Recommendations for a standardised educational program in robot assisted gynaecological surgery: Consensus from the Society of European Robotic Gynaecological Surgery (SERGS)

BACKGROUND

The Society of European Robotic Gynaecological Surgery (SERGS) aims at developing a European consensus on core components of a curriculum for training and assessment in robot assisted gynaecological surgery.

METHODS

A Delphi process was initiated among a panel of 12 experts in robot assisted surgery invited through the SERGS. An online questionnaire survey was based on a literature search for standards in education in gynaecological robot assisted surgery. The survey was performed in three consecutive rounds to reach optimal consensus. The results of this survey were discussed by the panel and led to consensus recommendations on 39 issues, adhering to general principles of medical education.

RESULTS

On review there appeared to be no accredited training programs in Europe, and few in the USA. Recommendations for requirements of training centres, educational tools and assessment of proficiency varied widely. Stepwise and structured training together with validated assessment based on competencies rather than on volume emerged as prerequisites for adequate and safe learning. An appropriate educational environment and tools for training were defined. Although certification should be competence based, the panel recommended additional volume based criteria for both accreditation of training centres and certification of individual surgeons.

CONCLUSIONS

Consensus was reached on minimum criteria for training in robot assisted gynaecological surgery. To transfer results into clinical practice, experts recommended a curriculum and guidelines that have now been endorsed by SERGS to be used to establish training programmes for robot assisted surgery.

Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit

The purpose of this study was to assess the effect of reducing prescription of fluoroquinolones in an intensive care unit (ICU) upon bacterial resistance, particularly as regards Pseudomonas aeruginosa. For six months between January 2001 and June 2001, administration of fluoroquinolones was kept to a minimum. A bacteriological screening of patients was performed to assess the incidence of fluoroquinolone-resistant bacteria. There was a 75.8% restriction in prescriptions of fluoroquinolones. There was no significant change in bacterial ecology between the periods preceding (12 months) and following (12 months) restriction. There was a significant recovery of sensitivity of P. aeruginosa to ciprofloxacin (P<or=0.01), with a decrease in resistant strains from 71.3% in the pre-restriction period to 52.4% in the post-restriction period. Regarding clinical data, no significant differences were noted between the pre-restriction and the post-restriction periods, except for the number of cases of ventilator-associated pneumonia with P. aeruginosa resistant to ciprofloxacin. This study demonstrated the possibility of introducing rotation of antibiotics in an ICU.

Preliminary study of the deposition of aerosol in the maxillary sinuses using a plastinated model

In spite of the widespread use of aerosols in respiratory diseases, very few studies have been performed in the field of ear, nose, and throat (ENT) disorders. The conditions for penetration of aerosols inside the sinus cavities are thus still not understood fully. The aim of this study was to investigate the penetration of aerosols inside maxillary sinuses in vitro, using plastinated models. Three plastinated specimens of the nose and sinuses were made from three different corpses. These specimens were validated by CT scans and were used to study deposition of aerosol in the maxillary sinuses. We performed scintigraphic images of the models in above, face, and profile views using a technetium (99mTc)-labelled solution to show aerosol deposition. We also counted the radioactivity deposited on gauze compresses placed inside the maxillary sinuses. In addition, we constructed a measuring unit with miniature humidity sensors placed inside the sinuses. We recorded the changes in relative humidity observed during nebulization. Results from these studies showed that scintigraphic images of the specimen, whatever the incidence of the views, were not accurate enough to differentiate the aerosol deposition in the maxillary sinuses from that in the nasal cavity. Using indirect counting on gauze compresses made possible the quantification of local aerosol deposition, and we found that aerosols entered into the sinuses. This confirmed that aerosols could reach the middle meatus, which is the main area for sinusitis disorders. The increased activity compared to background varied from 17 to 127%. The humidity sensors recorded changes in relative humidity during the nebulization. These humidity changes fitted a nonlinear model represented by the equation: y = b0 (1 - e(-b1t)), where b0 is the plateau and b1 is the speed to reach the plateau. These techniques may be useful in the future for in vitro characterization of aerosol penetration into the maxillary sinuses.

Studies on the supply of immunoglobulin G to newborn camel calves (Camelus dromedarius)

A major problem in camel productivity is the high mortality rate of camel calves in the first 3 months. The causes for mortality are mainly poor management practice and infectious diseases. The purpose of this research, carried out on a ranch in Kenya, was to determine the immunoglobulin G (IgG) concentration in camel colostrum as well as the extent of the calves' passive immunization by maternal antibodies. IgG concentration in colostrum and in the serum of the calf were measured during the first 3 d of life. Evaluation was carried out by comparing the respective values with those for horses and cattle. The average IgG concentration in the camel colostrum was higher than that found in literature for horses and cattle. IgG concentration in the serum of the camel calves reached its maximum 24 h after birth. In 39% of the examined calves, this maximum concentration was below 4 g/l, which is considered to be the critical value in horses and cattle. 61% of the calves achieved an IgG concentration of over 4 g/l. Since there is no correlation between IgG level in colostrum and early mortality, the results indicate that low colostrum intake during the first 24 h of life and not low IgG concentration in colostrum is presumably one of the main causes of early calf mortality. Therefore, it was recommended that the care of the newborn calves by herdsmen should be improved.

Evaluation of a new rapid urine screening analyser: cellFacts

The aim of this study was to evaluate a new urine screening analyser in a Hospital Bacteriology Laboratory: the Cellfacts Urine Screening Analyser (Microbial Systems Limited (MSL), Coventry, England). A cohort of 1036 urine specimens were analysed by both the CellFacts and routine traditional methods. Using the CDC urinary tract infection decision levels, and compared to reference methods, the sensitivity and specificity were respectively 88.9% and 76.2%, and the predictive negative value and predictive positive value respectively 93.3% and 64.8%. Compared to the microscopy, the correlations of white blood cell count and red blood cell count were good, respectively (r = 0.8, p < 0.0001) and (r = 0.6, p < 0.0001). These results indicate that, although several positive samples were not reported, CellFacts facilitates efficient, rapid screening of infected urine specimens. This leads to perform a cytobacteriological analysis only on those results screened as positive by the automatic analysis system.

Phase II study of a radiotherapy/etoposide combination for patients with newly malignant gliomas

PURPOSE

Etoposide, a semisynthetic derivative of podophyllotoxine, is a topoisomerase II inhibitor. This drug is currently used in several types of human cancer. The aim of this study was to evaluate the efficacity and tolerance of a near-concurrent association of radiotherapy and etoposide for newly malignant gliomas.

METHODS

From May 1995 to December 1996, 30 malignant glioma patients were included in this phase II study; 16 patients underwent surgical tumor resection, and a stereotactic biopsy was performed in 14 patients. Standard cranial irradiation and six courses of etoposide (100 mg/m2, x days 1-3) were administered. The first course of etoposide was administered on days 1-3 of radiotherapy and was resumed in the week following the end of radiotherapy. Treatment was consolidated by further courses of etoposide every 4 weeks.

RESULTS

Only 26 patients could be evaluated for the purpose of our study. The median age was 60.1 years, and the median Karnofsky performance score (KPS) was 80.2. The rate of objective response for evaluable patients was 34.6%, and four complete responses (CR) and five partial responses (PR) were noted. The median survival (MST) was 12 months, and the average overall survival was 12.5 months. Hematological toxicity was mild, and grade 3 or 4 neutropenia (white blood cell count < 1500/ml) was noted in three patients, without any sepsis or bleeding.

CONCLUSIONS

The results obtained in this study are comparable to the best reported results on the combination of radiotherapy and nitrosoureas. The near-concurrent combination of radiotherapy and etoposide seems to be effective and well tolerated in the treatment of newly malignant gliomas.

A standardized parameter for the distribution of individual red blood cell deformability with the cell transit analyzer

The purpose of this study was to identify a parameter allowing the standardization of the Cell Transit Analyzer (CTA) in order to study the individual deformability of each explored Red Blood Cell (RBC). Using theoretical arguments based on the principle of the CTA, we calculated the thickness "x" of the crown of fluid surrounding each RBC during its entry phase into the micropore. A mathematical equation (x = 62.5/magnitude of dU) was established between the difference of potential (dU, mV) that occurs during this phase and the corresponding thickness ("x", micron) of the crown. By exploring fresh control RBCs of healthy subjects and assuming that the rigid RBCs proportion in a fresh blood sample of healthy subject is less than 3.5%, we performed a thresholding of "x" to distinguish rigid RBC from deformable ones. That thresholding was necessary to stamp the variability of counts linked to polycarbonate filters (PF) used to carry out measures. According to the PF, the value of the threshold "Tx" provided by the thresholding ranged between 0.222 and 0.246 micron. Using the values of "Tx", we counted approximately 10-25% rigid RBCs in the pathological samples of four patients with sickle cells SS disease and of one diabetic patient with splenomegaly. We observed in addition that the percentages of rigid RBCs counted after thresholding are identical from a filter to another one with an absolute error less than 2% in fresh RBCs (normal or pathological) samples. We concluded that the method of standardization by thresholding presented here could be used in clinic routine to count the rigid RBCs percentage contained in a given sample.

Galen-In-Use: an EU Project applied to the development of a new national coding system for surgical procedures: NCAM

GALEN has developed a language independent common reference model based on a medically oriented ontology and practical tools and techniques for managing healthcare terminology including natural language processing. GALEN-IN-USE is the current phase which applied the modelling and the tools to the development or the updating of coding systems for surgical procedures in different national coding centre co-operating within the European Federation of Coding Centre (EFCC) to create a multilingual knowledge repository for multicultural Europe. NCAM (Nomenclature Commune des Actes Médicaux) is the new French multipurpose coding system for surgical procedures. The labels are processed from the intermediate dissections to the Grail representation and the natural language generation by the electronically related Medical Informatics research centres network of Saint Etienne, Manchester, Geneva and Nijmegen. The national coding centre is able to retrieve the initial labels with different categories of concepts, to compare the professional language proposed by expert clinicians to the French generated controlled vocabulary and to finalize the linguistic labels of the coding system in relation with the meanings of the conceptual system structure.

Effects of continuous environmental illumination on the albino rat hypothalamo-neurohypophysial system

Continuous environmental illumination or constant light (LL) exposure causes a suppression of daily water intake, and long-term exposure of greater than 19 days produces a hypertrophy of magnocellular neuroendocrine cells (MNCs) in the hypothalamus. These findings led Glantz to hypothesize that LL increases the secretion of vasopressin (VP). We wanted to determine whether LL could trigger morphological changes within the hypothalamo-neurohypophysial system (HNS) seen with other manipulations that result in enhanced hormone release. The posterior pituitary of male albino rats that were exposed to LL for 24 or 48 h were examined ultrastructurally for evidence of enhanced hormone release. In addition, water intake, plasma VP levels, and MNC size within the supraoptic nucleus (SON) were measured. After LL exposure, the posterior pituitary morphology was different, suggesting enhanced hormone release. LL exposure did not affect plasma VP or the size of SON MNCs, but did suppress drinking behavior. These data show that posterior pituitary morphology is affected rapidly by LL exposure. The HNS response to LL exposure may consist of changes within the first 24 h of LL found within the posterior pituitary followed later by hypertrophy of the SON MNCs.

Mismatch between radionuclide and contrast angiography in the assessment of the perfusion of a transplanted kidney

When early complications occur after a kidney transplant, radionuclide angiography may be useful in determining a possible vascular origin. The authors describe the case of a patient with anuria continuing 24 hours after transplantation. Radionuclide angiography showed a defect at the site of the renal graft, suggestive of arterial or venous thrombosis. Contrast angiography was performed immediately but showed no vascular abnormality; neither did radionuclide angiography performed the next day. The authors concluded that a spasm at the site of the renal artery anastomosis, overcome by contrast angiography, could explain this phenomenon.