compared between groups with the Mann-Whitney U, chi-square, and Fisher's exact tests (P ≤ .05). RESULTS In July 2013, 27 residents were assigned randomly (14 curriculum, 13 conventional). Both groups were similar at baseline. Twenty-one residents (10 curriculum, 11 conventional) completed the surgical procedure-based assessment in the operating room (September to December 2013). Our primary outcome indicated that curriculum-trained residents displayed superior performance at laparoscopic salpingectomy (P = .043). Secondary outcomes demonstrated that curriculum-trained residents had higher performance scores on the cognitive multiple-choice questions (P < .001), the nontechnical skills multiple-choice questions (P = .016), box trainer task time (P < .001), and all virtual reality simulator parameters. CONCLUSION Participation in a comprehensive simulation-based training curriculum for gynecologic laparoscopy leads to a superior improvement in knowledge and technical performance in the operating room compared with conventional residency training.
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Affiliation(s)
- Eliane M Shore
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada.
| | - Teodor P Grantcharov
- Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Heinrich Husslein
- Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - Lindsay Shirreff
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Nicolas J Dedy
- Department of Surgery, Gold Coast University Hospital, Southport, Australia
| | - Colleen D McDermott
- Department of Obstetrics and Gynaecology, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Guylaine G Lefebvre
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
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Husslein H, Shirreff L, Shore EM, Lefebvre GG, Grantcharov TP. The Generic Error Rating Tool: A Novel Approach to Assessment of Performance and Surgical Education in Gynecologic Laparoscopy. J Surg Educ 2015; 72:1259-65. [PMID: 26111823 DOI: 10.1016/j.jsurg.2015.04.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 04/14/2015] [Accepted: 04/29/2015] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Global rating scales are commonly used to rate surgeons' skill level. However, these tools lack granularity required for specific skill feedback. Recently, an alternative framework has been developed that is designed to measure technical errors during laparoscopy. The purpose of the present study was to gather validity evidence for the Generic Error Rating Tool (GERT) in gynecologic laparoscopy. DESIGN Video recordings of total laparoscopic hysterectomies were analyzed by 2 blinded reviewers using the GERT and the Objective Structured Assessment of Technical Skills (OSATS) scale. Several sources of validity were examined according to the unitary framework of validity. Main outcomes were interrater and intrarater reliability regarding total number of errors and events. Further, surgeons were grouped according to OSATS scores (OSATS ≥ 28 = high performers and OSATS < 28 = low performers), and the number of errors and events was compared between groups. Correlation analysis between GERT and OSATS scores was performed. Lastly, error distribution within procedure steps was explored and compared between high- and low-performing surgeons. SETTING University teaching hospital. PARTICIPANTS A total of 20 anonymized video recordings of total laparoscopic hysterectomies. RESULTS Interrater and intrarater reliability was high (intraclass correlation coefficient >0.95) for total number of errors and events. Low performers made significantly more errors than high performers did (median = 49.5 [interquartile range: 34.5-66] vs median = 31 [interquartile range: 16.75-35.25], p = 0.002). There was a significant negative correlation between individual OSATS scores and total number of errors (Spearman ρ = -0.76, p < 0.001, and ρ = -0.88, p < 0.001, for raters 1 and 2, respectively). Error distribution varied between operative steps, and low performers made more errors in some steps, but not in others. CONCLUSION GERT allows for objective and reproducible assessment of technical errors during gynecologic laparoscopy and could be used for performance analysis and personalized surgical education and training.
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Affiliation(s)
- Heinrich Husslein
- Division of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Medical University Vienna, Vienna, Austria.
| | - Lindsay Shirreff
- Division of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Eliane M Shore
- Division of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Guylaine G Lefebvre
- Division of Obstetrics and Gynaecology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Teodor P Grantcharov
- Division of General Surgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Shore EM, Raikhiln A, Yudin MH. Tubal granuloma. Am J Obstet Gynecol 2015; 213:107.e1-107.e2. [PMID: 25757640 DOI: 10.1016/j.ajog.2015.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/01/2015] [Accepted: 03/04/2015] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Evidence suggests that simulation leads to improved operative skill, shorter operating room time, and better patient outcomes. Currently, no standardized laparoscopy curriculum exists for gynecology residents. OBJECTIVE To design a structured laparoscopy curriculum for gynecology residents using Delphi consensus methodology. METHODS This study began with Delphi methodology to determine expert consensus on the components of a gynecology laparoscopic skills curriculum. We generated a list of cognitive content, technical skills, and nontechnical skills for training in laparoscopic surgery, and asked 39 experts in gynecologic education to rate the items on a Likert scale (1-5) for inclusion in the curriculum. Consensus was predefined as Cronbach α of ≥0.80. We then conducted another Delphi survey with 9 experienced users of laparoscopic virtual reality simulators to delineate relevant curricular tasks. Finally, a cross-sectional design defined benchmark scores for all identified tasks, with 10 experienced gynecologic surgeons performing the identified tasks at basic, intermediate, and advanced levels. RESULTS Consensus (Cronbach α=0.85) was achieved in the first round of the curriculum Delphi, and after 2 rounds (Cronbach α=0.80) in the virtual reality curriculum Delphi. Consensus was reached for cognitive, technical, and nontechnical skills as well as for 6 virtual reality tasks. Median time and economy of movement scores defined benchmarks for all tasks. CONCLUSIONS This study used Delphi consensus to develop a comprehensive curriculum for teaching gynecologic laparoscopy. The curriculum conforms to current educational standards of proficiency-based training, and is suggested as a standard in residency programs.
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Affiliation(s)
- Eliane M. Shore
- Corresponding author: Eliane M. Shore, MD, MSc, FRCSC, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8 Canada, 416.864.5384,
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Shore EM, Lefebvre GG, Grantcharov TP. Gynecology resident laparoscopy training: present and future. Am J Obstet Gynecol 2015; 212:298-301, 298.e1. [PMID: 25068561 DOI: 10.1016/j.ajog.2014.07.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 07/18/2014] [Accepted: 07/22/2014] [Indexed: 01/09/2023]
Abstract
Simulator education is essential to surgical training and it should be a requirement at all training programs across North America. Yet, in a survey of North American obstetrics and gynecology program directors (response rate 52%), we found that while 73% (n = 98) of programs teach laparoscopic skills, only 59% (n = 81) were satisfied with their curriculum. Most programs lacked standard setting in the form of theoretical examinations (94%, n = 127) or skills assessments (91%, n = 123) prior to residents performing surgery on patients in the operating room. Most programs (97%, n = 131) were interested in standardizing laparoscopy education by implementing a common curriculum. We present 3 core recommendations to ensure that gynecologists across North America are receiving adequate training in gynecologic laparoscopic surgery as residents: (1) uniform simulator education should be implemented at all training programs across North American residency programs; (2) a standardized curriculum should be developed using evidence-based techniques; and (3) standardized assessments should take place prior to operating room performance and specialty certification. Future collaborative research initiatives should focus on establishing the content of a standardized laparoscopy curriculum for gynecology residents utilizing a consensus method approach.
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Affiliation(s)
- Eliane M Shore
- Department of Obstetrics and Gynecology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada.
| | - Guylaine G Lefebvre
- Department of Obstetrics and Gynecology, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Teodor P Grantcharov
- Department of Surgery, St Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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Abstract
OBJECTIVE To determine whether pregnant women testing positive for Group B Streptococcus (GBS) are receiving appropriate antibiotic prophylaxis in labour based on sensitivity testing. METHODS We performed a retrospective chart review of all women who delivered at our institution from January 1 to December 31, 2008. We identified all GBS-positive women, and then abstracted data regarding demographic characteristics, method of GBS detection (recto-vaginal or urine culture), prevalence, and antibiotic use. The main outcome measure was the proportion of GBS-positive women who were managed appropriately. RESULTS During the study period 628 (22%) of 2878 women were identified as having GBS-positive cultures. Sensitivity testing was available for 481 of the recto-vaginal cultures. All were sensitive to penicillin. The rates of resistance for recto-vaginal culture were 22% for erythromycin, 19% for clindamycin, and 18% for both. Four hundred eighty-one women (93%) were treated with penicillin, 30 (6%) with clindamycin, three with cefazolin, and two with vancomycin. One hundred nine women (17%) who were GBS-positive did not receive antibiotics. Forty-four women (9%) did not receive appropriate antibiotic prophylaxis based on sensitivity testing. CONCLUSION Most GBS-positive women at our institution received an appropriate antibiotic during labour based on sensitivity testing. Our population reflects the Canadian GBS-positivity rate, which is similar to those observed in published studies from other populations. Future work should focus on developing strategies that re-emphasize GBS testing and treatment guidelines for prenatal care providers and on systems to ensure GBS-positive women are given the appropriate antibiotics during labour.
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Affiliation(s)
- Eliane M Shore
- Department of Obstetrics and Gynecology, University of Toronto, Toronto ON; Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto ON
| | - Mark H Yudin
- Department of Obstetrics and Gynecology, University of Toronto, Toronto ON; Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto ON
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Kaplan J, Kaplan FS, Shore EM. Restoration of normal BMP signaling levels and osteogenic differentiation in FOP mesenchymal progenitor cells by mutant allele-specific targeting. Gene Ther 2011; 19:786-90. [PMID: 22011642 DOI: 10.1038/gt.2011.152] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder of progressive heterotopic ossification for which there is presently no cure. FOP is caused by a recurrent heterozygous activating mutation (c.617G>A; R206H) of Activin receptor type IA/Activin-like kinase-2 (ACVR1/ALK2), a bone morphogenetic protein (BMP) type I receptor that occurs in all classically affected individuals. The FOP mutation dysregulates BMP signaling and initiates the formation of a disabling second skeleton of heterotopic bone. We generated allele-specific siRNA (ASP-RNAi) duplexes capable of specifically suppressing the expression of the mutant c.617A allele in mesenchymal progenitor cells from FOP patients and showed that this ASP-RNAi approach decreased the elevated BMP signaling that is characteristic of patient cells to levels similar to control cells and restored enhanced osteogenic differentiation to control levels. Our results provide proof-of-principle that ASP-RNAi has potential therapeutic efficacy for the treatment of FOP.
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Affiliation(s)
- J Kaplan
- Department of Orthopaedic Surgery, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Schimmel RJ, Pasmans SGMA, Xu M, Stadhouders-Keet SAE, Shore EM, Kaplan FS, Wulffraat NM. GNAS-associated disorders of cutaneous ossification: two different clinical presentations. Bone 2010; 46:868-72. [PMID: 19900597 PMCID: PMC3501213 DOI: 10.1016/j.bone.2009.11.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 11/02/2009] [Accepted: 11/02/2009] [Indexed: 11/23/2022]
Abstract
Progressive osseous heteroplasia (POH) is a rare genetic disorder characterized by dermal ossification during infancy and progressive ossification into deep connective tissue during childhood. POH is at the severe end of a spectrum of GNAS-associated ossification disorders that include osteoma cutis and Albright Hereditary Osteodystrophy (AHO). Here we describe two girls who have different clinical presentations that reflect the variable expression of GNAS-associated disorders of cutaneous ossification. Each girl had a novel heterozygous inactivating mutation in the GNAS gene. One girl had POH limited to the left arm with severe contractures and growth retardation resulting from progressive heterotopic ossification in the deep connective tissues. The other girl had AHO with widespread, superficial heterotopic ossification but with little functional impairment. While there is presently no treatment or prevention for GNAS-associated ossification disorders, early diagnosis is important for genetic counselling and for prevention of iatrogenic harm.
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Affiliation(s)
- R J Schimmel
- Department of Paediatric Dermatology and Allergology, Wilhelmina's Children Hospital, University Medical Center Utrecht, 3508 AB Utrecht, The Netherlands
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Adegbite NS, Xu M, Kaplan FS, Shore EM, Pignolo RJ. Diagnostic and mutational spectrum of progressive osseous heteroplasia (POH) and other forms of GNAS-based heterotopic ossification. Am J Med Genet A 2008; 146A:1788-96. [PMID: 18553568 DOI: 10.1002/ajmg.a.32346] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Progressive osseous heteroplasia (POH) is a rare, disabling disease of heterotopic ossification (HO) that progresses from skin and subcutaneous tissues into deep skeletal muscle. POH occurs in the absence of multiple developmental features of Albright hereditary osteodystrophy (AHO) or hormone resistance, clinical manifestations that are also associated with GNAS inactivation. However, occasional patients with AHO and pseudohypoparathyroidism 1a/c (PHP1a/c; AHO features plus hormone resistance) have also been described who have progressive HO. This study was undertaken to define the diagnostic and mutational spectrum of POH and progressive disorders of HO, and to distinguish them from related disorders in which HO remains confined to the skin and subcutaneous tissues. We reviewed the charts of 111 individuals who had cutaneous and subcutaneous ossification. All patients were assessed for eight characteristics: age of onset of HO, presence and location of HO, depth of HO, type of HO, progression of HO, features of AHO, PTH resistance, and GNAS mutation analysis. We found, based on clinical criteria, that POH and progressive HO syndromes are at the severe end of a phenotypic spectrum of GNAS-inactivating conditions associated with extra-skeletal ossification. While most individuals with superficial or progressive ossification had mutations in GNAS, there were no specific genotype-phenotype correlations that distinguished the more progressive forms of HO (e.g., POH) from the non-progressive forms (osteoma cutis, AHO, and PHP1a/c).
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Affiliation(s)
- N S Adegbite
- Department of Orthopaedic Surgery, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Kaplan FS, Xu M, Feldman G, Brown M, Cho TJ, Choi IH, Connor JM, Delai PLR, Economides AN, Glaser DL, Groppe J, Katagiri T, Le Merrer M, Morhart R, Ravazzolo R, Rogers JG, Smith R, Triffitt JT, Urtizberea JA, Zasloff M, Shore EM. Response to "Mutations of the NOGGIN and of the activin A type I receptor genes in fibrodysplasia ossificans progressiva (FOP)" by Lucotte et al. Genet Couns 2008; 19:357-363. [PMID: 18990993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Abstract
Fibrodysplasia ossificans progressiva (FOP) is a catastrophic genetic disorder of progressive heterotopic ossification associated with dysregulated production of bone morphogenetic protein 4 (BMP4), a potent osteogenic morphogen. Postnatal heterotopic ossification in FOP is often heralded by hectic episodes of severe post-traumatic connective tissue swelling and intramuscular edema, followed by an intense and highly angiogenic fibroproliferative mass. The abrupt appearance, intense size, and rapid intrafascial spread of the edematous preosseous fibroproliferative lesions implicate a dysregulated wound response mechanism and suggest that cells and mediators involved in inflammation and tissue repair may be conscripted in the growth and progression of FOP lesions. The central and coordinate role of inflammatory mast cells and their mediators in tissue edema, wound repair, fibrogenesis, angiogenesis, and tumor invasion prompted us to investigate the potential involvement of mast cells in the pathology of FOP lesions. We show that inflammatory mast cells are present at every stage of the development of FOP lesions and are most pronounced at the highly vascular fibroproliferative stage. Mast cell density at the periphery of FOP lesional tissue is 40- to 150-fold greater than in normal control skeletal muscle or in uninvolved skeletal muscle from FOP patients and 10- to 40-fold greater than in any other inflammatory myopathy examined. These findings document mobilization and activation of inflammatory mast cells in the pathology of FOP lesions and provide a novel and previously unrecognized target for pharmacologic intervention in this extremely disabling disease.
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Affiliation(s)
- F H Gannon
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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44
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Abstract
Fibrodysplasia ossificans progressiva (FOP) is an extremely rare and disabling genetic disorder of connective tissue. The condition is characterized by congenital malformation of the great toes and by progressive heterotopic ossification of the tendons, ligaments, fasciae, and striated muscles. Fibrodysplasia ossificans progressiva occurs sporadically and is transmitted as a dominant trait with variable expression and complete penetrance. Reproductive fitness is low. There are fewer than 150 known patients with the disorder in the United States. A point prevalence of one affected patient in every 2 million of population has been observed. There is no sexual, racial, or ethnic predilection. The disease presents in early life; its course is unavoidably progressive. Most patients are confined to a wheelchair by the third decade of life and often succumb to pulmonary complications in the 5th/6th decade of life. At present there is no effective prevention or treatment. The recent discovery of overproduction of bone morphogenetic protein-4 in lesional cells and lymphocytic cells of affected patients provides a clue to both the underlying pathophysiology and potential therapy. The FOP gene has recently been mapped to human chromosome 4q 27-31.
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Affiliation(s)
- S Mahboubi
- Department of Radiology, Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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45
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Abstract
Progressive osseous heteroplasia (POH) is a recently described genetic disorder of mesenchymal differentiation characterized by dermal ossification during infancy and progressive heterotopic ossification of cutaneous, subcutaneous, and deep connective tissues during childhood. The disorder can be distinguished from fibrodysplasia ossificans progressiva (FOP) by the presence of cutaneous ossification, the absence of congenital malformations of the skeleton, the absence of inflammatory tumorlike swellings, the asymmetric mosaic distribution of lesions, the absence of predictable regional patterns of heterotopic ossification, and the predominance of intramembranous rather than endochondral ossification. POH can be distinguished from Albright hereditary osteodystrophy (AHO) by the progression of heterotopic ossification from skin and subcutaneous tissue into skeletal muscle, the presence of normal endocrine function, and the absence of a distinctive habitus associated with AHO. Although the genetic basis of POH is unknown, inactivating mutations of the GNAS1 gene are associated with AHO. The report in this issue of the JBMR of 2 patients with combined features of POH and AHO--one with classic AHO, severe POH-like features, and reduced levels of Gsalpha protein and one with mild AHO, severe POH-like features, reduced levels of Gsalpha protein, and a mutation in GNAS1--suggests that classic POH also could be caused by GNAS1 mutations. This possibility is further supported by the identification of a patient with atypical but severe platelike osteoma cutis (POC) and a mutation in GNAS1, indicating that inactivating mutations in GNAS1 may lead to severe progressive heterotopic ossification of skeletal muscle and deep connective tissue independently of AHO characteristics. These observations suggest that POH may lie at one end of a clinical spectrum of ossification disorders mediated by abnormalities in GNAS1 expression and impaired activation of adenylyl cyclase. Analysis of patients with classic POH (with no AHO features) is necessary to determine whether the molecular basis of POH is caused by inactivating mutations in the GNAS1 gene.
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Affiliation(s)
- F S Kaplan
- Department of Orthopaedic Surgery, The University of Pennsylvania School of Medicine, Philadelphia, USA
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Yeh GL, Mathur S, Wivel A, Li M, Gannon FH, Ulied A, Audi L, Olmstead EA, Kaplan FS, Shore EM. GNAS1 mutation and Cbfa1 misexpression in a child with severe congenital platelike osteoma cutis. J Bone Miner Res 2000; 15:2063-73. [PMID: 11092389 DOI: 10.1359/jbmr.2000.15.11.2063] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We evaluated a 7-year-old girl with severe platelike osteoma cutis (POC), a variant of progressive osseous heteroplasia (POH). The child had congenital heterotopic ossification of dermis and subcutaneous fat that progressed to involve deep skeletal muscles of the face, scalp, and eyes. Although involvement of skeletal muscle is a prominent feature of POH, heterotopic ossification has not been observed in the head, face, or extraocular muscles. The cutaneous ossification in this patient was suggestive of Albright hereditary osteodystrophy (AHO); however, none of the other characteristic features of AHO were expressed. Inactivating mutations of the GNAS1 gene, which encodes the alpha-subunit of the stimulatory G protein of adenylyl cyclase, is the cause of AHO. Mutational analysis of GNAS1 using genomic DNA of peripheral blood and of lesional and nonlesional tissue from our patient revealed a heterozygous 4-base pair (bp) deletion in exon 7, identical to mutations that have been found in some AHO patients. This 4-bp deletion in GNAS1 predicts a protein reading frameshift leading to 13 incorrect amino acids followed by a premature stop codon. To investigate pathways of osteogenesis by which GNAS1 may mediate its effects, we examined the expression of the obligate osteogenic transcription factor Cbfa1/RUNX2 in lesional and uninvolved dermal fibroblasts from our patient and discovered expression of bone-specific Cbfa1 messenger RNA (mRNA) in both cell types. These findings document severe heterotopic ossification in the absence of AHO features caused by an inactivating GNAS1 mutation and establish the GNAS1 gene as the leading candidate gene for POH.
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Affiliation(s)
- G L Yeh
- Department of Orthopaedic Surgery, University of Pennsylvania, School of Medicine, Philadelphia 19104-6081, USA
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Eddy MC, Jan De Beur SM, Yandow SM, McAlister WH, Shore EM, Kaplan FS, Whyte MP, Levine MA. Deficiency of the alpha-subunit of the stimulatory G protein and severe extraskeletal ossification. J Bone Miner Res 2000; 15:2074-83. [PMID: 11092390 DOI: 10.1359/jbmr.2000.15.11.2074] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Progressive osseous heteroplasia (POH) is a rare disorder characterized by dermal ossification beginning in infancy followed by increasing and extensive bone formation in deep muscle and fascia. We describe two unrelated girls with typical clinical, radiographic, and histological features of POH who also have findings of another uncommon heritable disorder, Albright hereditary osteodystrophy (AHO). One patient has mild brachydactyly but no endocrinopathy, whereas the other manifests brachydactyly, obesity, and target tissue resistance to thyrotropin and parathyroid hormone (PTH). Levels of the alpha-subunit of the G protein (Gsalpha) were reduced in erythrocyte membranes from both girls and a nonsense mutation (Q12X) in exon 1 of the GNAS1 gene was identified in genomic DNA from the mildly affected patient. Features of POH and AHO in two individuals suggest that these conditions share a similar molecular basis and pathogenesis and that isolated severe extraskeletal ossification may be another manifestation of Gsalpha deficiency.
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Affiliation(s)
- M C Eddy
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, Missouri 63131, USA
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48
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Xu MQ, Feldman G, Le Merrer M, Shugart YY, Glaser DL, Urtizberea JA, Fardeau M, Connor JM, Triffitt J, Smith R, Shore EM, Kaplan FS. Linkage exclusion and mutational analysis of the noggin gene in patients with fibrodysplasia ossificans progressiva (FOP). Clin Genet 2000; 58:291-8. [PMID: 11076054 DOI: 10.1034/j.1399-0004.2000.580407.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Fibrodysplasia ossificans progressiva (FOP) is an extremely rare and disabling genetic disorder characterized by congenital malformation of the great toes and by progressive heterotopic endochondral ossification in predictable anatomical patterns. Although elevated levels of bone morphogenetic protein 4 (BMP4) occur in lymphoblastoid cells and in lesional cells of patients with FOP, mutations have not been identified in the BMP4 gene, suggesting that the mutation in FOP may reside in a BMP4-interacting factor or in another component of the BMP4 pathway. A powerful antagonist of BMP4 is the secreted polypeptide noggin. A recent case report described a heterozygous 42-bp deletion in the protein-coding region of the noggin gene in a patient with FOP. In order to determine if noggin mutations are a widespread finding in FOP, we examined 31 families with 1 or more FOP patients. Linkage analysis with an array of highly polymorphic microsatellite markers closely linked to the noggin gene was performed in four classically-affected multigenerational FOP families and excluded linkage of the noggin locus to FOP (the multipoint lod score was -2 or less throughout the entire range of markers). We sequenced the noggin gene in affected members of all four families, as well as in 18 patients with sporadic FOP, and failed to detect any mutations. Single-strand conformation polymorphism (SSCP) analysis of 4 of these patients plus an additional 9 patients also failed to reveal any mutations. Among the samples analyzed by SSCP and DNA sequencing was an independently obtained DNA sample from the identical FOP patient previously described with the 42-bp noggin deletion; no mutation was detected. Examination of the DNA sequences of 20 cloned noggin PCR products, undertaken to evaluate the possibility of a somatic mutation in the noggin gene which could be carried by a small subset of white blood cells, also failed to detect the presence of the reported 42-bp deletion. We conclude that mutations in the coding region of noggin are not associated with FOP.
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Affiliation(s)
- M Q Xu
- Department of Orthopaedic Surgery, The University of Pennsylvania School of Medicine, Philadelphia, USA
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Abstract
The formation of heterotopic bone within soft connective tissue is a common feature of at least three distinct genetic disorders of osteogenesis in humans: fibrodysplasia ossificans progressiva; progressive osseous heteroplasia; and Albright hereditary osteodystrophy. The pathobiologic characteristics of osteogenic induction, the histopathologic features of osteogenesis, the anatomic distribution of heterotopic lesions, and the developmental patterns of disease progression differ among all three conditions. The molecular and cellular basis of redirecting a mature connective tissue phenotype to form bone is a remarkable biological phenomenon with enormous implications for the control of bone regeneration, fracture healing, and disorders of osteogenesis.
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Affiliation(s)
- E M Shore
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia 19104, USA
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50
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Virdi AS, Shore EM, Oreffo RO, Li M, Connor JM, Smith R, Kaplan FS, Triffitt JT. Phenotypic and molecular heterogeneity in fibrodysplasia ossificans progressiva. Calcif Tissue Int 1999; 65:250-5. [PMID: 10441661 DOI: 10.1007/s002239900693] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Fibrodysplasia (myositis) ossificans progressiva (FOP) is an extremely rare inherited disorder in which progressive ossification of major striated muscles, often following injury, is associated with abnormal skeletal patterning. Altered expression of bone morphogenetic proteins may be a contributory cause. To examine this hypothesis, we compared the patterns of expression of bone morphogenetic proteins (BMPs) mRNAs from lymphoblastoid cell lines from two small multigenerational families with autosomal dominant transmission of FOP. Although affected members of both families showed the characteristic phenotype of FOP, one family was more severely affected than the other. Expression of mRNAs for BMP-1, 2, 3, 5, and 6 mRNAs were not detected within the more severely affected family, but BMP-4 mRNA was expressed in affected but not unaffected members of this family. The results of linkage exclusion analysis using a highly polymorphic microsatellite marker near the BMP-4 gene were consistent with linkage of FOP and BMP-4 in this family. Within the less severely affected family, affected and unaffected members showed similar levels of mRNA expression of BMPs 1, 2, 4, and 5, and linkage of FOP to the BMP-4 gene was excluded. It is concluded that clinical, radiographic, and biochemical data in these two families with FOP establish clinical and molecular heterogeneity and also suggest the possibility of genetic heterogeneity.
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Affiliation(s)
- A S Virdi
- MRC Bone Research Laboratory, Nuffield Department of Orthopaedic Surgery, University of Oxford, Nuffield Orthopaedic Centre, Headington, Oxford, England, OX3 7LD
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