Requirements for trainee logbooks

All trainees are required to keep a logbook as a record of the procedures they have carried out during their surgical training. However, the current logbook is only a record of work carried out and not of the outcome of the operations. It does not prepare the trainee for either a lifetime practice of surgical audit or for a lifetime of learning from the audit process. The logbook requirements of different training boards vary and consequently, trainees find the keeping of a logbook an inconsistent process with ill-defined learning objectives. The Royal Australasian College of Surgeons should define what needs to be collected, how data should be verified and how experience and learning should be reported, and should approve electronic databases that meet logbook standards. The choice of database software and format can then be left to the trainee. Although there are good examples of electronic logbooks being developed, there is, at present, no perfect logbook available. We recommend that all trainees, from the commencement of basic surgical training, should keep a logbook that contains the minimum and expanded datasets in addition to specific trainee data on supervision and learning. In addition to the current reporting format focused on procedural casemix and supervision level, quality/outcome reports and a record of learning are recommended.     

Risiko-Scores in der Erwachsenen-Herz-Chirurgie

The first risk models for cardiac surgery date back to the 1980s. Starting with the publication in 1999, the EuroSCORE was the most used risk model for several years; however, some years ago it was found that the EuroSCORE greatly overestimated the risk for mortality which was ascribed to the outdated database. This was the reason for the development of the EuroSCORE II risk model which was also criticized because the database was collated from 154 international hospitals with heterogeneous backgrounds. The Society of Thoracic Surgeons national database (STS-NDB) was the basis for the development of the three STS risk models which are applicable for seven different types of procedures. The STS risk models are still widely used as they are considered to be valid due to the large and relatively current database and due to the principle of specific models for different types of procedures. In Germany, external quality control led to the development of risk models which were specifically developed for isolated aortic valve replacement (German AV score), isolated coronary artery bypass grafting (German CABG score) and for the combination of both (KBA score). For these types of procedures these scoring systems are considered to be valid as the underlying database is relatively large and up to date. This is especially true as these risk models are regularly recalibrated on the basis of current data and the current version of the German AV score includes a large number of transcatheter aortic valve implantation (TAVI) interventions in the database. For the assessment of individual risks knowledge about the risk score used and specific additional risk factors of the patient which have not been taken into account in the development of the risk model are necessary.     

Dialysis access

Although hemodialysis access procedures are considered the most common vascular procedures performed by either general or vascular surgeons, there is a paucity of level-one evidence in the literature. Randomized controlled trials are limited, and most of these studies have small sample sizes compared with other areas of vascular surgery, that is, carotid or aneurysm studies. We summarize the results of the world's literature for arteriovenous access in table format as a tool for those specialists managing patients with arteriovenous access procedures.     

Cardiac surgical Database: Overview

Background Majority of the active cardiac surgical centers in India are still collecting the patient related data in a free flow manner. If the same information is collected in a structured manner, it is helpful in improving quality care of the patient, Resident training, Medical audit, and generation of new knowledge. Structured information is essential to computerize the data which will be useful for rapid analysis and for quick comparisons with published data. This type of format is mandatory to merge individual institutional data with National and International cardiac surgical databases. Methods A new format has been designed to collect the patient related information based on diseases and procedures. Compatible software (Dusk Data) distributed to various cardiac surgical centers in India for data entry and analysis. Results Several Cardiac surgical centers are collecting the data in this format. 10 out of 40 cardiac surgical centers are collecting the data in this format. Conclusions This Paper describes customized data collection forms for CABG, Heart Valve diseases, and common Congenital Heart diseases wider participation is urged for a meaningful National Cardiothoracic surgical registry.     

Differentiating among Hospitals Performing Physiologically Complex Operative Procedures in the Elderly

Background: The authors previously showed how a statewide discharge abstract database could be used to quantify for stakeholders how surgical practices differ among hospitals. The two pediatric hospitals in Iowa differ from other hospitals in Iowa based on their providing a more diverse, comprehensive, and physiologically complex selection of procedures in younger patients. Physiologically complex surgery performed in children aged 0-2 yr has been regionalized to a few high-volume facilities.

Methods: The same inpatient discharge abstract database was used to quantify physiologically complex operative procedures performed throughout Iowa in patients aged 80 yr and older during January through June 2001.

Results: In contrast to earlier results with pediatric patients using the same database, hospitals performing physiologically complex procedures in the elderly could not readily be differentiated from one another based on the numbers and types of procedures performed (P < 0.001 when comparing geriatrics vs. pediatrics in terms of the distributions of numbers of procedures, the distributions of numbers of different types of procedures, or the distributions of numbers of rare procedures performed at different hospitals). Additional analyses showed that one hospital did perform relatively more rare procedures in geriatric patients and had a relatively larger percentage of patients who traveled beyond their local county to reach it.     

Risque allergique en anesthésie pédiatrique

Objectives

To propose the different modalities of management of the allergic risk occurring during paediatric anaesthesia.

Study design

Literature analysis.

Methods

Literature research using the Medline^® database and MeSH format according to keywords, including publications in French and English since 1982.

Results

The overall incidence for anaphylactic reactions was estimated at one in 7741 anaesthetic procedures during paediatric anaesthesia. Latex anaphylaxis was mostly involved with an incidence at one in 10,159 anesthetic procedures. The risk factors of latex sensitization are known. Primary latex prophylaxis is efficient in patients at risk of latex sensitization. In contrast to adults, neuromuscular blocking agents (NMBAs) are rarely involved in children, with an incidence at 1 in 81,275 anaesthetic procedures. The Ring and Messmer clinical scale allows quantifying the severity and helps managing the care of immediate hypersensitivity reactions. Clinical symptoms associate cardiovascular, respiratory and cutaneous-mucous signs according to different severity grades. Epinephrine associated to fluid loading, remains the first-line agent in case of severe reactions. The allergological assessment is key to the management of these reactions and is required in order to identify the mechanism of the reaction and the culprit drug or substance involved.

Conclusions

Allergic reactions to NMBAs occurring during paediatric anaesthesia are rare whereas those with latex are more frequent. Therefore, the reduction of the allergic risk during paediatric anaesthesia essentially requires a latex-free environment.     

Video microsurgery: early experience with an alternative operating magnification system

Since Nylen first used an operating microscope in 1921, its basic design has remained fundamentally unchanged. Microsurgical procedures are still performed while viewing the subject through binocular eyepieces. This article examines the potential to perform microsurgery using video technology, operating with a television monitor. The development of the videomicroscope is discussed together with its early trials. The results show the potential to perform simple microsurgical procedures while viewing the procedure in a two-dimensional format. The advantages and disadvantages of such a system are discussed, together with future implications.     

A systematic review of information format and timing before scheduled adult surgery for peri‐operative anxiety

We included 34 trials with 3742 participants, identified through 6 database and supplementary searches (to May 2017): 29 were randomised; 4 were quasi‐randomised and 1 was cluster‐randomised. Disparate measurements and outcomes precluded meta‐analyses. Blinding was attempted in only 6 out of 34 (18%) trials. A multimedia format, alone or in combination with text or verbal formats, was studied in 20/34 (59%) trials: pre‐operative anxiety was unaffected in 10 out of 14 trials and reduced by the multimedia format in three; postoperative anxiety was unaffected in four out of five trials in which formats were compared. Multimedia formats increased knowledge more than text, which in turn increased knowledge more than verbal formats. Other outcomes were unaffected by information format. The timing of information did not affect pre‐operative anxiety, postoperative pain or length of stay. In conclusion, the effects of pre‐operative information on peri‐operative anxiety and other outcomes were affected little by format or timing.     

Operative Record Using Intraoperative Digital Data in Neurosurgery Technical Note

Summary  Background. The purpose of this study was to develop a new method for more efficient and accurate operative records using intra-operative digital data in neurosurgery, including macroscopic procedures and microscopic procedures under an operating microscope.  Methods. Macroscopic procedures were recorded using a digital camera and microscopic procedures were also recorded using a microdigital camera attached to an operating microscope. Operative records were then recorded digitally and filed in a computer using image retouch software and database base software.  Findings. The time necessary for editing of the digital data and completing the record was less than 30 minutes. Once these operative records are digitally filed, they are easily transferred and used as database. Using digital operative records along with digital photography, neurosurgeons can document their procedures more accurately and efficiently than by the conventional method (handwriting).  Interpretation. A complete digital operative record is not only accurate but also time saving. Construction of a database, data transfer and desktop publishing can be achieved using the intra-operative data, including intra-operative photographs.     

Differentiating among hospitals performing physiologically complex operative procedures in the elderly

BACKGROUND: The authors previously showed how a statewide discharge abstract database could be used to quantify for stakeholders how surgical practices differ among hospitals. The two pediatric hospitals in Iowa differ from other hospitals in Iowa based on their providing a more diverse, comprehensive, and physiologically complex selection of procedures in younger patients. Physiologically complex surgery performed in children aged 0-2 yr has been regionalized to a few high-volume facilities. METHODS: The same inpatient discharge abstract database was used to quantify physiologically complex operative procedures performed throughout Iowa in patients aged 80 yr and older during January through June 2001. RESULTS: In contrast to earlier results with pediatric patients using the same database, hospitals performing physiologically complex procedures in the elderly could not readily be differentiated from one another based on the numbers and types of procedures performed (P < 0.001 when comparing geriatrics vs. pediatrics in terms of the distributions of numbers of procedures, the distributions of numbers of different types of procedures, or the distributions of numbers of rare procedures performed at different hospitals). Additional analyses showed that one hospital did perform relatively more rare procedures in geriatric patients and had a relatively larger percentage of patients who traveled beyond their local county to reach it. CONCLUSIONS: Results observed for geriatric patients provide further evidence of the validity of these methods and the usefulness of discharge abstract data for comparing surgical practices among facilities. A hospital can use discharge abstract data to assist governmental agencies, charitable organizations, philanthropists, insurers, etc., in appreciating the unique contributions of individual hospitals to surgical care.     

Tele-diagnostic and therapeutic guidance in urology

PURPOSE: To design a Web-based network for diagnostic and therapeutic guidance in urology. MATERIALS AND METHODS: We designed an architectural model of a low-cost multimedia Web platform that runs on a collection of distributed collaborative network nodes to provide a set of urologist-oriented Web-enabled services. Any node of the platform was able to share patient-oriented data via automated processes with appropriate authorization, confidentiality, and high-security protocols. The urologist can show the details of the records of patients and additionally enrich the world experience with his or her own cases. Video clips maintained locally at the nodes will be accessible by clinicians in a trouble-free way with MS Windows Media player and a relatively small amount of source code. RESULTS AND CONCLUSIONS: The primary advantage of this architectural model is that it provides Web-enabled integrated urologic services while using a distributed storage scheme for urological video files (AVI format) and a global repository of laboratory results using Extensible Markup Language (XML) and Data Grid technologies. In addition, this model provides decision-support services (knowledge from a global database and predefined procedures). The architecture model is based entirely on HTTP, XML, GRID-like environment and DotNet technologies. Finally, the platform provides extensibility and scalability targeted to large-scale Web-enabled global urologic databases.     

Transforming surgical morbidity and mortality into a systematic case review

Background/PurposeThe surgical morbidity and mortality (M&M) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical M&M was migrated to this structured case review format to provide a platform for surgical performance improvement.MethodsAn online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 M&M data was performed using the archived paper system used prior to 2019.ResultsFor the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content.ConclusionCreation of an online database with interactive dashboard has allowed surgical M&M to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review.Type of StudyRetrospective Historical control; Quality improvement.Level of EvidenceLevel III.     

Cochrane Anaesthesia Review Group and the Cochrane Library. Useful resources for anaesthetists

The Cochrane Collaboration is an international non-profit organisation that aims to help clinicians in making well-informed decisions about health care issues.This is done through preparing, maintaining and disseminating systematic reviews on the effects of health care interventions.To facilitate this task, review groups have been established. These groups cover specific health care areas and form the organisational basis of the collaboration. They provide methodological and logistic help to the authors of the systematic reviews.The Cochrane Anaesthesia Review Group (CARG) covers anaesthesia, perioperative medicine, intensive care,pre-hospital medicine, resuscitation, and emergency medicine.Protocols and completed Cochrane reviews are published in a structured format in the electronic Cochrane Library.Beside this Cochrane database of systematic reviews, the Cochrane library contains a database with summaries of non-Cochrane systematic reviews (database of abstracts of reviews of effectiveness), and a comprehensive database with controlled clinical trials (Cochrane central register of controlled trials). Thus the Cochrane library is a useful source of information on health care interventions for anaesthetists.     

The electronic information revolution and how to exploit it.

Medical information is increasingly stored in electronic format, enabling faster and more flexible access to the literature. Online, compact disc and floppy disc databases are widely available. The origins and development of these different database media are described. The strengths and weaknesses of each, and the ways in which they complement each other, are examined. Ease of access to medical information can result in data management problems; the role of bibliographic software in ensuring full exploitation of the electronic information revolution is therefore emphasized.     

A practical approach to control of nonlinear discrete-time state-delay systems

The robust feedback stabilization of a class of nonlinear discrete-time systems with unknown constant state-delay and uncertain function of nonlinear perturbations is considered based on linear matrix inequality (LMI)-based analysis and design procedures. In both cases of nominal and resilient feedback designs, the trade-off between the size of the controller gains and the bounding factors is illuminated and incorporated into the design formalism. A dynamic output feedback controller is then designed for this class of systems. Seeking computational convenience, all the developed results are cast in the format of LMIs and several numerical examples are presented throughout the paper to demonstrate the advantages of the design methods. Copyright © 2007 John Wiley & Sons, Ltd.     

试述胃肠腔镜外科技术的规模化

随着循证医学资料的不断积累，针对早、中期胃肠肿瘤的腹腔镜手术正在从“可以这样做”转变为“应该这样做”。我们提出了针对这类疾病的胃肠腔镜规模化．按适应证选择手术方式。而不是按医生喜好取舍。胃肠腔镜规模化的提出。伴随着特定的教学模式产生．也将与胃肠腔镜规范化相互促进。     

The development and implementation of a computerized database for clinical research in minimal access surgery. An international pilot study

BACKGROUND: The measurement of outcomes after minimal access surgery (MAS) relies on the maintenance of an accurate, prospective clinical database. The development of a system for data management often proves to be challenging, expensive, and extremely time-consuming. METHODS: We developed a computerized relational database for MAS using Microsoft Access 97 to reside on a hospital server, taking advantage of existing network connections, security, and backup systems. The design of the database includes a point-and-click approach with dropdown boxes for diagnoses, procedures, and complications (limited free-text entry). A fundamental feature of this database allows surgeons and surgical trainees to record clinical information at the point and time of data acquisition. RESULTS: A "beta version" or fully functional draft of the database was presented to a group of surgeons from a variety of specialties (n = 8), and a structured interview based on a questionnaire was used to elicit the surgeon's evaluations of the database. Using the information from the interviews, the database was extensively revised and restructured. CONCLUSIONS: We have developed a relational database that reflects the needs of surgeons interested in clinical research. This database may serve as a template for other centers. It can be expanded to adopt new procedures or modified for other surgical specialties.     

Hand transplantation: comparisons and observations of the first four clinical cases

Twenty, 15, and 8 months after the first four successful human hand transplant procedures were performed in Lyon (France), Louisville (U. S.), and Guangzhou (China), the transplant teams convened in Louisville, Kentucky, to share their experiences at the Second International Symposium on Composite Tissue Allotransplantation. This article presents reconstructive and immunological data from these landmark procedures in tabular format, in an attempt to answer some key questions about early outcomes of clinical hand transplantation. On the basis of these data, the initial outcomes of the first four hand transplants are encouraging and warrant proceeding with additional hand transplantations.     

A rationale for assessing sports activity levels and limitations in knee disorders

Existing published knee rating systems that assess sports participation, knee function, and subjective symptomatology following ligamentous surgical procedures were analyzed. Major errors in questionnaire design and data reduction have led to invalid conclusions. A questionnaire containing a minimum set of rating criteria was formulated to validly assess athletic participation before and after treatment or surgery. Select questions and a data reduction format were established to assess the intensity of sports participation, changes in sports participation, the variables that produced the changes, self-assessed functional limitations, and the ability to participate in different types of sports. A clinical trial of the questionnaire was performed on 59 patients. An interview conducted upon completion of the questionnaire enabled the authors to detect difficulties or inconsistencies in the responses to the questions. The design format described in this report forms the basis for a subjective evaluation of ligamentous surgery. A standard format for analysis of sports participation and knee function is proposed to aid investigators in comparing variations in clinical results.