Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook

<p>Abstract</p> <p>Background</p> <p>There is concern about the adequacy of operative exposure in surgical training programmes, in the context of changing work practices. We aimed to quantify the operative exposure of all trainees on the National Basic Surgical Training (BST) programme in Ireland and compare the results with arbitrary training targets.</p> <p>Methods</p> <p>Retrospective analysis of data obtained from a web-based logbook (<url>http://www.elogbook.org</url>) for all general surgery and orthopaedic training posts between July 2007 and June 2009.</p> <p>Results</p> <p>104 trainees recorded 23,918 operations between two 6-month general surgery posts. The most common general surgery operation performed was simple skin excision with trainees performing an average of 19.7 (± 9.9) over the 2-year training programme. Trainees most frequently assisted with cholecystectomy with an average of 16.0 (± 11.0) per trainee. Comparison of trainee operative experience to arbitrary training targets found that 2-38% of trainees achieved the targets for 9 emergency index operations and 24-90% of trainees achieved the targets for 8 index elective operations. 72 trainees also completed a 6-month post in orthopaedics and recorded 7,551 operations. The most common orthopaedic operation that trainees performed was removal of metal, with an average of 2.90 (± 3.27) per trainee. The most common orthopaedic operation that trainees assisted with was total hip replacement, with an average of 10.46 (± 6.21) per trainee.</p> <p>Conclusions</p> <p>A centralised web-based logbook provides valuable data to analyse training programme performance. Analysis of logbooks raises concerns about operative experience at junior trainee level. The provision of adequate operative exposure for trainees should be a key performance indicator for training programmes.</p

The Cardiology Audit and Registration Data Standards (CARDS), European data standards for clinical cardiology practice

AIMS: Systematic registration of data from clinical practice is important for clinical care, local, national and international registries, and audit. Data to be collected for these different purposes should be harmonized. Therefore, during Ireland's Presidency of the European Union (EU) (January to June 2004), the Department of Health and Children worked with the European Society of Cardiology, the Irish Cardiac Society, and the European Commission to develop data standards for clinical cardiology. The Cardiology Audit and Registration Data Standards (CARDS) Project aimed to agree standards for three modules of cardiovascular health information systems: acute coronary syndromes (ACS), percutaneous coronary interventions (PCI), and clinical electrophysiology (pacemakers, implantable cardioverter defibrillators, and ablation procedures). METHODS AND RESULTS: Data items from existing registries and surveys were reviewed to derive draft data standards (variables, coding, and definitions). Variables common to the three modules include demographics, risk factors, medication, and discharge and follow-up data. Modules about a procedure contain variables on the l

Combined exome and whole-genome sequencing identifies mutations in ARMC4 as a cause of primary ciliary dyskinesia with defects in the outer dynein arm

Primary ciliary dyskinesia (PCD) is a rare, genetically heterogeneous ciliopathy disorder affecting cilia and sperm motility. A range of ultrastructural defects of the axoneme underlie the disease, which is characterised by chronic respiratory symptoms and obstructive lung disease, infertility and body axis laterality defects. We applied a next-generation sequencing approach to identify the gene responsible for this phenotype in two consanguineous families

Ten Years In: Implementing Strategic Approaches to Cyberspace

This book represents a look beyond theories and analogies to examine the challenges of strategy implementation. In the essays that follow, practitioners who are building cyberspace forces at-scale join scholars who study power and force in this new domain to collectively offer a unique perspective on the evolution and future of cyber strategy and operations.https://digital-commons.usnwc.edu/usnwc-newport-papers/1044/thumbnail.jp

The effects of melatonin versus placebo on delirium in hip fracture patients: study protocol of a randomised, placebo-controlled, double blind trial

<p>Abstract</p> <p>Background</p> <p>With an ageing population, older persons become a larger part of the hospital population. The incidence of delirium is high in this group, and experiencing delirium has major short- and long-term sequelae, which makes prevention crucial. During delirium, a disruption of the sleep-wake cycle is frequently observed. Melatonin plays an important role in the regulation of the sleep-wake cycle, so this raised the hypothesis that alterations in the metabolism of melatonin might play an important role in the development of delirium. The aim of this article is to describe the design of a randomised, placebo controlled double-blind trial that is currently in progress and that investigates the effects of melatonin versus placebo on delirium in older, postoperative hip fracture patients.</p> <p>Methods/Design</p> <p>Acutely hospitalised patients aged 65 years or older admitted for surgical repair of hip fracture are randomised (n = 452) into a treatment or placebo group. Prophylactic treatment consists of orally administered melatonin (3 mg) at 21:00 h on five consecutive days. The primary outcome is the occurrence of delirium, to be diagnosed according to the Confusion Assessment Method, within eight days after start of the study medication. Secondary outcomes are delirium severity, measured by the Delirium Rating Scale; duration of delirium; differences in subtypes of delirium; differences in total length of hospital stay; total dose of antipsychotics and/or benzodiazepine use during delirium; and in-hospital complications. In the twelve-month follow up visit, cognitive function is measured by a Mini-Mental state examination and the Informant Questionnaire on Cognitive Decline in the Elderly. Functional status is assessed with the Katz ADL index score (patient and family version) and grip strength measurement. The outcomes of these assessments are compared to the outcomes that were obtained during admission.</p> <p>Discussion</p> <p>The proposed study will contribute to our knowledge because studies on the prophylactic treatment of delirium with long term follow up remain scarce. The results may lead to a prophylactic treatment for frail older persons at high risk for delirium that is safe, effective, and easily implementable in daily practice.</p> <p>Trial registration</p> <p>Dutch Clinical Trial Registry: <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1576">NTR1576</a></p

Implementing glucose control in intensive care: a multicenter trial using statistical process control

Glucose control (GC) with insulin decreases morbidity and mortality of critically ill patients. In this study we investigated GC performance over time during implementation of GC strategies within three intensive care units (ICUs) and in routine clinical practice. All adult critically ill patients who stayed for >24 h between 1999 and 2007 were included. Effects of implementing local GC guidelines and guideline revisions on effectiveness/efficiency-related indicators, safety-related indicators, and protocol-related indicators were measured. Data of 17,111 patient admissions were evaluated, with 714,141 available blood glucose levels (BGL) measurements. Mean BGL, time to reach target, hyperglycemia index, sampling frequency, percentage of hyperglycemia events, and in-range measurements statistically changed after introducing GC in all ICUs. The introduction of simple rules on GC had the largest effect. Subsequent changes in the protocol had a smaller effect than the introduction of the protocol itself. As soon as the protocol was introduced, in all ICUs the percentage of hypoglycemia events increased. Various revisions were implemented to reduce hypoglycemia events, but levels never returned to those from pre-implementation. More intensive implementation strategies including the use of a decision support system resulted in better control of the process. There are various strategies to achieve GC in routine clinical practice but with variable success. All of them were associated with an increase in hypoglycemia events, but GC was never stopped. Instead, these events have been accepted and managed. Statistical process control is a useful tool for monitoring phenomena over time and captures within-institution change

Investigating the role of constitutively active truncated androgen receptor splice variants in prostate cancer

TX-1-968The androgen receptor (AR) is fundamental for the growth and survival of normal and malignant prostate cells. Therefore, androgen deprivation therapy remains the first?line treatment for disseminated disease, however, relapse and progression to a castration?resistant phenotype for which no durable treatment currently exists, is inevitable. Unequivocal evidence now exists that restored AR activity is fundamental in the progression to castration?resistant prostate cancer (CRPC). Multiple mechanisms by which AR is reactivated under androgen?depleted conditions may be involved in the development of this lethal phenotype. Recent studies have identified alternatively spliced transcripts encoding truncated AR isoforms that lack the ligand?binding domain which is the therapeutic target of androgen deprivation therapy. Many of these truncated AR variants function as constitutively active, ligand?independent transcription factors that can support androgen?independent expression of AR target genes, as well as ligand independent growth of prostate cancer cells. In this study, an AR variant gene signature independent of full?length AR consisting of 284 genes was identified in the 22Rv1 cell?based model of CRPC using whole?genome microarray. The clinical relevance of this AR variant gene signature was also determined in a cohort of prostate cancer specimens with the AR variant gene signature sufficient to distinguish between microdissected benign and malignant prostate cancer specimens. Furthermore, a number of putative AR variant regulated pro?oncogenes (TAX1BP1, NRP1, LEF1, LAMP3, IGFBP3) and tumor suppressor genes (SPRY2, RASD1, MBP, BNIP3L), upregulated and downregulated respectively with disease progression and biochemical recurrence were identified. These findings may provide a critical insight into the mechanism of disease progression mediated by truncated AR variants and reveal potential targets for therapeutic intervention in patients who progress despite androgen deprivation therapy