Objectives
The goal of this study was to investigate the effects of spaced versus massed practice on skill acquisition and retention in the context of laparoscopic motor skill training.
Background
...Reaching proficiency in performing laparoscopic surgery involves extensive training to acquire the required motor skills. Conventionally, training of such skills occurs during a full day training event utilizing surgical simulators that train specific motor skills pertinent to laparoscopic surgery. An important variable to consider is the optimal schedule for laparoscopic motor training.
Methods
In this study, two groups of trainees without prior experience were trained on a variety of physical box-trainer tasks on different time-schedules. One group received three 75-min training sessions on a single day (massed condition) and the other received one 75-min training session per week for three consecutive weeks (spaced condition). Short- and long-term retention were assessed 2 weeks and 1 year after the completion of training.
Results
Outcome measures indicated better performance at the end of training, at a 2-week delayed retention session and at a 1-year retention session for the group that received training on a spaced schedule. This spacing effect was most pronounced for the more difficult laparoscopic training tasks such as intra-corporeal suturing. On average, 21 % of participants in the massed group and 65 % in the spaced group reached proficiency by the end of training.
Conclusions
Spacing practice of laparoscopic motor skill training will facilitate skill acquisition, short-term and long-term retention, and thus, a more efficient learning process for trainees. Though more challenging in terms of logistics, training courses in medical centers should distribute practice sessions over longer time intervals.
OBJECTIVE:To evaluate the impact of changes in elective Abdominal Aortic Aneurysm (AAA) management on life-expectancy of AAA patients.
BACKGROUND:Over the past decades AAA repair underwent ...substantial changes, that is, the introduction of EVAR and implementation of intensified cardiovascular risk management. The question rises to what extent these changes improved longevity of AAA patients.
METHODS:National evaluation including all 12.907 (82.7% male) patients who underwent elective AAA repair between 2001 and 2015 in Sweden. The impact of changes in AAA management was established by a time-resolved analysis based on 3 timeframesopen repair dominated period (2001–2004, n = 2483), transition period (2005–2011, n = 6230), and EVAR-first strategy period (2012–2015, n = 4194). Relative survival was used to quantify AAA-associated mortality, and to adjust for changes in life-expectancy.
RESULTS:Relative survival of electively treated AAA patients was stable and persistently compromised 4-year relative survival and 95% confidence interval0.87 (0.85–0.89), 0.87 (0.86–0.88), 0.89 (0.86–0.91) for the 3 periods, respectively. Particularly alarming is the severely compromised survival of female patients (4-year relative survival females 0.78, 0.80, 0.70 vs males 0.89, 0.89, 0.91, respectively). Cardiovascular mortality remained the main cause of death (51.0%, 47.2%, 47.9%) and the proportion cardiovascular disease over non-cardiovascular disease death was stable over time.
CONCLUSIONS:Changes in elective AAA management reduced short-term mortality, but failed to improve the profound long-term survival disadvantage of AAA patients. The persistent high (cardiovascular) mortality calls for further intensification of cardiovascular risk management, and a critical appraisal of the basis for the excess mortality of AAA patients.
Doxycycline inhibits formation and progression of abdominal aortic aneurysms (AAAs) in preclinical models of the disease, but it is unclear whether and how this observation translates to humans.
To ...test whether doxycycline inhibits AAA progression in humans.
Randomized, placebo-controlled, double-blind trial. (Dutch Trial Registry: NTR 1345) SETTING: 14 Dutch hospitals.
286 patients with small AAAs between October 2008 and June 2011.
Daily dose of 100 mg of doxycycline (n = 144) or placebo (n = 142) for 18 months.
The primary outcome measure was aneurysm growth at 18 months, as estimated by repeated single-observer ultrasonography. Secondary outcomes included growth at 6 and 12 months and the need for elective surgery.
Mean aneurysm diameter (approximately 43 mm) and other baseline characteristics were similar in both groups. Doxycycline treatment was associated with increased aneurysm growth (4.1 mm in the doxycycline group vs. 3.3 mm in the placebo group at 18 months; difference, 0.8 mm 95% CI, 0.1 to 1.4 mm; P = 0.016 mm). Twenty-one patients receiving doxycycline and 22 patients receiving placebo had elective surgical repair (Kaplan–Meier estimates were 16.1% for those receiving doxycycline and 16.5% for those receiving placebo; difference, -0.4% CI, -9.3% to 8.5%; P = 0.83). Time to repair was similar in the groups (P = 0.92).
This study focuses on patients with small AAAs. As such, whether the data can be extrapolated to larger AAAs (>55 mm) is unclear. The high number of elective repairs (n = 43) was unanticipated. Moreover, the study did not follow patients who withdrew because of an adverse effect.
This trial found that 18 months of doxycycline therapy did not reduce aneurysm growth and did not influence the need for AAA repair or time to repair.
The Netherlands Organisation for Health Research and Development, and the NutsOhra Fund.
An evidence-based consensus for a female-specific intervention threshold for abdominal aortic aneurysms (AAAs) is missing. This study aims to analyze sex-related differences in the epidemiology of ...ruptured AAA to establish an intervention threshold for women.
The Dutch Surgical Aneurysm Audit (DSAA) is a compulsory, nation-wide registry of AAA repairs in The Netherlands. All patients with emergency or elective AAA repair between January 1, 2013, and December 31, 2015, were included in the analysis. The main outcomes were age, sex, AAA diameter at time of rupture, and 30-day postoperative mortality.
A total of 1561 ruptured AAA repairs (14.7% women) and 7063 cases of elective AAA repair (13.7% women) were included in the analysis. Women had significantly smaller mean ± standard deviation AAA diameter at time of rupture than men; 70.5 ± 14.4 mm and 78.6 ± 17.5 mm, respectively. In male patients, 8% of ruptures occurred at diameters below the 55 mm intervention threshold. The female equivalent of this eighth percentile is 52 mm. Female patients had significantly higher 30-day mortality after emergency repair, namely, 33% for women versus 24.2% for men, but were also significantly older, mean ± standard deviation age 76.7 ± 7.1 years and 73.9 ± 8.3 years for women and men, respectively. Correcting for age reduced the 30-day mortality risk for women after ruptured AAA repair from 1.53 (95% confidence interval, 1.14-2.04) to 1.27 (95% confidence interval, 0.92-1.73). Outcome after open elective repair was significantly worse for women compared with men, with a 30-day mortality of 7.97% 30 for women and 4.27% for men (P < .01).
The equivalent of the 55-mm intervention threshold for elective endovascular AAA repair in men is 52 mm in women. The almost doubled mortality risk for elective open repair in women implies that the optimal point for open repair is at higher diameters, very possibly at least 55 mm.
Background Direct comparisons between risk of contrast induced acute kidney injury (CI-AKI) after intra-arterial versus intravenous contrast administration are scarce. We estimated and compared the ...risk of CI-AKI and its clinical course after both modes of contrast administration in patients who underwent both. Methods One hundred seventy patients who received both intra-arterial and intravenous contrast injections within one year between 2001 and 2010 were included. Primary outcome was occurrence of CI-AKI. Secondary outcomes were duration of hospital stay, the need for dialysis, recovery of renal function, and mortality. Results The risk of CI-AKI was 24/170 (14.0%, 95% CI 9.6-20.2) after intra-arterial contrast injection versus 20/170 (11.7%, 95% CI 7.7-17.5) after intravenous contrast administration, which led to a relative risk of 1.2 (95% CI 0.7-2.1). None of the patients had a need for dialysis. Median duration of hospital stay in CI-AKI patients was 15.0 days (2.5-97.5, percentile 1-92) after intra-arterial and 15.5 days (2.5-97.5, percentile 0-38) after intravenous contrast procedures. Renal function recovered after CI-AKI in 13/24 after intra-arterial and in 10/20 patients after intravenous contrast administration. Mortality risks in CI-AKI patients were slightly higher than in non-CI-AKI patients, hazard ratios 1.6 (95% CI 0.7-3.7) for intra-arterial and 1.7 (95% CI 0.7-4.4) for intravenous contrast administration, adjusted for confounders. Conclusion The risk of CI-AKI, and its clinical course was similar after intra-arterial and intravenous contrast media administration, after adjustment by design for patient-related risk factors.
Carotid body tumors (CBTs) are rare highly vascularized and slow enlarging tumors arising from the paraganglionic tissue at the carotid bifurcation. Main treatment options for CBTs are surgical ...resection or “wait and scan” strategy. The choice for either strategy may be equally good medically in many patients. A structured “shared decision making” (SDM) might be helpful for guiding patients.
To develop an SDM strategy for the surgical treatment, we aim to (1) identify considerations and factors involved in the decision making of patients with CBTs and (2) evaluate the current practice in our clinic and explore the opinions of patients on their treatment.
This exploratory study was conducted in patients of the Leiden University Medical Centre (LUMC), The Netherlands. Patients who met the inclusion criteria were invited for a semi-structured interview. All conversations were fully audiotaped and transcripted.
Fifteen patients were included and interviewed. Ten of these patients underwent previously surgical resection of at least one tumor. Five patients underwent the wait and scan policy. The most important factors influencing decision making in CBT treatment are family, fears, co-consultants, and doctor-patient relationship.
This study has identified the factors influencing decision making in CBT and should be considered during consultations. The decision for surgery or not was mainly influenced by physician preferences and family members' prior experiences.
Cell therapies involving the administration of bone marrow-derived mononuclear cells (BM-MNCs) for patients with chronic limb-threatening ischemia (CLTI) have shown promise; however, their overall ...effectiveness lacks evidence, and the exact mechanism of action remains unclear. In this study, we examined the angiogenic effects of well-controlled human bone marrow cell isolates on endothelial cells. The responses of endothelial cell proliferation, migration, tube formation, and aortic ring sprouting were analyzed in vitro, considering both the direct and paracrine effects of BM cell isolates. Furthermore, we conducted these investigations under both normoxic and hypoxic conditions to simulate the ischemic environment. Interestingly, no significant effect on the angiogenic response of human umbilical vein endothelial cells (HUVECs) following treatment with BM-MNCs was observed. This study fails to provide significant evidence for angiogenic effects from human bone marrow cell isolates on human endothelial cells. These in vitro experiments suggest that the potential benefits of BM-MNC therapy for CLTI patients may not involve endothelial cell angiogenesis.
With the intention to gain support for the hypothesis that incident ischemic complications of atherosclerotic disease involve a stochastic aspect, we performed a histological, qualitative evaluation ...of the epidemiology of coronary atherosclerotic disease in a cohort of aortic valve donors.
Donors (n = 695, median age 54, range 11-65 years) were dichotomized into a non-cardiovascular (non-CVD) and a cardiovascular disease death (CVD) group. Consecutive 5 mm proximal left coronary artery segments were Movat stained, and the atherosclerotic burden for each segment was graded (revised AHA-classification).
Non-CVD and CVD groups showed steep increase of atherosclerosis severity beyond the age of 40, resulting in an endemic presence of advanced atherosclerosis in men over 40 and women over 50 years. In fact, only 19% of the non-CVD and 6% of the CVD donors over 40 years were classified with a normal LCA or a so called non-progressive lesion type. Fibrous calcified plaques (FCP), the consolidated remnants of earlier ruptured lesions, dominated in both non-CVD and CVD donors. Estimates of the atherosclerosis burden (i.e. average lesion grade, proportion of FCPs, and average number of FCPs per cross-section) were all higher in the CVD group (p<1.10-16, p<0.0001, and p<0.05, respectively).
Dominance of consolidated FCP lesions in males over 40 and females over 50 years, show that plaque ruptures in the left coronary artery are common. However, the majority of these ruptures remain asymptomatic. This implies that the atherosclerotic process is repetitive. A relative difference in disease burden between CVD and non-CVD donors supports the concept that complications of atherosclerotic disease involve a stochastic element.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Diagnosing peripheral arterial disease (PAD) can be challenging owing to medial arterial calcification (MAC) in patients with diabetes mellitus (DM) and chronic kidney disease (CKD). Current bedside ...tests, such as the ankle-brachial index and toe-brachial index, are often insufficient. The maximal systolic acceleration (ACC
) is a velocimetric Doppler-derived parameter and could be a new promising test in the diagnostic workup of these patients. The primary aim of this study was to evaluate the diagnostic performance of the ACC
to detect PAD.
A retrospective cohort study was performed in a tertiary referral hospital. Patients ≥18 years old with suspected PAD who underwent ACC
measurement(s) along with computed tomography angiography of the abdominal aorta and lower extremities (reference test) were eligible for inclusion. ACC
measurements of the posterior tibial artery, anterior tibial artery and peroneal artery were collected. Diagnostic performance was assessed by using sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and area under the curve (AUC).
In total, 340 patients (618 limbs) were included. Approximately 40% suffered from DM and 30% had CKD. Diagnostic performance of the ACC
to detect PAD for the posterior tibial artery showed a sensitivity of 90%, specificity of 93%, positive likelihood ratio of 12.83, and negative likelihood ratio of 0.11 (AUC, 0.953). For the anterior tibial artery, these results were 94%, 97%, 32.06, and 0.06 (same sequence as presented before) with an AUC of 0.984. The peroneal artery had a performance of 86%, 89%, 7.51, and 0.16, respectively (AUC, 0.893). Diagnostic accuracy of the ACC
did not diminish in subgroup analysis for patients with DM or CKD.
The ACC
showed excellent diagnostic performance to detect PAD, independent of patients prone to medial arterial calcification.
The aim of this time-trend analysis is to estimate long-term excess-mortality and associated cardiovascular risk for abdominal aortic aneurysm (AAA) patients after elective repair, while addressing ...the changes in AAA management and patient selection over time.
Despite the intensification of endovascular aneurysm repair (EVAR) and cardiovascular risk management (CVRM), Swedish population data suggest that AAA patients retain a persistently high long-term mortality after elective repair. The question is whether this reflects sub-optimal treatment, a changing patient population over time, or a national phenomenon.
Nationwide time-trend analysis including 40730 patients (87% men) following elective AAA repair between 1995-2017. Three timeframes were compared, each reflecting changes in the use of EVAR and intensification of CVRM. Relative survival analyses were used to estimate disease-specific excess-mortality. Competing risk of death analysis evaluated the risk of cardiovascular versus non-cardiovascular death. Sensitivity analysis evaluated the impact of changes in patient selection over time.
Short-term excess-mortality significantly improved over time. Long-term excess-mortality remained high with a doubled mortality risk for women (RER 1.87 (95%CI 1.73-2.02)). Excess-mortality did not differ between age-categories. The risk of cardiovascular versus non-cardiovascular death remained similar over time, with a higher risk of cardiovascular death for women. Changes in patient population (i.e. older and more comorbid patients in the latter period) marginally impacted excess-mortality (2%).
Despite changes in AAA care, patients retain a high long-term excess-mortality after elective repair with a persistent high cardiovascular mortality risk. In this a clear sex- but no age disparity stands out.
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