Optimizing a living kidney donation program: transition to hand-assisted retroperitoneoscopic living donor nephrectomy and introduction of a passive polarizing three-dimensional display system.

BACKGROUND: Optimizing a living kidney donation program is important to guarantee a high grade of acceptance among potential donors. Hand-assisted retroperitoneoscopic donor nephrectomy (HARP) is an alternative to the open anterior approach (AA) technique. Problems associated to the learning curve could hinder a transition. 3D display technique seems to ease minimally invasive surgery. Aim of this study was to evaluate the learning curve during the transition from AA to HARP and the influence of the 3D display system on the established technique. METHODS: Observational study (n = 207) during transition to HARP and introduction of 3D display technique. RESULTS: Operation time (OT), warm ischemia time (WIT) and blood loss (BL) of HARP decreased during transition. Pairwise group comparison for OT showed a significant learning effect for the first 30 out of 50 HARPs without influence on graft function. Between AA and HARP no significant difference in OT (133 ± 24 vs. 127 ± 19 min, p = 0.25) but for WIT (23 ± 28 vs. 126 ± 40 s, p < 0.005) and BL (328 ± 207 vs. 54 ± 35 ml, p < 0.005) was seen. There was neither a significant difference in donors' nor recipients' eGFR. OT (98 ± 16 vs. 106 ± 19 min, p = 0.036) and WIT (97 ± 37 vs. 120 ± 57 s, p = 0.023) were significantly shorter for the 3D technique compared to 2D. CONCLUSION: A transition to HARP is possible without additional risk for the donor or loss of quality for the recipient. The learning curve for HARP is steep and short. The introduction of 3D display technique after transition facilitates the surgical preparation and could further help to optimize HARP.

Web-Based Immersive Virtual Patient Simulators: Positive Effect on Clinical Reasoning in Medical Education.

BACKGROUND: Clinical reasoning is based on the declarative and procedural knowledge of workflows in clinical medicine. Educational approaches such as problem-based learning or mannequin simulators support learning of procedural knowledge. Immersive patient simulators (IPSs) go one step further as they allow an illusionary immersion into a synthetic world. Students can freely navigate an avatar through a three-dimensional environment, interact with the virtual surroundings, and treat virtual patients. By playful learning with IPS, medical workflows can be repetitively trained and internalized. As there are only a few university-driven IPS with a profound amount of medical knowledge available, we developed a university-based IPS framework. Our simulator is free to use and combines a high degree of immersion with in-depth medical content. By adding disease-specific content modules, the simulator framework can be expanded depending on the curricular demands. However, these new educational tools compete with the traditional teaching OBJECTIVE: It was our aim to develop an educational content module that teaches clinical and therapeutic workflows in surgical oncology. Furthermore, we wanted to examine how the use of this module affects student performance. METHODS: The new module was based on the declarative and procedural learning targets of the official German medical examination regulations. The module was added to our custom-made IPS named ALICE (Artificial Learning Interface for Clinical Education). ALICE was evaluated on 62 third-year students. RESULTS: Students showed a high degree of motivation when using the simulator as most of them had fun using it. ALICE showed positive impact on clinical reasoning as there was a significant improvement in determining the correct therapy after using the simulator. ALICE positively impacted the rise in declarative knowledge as there was improvement in answering multiple-choice questions before and after simulator use. CONCLUSIONS: ALICE has a positive effect on knowledge gain and raises students' motivation. It is a suitable tool for supporting clinical education in the blended learning context.

Endothelial microparticle uptake in target cells is annexin I/phosphatidylserine receptor dependent and prevents apoptosis.

OBJECTIVE: Endothelial microparticles (EMP) are released from activated or apoptotic cells, but their effect on target cells and the exact way of incorporation are largely unknown. We sought to determine the uptake mechanism and the biological effect of EMP on endothelial and endothelial-regenerating cells. METHODS AND RESULTS: EMP were generated from starved endothelial cells and isolated by ultracentrifugation. Caspase 3 activity assay and terminal deoxynucleotidyl transferase dUTP nick end labeling assay showed that EMP protect target endothelial cells against apoptosis in a dose-dependent manner. Proteomic analysis was performed to identify molecules contained in EMP, which might be involved in EMP uptake. Expression of annexin I in EMP was found and confirmed by Western blot, whereas the corresponding receptor phosphatidylserine receptor was present on endothelial target cells. Silencing either annexin I on EMP or phosphatidylserine receptor on target cells using small interfering RNA showed that the uptake of EMP by human coronary artery endothelial cells is annexin I/phosphatidylserine receptor dependent. Annexin I-downregulated EMP abrogated the EMP-mediated protection against apoptosis of endothelial target cells. p38 activation was found to mediate camptothecin-induced apoptosis. Finally, human coronary artery endothelial cells pretreated with EMP inhibited camptothecin-induced p38 activation. CONCLUSIONS: EMP are incorporated by endothelial cells in an annexin I/phosphatidylserine receptor-dependent manner and protect target cells against apoptosis. Inhibition of p38 activity is involved in EMP-mediated protection against apoptosis.

Embedding a Virtual Patient Simulator in an Interactive Surgical lecture.

BACKGROUND: Lectures are traditionally used for teaching declarative knowledge. One established tool for clinical education is the demonstration of a real patient. The use of real patients in the daily clinical environment is increasingly difficult. The use of a virtual patient simulator (VPS) can potentially circumvent these problems. Unlimited availability and the opportunity of an electronic feedback system could possibly enrich traditional lectures by enabling more interactivity that meets the expectations of the current student generation. As students face the consequences of their own decisions they take a more active role in the lecture. VPS links declarative knowledge with visual perception that is known to influence students' motivation. Until now, there have been no reports covering the usage and validation of interactive VPS for supporting traditional lectures. AIM: In this study, we (1) described the development of a custom-made three-dimensional (3D) VPS for supporting the traditional lecture and (2) performed a feasibility study including an initial assessment of this novel educational concept. METHODS: Conceptualization included definition of curricular content, technical realization and validation. A custom-made simulator was validated with 68 students. The degree of student acceptance was evaluated. Furthermore, the effect on knowledge gain was determined by testing prelecture and postlecture performance. RESULTS: A custom-made simulator prototype that displays a 3D virtual clinic environment was developed and linked to a PowerPoint presentation. Students were able to connect to the simulator via electronic devices (smartphones and tablets) and to control the simulator via majority vote. The simulator was used in 6 lectures and validated in 2 lectures with 68 students each. Student acceptance and their opinion about effectiveness and applicability were determined. Students showed a high level of motivation when using the simulator as most of them had fun using it. Effect on knowledge gain was proven by comparison of chosen therapeutic workflow before and after the lecture. Students showed significantly (p < 0.05) more correct answers in determination of the therapeutic workflow after the lecture. CONCLUSIONS: We successfully developed and evaluated a custom-made 3D VPS for supporting the traditional lecture. VPS is probably an effective instrument that might replace real patients in selected lectures and prepare students for bedside teaching.

Design, Realization, and First Validation of an Immersive Web-Based Virtual Patient Simulator for Training Clinical Decisions in Surgery.

BACKGROUND: Immersive patient simulators (IPS) allow an illusionary immersion into a synthetic world where the user can freely navigate through a 3-dimensional environment similar to computer games. Playful learning with IPS allows internalization of medical workflows without harming real patients. Ideally, IPS show high student acceptance and can have positive effect on knowledge gain. Development of IPS with high technical quality is resource intensive. Therefore most of the "high-fidelity" IPS are commercially driven. Usage of IPS in the daily curriculum is still rare. There is no academic-driven simulator that is freely accessible to every student and combines high immersion grade with a profound amount of medical content. AIM: Therefore it was our aim to develop an academic-driven IPS prototype that is free to use and combines a high immersion grade with profound medical content. In addition, a first validation of the prototype was conducted. METHODS: The conceptual design included definition of the following parameters: amount of curricular content, grade of technical quality, availability, and level of validation. A preliminary validation was done with 25 students. Students' opinion about acceptance was evaluated by a Likert-scale questionnaire. Effect on knowledge gain was determined by testing concordance and predictive validity. RESULTS: A custom-made simulator prototype (Artificial learning interface for clinical education [ALICE]) displays a virtual clinic environment that can be explored from a first-person view similar to a video game. By controlling an avatar, the user navigates through the environment, is able to treat virtual patients, and faces the consequence of different decisions. ALICE showed high students' acceptance. There was positive correlation for concordance validity and predictive validity. Simulator usage had positive effect on reproduction of trained content and declarative knowledge. CONCLUSIONS: We successfully developed a university-based, IPS prototype (ALICE) with profound medical content. ALICE is a nonprofit simulator, easy to use, and showed high students' acceptance; thus it potentially provides an additional tool for supporting student teaching in the daily clinical curriculum.