ESPRAS Survey on Continuing Education in Plastic, Reconstructive and Aesthetic Surgery in Europe

Background Specialty training in plastic, reconstructive and aesthetic surgery is a prerequisite for safe and effective provision of care. The aim of this study was to assess and portray similarities and differences in the continuing education and specialization in plastic surgery in Europe. Material and Methods A detailed questionnaire was designed and distributed utilizing an online survey administration software. Questions addressed core items regarding continuing education and specialization in plastic surgery in Europe. Participants were addressed directly via the European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS). All participants had detailed knowledge of the organization and management of plastic surgical training in their respective country. Results The survey was completed by 29 participants from 23 European countries. During specialization, plastic surgeons in Europe are trained in advanced tissue transfer and repair and aesthetic principles in all parts of the human body and within several subspecialties. Moreover, rotations in intensive as well as emergency care are compulsory in most European countries. Board certification is only provided for surgeons who have had multiple years of training regulated by a national board, who provide evidence of individually performed operative procedures in several anatomical regions and subspecialties, and who pass a final oral and/or written examination. Conclusion Board certified plastic surgeons meet the highest degree of qualification, are trained in all parts of the body and in the management of complications. The standard of continuing education and qualification of European plastic surgeons is high, providing an excellent level of plastic surgical care throughout Europe

What are we measuring? A critique of range of motion methods currently in use for Dupuytren's disease and recommendations for practice

Background: Range of motion is the most frequently reported measure used in practice to evaluate outcomes. A goniometer is the most reliable tool to assess range of motion yet, the lack of consistency in reporting prevents comparison between studies. The aim of this study is to identify how range of motion is currently assessed and reported in Dupuytren’s disease literature. Following analysis recommendations for practice will be made to enable consistency in future studies for comparability. This paper highlights the variation in range of motion reporting in Dupuytren’s disease. Methods: A Participants, Intervention, Comparison, Outcomes and Study design format was used for the search strategy and search terms. Surgery, needle fasciotomy or collagenase injection for primary or recurrent Dupuytren’s disease in adults were included if outcomes were monitored using range of motion to record change. A literature search was performed in May 2013 using subject heading and free-text terms to also capture electronic publications ahead of print. In total 638 publications were identified and following screening 90 articles met the inclusion criteria. Data was extracted and entered onto a spreadsheet for analysis. A thematic analysis was carried out to establish any duplication, resulting in the final range of motion measures identified. Results: Range of motion measurement lacked clarity, with goniometry reportedly used in only 43 of the 90 studies, 16 stated the use of a range of motion protocol. A total of 24 different descriptors were identified describing range of motion in the 90 studies. While some studies reported active range of motion, others reported passive or were unclear. Eight of the 24 categories were identified through thematic analysis as possibly describing the same measure, ‘lack of joint extension’ and accounted for the most frequently used. Conclusions: Published studies lacked clarity in reporting range of motion, preventing data comparison and meta-analysis. Percentage change lacks context and without access to raw data, does not allow direct comparison of baseline characteristics. A clear description of what is being measured within each study was required. It is recommended that range of motion measuring and reporting for Dupuytren’s disease requires consistency to address issues that fall into 3 main categories:- Definition of terms Protocol statement Outcome reportin

5-HTT deficiency affects neuroplasticity and increases stress sensitivity resulting in altered spatial learning performance in the Morris water maze but not in the Barnes maze.

The purpose of this study was to evaluate whether spatial hippocampus-dependent learning is affected by the serotonergic system and stress. Therefore, 5-HTT knockout (-/-), heterozygous (+/-) and wildtype (+/+) mice were subjected to the Barnes maze (BM) and the Morris water maze (WM), the latter being discussed as more aversive. Additionally, immediate early gene (IEG) expression, hippocampal adult neurogenesis (aN), and blood plasma corticosterone were analyzed. While the performance of 5-HTT-/- mice in the BM was undistinguishable from both other genotypes, they performed worse in the WM. However, in the course of the repeated WM trials 5-HTT-/- mice advanced to wildtype level. The experience of a single trial of either the WM or the BM resulted in increased plasma corticosterone levels in all genotypes. After several trials 5-HTT-/- mice exhibited higher corticosterone concentrations compared with both other genotypes in both tests. Corticosterone levels were highest in 5-HTT-/- mice tested in the WM indicating greater aversiveness of the WM and a greater stress sensitivity of 5-HTT deficient mice. Quantitative immunohistochemistry in the hippocampus revealed increased cell counts positive for the IEG products cFos and Arc as well as for proliferation marker Ki67 and immature neuron marker NeuroD in 5-HTT-/- mice compared to 5-HTT+/+ mice, irrespective of the test. Most differences were found in the suprapyramidal blade of the dentate gyrus of the septal hippocampus. Ki67-immunohistochemistry revealed a genotype x environment interaction with 5-HTT genotype differences in naïve controls and WM experience exclusively yielding more Ki67-positive cells in 5-HTT+/+ mice. Moreover, in 5-HTT-/- mice we demonstrate that learning performance correlates with the extent of aN. Overall, higher baseline IEG expression and increased an in the hippocampus of 5-HTT-/- mice together with increased stress sensitivity may constitute the neurobiological correlate of raised alertness, possibly impeding optimal learning performance in the more stressful WM

Increased number of cells expressing the immediate early genes cFos and Arc in the granule cell layer of the hippocampus of 5-HTT-/- compared to 5-HTT+/+ mice.

<p>In the quantitative immunohistochemistry study septal and temporal hippocampus as well as suprapyramidal and infrapyramidal blade of the GCL were analyzed separately. Significant differences of the number of cFos and Arc-immunoreactive (ir) cells were exclusively revealed between mice of the two 5-HTT genotypes investigated. Different treatments such as the experience of BM, WM or control situation did not significantly impact the expression of these two immediate early genes. (A) Representative image of the dentate gyrus of the hippocampus after cFos immunohistochemistry. Most of the cFos-ir cell nuclei (dark brown) are located in the granule cell layer as indicated by arrows in (a). (C) Quantitative evaluation of cFos-ir cells. (B) Representative image of the dentate gyrus after Arc immunohistochemistry. Most of the Arc-ir cells are located in the GCL. In (b) Arc-ir cells bodies are indicated by black arrows and stained processes by grey arrow heads. (D) Quantitative evaluation of Arc-ir cells. Two-way ANOVA, Bars represent the mean number of ir-cells per section +SEM; #=p<0.1; *=p<0.05; ***=p≤ 0.005. GCL, granule cell layer; SGZ, subgranular zone; Hi, hilus; CONT, control mice; BM, Barnes maze tested mice; WM, Morris water maze tested mice. Scale bar in A represents 200 μm for A and B, Scale bar in a represents 60 μm for a and b. </p

In 5-HTT-/- mice subjected to the WM a low number of NeuroD positive cells is correlated with a poor performance in the Morris water maze.

<p>Applying the Spearman`s test in the quantitative immunohistochemistry study revealed a linear dependence between the learning performance (decreasing learning performance is expressed as increasing area under the learning curve; AuC) and the number of NeuroD-immunoreactive (ir) cells could be found in the temporal hippocampus of 5-HTT-/- WM mice. A significant negative correlation between AuC and the number of NeuroD-ir (Data represent arithmetic mean per section) cells in both, the suprapyramidal blade of the subgranular zone (SGZ) as well as in both blades of the SGZ. A trend towards a negative correlation was found in the infrapyramidal blade of the SGZ. </p

Learning performance in the Morris water maze.

<p>Mice of all three genotypes (5-HTT+/+, 5-HTT+/-, 5-HTT-/-) were tested three times per day for 4 consecutive days (acquisition phase; trials 1 - 12). Trials on day five represent reversal trials (trials 13-15). (A) Learning curve for the latency to find the platform. RM-ANOVA revealed a significant effect of trial (indicating learning performance) and a significant genotype effect. (B) The area under the learning curve (AuC) was calculated for each individual for statistical comparison of learning in the acquisition phase. ANOVA revealed a significant effect of genotype. Post hoc analysis using Bonferroni corrected t-tests revealed significant differences between 5-HTT-/- and both other genotypes. (C) Curve depicting the number of stops for each trial. RM-ANOVA revealed a significant effect of trial and genotype. (D) The AuC for the number of stops revealed a significant effect of genotype. Post hoc analysis using Bonferroni corrected t-tests revealed significant differences between 5-HTT-/- and both other genotypes. Data in all figures represent means + SEM. ***=p<0.001. </p

Increased number of cells expressing the two adult neurogenesis marker Ki67 and NeuroD in the granule cell layer of the hippocampus of 5-HTT-/- compared to 5-HTT+/+ mice and gene by environment interaction of the number of Ki67-positive proliferating cells in both blades of the SGZ of the septal hippocampus.

<p>In the quantitative immunohistochemistry study septal and temporal hippocampus as well as suprapyramidal and infrapyramidal blade of the GCL were analyzed separately. Significant differences of the number of Ki67 and NeuroD-immunoreactive (ir) cells were primarily revealed between mice of the two 5-HTT genotypes (5-HTT-/- and 5-HTT+/+) investigated. Only in both blades of the SGZ the number of Ki67-ir cells was significantly increased in 5-HTT+/+ mice after WM treatment vs. naïve 5-HTT+/+ mice (CONT). Additionally, a trend towards higher amounts of Ki67-ir cells in naïve 5-HTT-/- compared to naïve 5-HTT+/+ was found. (A) Representative image of the dentate gyrus of the hippocampus after Ki67 immunohistochemistry. Most of the Ki67-ir cell nuclei (dark brown) are located in the subgranular zone (SGZ) as inidicated by arrows in (a). (C) Quantitative evaluation of Ki67-ir cells. (B) Representative image of the dentate gyrus after NeuroD immunohistochemistry. Most of the NeuroD-ir cell nuclei are located in the SGZ as indicated by arrows in (b). (D) Quantitative evaluation of NeuroD-ir cells. Two-way ANOVA, data represent arithmetic means of the number of ir-cells per section + SEM; #=p<0.1; *=p<0.05. GCL, granule cell layer; SGZ, subgranular zone; Hi, hilus; CONT, control mice; BM, Barnes maze tested mice; WM, Morris water maze tested mice. Scale bar in A represents 200 μm for A and B, Scale bar in a represent 60 μm for a and b. </p