The success of peritoneal dialysis (PD) is dependent on timely and adequate PD catheter access. In many centres, including our own, PD catheter insertion technique has evolved by laparoscopic ...surgery. An alternative method of catheter insertion is performed by radiologists using a percutaneous modified Seldinger technique under fluoroscopic guidance. However, there are no clinical trials comparing these two methods of catheter insertion.
From 1 April 1999 to 30 August 2004, we randomly assigned 113 pre-dialysis patients to receive PD catheter insertion using fluoroscopic guidance under local anaesthesia by radiologists or insertion using laparoscopy under general anaesthesia by a surgeon. The primary endpoint was the occurrence of dialysis catheter complications (complication-free catheter survival) by Day 365, a composite endpoint that included complications secondary to mechanical and infectious causes. Secondary endpoints were the occurrence of catheter removal (overall catheter survival) and death from any cause (patient survival) by Day 365, procedure pain, procedure time, procedure room utilization time, length of inpatient admission and direct hospital costs. Results were analysed by univariate and multivariate methods and by Kaplan-Meier survival curves.
Complication-free catheter survival was significantly higher at 42.5% 95% confidence interval (CI) 29.3-55 in the radiological group compared with 18.1% (95% CI 8.9-29.8) in the laparoscopic group (P-value = 0.03). Excess complications in the laparoscopic group included peritonitis, peritoneal dialysate leaks and umbilical herniae. One-year overall catheter survival and 1-year subject survival were not different between the groups. Hospital costs were significantly higher in the laparoscopic group by almost a factor of two.
Radiological insertion of first PD catheters using fluoroscopy is a clinically non-inferior and cost-effective alternative to surgical laparoscopic insertion.
Rationale
Various occupational groups are required to maintain optimal physical and cognitive function during overnight periods of wakefulness, often with less than optimal sleep. Strategies are ...required to help mitigate the impairments in cognitive function to help sustain workplace safety and productivity.
Objectives
To test the effectiveness of repeated 200 mg doses of caffeine on cognitive function and live-fire marksmanship with soldiers during three successive nights of sustained wakefulness followed by 4-h afternoon sleep periods.
Methods
Twenty Special Forces personnel (28.6 ± 4.7 years, 177.6 ± 7.5 cm and 81.2 ± 8.0 kg) were randomly assigned to receive four 200-mg doses of caffeine (
n
= 10) or placebo (
n
= 10) during the late evening and early morning hours during three successive days. An afternoon 4-h sleep period followed. The psychomotor (PVT) and field (FVT) vigilance, logical reasoning (LRT) tests and a vigilance monitor assessed cognitive function throughout the study. Live-fire marksmanship requiring friend–foe discrimination was assessed.
Results
Caffeine maintained speed on the PVT (
p
< 0.02), improved detection of events during FVT (
p
< 0.001), increased number of correct responses to stimuli as assessed by the vigilance monitor (
p
< 0.001) and increased response speed during the LRT (
p
< 0.001) throughout the three overnight testing periods. Live-fire marksmanship was not altered by caffeine.
Conclusions
A total daily dose of 800 mg caffeine during successive overnight periods of wakefulness is an effective strategy to maintain cognitive function when optimal sleep periods during the day are not available.
The clinical benefits of using "biocompatible" neutral pH solutions containing low levels of glucose degradation products for peritoneal dialysis compared with standard solutions are uncertain. In ...this multicenter, open-label, parallel-group, randomized controlled trial, we randomly assigned 185 incident adult peritoneal dialysis patients with residual renal function to use either biocompatible or conventional solution for 2 years. The primary outcome measure was slope of renal function decline. Secondary outcome measures comprised time to anuria, fluid volume status, peritonitis-free survival, technique survival, patient survival, and adverse events. We did not detect a statistically significant difference in the rate of decline of renal function between the two groups as measured by the slopes of GFR: -0.22 and -0.28 ml/min per 1.73 m(2) per month (P=0.17) in the first year in the biocompatible and conventional groups, respectively, and, -0.09 and -0.10 ml/min per 1.73 m(2) per month (P=0.9) in the second year. The biocompatible group exhibited significantly longer times to anuria (P=0.009) and to the first peritonitis episode (P=0.01). This group also had fewer patients develop peritonitis (30% versus 49%) and had lower rates of peritonitis (0.30 versus 0.49 episodes per year, P=0.01). In conclusion, this trial does not support a role for biocompatible fluid in slowing the rate of GFR decline, but it does suggest that biocompatible fluid may delay the onset of anuria and reduce the incidence of peritonitis compared with conventional fluid in peritoneal dialysis.
Bullying has been recognized as a phenomenon that detrimentally affects the lives of many, and researchers continue to explore its various influences and correlates. We examined the relationship ...between the global belief in a just world (BJW; a person’s tendency to believe that life is fair and people get what they deserve) and reactions to bullying. Although BJW is undergirded by a justice motive, and although previous research found that global BJW is associated with more negative explicit attitudes toward bullying in the abstract, we hypothesized that strong global BJW beliefs would instead predict more tolerance and less condemnation when participants were presented with specific behaviors that could be construed as bullying. In two vignette-based experiments, global BJW (but not personal BJW), predicted less negative reactions to bullying, and did so regardless of whether the behavior was explicitly labeled as being a case of bullying. Implications of these results are discussed.
Objectives/Hypothesis:
To assess whether practice on a virtual‐reality (VR) temporal bone simulator improves acquisition of technical skills in mastoid surgery.
Study Design:
Prospective blinded ...study.
Methods:
Using a previously validated objective structured assessment of technical skills (OSATS) tool, performance was assessed in 12 residents for two tasks of cortical mastoidectomy: 1) identifying and defining the tegmen and 2) defining the sigmoid sinus and sinodural angle. These surgical tasks were chosen as key steps in mastoid dissection because they were of intermediate complexity. Videos of virtual dissections were captured at baseline and again after practicing each task four to six times.
Results:
OSATS scores for the tegmen task increased from 2.125 ± 1.25 to 3.1 ± 0.85 (P = .026), whereas for the sigmoid task scores increased from 2 ± 0.45 to 2.75 ± 1.125 (P = .0098). The time to complete the tasks decreased from 8.37 ± 4.78 minutes to 5.39 ± 3.06 minutes (P = .018) for the tegmen task and from 8.99 ± 6.7 minutes to 8.68 ± 5.98 minutes (P = .594) for the sigmoid task. There was a decline in number of injuries from 0.5 ± 1.5 to 0 ± 0.5 (P = .594) for the tegmen task and from 2.5 ± 4 to 0.5 ± 1 (P = .029) for the sigmoid task.
Conclusions:
Technical skills in mastoidectomy surgery can be acquired during even brief practice on the VR temporal bone simulator. It is anticipated that longer periods of practice presented within the fundamentals of comprehensive curriculum will facilitate procedural learning. Further studies are required to elucidate evidence of transference of these skills to the operating room and to procedures of greater complexity.
ObjectivesIn 2019, under the World Kidney Day theme of ‘Kidney health for everyone everywhere’, the National Kidney Foundation of Samoa undertook an extensive community screening campaign to detect ...the estimated prevalence of chronic kidney disease (CKD) and its associated risk factors in the community.SettingFifteen screening sites, with 11 urban and rural sites on the main island of Upolu, and 4 in different rural areas on the island of Savaii.ParticipantsAll participants were self-referrals to the various screening sites. In total, 1163 Samoans were screened, with similar numbers from both urban and rural areas and similar numbers of female and male.Screening activitiesAll participants were screened for CKD using point of care serum creatinine determinations, with calculation of estimated glomerular filtration rate using the CKD-EPI formula and dipstix urinalysis. A standardised screening survey was used to capture demographic and medical history with associated risk factors of obesity, diabetes, using point of care determination of HbA1c and hypertension. Logistic regression was used to investigate the association of CKD with risk factors.ResultsIn total, 1163 people were screened for CKD within the month of March 2019. The prevalance of CKD (grades 1–5) was 44.5% (95% CI 41.6% to 47.4) with individual grade prevalence CKD 1: 3.7%, CKD 2: 6.1%, CKD 3: 30.7%, CKD 4: 2.9% and CKD 5: 1.0%. The prevalence of obesity (body mass index ≥32), diabetes and hypertension was 66.3%, 30.8% and 54.3%, respectively.ConclusionsThis is the first paper to report the estimated prevalence of CKD in Samoa or any other Pacific Island nation. It reveals an urgent need for further studies on the epidemiology of CKD in Samoa, to develop country-specific prevention strategies to mitigate this growing burden and prevent subsequent CKD associated complications including development of kidney failure and premature death.
Objectives/Hypothesis
The goal of our study is to identify the number of Endoscopic Sinus Surgery (ESS) cases required to obtain competency in ESS, using a previously validated assessment tool.
Study ...Design
Prospective observational study.
Methods
Seventeen residents from Johns Hopkins Otolaryngology–Head & Neck Surgery residency program were evaluated as they performed endoscopic sinus surgery in the operating room. Global and checklist parts of the ESS instrument were used for assessment purposes. Items on the tool were grouped into three different milestones for analysis of data (Milestone 1 = Maxillary Antrostomy + Anterior Ethmoidectomy, Milestone 2 = Posterior Ethmoidectomy + Sphenoidostomy, Milestone 3 = Frontal Sinusotomy). Residents were deemed competent if they achieved a minimum score of 3 on a 5‐point Likert scale on each step of the surgery.
Results
A total of 73 evaluations were completed for 17 residents (Postgraduate Level 2–5) by eight evaluators between 2009 and 2011. A 60% probability of achieving competency in performance of all milestones of ESS is obtained with performing 42 ESS procedures and the probability is increased to a 100% with performance of 55 endoscopic sinus surgery procedures. On average it took residents 23 cases to become competent in performance of maxillary antrostomy and anterior ethmoidectomy.
Conclusions
Our results suggest that it requires 42 ESS procedures to attain a 60% probability of competency in ESS. These results have implications for otolaryngology residency programs when developing curriculum and benchmarks for the training residents. Laryngoscope, 123:2932–2934, 2013
To validate the VOXEL-MAN TempoSurg simulator for temporal bone dissection.
Prospective international study.
Otolaryngology departments of 2 academic health care institutions in the United Kingdom ...and United States.
Eighty-five subjects were recruited consisting of an experienced and referent group. Participants performed a standardized familiarization session and temporal bone dissection task. Realism, training effectiveness, and global impressions were evaluated across 21 domains using a 5-point Likert-type scale. A score of 4 was the minimum threshold for acceptability.
The experienced group comprised 25 otolaryngology trainers who had performed 150 mastoid operations. The referent group comprised 60 trainees (mean otolaryngology experience of 2.9 years). Familiarization took longer in the experienced group (P = .01). User-friendliness was positively rated (mean score 4.1). Seventy percent of participants rated anatomical appearance as acceptable. Trainers rated drill ergonomics worse than did trainees (P = .01). Simulation temporal bone training scored highly (mean score 4.3). Surgical anatomy, drill navigation, and hand-eye coordination accounted for this. Trainees were more likely to recommend temporal bone simulation to a colleague than were trainers (P = .01). Transferability of skills to the operating room was undecided (mean score 3.5).
Realism of the VOXEL-MAN virtual reality temporal bone simulator is suboptimal in its current version. Nonetheless, it represents a useful adjunct to existing training methods and is particularly beneficial for novice surgeons before performing cadaveric temporal bone dissection. Improvements in realism, specifically drill ergonomics and visual-spatial perception during deeper temporal bone dissection, are warranted.
Objectives/Hypothesis
This study explores the influence of selected factors on achievement of competency in mastoid surgery.
Study Design
A prospective study of surgical performance and a ...retrospective survey of learner and training factors.
Methods
The longitudinal performance of 15 residents was evaluated using the mastoidectomy task‐based checklist (TBC). The influence of surgical experience, resident interest, and training factors (course attendance, voluntary use of simulation laboratory) was also examined and compared for the acquisition of distinct levels of technical skill difficulty (cortical mastoidectomy vs. facial recess).
Results
Ninety‐six observations made during the first otology rotation were analyzed. Cortical mastoidectomy tasks showed positive associations with cumulated case numbers (OR 1.13, CI 1.04–1.23, P = .003) and interest in otology (OR 3.86, CI 1.21–12.27, P = .022). Facial recess tasks showed a larger positive association with interest in otology (OR 10.38, CI 2.25–47.94, P = .003), and negative association with extra time spent in laboratory practice (OR .05, CI 0.011–0.23, P = .000).
Conclusions
Learning trajectory for cortical mastoidectomy and facial recess may be influenced by different factors. Interest in otology, in particular, may have a moderating effect on the acquisition of more complex skills in mastoid surgery. A negative association between self‐directed laboratory simulation and performance may reflect the impact of assessment‐guided feedback in promoting deliberate practice. Further investigations are suggested to explore the interactions between individual trainee differences, educational models, and learning outcomes.
Level of Evidence
N/A. Laryngoscope, 123:3162–3167, 2013
In this paper we discuss new split-step methods for solving systems of Itô stochastic differential equations (SDEs). The methods are based on a L-stable (strongly stable) second-order split ...Adams-Moulton Formula for stiff ordinary differential equations in collusion with Milstein methods for use on SDEs which are stiff in both the deterministic and stochastic components. The L-stability property is particularly useful when the drift components are stiff and contain widely varying decay constants. For SDEs wherein the diffusion is especially stiff, we consider balanced and modified balanced split-step methods which posses larger regions of mean-square stability. Strong order convergence one is established and stability regions are displayed. The methods are tested on problems with one and two noise channels. Numerical results show the effectiveness of the methods in the pathwise approximation of stiff SDEs when compared to some existing split-step methods.
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