Cadaveric simulation for improving surgical training in dermatology.

Simulation models are rapidly changing medical education, especially the training of dermatology residents. Various models are available, including cadaveric simulations. Our study evaluates the impact of a cadaveric simulation on the training of dermatology residents. Over a period of three years, cadaveric simulation was shown to increase the surgical knowledge of residents. Residents were more confident in their knowledge of surgical anatomy and also surgical skills. Cadaveric simulation may offer a positive impact on resident training in dermatology

Systematic review of the current status of cadaveric simulation for surgical training

Background: There is growing interest in and provision of cadaveric simulation courses for surgical trainees. This is being driven by the need to modernize and improve the efficiency of surgical training within the current challenging training climate. The objective of this systematic review is to describe and evaluate the evidence for cadaveric simulation in postgraduate surgical training. Methods: A PRISMA‐compliant systematic literature review of studies that prospectively evaluated a cadaveric simulation training intervention for surgical trainees was undertaken. All relevant databases and trial registries were searched to January 2019. Methodological rigour was assessed using the widely validated Medical Education Research Quality Index (MERSQI) tool. Results: A total of 51 studies were included, involving 2002 surgical trainees across 69 cadaveric training interventions. Of these, 22 assessed the impact of the cadaveric training intervention using only subjective measures, five measured impact by change in learner knowledge, and 23 used objective tools to assess change in learner behaviour after training. Only one study assessed patient outcome and demonstrated transfer of skill from the simulated environment to the workplace. Of the included studies, 67 per cent had weak methodology (MERSQI score less than 10·7). Conclusion: There is an abundance of relatively low‐quality evidence showing that cadaveric simulation induces short‐term skill acquisition as measured by objective means. There is currently a lack of evidence of skill retention, and of transfer of skills following training into the live operating theatre

The economic implications of HLA matching in cadaveric renal transplantation.

Abstract Background: The potential economic effects of the allocation of cadaveric kidneys on the basis of tissue-matching criteria are controversial. We analyzed the economic costs associated with the transplantation of cadaveric kidneys with various numbers of HLA mismatches and examined the potential economic benefits of a local, as compared with a national, system designed to minimize HLA mismatches between donor and recipient in first cadaveric renal transplantations. Methods: All data were supplied by the U.S. Renal Data System. Data on all payments made by Medicare from 1991 through 1997 for the care of recipients of a first cadaveric renal transplant were analyzed according to the number of HLA-A, B, and DR mismatches between donor and recipient and the duration of cold ischemia before transplantation. Results: Average Medicare payments for renal-transplant recipients in the three years after transplantation increased from $60,436 per patient for fully HLA-matched kidneys (those with no HLA-A, B, or DR mismatches) to$80,807 for kidneys with six HLA mismatches between donor and recipient, a difference of 34 percent (P\u3c0.001). By three years after transplantation, the average Medicare payments were $64,119 for transplantations of kidneys with less than 12 hours of cold-ischemia time and$74,997 for those with more than 36 hours (P\u3c0.001). In simulations, the assignment of cadaveric kidneys to recipients by a method that minimized HLA mismatching within a local geographic area (i.e., within one of the approximately 50 organ-procurement organizations, which cover widely varying geographic areas) produced the largest cost savings ($4,290 per patient over a period of three years) and the largest improvements in the graft-survival rate (2.3 percent) when the potential costs of longer cold-ischemia time were considered. Conclusions: Transplantation of better-matched cadaveric kidneys could have substantial economic advantages. In our simulations, HLA-based allocation of kidneys at the local level produced the largest estimated cost savings, when the duration of cold ischemia was taken into account. No additional savings were estimated to result from a national allocation program, because the additional costs of longer cold-ischemia time were greater than the advantages of optimizing HLA matching

Teaching percutaneous renal biopsy using unfixed human cadavers

Background: Percutaneous renal biopsy (PRB) is an important diagnostic procedure. Despite advances in its safety profile there remains a small but significant risk of bleeding complications. Traditionally, operators train to perform PRB through tutor instruction and directly supervised PRB attempts on real patients. We describe an approach to teaching operators to perform PRB using cadaveric simulation. Methods: We devised a full day course hosted in the Clinical Anatomy Skills Centre, with places for nine candidates. Course faculty consisted of two Consultant Nephrologists, two Nephrology trainees experienced in PRB, and one Radiologist. Classroom instruction included discussion of PRB indications, risk minimisation, and management of complications. Two faculty members acted as models for the demonstration of kidney localisation using real-time ultrasound scanning. PRB was demonstrated using a cadaveric model, and candidates then practised PRB using each cadaver model. Results: Written candidate feedback was universally positive. Faculty considered the cadaveric model a realistic representation of live patients, while the use of multiple cadavers introduced anatomical variation. Conclusions: Our model facilitates safe simulation of a high risk procedure. This might reduce serious harm associated with PRB and improve patient safety, benefiting trainee operators and patients alike

"Suboptimal" kidney donors: The experience with tacrolimus-based immunosuppression

Female, pediatric, and older donors have been associated with inferior graft survival after renal transplantation. We analyzed these three subgroups in 397 patients receiving tacrolimus-based immunosuppression. There were no differences in recipient age, incidence of retransplantation, or percentage of sensitized patients. Female donors, compared with male donors, were associated with comparable 1- and 3-year patient survival rates (96% and 93% vs. 95% and 92%, respectively) and comparable 1- and 3-year graft survival rates (90% and 80% vs. 88% and 81%, respectively). Renal function was also similar. Recipients of pediatric en bloc kidneys, when compared with recipients of other cadaveric kidneys, also had comparable 1- and 3-year patient survival rates (94% and 94% vs. 95% and 91%, respectively) and comparable 1- and 3-year graft survival rates (84% and 84% vs. 89% and 79%, respectively). Renal function was better in recipients of en bloc kidneys, with a mean serum creatinine level of 1.4±1.8 mg/dl vs. 2.0±1.5 mg/dl (P=0.01). In contrast to the first two subgroups, donors over 60 years of age, when compared with donors under 60 years of age, were associated with worse 1- and 3-year patient survival rates (88% and 80% vs. 96% and 94%, respectively; P<0.03) and worse 1- and 3-year graft survival rates (74% and 62% vs. 91% and 83%, respectively; P<0.0001). Renal function was worse in the older donor group, with a serum creatinine level of 2.7±1.2 mg/ml vs. 1.9±1.5 mg/dl (P=0.01). We conclude that, under tacrolimus-based immunosuppression, kidneys from female or very young pediatric donors are not associated with adverse outcomes, whereas kidneys from donors over 60 years of age are associated with inferior outcomes

Sequential Sectioning of the Ulnar Collateral Ligament of the Elbow in Cadaveric Arms with Ulnohumeral Laxity Assessed by Dynamic Ultrasonography

Objectives: Injury of the ulnar collateral ligament (UCL), whether acute or chronic, is potentially career-threatening for elite overhead throwing athletes. Dynamic ultrasound (DUS) allows for rapid, cost-effective, non-invasive, and non-radiating evaluation of the UCL and elbow joint both at rest and with applied stress. The purpose of this study was to determine the amount of cadaveric elbow valgus laxity with sequential UCL sectioning using DUS. Our objective was to quantify which portions of the UCL must be injured to cause the varying levels of laxity seen clinically on DUS testing. No prior study has used DUS to quantify valgus joint laxity with sequential cadaveric UCL sectioning. It was hypothesized that the change in laxity due to release of the anterior band of the UCL would be greater than that seen when the posterior and transverse bands were cut. Methods: Twelve cadaveric elbows were dissected free of skin and subcutaneous tissue by an experienced orthopaedic surgeon. Baseline DUS at rest and with applied valgus stress was then performed by an experienced ultrasonographer. Sequential sectioning of the medial elbow soft-tissue stabilizing structures was then carried out with valgus stress applied to the joint at each sectioning interval utilizing a standardized device (Telos, Marburg, Germany). First the transverse band of the UCL was released, followed by the posterior band, then the anterior bundle of the anterior band, the remaining posterior bundle of the anterior band, and finally the complete flexor pronator mass. Results: Mean ulnohumeral laxity in millimeters with 95% CIs was calculated for each step of the sequence. The deltas between each step of the dissection were also calculated with means and 95% CIs. Mean baseline laxity of the unstressed ulnohumeral joint at rest was 3.2 mm (CI, 2.2-4.2); with the addition of valgus stress, mean laxity was 4.7 mm (CI, 3.5-6.0). When the transverse band was cut, ulnohumeral laxity increased to a mean of 5.5 mm (CI, 4.0-7.0). With release of the posterior band, mean laxity was 6.4 mm (CI, 4.3-8.5). When the anterior bundle of the anterior band of the UCL was cut, mean ulnohumeral laxity was 8.4 mm (CI, 5.7-11.0) and when the entire anterior band was released, mean laxity was 10.9 mm (CI, 7.8-14.0). Complete release of the flexor pronator muscle mass resulted in mean ulnohumeral laxity of 15.5 mm (CI, 12.9-18.1). The largest deltas were observed with release of the anterior bundle of the anterior band (2.0 mm; CI, 1.0-3.0), the entire anterior band (2.6 mm; CI, 1.3-3.8), and flexor pronator mass (4.6 mm; CI, 1.3-3.8). Release of the transverse and posterior bands of the UCL resulted in deltas of 0.74 mm (CI, 0.1-1.3) and 0.9 mm (CI, 0.3-1.5) respectively. Conclusion: DUS allows for rapid, cost-effective, non-invasive, non-radiating evaluation of the elbow joint and UCL both at rest and with applied valgus stress. Previous studies have indicated that DUS can identify abnormalities of the UCL associated with chronic degeneration and ligamentous injury including thickening of the anterior band of the UCL as well as hypoechoic foci/calcifications. The results of the current cadaveric study suggest that different changes in clinical laxity are seen on DUS with injury of particular bands of the UCL. Early identification and localization of injury to a particular band of the UCL may allow more appropriate selection of patients who will benefit from operative treatment. © The Author(s) 2013

Steps in immunosuppression for renal transplantation

The authors provide a historical survey of the immunosuppressive agents that have been used to prevent allograft rejection. Attention is given to the expected effect of cyclosporin in kidney translations

Procuring organs for transplantation : a European perspective

Background: The shortage of organs for transplant In Europe has been considerable for many years. A number of different policies have been implemented in an attempt to address this problem. These have had varying degrees of success from country to country. Methods: This article provides an up-to-date review of organ procurement policies throughout Europe. Alternative and In some cases controversial organ procurement programmes are also considered to establish whether the increasing demand for organs can be met elsewhere. Results: Transplant waiting lists are the greatest by far for those patients waiting for a kidney replacement. Norway has best managed to address this need through adopting a positive policy choice towards live donation whilst still maintaining an active cadaveric donation policy. Conclusion: With the lowering of both physical and social barriers In Europe, there has been a recent shift towards co-operation between some European countries in promoting transplant activity. This ensures that if an organ becomes available in one country and has no suitable recipient, then it can be used elsewhere. The future may show and increasing trend towards this level of European cooperation in order to make transplant activity more efficient

The University of Pittsburgh: a three and three-quarter-year experience with cadaveric renal transplantation under the point system.

Eight hundred and sixty kidney transplants were performed at the University of Pittsburgh over a 3.75-year period between January 1, 1986 and October 19, 1989. Recipient selection was by means of a computerized point system designed to allocate organs equitably. Ninety-three percent 1-year patient survival and 74% 1-year graft survival were obtained in the overall group; 80% 1-year graft survival was obtained in patients receiving immunosuppression with CsA, azathioprine, and prednisone. These data serve as a measure of what can be achieved with an equitably based allocation system and can serve as a basis of comparison with other allocation protocols or new immunosuppressive regimens

Thoracic duct fistula and renal transplantation

Thoracic duct drainage (TDD) was established for 21-115 days in 40 kidney recipients with an average removal per patient day of 4.7 1 lymph and 1.88 billion cells. Cellular and humoral immunity were depressed. TDD and immunosuppressive drugs were started at transplantation in 35 recipients of cross-match negative grafts. Although the results were better than in precedent non-TDD controls, eight patients rejected their grafts before a full TDD effect, and three of the eight developed predominantly anti-B lymphocyte cytotoxic antibodies which were probably responsible for positive cross-matches with their next donors. With continuing TDD, all eight patients had good initial function after early retransplantation. In five more 'nontransplantable' patients with performed cytotoxic antibodies, TDD was started 30-56 days before transplantation. In these five pretreated patients, antibodies persisted with positive antidonor cross-matches. Hyperacute rejection occurred repeatedly in two patients with high anti-T (and anti-B) titers, but was surmounted in three patients with lower titers. From the clinical and immunologic data, we have concluded that TDD should be used for pretreatment of all cases with or without prior antibodies, and have suggested an adjustable management plan that takes into account new developments in antibody monitoring