Video Playback as an Educational Tool for Improving Resident Laparoscopic Performance: A Randomized Controlled Trial.

STUDY OBJECTIVE: In this single-masked randomized controlled study, we evaluate whether watching video recordings of oneself performing Fundamentals of Laparoscopic Skills (FLS) exercises results in an improvement on the 30-point Global Operative Assessment of Laparoscopic Skills (GOALS) assessment among Obstetrics and Gynecology (Ob/Gyn) residents. DESIGN: Twenty-three Ob/Gyn residents in the 2020-2021 academic year completed the FLS exercises while being timed, video recorded, and receiving real-time feedback from an Ob/Gyn faculty member. Baseline GOALS assessment was completed by participants and faculty. After the intervention, all participants then repeated the FLS exercises while being timed and were again scored using the GOALS assessment. Each participant completed the study in a single session. In addition, all participants completed a pre- and post-test survey. SETTING: University of Louisville Laparoscopic Skills Labortaory. PARTICIPANTS: University of Louisville Ob/Gyn residents in the 2020-2021 academic year. INTERVENTION: Twelve participants were randomized to the intervention and were allowed to watch their video recording in addition to receiving verbal feedback whereas the remaining 11 received verbal feedback only. MEASUREMENTS AND MAIN RESULTS: There were significant improvements in faculty (p <.01) and self-reported GOALS scores (p <.01) when comparing both the intervention and control group with baseline scores. The intervention group improved by 3.2 points more than that of the control group based on masked faculty evaluation (95% confidence interval, 1.4-5.0 points; p <.01). The difference was not significant in resident self-scores. Overall time improved for all participants (15:54 ± 0.21 minutes before and 13:13 ± 0.14 minutes after), but this difference was not significant between the 2 groups. Higher postgraduate year (PGY) residents reported significantly more comfort performing laparoscopic tasks, earned higher GOALS score (faculty and self-scores), and completed the first set of exercises in less time. A significant interaction between PGY and intervention was detected with improvement in GOALS score most strongly associated with PGY4 residents (p <.01). CONCLUSION: Although all learners objectively benefit from watching recordings of themselves performing surgical tasks, advanced learners may benefit the most when video recordings are used as an educational tool.

Evaluation of model materials for CAD/CAM in vitro studies.

AIM: Evaluation of appropriate models for computer-aided design/computer-aided manufacturing (CAD/CAM) in vitro studies by investigation of different model materials regarding suitability for intraoral scanners and dimensional stability. MATERIALS AND METHODS: A typodont model was prepared to accommodate a 10-unit prosthesis. The model was duplicated using six different materials: class IV die stone (DS), cobalt-chrome molybdenum (CoCrMo), epoxy resin (EPOX), polyurethane (PU), titanium (TI), and zirconia (ZI). An intraoral scanner was used to obtain three scans of each model. Reference datasets were generated using micro-computed tomography (micro-CT). The first scan was compared with the corresponding reference micro-CT dataset to assess its trueness. The precision was measured by comparing all scans within one test group. For the evaluation of dimensional stability, micro-CT was used to generate three-dimensional (3D) datasets of the models at different time intervals over a 6-week period. The models were kept under constant conditions during the study. All datasets were analyzed with software that determined the deviation of two datasets by alignment using a best-fit algorithm. RESULTS: The criterion of trueness was fulfilled by CoCrMo, EPOX, PU, and the typodont model. Scans of CoCrMo and ZI showed the best precision. PU and the typodont model did not meet the requirement of dimensional stability, whereas EPOX and gypsum were stable only for a period of 10 days. CONCLUSION: The CoCrMo model was the only one that met all the criteria for an appropriate model for CAD/CAM in vitro studies. The other investigated materials either lacked dimensional stability or could not be scanned accurately and reproducibly.

Cranial epidural hematomas: A case series and literature review of this rare complication associated with sickle cell disease.

BACKGROUND: Patients with sickle cell disease (SCD) may experience many complications of the central nervous system (CNS) including stroke, silent cerebral infarcts, and neuropsychological deficits. Cranial epidural hematoma is a rare but potentially serious complication. PROCEDURE: Case series of cranial epidural hematomas in children with SCD from three different institutions is considered, along with a literature review of cranial epidural hematomas in this population. RESULTS: Seven children with SCD with cranial epidural hematomas were identified from three different institutions. All patients were male and the age at presentation ranged from 10 to 18 years. Two patients presented with headache (28.6%), while the rest had no neurologic symptoms at presentation. Four patients required urgent neurosurgical intervention (57.1%) and one patient died (14.3%). A literature review identified 18 additional cases of cranial epidural hematomas in children with SCD. Of these, treatment ranged from supportive care to neurosurgical intervention. Twelve patients completely recovered (66.7%), one patient had long-term cognitive impairment (5.6%), and four patients died (22.2%). Combined with our data, cranial epidural hematomas have a mortality rate of 20.0%. CONCLUSIONS: Although rare, cranial epidural hematoma can be fatal and should be considered in patients with acute neurological symptoms.

Maintaining High Level of Care at Satellite Sickle Cell Clinics.

Traveling to and from university-based clinics is a major health care barrier for children with sickle cell disease in Alabama. To reduce this barrier, the University of Alabama at Birmingham (UAB) developed satellite clinics. This study seeks to determine if these satellite clinics provide a similar level of comprehensive care when compared with the university-based clinic using four surrogate markers: 1) attendance rates, 2) percentage of patients on hydroxyurea, 3) percentage of screening MRIs obtained, and 4) percentage of transcranial dopplers (TCD) completed. A retrospective review of sickle cell visits from June 1, 2012 to May 31, 2013 demonstrated that satellite clinics can provide levels of medical care for children with sickle cell disease similar to those provided by university-based clinics.

Absorbance and redox based approaches for measuring free heme and free hemoglobin in biological matrices.

Cell-free heme (CFH) and hemoglobin (Hb) have emerged as distinct mediators of acute injury characterized by inflammation and microcirculatory dysfunction in hemolytic conditions and critical illness. Several reports have shown changes in Hb and CFH in specific pathophysiological settings. Using PBS, plasma from patients with sickle cell disease, acute respiratory distress syndrome (ARDS) patients and supernatants from red cells units, we found that commonly used assays and commercially available kits do not distinguish between CFH and Hb. Furthermore, they suffer from a variety of false-positive interferences and limitations (including from bilirubin) that lead to either over- or underestimation of CFH and/or Hb. Moreover, commonly used protocols to separate CFH and Hb based on molecular weight (MWt) are inefficient due to CFH hydrophobicity. In this study, we developed and validated a new approach based on absorbance spectrum deconvolution with least square fitting analyses that overcomes these limitations and simultaneously measures CFH and Hb in simple aqueous buffers, plasma or when associated with red cell derived microvesicles. We show how incorporating other plasma factors that absorb light over the visible wavelength range (specifically bilirubin), coupled with truncating the wavelength range analyzed, or addition of mild detergent significantly improves fits allowing measurement of oxyHb, CFH and metHb with >90% accuracy. When this approach was applied to samples from SCD patients, we observed that CFH levels are higher than previously reported and of similar magnitude to Hb.

Transcriptional regulators TRIM28, SETDB1, and TP53 are aberrantly expressed in porcine embryos produced by in vitro fertilization in comparison to in vivo- and somatic-cell nuclear transfer-derived embryos.

In vitro embryo production is important for research in animal reproduction, embryo transfer, transgenics, and cloning. Yet, in vitro-fertilized (IVF) embryos are generally developmentally delayed and are inferior to in vivo-derived (IVV) embryos; this discrepancy is likely a result of aberrant gene expression. Transcription of three genes implicated to be important in normal preimplantation embryo development, TRIM28, SETDB1, and TP53, was determined by quanitative PCR in IVF, somatic-cell nuclear transfer (SCNT), parthenogenetic, and IVV porcine oocytes and embryos. There was no difference in TRIM28 or SETDB1 abundance between oocytes matured in vitro versus in vivo (P > 0.05), whereas TP53 levels were higher in in vitro-matured oocytes. TRIM28 increased from metaphase-II oocytes to the 4-cell and blastocyst stages in IVF embryos, whereas IVV embryos showed a reduction in TRIM28 abundance from maturation throughout development. The relative abundance of TP53 increased by the blastocyst stage in all treatment groups, but was higher in IVF embryos compared to IVV and SCNT embryos. In contrast, SETDB1 transcript levels decreased from the 2-cell to blastocyst stage in all treatments. For each gene analyzed, SCNT embryos of both hard-to-clone and easy-to-clone cell lines were more comparable to IVV than IVF embryos. Knockdown of TRIM28 also had no effect on blastocyst development or expression of SETDB1 or TP53. Thus, TRIM28, SETDB1, and TP53 are dynamically expressed in porcine oocytes and embryos. Furthermore, TRIM28 and TP53 abundances in IVV and SCNT embryos are similar, but different from quantities in IVF embryos.

Dynamics of TET family expression in porcine preimplantation embryos is related to zygotic genome activation and required for the maintenance of NANOG.

Dynamic changes in DNA methylation are observed during embryo development. Recent studies show that the TET family is involved in these changes by converting 5-methylcytosine (5mec) to 5-hydroxymethylcytosine (5hmec). Specifically, TET3 is responsible for the conversion in the early stages, and then TET1 is a key regulator at later stages of embryo development. From previous mouse reports and our preliminary data in porcine embryos, we hypothesized that TET1 becomes the main regulator at the time of the maternal to zygotic transition (MZT). Transcript abundance of TET3 was high only at the zygote and 2-cell stage. The abundance of TET1 mRNA was high in the blastocysts and TET1 protein was present at the 4-cell stage and the blastocysts. The dynamic was similar in porcine somatic cell nuclear transfer (SCNT) embryos however; abnormally upregulated TET3 was detected at the 4-cell stage. When transcription or translation was blocked at the 2-cell stage, TET3 mRNA remained high at the 4-cell stage suggesting that degradation of TET3 is related to the MZT. Downregulation of TET3 before fertilization resulted in the reduction of 5hmec in zygotes indicating that TET3 is a key molecule for 5hmec synthesis. This misregulation of 5hmec in zygotes also affected the level of NANOG expression in the blastocysts. We show here that the porcine TET family shows dynamic expression patterns during embryogenesis, and is responsible for the appearance of 5hmec in the zygotes by TET3. This appearance of 5hmec in zygote is important for the expression of NANOG in the blastocysts.

Laparoscopic resection of small bowel sarcoma.

A 45-year-old female who presented with nausea, vomiting, abdominal pain, and anemia was found to have an 8 × 5 × 5 cm ileal tumor on CT imaging. Laparoscopic evaluation and small bowel resection was performed with clear margins with a diagnosis of low-grade leiomyosarcoma. Small intestine leiomyosarcoma is very rare, and there are no prior reports of laparoscopic resection.

Buccal misoprostol to prevent hemorrhage at cesarean delivery: a randomized study.

OBJECTIVE: The purpose of this study was to assess the efficacy of buccal misoprostol to decrease uterine atony, hemorrhage, and the need for additional uterotonic agents during cesarean delivery. STUDY DESIGN: Patients who underwent cesarean delivery were assigned randomly to either 200-microg misoprostol or placebo placed in the buccal space. A dilute intravenous oxytocin infusion was given to all patients at delivery of the placenta. The primary outcome variable was the need for additional uterotonic agents. RESULTS: A total of 352 women received random assignments. Demographic and intrapartum characteristics were similar between the groups. More women in the placebo group required 1 additional uterotonic agent (43% vs 26%; P < .01; relative risk, 1.3; 95% CI, 1.10, 1.50). There was not a difference between the groups in the incidence of postpartum hemorrhage or a difference in preoperative and postoperative hemoglobin level. CONCLUSION: Buccal misoprostol reduces the need for additional uterotonic agents during cesarean delivery.

Buccal misoprostol to decrease blood loss after vaginal delivery: a randomized trial.

OBJECTIVE: To assess the efficacy of buccal misoprostol to decrease bleeding after vaginal delivery. METHODS: This was a randomized study of patients between 22 weeks and 42 weeks of gestation with anticipated vaginal delivery. Patients were given either a 200-mug misoprostol tablet or placebo in the buccal space at the time of cord clamping. A continuous dilute intravenous oxytocin infusion was given to all patients at delivery of the placenta. Postpartum hemorrhage was defined as blood loss exceeding 500 mL. Sample size calculations based on previous studies assumed a 13% incidence of postpartum hemorrhage in the control group. To show a statistically significant reduction of postpartum hemorrhage a total of 1,604 patients would be required in each group. RESULTS: A total of 848 patients were enrolled and 756 randomly assigned, 377 in the misoprostol group and 379 in the placebo group. Demographic, antepartum, and intrapartum characteristics were similar between the groups. The incidence of postpartum hemorrhage, 3% compared with 5%, (relative risk 0.65, 95% confidence interval 0.33-1.29, P = .22), mean estimated blood loss, 322 compared with 329 mL, (P = .45), and mean minutes of the third stage of labor, 6.7 compared with 6.9 (P = .52) were similar between the groups, misoprostol and placebo, respectively. Hemoglobin difference before and after delivery, need for second or third uterotonic agent, and all measured neonatal variables including birth weights, and umbilical cord pH were similar between the groups. CONCLUSION: Buccal misoprostol at cord clamping is no more effective than placebo in reducing postpartum hemorrhage.