Immersive virtual reality-based training improves response in a simulated operating room fire scenario.

BACKGROUND: SAGES FUSE curriculum provides didactic knowledge on OR fire prevention. The objective of this study is to evaluate the impact of an immersive virtual reality (VR)-based OR fire training simulation system in combination with FUSE didactics. METHODS: The study compared a control with a simulation group. After a pre-test questionnaire that assessed the baseline knowledge, both groups were given didactic material that consists of a 10-min presentation and reading materials about precautions and stopping an OR fire from the FUSE manual. The simulation group practiced on the OR fire simulation for one session that consisted of five trials within a week from the pre-test. One week later, both groups were reassessed using a questionnaire. A week after the post-test both groups also participated in a simulated OR fire scenario while their performance was videotaped for assessment. RESULTS: A total of 20 subjects (ten per group) participated in this IRB approved study. Median test scores for the control group increased from 5.5 to 9.00 (p = 0.011) and for the simulation group it increased from 5.0 to 8.5 (p = 0.005). Both groups started at the same baseline (pre-test, p = 0.529) and reached similar level in cognitive knowledge (post-test, p = 0.853). However, when tested in the mock OR fire scenario, 70% of the simulation group subjects were able to perform the correct sequence of steps in extinguishing the simulated fire whereas only 20% subjects in the control group were able to do so (p = 0.003). The simulation group was better than control group in correctly identifying the oxidizer (p = 0.03) and ignition source (p = 0.014). CONCLUSIONS: Interactive VR-based hands-on training was found to be a relatively inexpensive and effective mode for teaching OR fire prevention and management scenarios.

Proficiency-based preparation significantly improves FES certification performance.

BACKGROUND: The Fundamentals of Endoscopic Surgery (FES) certification has recently been mandated by the American Board of Surgery but best methods for preparing for the exam are lacking. Our previous work demonstrated a 40% pass rate for PGY5 residents in our program. The purpose of this study was to determine the effectiveness of a proficiency-based skills and cognitive curriculum for FES certification. METHODS: Residents who agreed to participate (n = 15) underwent an orientation session, followed by skills pre-testing using three previously described models (Trus, Operation targeting task, and Kyoto) as well as the actual FES skills exam (vouchers provided by the FES committee). Participants then trained to proficiency on all three models for the skills curriculum and completed the FES online didactic material for the cognitive curriculum. Finally, participants post-tested on the models and took the actual FES certification exam. Values are mean ± SD; p < 0.05 was considered significant. RESULTS: Of 15 residents who participated, 8 (53%) passed the FES skills exam at baseline. Participants required 2.7 ± 1.3 h to achieve proficiency on the models and approximately 3 h to complete the cognitive curriculum. At post-test, 14 (93%, vs. pre-test 53%, p = 0.041) passed the FES skills exam. 14 (93%) passed the FES cognitive exam and 13/15 (87%) passed both the skills and cognitive exam and achieved FES certification. CONCLUSIONS: Our traditional clinical endoscopy curricula were not sufficient for senior residents to pass the FES exam. Implementation of a proficiency-based flexible endoscopy curriculum using bench-top models and the FES online materials was feasible and effective for the majority of learners. Importantly, with a modest amount of additional training, 87% of our trainees were able to pass the FES examination, which represents a significant improvement for our program. We expect that additional refinements of this curriculum may yield even better results for preparing future residents for the FES examination.

A randomized comparison of laparoscopic, flexible endoscopic, and wired and wireless magnetic cameras on ex vivo and in vivo NOTES surgical performance.

BACKGROUND: The influence of endoscopic video camera (VC) image quality on surgical performance has not been studied. Flexible endoscopes are used as substitutes for laparoscopes in natural orifice translumenal endoscopic surgery (NOTES), but their optics are originally designed for intralumenal use. Manipulable wired or wireless independent VCs might offer advantages for NOTES but are still under development. OBJECTIVE: To measure the optical characteristics of 4 VC systems and to compare their impact on the performance of surgical suturing tasks. METHODS: VC systems included a laparoscope (Storz 10 mm), a flexible endoscope (Olympus GIF 160), and 2 prototype deployable cameras (magnetic anchoring and guidance system [MAGS] Camera and PillCam). In a randomized fashion, the 4 systems were evaluated regarding standardized optical characteristics and surgical manipulations of previously validated ex vivo (fundamentals of laparoscopic surgery model) and in vivo (live porcine Nissen model) tasks; objective metrics (time and errors/precision) and combined surgeon (n = 2) performance were recorded. RESULTS: Subtle differences were detected for color tests, and field of view was variable (65°-115°). Suitable resolution was detected up to 10 cm for the laparoscope and MAGS camera but only at closer distances for the endoscope and PillCam. Compared with the laparoscope, surgical suturing performances were modestly lower for the MAGS camera and significantly lower for the endoscope (ex vivo) and PillCam (ex vivo and in vivo). CONCLUSIONS: This study documented distinct differences in VC systems that may be used for NOTES in terms of both optical characteristics and surgical performance. Additional work is warranted to optimize cameras for NOTES. Deployable systems may be especially well suited for this purpose.

Proficiency-based training for robotic surgery: construct validity, workload, and expert levels for nine inanimate exercises.

BACKGROUND: We previously developed nine inanimate training exercises as part of a comprehensive, proficiency-based robotic training curriculum that addressed 23 unique skills identified via task deconstruction of robotic operations. The purpose of this study was to evaluate construct validity, workload, and expert levels for the nine exercises. METHODS: Expert robotic surgeons (n = 8, fellows and faculty) and novice trainees (n = 4, medical students) each performed three to five consecutive repetitions of nine previously reported exercises (five FLS models with or without modifications and four custom-made models). Each task was scored for time and accuracy using modified FLS metrics; task scores were normalized to a previously established (preliminary) proficiency level and a composite score equaled the sum of the nine normalized task scores. Questionnaires were administered regarding prior experience. After each exercise, participants completed a validated NASA-TLX Workload Scale to rate the mental, physical, temporal, performance, effort, and frustration levels of each task. RESULTS: Experts had performed 119 (range = 15-600) robotic operations; novices had observed ≤ 1 robotic operation. For all nine tasks and the composite score, experts achieved significantly better performance than novices (932 ± 67 vs. 618 ± 111, respectively; P < 0.001). No significant differences in workload between experts and novices were detected (32.9 ± 3.5 vs. 32.0 ± 9.1, respectively; n.s.). Importantly, frustration ratings were relatively low for both groups (4.0 ± 0.7 vs. 3.8 ± 1.6, n.s.). The mean performance of the eight experts was deemed suitable as a revised proficiency level for each task. CONCLUSION: Using objective performance metrics, all nine exercises demonstrated construct validity. Workload was similar between experts and novices and frustration was low for both groups. These data suggest that the nine structured exercises are suitable for proficiency-based robotic training.

Comprehensive proficiency-based inanimate training for robotic surgery: reliability, feasibility, and educational benefit.

BACKGROUND: We previously developed a comprehensive proficiency-based robotic training curriculum demonstrating construct, content, and face validity. This study aimed to assess reliability, feasibility, and educational benefit associated with curricular implementation. METHODS: Over an 11-month period, 55 residents, fellows, and faculty (robotic novices) from general surgery, urology, and gynecology were enrolled in a 2-month curriculum: online didactics, half-day hands-on tutorial, and self-practice using nine inanimate exercises. Each trainee completed a questionnaire and performed a single proctored repetition of each task before (pretest) and after (post-test) training. Tasks were scored for time and errors using modified FLS metrics. For inter-rater reliability (IRR), three trainees were scored by two raters and analyzed using intraclass correlation coefficients (ICC). Data from eight experts were analyzed using ICC and Cronbach's α to determine test-retest reliability and internal consistency, respectively. Educational benefit was assessed by comparing baseline (pretest) and final (post-test) trainee performance; comparisons used Wilcoxon signed-rank test. RESULTS: Of the 55 trainees that pretested, 53 (96 %) completed all curricular components in 9-17 h and reached proficiency after completing an average of 72 ± 28 repetitions over 5 ± 1 h. Trainees indicated minimal prior robotic experience and "poor comfort" with robotic skills at baseline (1.8 ± 0.9) compared to final testing (3.1 ± 0.8, p < 0.001). IRR data for the composite score revealed an ICC of 0.96 (p < 0.001). Test-retest reliability was 0.91 (p < 0.001) and internal consistency was 0.81. Performance improved significantly after training for all nine tasks and according to composite scores (548 ± 176 vs. 914 ± 81, p < 0.001), demonstrating educational benefit. CONCLUSION: This curriculum is associated with high reliability measures, demonstrated feasibility for a large cohort of trainees, and yielded significant educational benefit. Further studies and adoption of this curriculum are encouraged.

Magnetically anchored camera and percutaneous instruments maintain triangulation and improve cosmesis compared with single-site and conventional laparoscopic cholecystectomy.

BACKGROUND: This study evaluated operative outcomes and ergonomics for a magnetic camera (MAGS) used in conjunction with percutaneous instruments [percutaneous surgical set (PSS)] compared with single-site laparoscopic (SSL) and conventional laparoscopic (LAP) cholecystectomy techniques. METHODS: Four surgical trainees each performed three porcine cholecystectomies using three randomized techniques including MAGS/PSS, SSL, and LAP. The operative outcomes, procedure-specific ratings (1-5 scale; 1 = superior), workload (1-10 scale; 1 = superior), and global impressions (1-10 scale; 10 = superior) were recorded. Comparisons used analysis of variance (ANOVA) on ranks (Kruskal-Wallis), and p values lower than 0.05 were considered significant. RESULTS: The operative outcomes were similar except for significantly higher blood loss with SSL (16.3 ± 10.3) versus LAP (2.8 ± 1.5; p < 0.05) but not with MAGS/PSS (4.8 ± 3.8). Several inadvertent tissue-damaging events occurred with SSL but not with MAGS/PSS or LAP. The incision was significantly shorter with MAGS/PSS (29.3 ± 2.8 mm) and SSL (29.3 ± 2.5 mm) than with LAP (48.0 ± 3.6 mm; p < 0.05). Compared with SSL (3.6 ± 0.5), the procedure-specific ratings significantly favored MAGS/PSS (2.8 ± 0.4) and LAP (1.7 ± 0.2; p < 0.05). Ergonomics and technical challenges both were rated significantly inferior with SSL (4.3 ± 1.0 and 3.8 ± 0.5, respectively) versus LAP (1.5 ± 0.6 and 2.0 ± 0.8, respectively; p < 0.05) but not with MAGS/PSS (2.5 ± 1.0 and 3.0 ± 0.8, respectively). Both MAGS/PSS (4.5 ± 0.5) and SSL (4.8 ± 1.0) were associated with a significantly greater workload than LAP (2.5 ± 0.6; p < 0.05). Global impression ratings were significantly higher for LAP (8.7 ± 1.3) versus SSL (5.8 ± 2.0; p < 0.05) but not for MAGS/PSS (7.1 ± 1.8). Cosmesis was significantly better with MAGS/PSS (9.5 ± 0.6) versus LAP (6.5 ± 2.4; p < 0.05) but not with SSL (8.8 ± 1.3). CONCLUSION: The MAGS/PSS technique allows better triangulation and fewer technical difficulties than SSL and better cosmesis than LAP. Further development of these devices is warranted.

A randomized comparison of laparoscopic, magnetically anchored, and flexible endoscopic cameras in performance and workload between laparoscopic and single-incision surgery.

BACKGROUND: This study aimed to evaluate the surgeon performance and workload of a next-generation magnetically anchored camera compared with laparoscopic and flexible endoscopic imaging systems for laparoscopic and single-site laparoscopy (SSL) settings. METHODS: The cameras included a 5-mm 30° laparoscope (LAP), a magnetically anchored (MAGS) camera, and a flexible endoscope (ENDO). The three camera systems were evaluated using standardized optical characteristic tests. Each system was used in random order for visualization during performance of a standardized suturing task by four surgeons. Each participant performed three to five consecutive repetitions as a surgeon and also served as a camera driver for other surgeons. Ex vivo testing was conducted in a laparoscopic multiport and SSL layout using a box trainer. In vivo testing was performed only in the multiport configuration and used a previously validated live porcine Nissen model. RESULTS: Optical testing showed superior resolution for MAGS at 5 and 10 cm compared with LAP or ENDO. The field of view ranged from 39 to 99°. The depth of focus was almost three times greater for MAGS (6-270 mm) than for LAP (2-88 mm) or ENDO (1-93 mm). Both ex vivo and in vivo multiport combined surgeon performance was significantly better for LAP than for ENDO, but no significant differences were detected for MAGS. For multiport testing, workload ratings were significantly less ex vivo for LAP and MAGS than for ENDO and less in vivo for LAP than for MAGS or ENDO. For ex vivo SSL, no significant performance differences were detected, but camera drivers rated the workload significantly less for MAGS than for LAP or ENDO. CONCLUSION: The data suggest that the improved imaging element of the next-generation MAGS camera has optical and performance characteristics that meet or exceed those of the LAP or ENDO systems and that the MAGS camera may be especially useful for SSL. Further refinements of the MAGS camera are encouraged.

Acquisition of Teamwork and Communication Skills Using High-Technology Simulation for Preclerkship Medical Students.

INTRODUCTION: Teamwork failures are a major source of preventable error in medicine. Acquisition of skills early in training seems beneficial for impacting system-level change. Simulation-based curricula provide a psychologically safe and formative environment to learn and practice team skills. This project aims to assess teamwork and communication skill acquisition in preclerkship medical students during a longitudinal simulation-based curriculum. METHODS: This is a prospective, observational study of medical students participating in a high-technology simulation curriculum on team principles. Students, in groups of 5 to 7, participated in 6 mannequin-based simulation sessions over 10 months coordinated with an organ system-based preclerkship course. Each scenario was executed by a simulation technologist and guided by a simulation educator who functioned as a bedside nurse and led a postsimulation debrief. Likert-based, self- and global assessments completed by students and facilitators, respectively, were used to evaluate the teams. Descriptive statistics and Mann-Whitney U test were used to analyze data using a P value of less than 0.05 for statistical significance and a null hypothesis stating that there would be no change in behavior. The primary outcome measure was improvement in the teamwork and communication domains of both assessments. RESULTS: Students (N = 231) were divided into the same 32 groups during every session. At the end of every session, each student completed a self-assessment and each educator completed the team's global assessment for teamwork. Median scores for teamwork and communication domains increased between the first and sixth sessions on both assessments. Mann-Whitney U analysis of self-assessment scores showed Z values between -5.30 and -8.83 and P values of less than 0.00001. Mann-Whitney U analysis of global assessment scores showed Z values ranging from -3.43 to -5.24 and P values between 0.0031 and less than 0.00001. CONCLUSIONS: There was meaningful improvement in scores in the domains of teamwork and communication over the 10-month, simulation-based curriculum designed to teach and hone teamwork skills.

Assessing quality and resources during campus-wide simulation integration.

INTRODUCTION: Our simulation center, supported by four departments (Surgery, OB/GYN, Urology, and Anesthesiology), is accredited as a comprehensive Accredited Educational Institute (AEI) and is now expanding to accommodate all departments on campus. METHODS: A 61-point questionnaire was administered to 44 stakeholders, representing all of UME and GME. Data were compared for AEI vs. non-AEI activities. RESULTS: Responses were collected from all 44 groups (100% response rate). Overall, 43 simulation activities were hosted within the AEI and 40 were hosted by non-AEI stakeholders. AEI activities were more likely to be mandatory (93% vs. 75%, p = 0.02), have written learning objectives (79% vs 43%, p < 0.001), and use validated assessment metrics (33% vs. 13%, p = 0.03). CONCLUSION: These data suggest that the AEI courses are more robust in terms of structured learning and assessment compared to non-AEI courses. Campus-wide application of uniform quality standards is anticipated to require significant faculty, course, and program development.

A proficiency-based surgical boot camp May not provide trainees with a durable foundation in fundamental surgical skills.

BACKGROUND: Pre-internship boot camps have become popular platforms to rapidly teach skills to surgical interns. This study aimed to analyze psychomotor skill retention four months after completing a boot camp program. METHODS: Surgical interns (n = 20) took a baseline pre-test and then trained to proficiency (based on time and errors) for 5 knot tying, 4 simple suturing, and 2 running suturing tasks during a three-day boot camp. Three months later, all interns took a retention test. RESULTS: Proficiency scores significantly improved on all task types from pre-test to post test and significantly regressed on all task types from post-test to retention test. Normalized scores decreased as the tasks became more complex (knot tying = 93.5, simple suturing = 89.1, running suturing = 85.2, p = 0.05). CONCLUSIONS: Boot camp style training can rapidly teach fundamental surgical skills to novices; however, skills regress significantly over time with a greater degree of regression seen on more complex skills.

Gastrojejunal stomal reduction with the T-tag device in porcine models (with videos).

BACKGROUND: Roux-en-Y gastric bypass is the most commonly performed bariatric operation in the United States. Gastrojejunal (GJ) stomal dilatation associated with weight regain is a late complication. Surgical revision is usually required for stomal or pouch reduction. OBJECTIVE: Our purpose was to evaluate the technical feasibility, efficacy, and safety of stomal reduction with endoscopic T-tag devices. DESIGN: Prospective nonsurvival studies were conducted in pigs (n = 2, 110 pounds each). INTERVENTIONS: Three GJ stomas were created in each pig through a midline laparotomy by using circular staplers. Endoscopic GJ stomal reduction/revision was performed on these newly created stomas with an Olympus T-tag device. Necropsy was performed to examine the deployed T-tag locations and procedure-related adjacent tissue/organ injury and to assess the effectiveness of stomal reduction. RESULTS: Endoscopic stomal revision was performed on 5 stomas with moderate stomal reduction. One GJ stoma could not be accessed easily by endoscopy because of the small size of the gastric pouch. An average of 4 T-tag devices was deployed around each stoma. The procedural time was about 61 +/- 12 minutes for each stomal reduction. Overall, 26 of 39 (66.7%) T-bars were deployed in accepted locations. The stomas were reduced from 1.60 +/- 0.21 mm x 1.44 +/- 0.14 mm to 1.28 +/- 0.29 mm x 0.98 +/- 0.17 mm and the percentage of stomal reduction was 27.3% +/- 13.3%. In the end, a therapeutic gastroscope could not be advanced through the reduced stomas. In 2 stomas, 5 of 39 (12.8%) T-bars injured or attached to the adjacent organs: isolated stomach and abdominal wall. LIMITATION: Nonsurvival pig studies. CONCLUSIONS: Endoscopic stomal reduction with T-tag device is technically feasible and effective in two thirds of trials. However, it is associated with a small risk of adjacent organ/tissue injury with the current prototype device and deployment method.

Setting goals, not just roles: Improving teamwork through goal-focused debriefing.

INTRODUCTION: The role of goal setting within post-simulation debriefing is not well known. This study sought to examine how inclusion of group-level goals, individual-level goals, or no goals in the debriefing process impacts teamwork. METHODS: Students participated in two high-fidelity team training scenarios. Between scenarios, teams were assigned to one of three debriefing groups: jointly creating five teamwork goals for the group to achieve (group-level goals); independently creating five teamwork goals for each individual to attain (individual-level goals); or no goals. Paired-samples t tests and one-way ANOVA with post-hoc Tukey tests were used to examine performance improvements and differences between groups. RESULTS: 86 MS3s participated in the training program across 22 groups. Percentage of items achieved on the teamwork tool from first to second scenario were 61.7±20.4 to 60.2±8.8 (no goals; ns), 59.8±14.0 to 76.8±7.0 (individual goals; p<0.01), and 62.5±9.5 to 67.0±10.0 (group goals; ns). Performance improvement in the individual goals group was significantly higher than the no goals group (p<0.05). CONCLUSIONS: Debriefing facilitators should encourage learners to focus on creating and achieving personal goals contributing to teamwork.

Splenectomy impairs diffusive oxygen transport in the lung of dogs.

The spleen acts as an erythrocyte reservoir in highly aerobic species such as the dog and horse. Sympathetic-mediated splenic contraction during exercise reversibly enhances convective O2 transport by increasing hematocrit, blood volume, and O2-carrying capacity. Based on theoretical interactions between erythrocytes and capillary membrane (Hsia CCW, Johnson RL Jr, and Shah D. J Appl Physiol 86: 1460-1467, 1999) and experimental findings in horses of a postsplenectomy reduction in peripheral O2-diffusing capacity (Wagner PD, Erickson BK, Kubo K, Hiraga A, Kai M, Yamaya Y, Richardson R, and Seaman J. Equine Vet J 18, Suppl: 82-89, 1995), we hypothesized that splenic contraction also augments diffusive O2 transport in the lung. Therefore, we have measured lung diffusing capacity (DL(CO)) and its components during exercise by a rebreathing technique in six adult foxhounds before and after splenectomy. Splenectomy eliminated exercise-induced polycythemia, associated with a 30% reduction in maximal O2 uptake. At any given pulmonary blood flow, DL(CO) was significantly lower after splenectomy owing to a lower membrane diffusing capacity, whereas pulmonary capillary blood volume changed variably; microvascular recruitment, indicated by the slope of the increase in DL(CO) with respect to pulmonary blood flow, was also reduced. We conclude that splenic contraction enhances both convective and diffusive O2 transport and provides another compensatory mechanism for maintaining alveolar O2 transport in the presence of restrictive lung disease or ambient hypoxia.

Comparison of basic elements of human performance scores between urologists with various extents of experience.

BACKGROUND AND PURPOSE: An objective evaluation of innate ability and its ability to predict potential success as a surgical trainee is an appealing concept for the selection process of residency applications. The objective of this study was to evaluate whether basic elements of performance (BEP) could discriminate among resident applicants and urologists with various extents of surgical experience. SUBJECTS AND METHODS: One hundred forty-five participants were divided into four study groups: group A, 57 urology residency applicants to the 2002 and 2003 interview process; group B, 8 post-internship urology residents; group C, 19 urologists tested with BEP within 10 years of graduation from their residency training program; and group D, 61 urologists who had graduated from their residency training program more than 10 years prior to testing. The BEP measures consisted of 13 basic performance resources (BPR) including visual-information processing speed, visual-spatial immediate-recall capacity, and neuromotor channel capacity. RESULTS: The four study groups differed significantly in their mean age: group A=27.6 years, group B=29.1 years, group C=37.1 years, and group D=48.9 years (P<0.0005). There was essentially no significant difference between the groups with regard to immediate-recall memory, reaction time simple, or reaction time complicated. The younger participants (groups A and B) were faster than the older surgeons (groups C and D) (P<0.02). However, the older surgeons (groups C and D) were significantly more accurate than the younger groups (A and B) (P<0.0005). The only sex differences noted were in hand-grip strength and shoulder-strength scores, which were all higher in the men. CONCLUSIONS: There generally appears to be a lack of direct correlation between innate abilities and surgical experience. Urology resident applicants with no surgical experience and urology residents with limited surgical experience are faster but less accurate in innate skills testing than experienced practicing urologists.

The impact of goal setting and goal orientation on performance during a clerkship surgical skills training program.

BACKGROUND: The purpose of this study was to integrate relevant goal-setting theory and to identify if trainees' goal orientations have an impact on the assigned goals-performance relationship. METHODS: Trainees attended 1 of the 3 goal-training activities (do your best, performance, or learning goals) for knot tying (KT) and camera navigation (CN) during the 3rd-year clerkship rotation. Questionnaires and pretests and/or post-tests were completed. RESULTS: One twenty-seven 3rd-year medical students (age: 25 ± 2.6; 54% women) participated in the training program. Pretraining to post-training performance changes were significant for all groups on both tasks (P < .01), but the increase was significantly greater (P < .01) for the learning goals group (do your best: KTΔ = 2.14, CNΔ = 1.69; performance: KTΔ = 2.49, CNΔ = 2.24; learning: KTΔ = 3.04 CNΔ = 2.76). Correlations between goal orientations and improvement were examined, revealing a unique role of goal orientation for performance improvement. CONCLUSIONS: These data indicate that consideration of goal type and trainee goal orientation must be considered during curriculum development to maximize educational value.

Ventilatory acclimatization in awake guinea pigs raised at high altitude.

To determine if laboratory strains of guinea pigs bred at sea level (SL) are "pre-adapted" to high altitude (HA), we raised litter-matched weanling Hartley guinea pigs for 4 months at SL, intermediate altitude (IA, 1250 m) or HA (3800 m) and exposed them acutely to 100, 21 and 12% inspired O2 at their respective altitude of residence. Control animals raised at SL were also exposed acutely to 10 and 8% inspired O2. In awake spontaneously breathing guinea pigs raised at SL, resting minute ventilation and tidal volume increased significantly when inspired O2 tension fell below about 60 mm Hg. In guinea pigs raised at IA or HA, ventilation was higher at any given inspired O2 tension in direct relationship to the altitude of residence. Resting hematocrit was also higher in animals raised at HA than at SL. We conclude that the pattern of ventilatory acclimatization to HA exposure in Hartley guinea pigs is similar to that in laboratory rats and human lowlanders; therefore laboratory guinea pigs are not pre-adapted and are suitable animals for the study of adaptation to high altitude.

Retinoic acid-induced alveolar cellular growth does not improve function after right pneumonectomy.

To determine whether all-trans retinoic acid (RA) treatment enhances lung function during compensatory lung growth in fully mature animals, adult male dogs (n = 4) received 2 mg x kg(-1) x day(-1) po RA 4 days/wk beginning the day after right pneumonectomy (R-PNX, 55-58% resection). Litter-matched male R-PNX controls (n = 4) received placebo. After 3 mo, transpulmonary pressure (TPP)-lung volume relationship, diffusing capacities for carbon monoxide and nitric oxide, cardiac output, and septal volume (V(tiss-RB)) were measured under anesthesia by a rebreathing technique at two lung volumes. Lung air and tissue volumes (V(air-CT) and V(tiss-CT)) were also measured from high-resolution computerized tomographic (CT) scans at a constant TPP. In RA-treated dogs compared with controls, TPP-lung volume relationships were similar. Diffusing capacities for carbon monoxide and nitric oxide were significantly impaired at a lower lung volume but similar at a high lung volume. Whereas V(tiss-RB) was significantly lower at both lung volumes in RA-treated animals, V(air-CT) and V(tiss-CT) were not different between groups; results suggest uneven distribution of ventilation consistent with distortion of alveolar geometry and/or altered small airway function induced by RA. We conclude that RA does not improve resting pulmonary function during the early months after R-PNX despite histological evidence of its action in enhancing alveolar cellular growth in the remaining lung.

Development, validation, and implementation of a cost-effective intermediate-level proficiency-based knot-tying and suturing curriculum for surgery residents.

BACKGROUND: The purpose of this study was to develop an intermediate-level proficiency-based knot-tying and suturing curriculum, evaluate construct validity, determine feasibility, document educational benefit, and quantify cost-effectiveness of implementation within a surgery residency program. METHODS: Six tasks with standardized metrics were developed using commercially available bench models; 39 PGY-1 surgery residents were enrolled in a 2-month curriculum (orientation/pre-test, self-practice, and a proctored post-test). Baseline trainee and expert performance were compared to assess construct validity. RESULTS: Baseline trainee and expert performance were significantly different (451 ± 83 vs 644 ± 10, p < 0.001), supporting construct validity. All trainees achieved proficiency during self-practice, completing 30 ± 17 repetitions over 3.4 ± 3.8 hours. Significant differences were detected between baseline and final trainee composite scores (451 ± 83 vs 607 ± 34, p < 0.001). CONCLUSIONS: Implementation of this curriculum was feasible and cost-effective. Construct validity and educational benefit in terms of skill acquisition were demonstrated. The purpose of this study was to develop an intermediate-level proficiency-based knot-tying and suturing curriculum, evaluate construct validity, determine feasibility, document educational benefit, and quantify cost-effectiveness of implementation within a robust surgery residency training program.

Content and face validity of a comprehensive robotic skills training program for general surgery, urology, and gynecology.

BACKGROUND: The authors previously developed a comprehensive, proficiency-based robotic training curriculum that aimed to address 23 unique skills identified via task deconstruction of robotic operations. The purpose of this study was to determine the content and face validity of this curriculum. METHODS: Expert robotic surgeons (n = 12) rated each deconstructed skill regarding relevance to robotic operations, were oriented to the curricular components, performed 3 to 5 repetitions on the 9 exercises, and rated each exercise. RESULTS: In terms of content validity, experts rated all 23 deconstructed skills as highly relevant (4.5 on a 5-point scale). Ratings for the 9 inanimate exercises indicated moderate to thorough measurement of designated skills. For face validity, experts indicated that each exercise effectively measured relevant skills (100% agreement) and was highly effective for training and assessment (4.5 on a 5-point scale). CONCLUSIONS: These data indicate that the 23 deconstructed skills accurately represent the appropriate content for robotic skills training and strongly support content and face validity for this curriculum.

Developing a comprehensive, proficiency-based training program for robotic surgery.

INTRODUCTION: Robotically assisted surgery has become very popular for numerous surgical disciplines, yet training practices remain variable with little to no validation. The purpose of this study was to develop a comprehensive, proficiency-based robotic training program. METHODS: A skill deconstruction list was generated by observation of robotic operations and interviews with experts. Available resources were used, and other components were developed as needed to develop a comprehensive, proficiency-based curriculum to teach all deconstructed skills. Preliminary construct and content validity and curriculum feasibility were evaluated. RESULTS: The skill deconstruction list contained 23 items. Curricular components included an online tutorial, a half-day interactive session, and 9 inanimate exercises with objective metrics. Novice (546 ± 26) and expert (923 ± 60) inanimate composite scores were different (P < .001), supporting construct validity, and substantial pre-test to post-test improvement was noted after successful training completion. All 23 deconstructed skills were rated as highly relevant (4.9 ± 0.5; 5-point scale), and no skills were absent from the curriculum, supporting content validity. CONCLUSION: These data suggest that this proficiency-based training curriculum comprehensively addresses the skills necessary to perform robotic operations with early construct and content validity and feasibility demonstrated. Further validation is encouraged.