Pain in intensive care unit patients-A longitudinal study.

Aim: To assess occurrence of pain during the first 6 days of intensive care unit (ICU) stay and evaluate associations between occurrence of pain and selected patient-related variables. Design: A longitudinal study. Methods: Adult ICU patients from three units were included. Patients' pain was assessed with valid pain assessment tools every 8 hr during their first 6 days in ICU. Possible associations between occurrence of pain and selected patient-related variables were modelled using multiple logistic regression. Results: When pain was assessed regularly with pain assessment tools, 10% of patients were in pain at rest and 27% were in pain during turning. The proportions of patients who were in pain were significantly higher for patients able to self-report pain, compared with patients not able to self-report (p < .001). Several predictors were associated with being in pain. It is important to be aware of these predictors in order to improve pain management.

A preliminary study of cortical morphology in schizophrenia patients with a history of violence.

Clinical studies of patients with schizophrenia and a history of violence are challenging both from an ethical and practical perspective, and the neurobiological underpinnings remain largely unknown. We here present a comprehensive account of the brain cortical characteristics associated with violence in schizophrenia. We obtained 3T MRI scans and thorough clinical characterization of schizophrenia patients with a history of violence (murder, attempted murder, criminal assault, SCZ-V, n = 11), schizophrenia patients with no history of violence (SCZ-NV, n = 17), and healthy controls (HC, n = 19). Cortical thickness, area, and folding were analyzed vertex-wise across the cortical mantle (FreeSurfer). SCZ-V had significantly increased cortical folding in the visual and orbitofrontal cortex, and reduced cortical thickness within the precentral-, parietal-, temporal-, and fusiform cortex compared to SCZ-NV, as well as widespread regional thinning and increased folding compared to HC. There were no group differences in cortical area. A major limitation is the small subject sample. If replicated, the results from this pilot study suggest cortical abnormalities in areas involved in sensory processing, emotion recognition, and reward to be of importance to the neurobiology of violence in schizophrenia.

Validation of the Vascular quality of life questionnaire - 6 for clinical use in patients with lower limb peripheral arterial disease.

BACKGROUND: The VascuQoL-6 (VQ-6) health-related quality of life questionnaire, a short version of the disease-specific VascuQoL-25, was developed for clinical practice and use in vascular registries. The study purpose was to evaluate the validity and reliability of VQ-6. METHODS: VQ-6 was translated to Norwegian with linguistic validation and face value evaluation, and consecutive patients with intermittent claudication (IC) or critical limb ischemia (CLI) were included. All patients completed VQ-6 and Short Form-36 (SF-36), and were evaluated with ankle-brachial index (ABI) measurement pre- and post-exercise, a constant load treadmill test and clinical consultation at baseline and after 4 weeks. Correlation analysis, change statistics and receiver operator characteristics (ROC) curves were used to evaluate reliability, validity and responsiveness to change. RESULTS: One hundred seventy-one patients with peripheral arterial disease (PAD) were included, 70 (41%) female. 147 (86%) of the patients suffered from IC. The reliability of VQ-6 was good, Cronbachs-α 0.82. The ability of VQ-6 to differentiate between IC and CLI was good, area under the curve (AUC) 0.754. There was good correlation between SF-36 physical domains and component scores and VQ-6 score (r = 0.55-0.62) and excellent responsiveness to change after treatment, standard response mean (SRM) 1.12. The clinical anchors of ABI at rest, treadmill walking performance and Fontaine class improvement were less responsive to change than VQ-6, SF-36 and the vascular surgeon's evaluation. CONCLUSIONS: VQ-6 is reliable and valid, and can be used to evaluate PAD treatment in clinical practice and in vascular registries. Further research is necessary to determine the clinically important change over time. TRIAL REGISTRATION: ISRCTN14846962 (retrospectively registered).

Experiences with 99mTc-HMPAO in a Diagnostic Pathway for Violent Patients with Schizophrenic Spectrum Disorders.

BACKGROUND AND OBJECTIVE: In a security ward we assessed the diagnostic contribution of single photon scintigraphy [SPECT] in our diagnostic pathway for patients with serious mental disease and a history of violence. METHODS: Twenty patients were examined between 2012 and 2015 and the findings compared to those in nine patients with the same diagnosis, but no history of violence. RESULTS: All violent patients had areas with reduced accumulation of 99mTc-HMPAO frontally and in the temporal lobe, in the non-violent group only two patients demonstrated these findings. CONCLUSION: Traditionally, low accumulation of the tracer in SPECT is related to reduced perfusion of brain tissue. We discuss our findings in the light of other possible pathophysiological mechanisms.

The Soil Bacterium Methylococcus capsulatus Bath Interacts with Human Dendritic Cells to Modulate Immune Function.

The prevalence of inflammatory bowel disease (IBD) has increased in Western countries during the course of the twentieth century, and is evolving to be a global disease. Recently we showed that a bacterial meal of a non-commensal, non-pathogenic methanotrophic soil bacterium, Methylococcus capsulatus Bath prevents experimentally induced colitis in a murine model of IBD. The mechanism behind the effect has this far not been identified. Here, for the first time we show that M. capsulatus, a soil bacterium adheres specifically to human dendritic cells, influencing DC maturation, cytokine production, and subsequent T cell activation, proliferation and differentiation. We characterize the immune modulatory properties of M. capsulatus and compare its immunological properties to those of another Gram-negative gammaproteobacterium, the commensal Escherichia coli K12, and the immune modulatory Gram-positive probiotic bacterium, Lactobacillus rhamnosus GG in vitro. M. capsulatus induces intermediate phenotypic and functional DC maturation. In a mixed lymphocyte reaction M. capsulatus-primed monocyte-derived dendritic cells (MoDCs) enhance T cell expression of CD25, the γ-chain of the high affinity IL-2 receptor, supports cell proliferation, and induce a T cell cytokine profile different from both E. coli K12 and Lactobacillus rhamnosus GG. M. capsulatus Bath thus interacts specifically with MoDC, affecting MoDC maturation, cytokine profile, and subsequent MoDC directed T cell polarization.

Quality of life improves in patients with chronic heart failure and Cheyne-Stokes respiration treated with adaptive servo-ventilation in a nurse-led heart failure clinic.

AIMS AND OBJECTIVES: The aim of this study was to investigate if quality of life improved in chronic heart failure patients with Cheyne-Stokes respiration treated with adaptive servo-ventilation in nurse-led heart failure clinic. BACKGROUND: Cheyne-Stokes respiration is associated with decreased quality of life in patients with chronic heart failure. Adaptive servo-ventilation is introduced to treat this sleep-disordered breathing. DESIGN: Randomised, controlled design. METHODS: Fifty-one patients (ranging from 53-84 years), New York Heart Association III-IV and/or left ventricular ejection fraction ≤40% and Cheyne-Stokes respiration were randomised to an intervention group who received adaptive servo-ventilation or a control group. Minnesota Living with Heart Failure Questionnaire was used to assess quality of life at randomisation and after three months. Both groups were followed in the nurse-led heart failure clinic. RESULT: Adaptive servo ventilation improved quality of life-scores both in a per protocol analysis and in an intention to treat analysis. Twenty-one patients dropped out of the study, nine in the control and 12 in the intervention group. CONCLUSION: Use of adaptive servo-ventilation improved quality of life in chronic heart failure patients with Cheyne-Stokes respiration. However, the drop-out rate was high. RELEVANCE TO CLINICAL PRACTICE: Chronic heart failure patients come regularly to the nurse-led heart failure clinic. The heart failure nurses' competency has to include knowledge of equipment to provide support and continuity of care to the patients.

Additional functional outcomes after endovascular treatment for intermittent claudication.

Background Endovascular treatment (EVT) for intermittent claudication (IC) is performed in selected patients where conservative treatment and training fail. Treatment outcomes reported in vascular registries (survival, limb-survival, and re-intervention rate) are inadequate for low-risk patients with IC. Additional measurements of blood flow reduction and functional impairment clarify the indication for treatment and facilitate outcome evaluation. Purpose To analyze the additional outcome information on peripheral arterial pressures and walking capacity obtained from a local registry of EVT. Material and Methods Patients with IC treated with endovascular technique (angioplasty or stent) were prospectively entered into a local registry in addition to the national registry (NORKAR), with information on arterial pressures (ankle brachial index [ABI]) and treadmill performance (maximum walking distance [MWD]). Results A total of 242 consecutive patients (41% women; median age, 70 years) receiving the first treatment between July 2010 and December 2012 were included, 61% with aorto-iliac lesions. After 3 months, mean ABI increased from 0.62 (0.59-0.64) to 0.85 (0.83-0.87). The median MWD increased from 160 m to 410 m. Sixty-two percent reached the test maximum of 10 min. The improvement in ABI and MWD persisted after 1 year. When preoperative ABI was moderately reduced (0.5-0.9), ABI was normal in 61% after 3 months and in 55% after 1 year. When preoperative ABI was low (<0.5), ABI was normal in 43% both after 3 months and 1 year. Conclusion ABI and walking capacity were important outcome variables and improved after EVT. ABI improvement was better for patients with moderately reduced preoperative ABI than with low ABI.

A retrospective analysis of cardiovascular outcomes in patients treated with ASV.

OBJECTIVES: The effect of long-term adaptive servo-ventilation (ASV) on cardiovascular mortality and admission rates in patients with chronic heart failure (CHF) and Cheyne-Stokes respiration (CSR) has not been much studied. The aim of this study was primarily to investigate whether ASV therapy significantly reduced these parameters. DESIGN: We included 75 CHF patients on optimal medication and CSR ≥25% of sleeping time, in New York Heart Association (NYHA) classes II-IV and left ventricular ejection fraction (LVEF) ≤ 45%. Thirty-one patients were treated with ASV for >3-18 months and 44 patients served as a control group. RESULTS: Seven deaths (16%) in the control group and one death (3%) in the ASV treatment group had cardiovascular etiology. There was no significant difference between the two groups regarding cardiovascular death (log rank p = 0.07; HR 0.18 (95% CI 0.02-1.44), p = 0.11) and combined cardiovascular death or readmissions, but there was a trend toward better outcome regarding cardiovascular event-free survival (log rank p = 0.06; HR 0.53 (95% CI 0.27-1.05). CONCLUSIONS: In CHF patients with CSR, 18 months ASV treatment did not significantly affect cardiovascular death or combined cardiovascular death or hospital admissions. But there was a trend toward better combined outcome.

Results of implementing a pain management algorithm in intensive care unit patients: The impact on pain assessment, length of stay, and duration of ventilation.

PURPOSE: This study aimed to measure the impact of implementing a pain management algorithm in adult intensive care unit (ICU) patients able to express pain. No controlled study has previously evaluated the impact of a pain management algorithm both at rest and during procedures, including both patients able to self-report and express pain behavior, intubated and nonintubated patients, throughout their ICU stay. MATERIALS AND METHODS: The algorithm instructed nurses to assess pain, guided them in pain treatment, and was implemented in 3 units. A time period after implementing the algorithm (intervention group) was compared with a time period the previous year (control group) on the outcome variables: pain assessments, duration of ventilation, length of ICU stay, length of hospital stay, use of analgesic and sedative medications, and the incidence of agitation events. RESULTS: Totally, 650 patients were included. The number of pain assessments was higher in the intervention group compared with the control group. In addition, duration of ventilation and length of ICU stay decreased significantly in the intervention group compared with the control group. This difference remained significant after adjusting for patient characteristics. CONCLUSION: Several outcome variables were significantly improved after implementation of the algorithm compared with the control group.

Development of a pain management algorithm for intensive care units.

OBJECTIVES: To develop a pain management algorithm for intensive care unit (ICU) patients and to evaluate the psychometric properties of the translated tools used in the algorithm. BACKGROUND: Many ICU patients experience pain. However, an evidence-based algorithm for pain management does not exist. METHODS: Literature review, expert panel, and pilot testing were used to develop the algorithm. The tools were evaluated for inter-rater reliability between two nurses. Discriminant validity was evaluated by comparing pain during turning and rest. RESULTS: An algorithm was developed. The Behavioral Pain Scale (BPS) and the Behavioral Pain Scale-Non Intubated (BPS-NI) discriminated between pain scores during turning and rest. Inter-rater reliability for the BPS varied from moderate (0.46) to very good (1.00). Inter-rater reliability for the BPS-NI varied from fair (0.21) to good (0.63). CONCLUSIONS: The content of the pain management algorithm is consistent with the latest clinical practice guideline recommendations. It may be a useful tool to improve pain assessment and management in adult ICU patients.

Implementation of a pain management algorithm in intensive care units and evaluation of nurses' level of adherence with the algorithm.

OBJECTIVES: To implement a pain management algorithm in intensive care units (ICU) and to evaluate nurses' level of adherence with the algorithm. BACKGROUND: Many ICU patients experience pain. Therefore, an evidence-based algorithm for pain management was developed. METHODS: A pain management algorithm was implemented in three units over three weeks. Nurses' level of adherence with the algorithm and associations between level of adherence and patient and unit characteristics over 22 weeks were evaluated using multivariate regression analysis. RESULTS: Nurses' level of adherence was 74.6%. Adherence rates were lower on the evening and night shifts compared to the day shift. Males were assessed significantly less frequently than females. Patients with "injury, poisoning, or certain other consequences of external causes" were assessed significantly less frequently than patients with "diseases of the respiratory system." CONCLUSIONS: ICU nurses can use a pain management algorithm consistently. Findings from this study suggest that a pain management algorithm is a useful tool to increase ICU nurses' adherence with pain assessment.

Effects of the non-commensal Methylococcus capsulatus Bath on mammalian immune cells.

Dietary inclusions of a bacterial meal consisting mainly of the non-commensal, methanotrophic bacteria Methylococcus capsulatus Bath have been shown to ameliorate symptoms of intestinal inflammation in different animal models. In order to investigate the molecular mechanisms causing these effects, we have studied the influence of this strain on different immune cells central for the regulation of inflammatory responses. Effects were compared to those induced by the closely related strain M. capsulatus Texas and the well-described probiotic strain Escherichia coli Nissle 1917. M. capsulatus Bath induced macrophage polarization toward a pro-inflammatory phenotype, but not to the extent observed after exposure to E. coli Nissle 1917. Likewise, dose-dependent abilities to activate NF-κB transcription in U937 cells were observed, with E. coli Nissle 1917 being most potent. High levels of CD141 on human primary monocyte-derived dendritic cells (moDCs) were only detected after exposure to E. coli Nissle 1917, which collectively indicate a superior capacity to induce Th1 cell responses for this strain. On the other hand, the M. capsulatus strains were more potent in increasing the expression of the maturation markers CD80, CD83 and CD86 than E. coli Nissle 1917. M. capsulatus Bath induced the highest levels of IL-6, IL-10 and IL-12 secretion from dendritic cells, suggesting that this strain generally the post potent inducer of cytokine secretion. These results show that M. capsulatus Bath exhibit immunogenic properties in mammalian in vitro systems which diverge from that of E. coli Nissle 1917. This may provide clues to how M. capsulatus Bath influence the adaptive immune system in vivo. However, further in vivo experiments are required for a complete understanding of how this strain ameliorates intestinal inflammation in animal models.

Computational and experimental analysis of the secretome of Methylococcus capsulatus (Bath).

The Gram-negative methanotroph Methylococcus capsulatus (Bath) was recently demonstrated to abrogate inflammation in a murine model of inflammatory bowel disease, suggesting interactions with cells involved in maintaining mucosal homeostasis and emphasizing the importance of understanding the many properties of M. capsulatus. Secreted proteins determine how bacteria may interact with their environment, and a comprehensive knowledge of such proteins is therefore vital to understand bacterial physiology and behavior. The aim of this study was to systematically analyze protein secretion in M. capsulatus (Bath) by identifying the secretion systems present and the respective secreted substrates. Computational analysis revealed that in addition to previously recognized type II secretion systems and a type VII secretion system, a type Vb (two-partner) secretion system and putative type I secretion systems are present in M. capsulatus (Bath). In silico analysis suggests that the diverse secretion systems in M.capsulatus transport proteins likely to be involved in adhesion, colonization, nutrient acquisition and homeostasis maintenance. Results of the computational analysis was verified and extended by an experimental approach showing that in addition an uncharacterized protein and putative moonlighting proteins are released to the medium during exponential growth of M. capsulatus (Bath).

Three-month treatment with adaptive servoventilation improves cardiac function and physical activity in patients with chronic heart failure and cheyne-stokes respiration: a prospective randomized controlled trial.

BACKGROUND: Cheyne-Stokes respiration frequently occurs in patients with congestive heart failure (CHF). Adaptive servoventilation (ASV) is a novel therapy with potential benefits. This prospective randomized trial investigated the effects of ASV on myocardial function and physical capacity. METHODS: Patients with severe CHF, despite optimal cardiac medication and/or left ventricular ejection fraction (LVEF) ≤40% and Cheyne-Stokes breathing for >25% of sleeping time were included. Fifty-one patients, age 57-81 years (4 were women), were randomized to either an ASV or a control group; 30 patients completed the study (15 from each group). The primary end point was any change in LVEF. The secondary end points were alterations in physical capacity according to the 6-min walk test or the New York Heart Association (NYHA) class. RESULTS: In the ASV-treatment group, LVEF improved from baseline (32 ± 11%) to study end (36 ± 13%), p = 0.013. The 6-min walk test improved from 377 ± 115 to 430 ± 123 m (p = 0.014) and the NYHA class from 3.2 (3.0-3.0) to 2.0 (2.0-3.0) (p < 0.001). No changes occurred in the control group. CONCLUSION: Three months of ASV treatment improved LVEF and physical capacity in CHF patients with Cheyne-Stokes respiration. These results suggest that ASV may be a beneficial supplement to standard medication in these patients.

The value of mucosal allergen challenge for the diagnosis of food allergy.

PURPOSE OF REVIEW: The incidence of food allergy is increasing. Correct diagnosis is dependent on food challenges, which are not always performed, but more often based on history, skin prick test and specific IgE, leading to possible misdiagnoses. Mucosal provocation tests have been proposed as possible new diagnostic tools during recent decades. RECENT FINDINGS: The databases EMBASE, PUBMED and Cochraine Review were used. Seven full text articles fulfilled criteria for mucosal challenge and food allergy, only one from the last 12 months. Conjunctival, nasal, buccal, gastric and coecal/rectal mucosa have been challenged. All authors find mucosal changes after challenge, but the lack of validation against double-blind placebo-controlled challenges makes evaluation difficult, with the exception of the conjunctival provocation test. SUMMARY: As most mucosal surfaces are easily available, and small amounts of allergen are needed for an obvious reaction, this tool for diagnosing food allergy is promising. Further studies are however needed.

The noncommensal bacterium Methylococcus capsulatus (Bath) ameliorates dextran sulfate (Sodium Salt)-Induced Ulcerative Colitis by influencing mechanisms essential for maintenance of the colonic barrier function.

Dietary inclusion of a bacterial meal has recently been shown to efficiently abolish soybean meal-induced enteritis in Atlantic salmon. The objective of this study was to investigate whether inclusion of this bacterial meal in the diet could abrogate disease development in a murine model of epithelial injury and colitis and thus possibly have therapeutic potential in human inflammatory bowel disease. C57BL/6N mice were fed ad libitum a control diet or an experimental diet containing 254 g/kg of body weight BioProtein, a bacterial meal consisting of Methylococcus capsulatus (Bath), together with the heterogenic bacteria Ralstonia sp., Brevibacillus agri, and Aneurinibacillus sp. At day 8, colitis was induced by 3.5% dextran sulfate sodium (DSS) ad libitum in the drinking water for 6 days. Symptoms of DSS treatment were less profound after prophylactic treatment with the diet containing the BioProtein. Colitis-associated parameters such as reduced body weight, colon shortening, and epithelial damage also showed significant improvement. Levels of acute-phase reactants, proteins whose plasma concentrations increase in response to inflammation, and neutrophil infiltration were reduced. On the other, increased epithelial cell proliferation and enhanced mucin 2 (Muc2) transcription indicated improved integrity of the colonic epithelial layer. BioProtein mainly consists of Methylococcus capsulatus (Bath) (88%). The results that we obtained when using a bacterial meal consisting of M. capsulatus (Bath) were similar to those obtained when using BioProtein in the DSS model. Our results show that a bacterial meal of the noncommensal bacterium M. capsulatus (Bath) has the potential to attenuate DSS-induced colitis in mice by enhancing colonic barrier function, as judged by increased epithelial proliferation and increased Muc2 transcription.

Draft genome sequence of the methane-oxidizing bacterium Methylococcus capsulatus (Texas).

Methanotrophic bacteria perform major roles in global carbon cycles via their unique enzymatic activities that enable the oxidation of one-carbon compounds, most notably methane. Here we describe the annotated draft genome sequence of the aerobic methanotroph Methylococcus capsulatus (Texas), a type strain originally isolated from sewer sludge.

Probiotics, symptoms, and gut microbiota: what are the relations? A randomized controlled trial in subjects with irritable bowel syndrome.

Introduction. Knowledge of the mechanism of action of probiotics in subjects with irritable bowel syndrome (IBS) is imperfect. Objective. This trial aimed at discriminating between a direct effect on the gut wall and an indirect effect caused by modulation of the fecal microbiota. Design. Randomized, double-blind, crossover trial. Material and Methods. Patients with IBS were given one capsule of 10(10) CFU L. plantarum MF 1298 or placebo once daily. Symptoms were registered (score 0-15) and feces collected at the end of each period. The gut microbiota was analyzed with 16S rRNA gene analyses and results reported as proportions of Bacteroides, Faecalibacterium, and Lachnospiraceae and Simpson's D diversity score. Results. Sixteen participants (11 women) with a mean age of 50 years (SD 11) were available for the analyses. Intake of L. plantarum MF 1298 was associated with a significant aggravation of symptoms, but neither intake of L. plantarum MF 1298 nor symptoms were associated with the composition of the fecal microbiota (P values >0.10). Conclusions. The trial indicates that the symptomatic aggravation related to intake of L. plantarum MF 1298 was a direct effect of the microbe on the gut wall and not caused by changes in the fecal microbiota.

mRNA expression of adipocytokines and glucocorticoid-related genes are associated with downregulation of E-cadherin mRNA in colorectal adenocarcinomas.

BACKGROUND: There is a consistently reported relationship between the incidence of colon cancer and obesity. It is thought that adipose tissue, particularly visceral fat, which secretes systemic factors that alter immunological, metabolic and endocrine milieu and promotes insulin resistance by producing adipocytokines, is important in cancer progression. Systemic high concentrations of adipocytokines, such as tumour necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), and glucocorticoid metabolism-related genes have been associated with gastrointestinal cancer. However, limited information exists about the expression of these cytokines within tumour tissue. MATERIAL AND METHODS: mRNA expression of TNF-α, IL-6,IL-8, IL-10, IL-1RN, glucocorticoid receptor alpha (GR-α), 11ß-hydroxysteroid dehydrogenase type 1 (11ß-HSD1), plasminogen activator inhibitor-1 (PAI-1), Slug, vimentin, Snail and E-cadherin was analysed in paired samples of tumour tissue and normal mucosa in 60 surgical patients for Dukes B and C colorectal adenocarcinomas using quantitative reverse transcription PCR and microarray technology. The mRNA expression level of analysed genes was compared between tumour tissue and normal mucosa from the same patients, and a correlation to mRNA expression of E-cadherin in the same tissue samples was also performed. RESULTS: A highly significant difference in mRNA expression level of several of the analysed genes was observed between tumour tissue and the normal intestinal mucosa. Inverse correlation between mRNA expression of 11ßHSD1, IL-6, GR-α and PAI-1 on one hand and mRNA expression of E-cadherin on the other hand was observed. CONCLUSION: Results show that the adipocytokines and glucocorticoid metabolism-related genes are overexpressed in colorectal adenocarcinomas, and expression of these genes is associated with the downregulation of E-cadherin mRNA, connecting these genes to carcinogenesis and progression of colorectal cancer.

Construction of an evidence-based, graduated training curriculum for D-box, a webcam-based laparoscopic basic skills trainer box.

BACKGROUND: Surgical training programs are now including simulators as training tools for teaching laparoscopic surgery. The aim of this study was to develop a standardized, graduated, and evidence-based curriculum for the newly developed D-box (D-box Medical, Lier, Norway) for training basic laparoscopic skills. METHODS: Eighteen interns with no laparoscopic experience completed a training program on the D-box consisting of 8 sessions of 5 tasks with assessment on a sixth task. Performance was measured by the use of 3-dimensional electromagnetic tracking of hand movements, path length, and time taken. Ten experienced surgeons (>100 laparoscopic surgeries, median 250) were recruited for establishing benchmark criteria. RESULTS: Significant learning curves were obtained for all construct valid parameters for tasks 4 (P < .005) and 5 (P < .005) and reached plateau levels between the fifth and sixth session. Within the 8 sessions of this study, between 50% and 89% of the interns reached benchmark criteria on tasks 4 and 5. CONCLUSIONS: Benchmark criteria and an evidence-based curriculum have been developed for the D-box. The curriculum is aimed at training and assessing surgical novices in basic laparoscopic skills.