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BACKGROUND: Research implicates inflammation in the vicious cycle between depression and obesity, yet few longitudinal studies exist. The rapid weight loss induced by bariatric surgery is known to improve depressive symptoms dramatically, but preoperative depression diagnosis may also increase the risk for poor weight loss. Therefore, we investigated longitudinal associations between depression and inflammatory markers and their effect on weight loss and clinical outcomes in bariatric patients. METHODS: This longitudinal observational study of 85 patients with obesity undergoing bariatric surgery included 41 cases with depression and 44 controls. Before and 6 months after surgery, we assessed depression by clinical interview and measured serum high-sensitivity C-reactive protein (hsCRP) and inflammatory cytokines, including interleukin (IL)-6 and IL-10. RESULTS: Before surgery, depression diagnosis was associated with significantly higher serum hsCRP, IL-6, and IL-6/10 ratio levels after controlling for confounders. Six months after surgery, patients with pre-existing depression still had significantly higher inflammation despite demonstrating similar weight loss to controls. Hierarchical regression showed higher baseline hsCRP levels predicted poorer weight loss (ß = -0.28, p = 0.01) but had no effect on depression severity at follow-up (ß = -0.02, p = 0.9). Instead, more severe baseline depressive symptoms and childhood emotional abuse predicted greater depression severity after surgery (ß = 0.81, p < 0.001; and ß = 0.31, p = 0.001, respectively). CONCLUSIONS: Depression was significantly associated with higher inflammation beyond the effect of obesity and other confounders. Higher inflammation at baseline predicted poorer weight loss 6 months after surgery, regardless of depression diagnosis. Increased inflammation, rather than depression, may drive poor weight loss outcomes among bariatric patients.
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Cirurgia Bariátrica , Obesidade Mórbida , Humanos , Criança , Estudos Longitudinais , Proteína C-Reativa/análise , Depressão/epidemiologia , Interleucina-6 , Inflamação , Obesidade/complicações , Obesidade/cirurgia , Obesidade/psicologia , Cirurgia Bariátrica/psicologia , Redução de Peso , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgiaRESUMO
BACKGROUND: Hypothalamic-pituitary-adrenal (HPA) axis dysregulation has been suggested to play a role in the association between depression and obesity. The study aimed to investigate differences in cortisol levels in individuals with obesity with and without depression and the role of perceived stress on these differences. METHODS: Saliva samples were collected at awakening, 15-, 30- and 60-minutes post-awakening from 66 individuals with obesity (30 with major depressive disorder and 36 without major depressive disorder). Salivary cortisol was analysed using ELISA technique. Linear Mixed Models were used for group differences in cortisol awakening response (CAR) with adjustment for socio-demographic confounders and binge eating. RESULTS: Individuals with obesity and depression had lower CAR compared with individuals with obesity without depression (ß = -0.44; p = 0.036). When controlling for perceived stress, CAR was no longer influenced by depression (ß = -0.09; p = 0.75), but individuals with moderate/high stress had lower CAR compared with those with low stress (ß = -0.63; p = 0.036). CONCLUSIONS: Our results suggest that differences in CAR between individuals with obesity with and without depression could be due to higher levels of perceived stress in the depressed subjects.
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Transtorno Depressivo Maior , Humanos , Estudos Transversais , Hidrocortisona , Depressão , Obesidade , Sistema Hipotálamo-Hipofisário , Sistema Hipófise-Suprarrenal , Estresse Psicológico , SalivaRESUMO
AIMS: Making correct decisions is an integral part of surgical competency and excellence. The learning of this expert skill takes years to accumulate during training. To date there has not been an attempt to accelerate this learning process by developing a tool. In our present study we develop a self-appraisal computer software learning and assessment decision-making tool for laparoscopic surgery. It aims to accumulate several years of varied surgical experience, so the trainee can start to learn the complexities of surgical decision making in various types of cases. In this study we aim to validate the tool. METHODS: Three decision-making modules were developed in a computer program for laparoscopic cholecystectomy: knowledge of operation, operative surgical technique and operative task completion. The latter two modules were based on answering questions based on watching recorded live operations from a library of 100 recorded laparoscopic cholecystectomies of various grades. The questions were devised by two experienced surgeons with more than 14 years postgraduate surgical experience. To validate the tool two groups with varying surgical experience were assessed: intermediate and expert surgeons. These groups were determined by the number of laparoscopic cholecystectomies performed as well as of number of years of operative surgical experience. RESULTS: A total of 20 subjects were assessed, 12 intermediate and 8 experts surgeons. Mean time to perform the programme was 21 min (range 18-45 min). Using the Mann-Whitney test, p < 0.05, construct validity was demonstrated in the surgical technique and completion of task modules as well as the total combined scores. CONCLUSIONS: Our computer-based decision-making learning tool for laparoscopic cholecystectomy seems to have face, content, concurrent and construct validities. Surgical decision making is a multifaceted process; by assessing how and why decisions are made effectively, focussed surgical training may be achieved. We aim in the future to determine if the self-appraisal decision-making tool improves or accelerates surgical training.
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Colecistectomia Laparoscópica/educação , Competência Clínica , Instrução por Computador , Currículo , Tomada de Decisões , Formação de Conceito , Feminino , Humanos , Masculino , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Generic technical skills are required by a surgeon to perform a complete operation or procedure. They alone do not form a task or subtask but allow the surgeon to perform so. Specific technical skills are required to complete a task or subtask, which can be depicted by hierarchical task analysis (HTA). In this study we aim to demonstrate a reliable and valid method to construct a surgical HTA. METHODS: One hundred thirty video recordings of operations and procedures (30 laparoscopic cholecystectomies, 20 open inguinal hernia repairs, 20 saphenofemoral junction ligations, 20 upper GI and 40 lower GI endoscopies) from 37 different expert surgeons were assessed in view of constructing a HTA. Three research surgeons with more than eight years of postgraduate surgical experience assessed each operation or procedure blindly and independently and constructed a HTA. Each consultant surgeon assessed the HTA constructed by the researchers and modified it according to his/her own technical style. RESULTS: For tasks there was a 100% correlation between the researchers and individual expert surgeons. Mean interrater reliability for subtasks was k = 0.89 (range = 0.81-0.95), p < 0.05. Content and face validities of the HTA were confirmed by the expert surgeons. CONCLUSIONS: This study outlines a valid and reliable method of constructing a surgical task analysis and HTA for any operation or procedure, which could be used to assess and evaluate trainees' and expert surgeons' specific technical skills.
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Competência Clínica , Laparoscopia/normas , Análise e Desempenho de Tarefas , Educação Baseada em Competências , Educação de Pós-Graduação em Medicina/métodos , Feminino , Cirurgia Geral/educação , Humanos , Relações Interprofissionais , Masculino , Sensibilidade e Especificidade , Reino UnidoRESUMO
BACKGROUND: Laparoscopic suturing has been regarded as an advanced operative task, and courses to develop this skill are aimed at senior trainees and consultants. This study evaluates the role of laparoscopic suturing courses in the modern operative training curriculum. METHODS: The performance of 9 senior operative trainees (course A) was compared to that of 14 junior operative trainees (course B) at identical, 2-day laparoscopic suturing courses. Pre- and post-course assessments measured time taken, dexterity, and quality for the placement of 1 intracorporeal suture on synthetic bowel. Post-course data was compared to the performance of a group of 6 experts. RESULTS: The median number of laparoscopic procedures carried out unassisted was 130 for surgeons on course A, and 0 for those on course B. At the pre-course assessment, senior trainees (course A) were significantly faster, more dexterous, and had higher checklist scores then those on course B. Both groups had improved significantly by the end of each the course. Post-course comparison between the 2 groups showed equivalent path length and checklist scores, although group A remained faster (P = .003) and made fewer movements (P = .033). Senior trainees had similar performance data to the group of expert surgeons, although this was not the case for junior trainees. CONCLUSIONS: Endoscopic suturing is a task that can be learned by operative trainees during short skills courses, regardless of baseline laparoscopic experience. Skills training in laparoscopic suturing should thus not be reserved only for those contemplating advanced laparoscopic operation.
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Cirurgia Geral/educação , Internato e Residência , Laparoscopia/métodos , Técnicas de Sutura/educação , HumanosRESUMO
BACKGROUND: Assessing live laparoscopic surgery using structured methodology is still in its infancy; however, it removes bias and subjectivity. We critique a new assessment tool for technical skills in laparoscopic surgery. METHODS: A hierarchical task analysis was done for laparoscopic cholecystectomy (LC), and a global assessment for generic and specific technical skills for LC was developed. Two experienced surgeons with >12 years of postgraduate experience assessed 50 full-length LC operations blindly and independently. RESULTS: Five consultant/attending and 4 registrar/resident surgeons were recruited. Interrater reliability was k = 0.86 and k = 0.84 (P < .05) for generic and specific technical skills, respectively. Mean time for consultants was 32 minutes (range 15 to 70) and for registrars was 53 minutes (range 20 to 90). Parametric Student t test analysis was significant for time between the 2 groups, P < .05. Nonparametric analysis of variance between the 2 groups for generic and specific technical skills was significant at P < .05. CONCLUSIONS: This assessment tool for live laparoscopic surgery may have face, content, concurrent, construct, and predictive validities for generic and specific technical skills. We aim to continue the study and expand assessment to other surgical techniques.
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Laparoscopia/normas , Colecistectomia Laparoscópica/normas , Competência Clínica , Humanos , Estatística como AssuntoRESUMO
This study is the first national baseline survey of blood lead levels (BLLs) conducted on primary school children (ages 5-7 years) in Trinidad and Tobago. A total of 1,761 students from 61 schools participated in the study over a 3-month period. Measurements of capillary BLLs were assessed as well as responses to a risk assessment questionnaire. BLLs ranged from <1 microg/dL to 28.6 microg/dL with a geometric mean of 2.8 microg/dL, which compared favourably with results from the U.S. 1991-94 National Health and Nutrition Examination Survey. Fifteen (0.9%) children had a BLL>or=10 microg/dL (10.8-28.6 microg/dL) of which three (0.2%) met the U.S. criteria for lead poisoning (BLL>or=20 microg/dL). Further environmental investigations are required to identify source(s) of lead exposure in cases with high BLL.
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Poluentes Ambientais/sangue , Chumbo/sangue , Criança , Pré-Escolar , Monitoramento Ambiental , Feminino , Humanos , Masculino , Medição de Risco , Trinidad e TobagoRESUMO
Appendiceal mucoceles are mainly due to cystadenoma or cystadenocarcinoma. Definite diagnosis is difficult preoperatively and is usually peroperatively. Surgical excision, either by laparoscopy or by laparotomy, is the mainstay of treatment. Rupture of the lesion causes pseudomyxoma peritonei. We present a case to highlight this point and especially deplore the use of laparoscopy if the tumor clearly extends beyond the appendix.
Assuntos
Neoplasias do Apêndice/cirurgia , Cistadenoma Mucinoso/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Idoso de 80 Anos ou mais , Neoplasias do Apêndice/diagnóstico por imagem , Cistadenoma Mucinoso/diagnóstico por imagem , Tomada de Decisões , Humanos , Laparoscopia , Laparotomia , Masculino , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVES: Surgical appraisal and revalidation are key components of good surgical practice and training. Assessing technical skills in a structured manner is still not widely used. Laparoscopic surgery also requires the surgeon to be competent in technological aspects of the operation. METHODS: Checklists for generic, specific technical, and technological skills for laparoscopic cholecystectomies were constructed. Two surgeons with >12 years postgraduate surgical experience assessed each operation blindly and independently on DVD. The technological skills were assessed in the operating room. RESULTS: One hundred operations were analyzed. Eight trainees and 10 consultant surgeons were recruited. No adverse events occurred due to technical or technological skills. Mean interrater reliability was kappa=0.88, P=<0.05. Construct validity for both technical and technological skills between trainee and consultant surgeons were significant, Mann-Whitney P=<0.05. CONCLUSIONS: Our study demonstrates that technical and technological skills can be measured to assess performance of laparoscopic surgeons. This technical and technological assessment tool for laparoscopic surgery seems to have face, content, concurrent, and construct validities and could be modified and applied to any laparoscopic operation. The tool has the possibility of being used in surgical training and appraisal. We aim to modify and apply this tool to advanced laparoscopic operations.
Assuntos
Competência Clínica/normas , Laparoscopia/normas , Adulto , Idoso , Colecistectomia Laparoscópica/normas , Ética Médica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Staple line bleeding (SLB) is a common intraoperative complication following resection in laparoscopic sleeve gastrectomy (SG). Opinion is divided on the best measure to deal with SLB which includes expensive reinforcement strategies, suturing the staple line or diathermy. Tranexemic acid is a relatively inexpensive drug known to reduce bleeding in trauma and surgery. The aim of this study was to evaluate whether intraoperative tranexemic acid reduces staple line bleeding. METHODS: In this prospective matched comparative study of SG, one cohort of patients was administered tranexemic acid (1 g) after induction and compared to a control group. The primary outcome compared the number of staple line bleeding points requiring intervention intra-operatively. Secondary outcomes included estimated blood loss and operating time. The anaesthetic and thromboprophylaxis protocols were uniform. Operative technique and stapling equipment were identical in all patients. RESULTS: Twenty-five patients were allocated to both the control and treatment arms. Patient characteristics in both groups were similar in age (median 34 vs 43 years), body mass index (median 54.7 vs 52 kg/m(2)), gender distribution (female:male = 20:5) and co-morbidities. The treatment group receiving tranexemic acid, required significantly less number of haemostatic stitches for staple line bleeding (19 vs 46, p < 0.05), incurred less intraoperative blood loss (p < 0.01) and had quicker operating times (median 66 vs 80 min, p < 0.05). There was no difference in morbidity or mortality in both groups. CONCLUSION: Intraoperative prophylactic tranexemic acid use is a simple and economical option for effectively reducing staple line bleeds leading to significant decrease in operating times.
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Antifibrinolíticos/uso terapêutico , Obesidade Mórbida/cirurgia , Hemorragia Pós-Operatória/prevenção & controle , Grampeamento Cirúrgico/métodos , Ácido Tranexâmico/uso terapêutico , Adulto , Antifibrinolíticos/administração & dosagem , Feminino , Gastrectomia/métodos , Humanos , Laparoscopia/métodos , Masculino , Estudos Prospectivos , Ácido Tranexâmico/administração & dosagem , Resultado do TratamentoRESUMO
A best evidence topic has been constructed using a described protocol. The three-part question addressed was: In morbidly obese patients undergoing bariatric surgery, when a ventral hernia is picked up in clinic or intraoperatively is concurrent repair of the hernia better than delayed repair after weight loss with regards to complication rates? Using the reported search, 179 papers were found. 5 studies were deemed to be suitable to answer the question. All 5 studies assessed were non randomised studies either retrospective or prospective and the overall quality of these studies was poor. The outcomes assessed were incidence of complications associated with hernia repair (recurrence, infection) and deferral of repair (small bowel obstruction). The patient's symptoms and anatomy is important in determining the timing of repair. The evidence does not provide a consensus for the optimal timing of ventral hernia repair for patients undergoing bariatric surgery, with some of the selected studies contradicting each other. However, the studies do affirm the risk of small bowel obstruction if hernias are left alone. The reported rate of surgical site infection is low when mesh repair is performed at the same time as weight loss surgery. Until large volume, high quality randomized control trials can be performed, a case by case approach is best, where the patients' symptoms, anatomy, type of bariatric surgery and their personal preferences are considered, and an open discussion on the risks and benefits of each approach is undertaken.
RESUMO
BACKGROUND: Recent attention has been directed at developing quantitative assessments of surgical skill. This study aims to demonstrate whether objectively measuring differences in manual dexterity has an impact on a simulated surgical procedure. METHODS: Six general surgical trainees performed 5 polytetrafluoroethylene graft to artery anastomoses on a vascular model by using a standardized technique. Manual dexterity was objectively measured with (1) electromagnetic motion analysis: trackers applied to the backs of hands recorded and analyzed both hand movements and procedural time and (2) 4-parameter evaluation of the final product. Outcome parameters were assessed by (1) rate of anastomotic leakage and (2) smallest cross-sectional area of the anastomosis. RESULTS: The 2 objective measures of manual dexterity correlated closely (Pearson coefficient, 0.423; P <.02). Trainees with better manual dexterity scores produced better outcome measures. Those with better motion analysis scores produced anastomoses that leaked less (Pearson coefficient, 0.514; P <.01) and those with higher global evaluation scores had a larger anastomotic cross-sectional area (Pearson coefficient, 0.495; P <.01). Time taken for the procedure did not appear to influence either outcome measure. CONCLUSIONS: There is a significant correlation between objective measures of manual dexterity and the outcome measures in this model. This suggests that the outcome of a procedure can be predicted by measuring surgical skill.
Assuntos
Prótese Vascular , Competência Clínica , Destreza Motora , Prótese Vascular/efeitos adversos , Humanos , Modelos Cardiovasculares , Politetrafluoretileno , Resultado do TratamentoRESUMO
This study was carried out to provide some evidence for the interruption of transmission of lymphatic filariasis (LF) among schoolchildren in Trinidad and Tobago. A cross-sectional survey for LF antigenaemia was performed among 63 (13.2%) of the 479 primary schools located in eight administrative (and geographical) regions of Trinidad and Tobago. From these communities, 2597 schoolchildren aged 6-12 years were sequentially selected for a survey of bancroftian antigenaemia. From each child, 100 microl (finger-prick) whole blood sample was applied to a Binax immunochromatographic card test (ICT), and read for the presence of antigenaemia. The ICT results showed a negative finding for LF antigenaemia and suggest that LF transmission has been interrupted in the survey areas.
Assuntos
Filariose Linfática/transmissão , Animais , Antígenos de Helmintos/sangue , Criança , Estudos Transversais , Filariose Linfática/sangue , Filariose Linfática/epidemiologia , Humanos , Trinidad e Tobago/epidemiologia , Wuchereria bancrofti/imunologiaRESUMO
BACKGROUND: Recent attempts to gain a more objective measure of surgical technical skill include the use of structured checklists and motion analysis of surgeons' hand movements. We aim to show whether a correlation exists between these two methods of assessment. METHODS: Fifty subjects were recruited from four experience groups in general surgery, ranging from basic surgical trainees to consultants and were assessed performing a standardized laboratory-based task. Motion analysis using the Imperial College Surgical Assessment Device (ICSAD), which measures hand movements and time taken, and the Objective Structured Assessment of Technical Skill (OSATS) technique were used to measure skill. RESULTS: Number of movements made, time taken, and global rating score discriminated between performance and experience group (Kruskal-Wallis, P <0.001, P <0.01, P <0.001, respectively). There was a significant correlation between movements made and global rating score (Spearman coefficient 0.53, P <0.01). Checklist scoring was not an accurate predictor of experience. CONCLUSIONS: There is a strong correlation between hand motion analysis using ICSAD and OSATS global rating assessments in this model.
Assuntos
Competência Clínica , Cirurgia Geral , Mãos/fisiologia , Movimento , Análise e Desempenho de Tarefas , Procedimentos Cirúrgicos Vasculares , Humanos , Destreza MotoraRESUMO
INTRODUCTION: Appendices epiploicae are affected by spontaneous torsion, calcification, primary or secondary inflammation, enlargement by lipomas or metastases and incarceration in hernias. CASE PRESENTATION: A 20-year-old Asian man was admitted with non-specific abdominal pain, which later evolved to intestinal obstruction. Operative findings showed the small bowel obstruction was due to an omental band adhered to a nodule. Histopathology of the nodule revealed an infarcted appendix epiploica. CONCLUSION: Heightened suspicion and increased awareness of this entity would have led to an earlier diagnosis. Acute torsion of an appendage usually manifests as localised abdominal pain in one of the lower quadrants. Untreated, peritonitis or intestinal obstruction may result. Use of diagnostic laparoscopy in non-resolving abdominal pain would help to resolve the issue at an earlier stage and prevent additional morbidity.
RESUMO
Laparoscopic stapling devices are used widely in laparoscopic surgery, for division of vessels and creation of anastomoses. Their use in the division of a widened cystic duct at laparoscopic cholecystectomy has been reported earlier. We present 3 different complications occurring after division of the cystic duct using the EndoGIA stapling device. A review of the literature has been performed and safe alternative techniques for laparoscopic ligation of the cystic duct are proposed.
Assuntos
Colecistectomia Laparoscópica/efeitos adversos , Ducto Cístico/cirurgia , Grampeamento Cirúrgico/efeitos adversos , Adulto , Idoso , Anastomose em-Y de Roux , Colangiopancreatografia Retrógrada Endoscópica , Colecistite/cirurgia , Coledocolitíase/cirurgia , Eletrocoagulação , Feminino , Humanos , Icterícia Obstrutiva/cirurgia , Masculino , Pessoa de Meia-Idade , Peritonite/etiologia , Peritonite/cirurgia , Reoperação , Fatores de Risco , SegurançaRESUMO
AIMS: Correct decision making is pivotal and an integral part of surgical competency. To date there has not been an attempt to assess surgeons making decisions whilst operating. In our present study we aim to assess operative decision making by trainee and expert surgeons by using hierarchical task analysis (HTA) as a method to map out decision making in surgery. METHODS: One hundred and forty live laparoscopic operations were prospectively analyzed, independently and blindly. The operations were compared to an operative HTA, and individual case reasons for deviations noted. Factors in the operating theatre which may influence the surgeons' decisions whilst operating were assessed using a checklist. RESULTS: One hundred and nineteen elective and 21 emergency laparoscopic operations performed by 12 consultants and 14 registrars were analysed. Factors from the HTA and theatre environment checklists were categorised. Inter-rater reliability was k=0.95, k=1.00 for sub-tasks and tasks, respectively, and 0.98 between the surgeon and independent observer for the operating theatre checklist. From these data sets a psychomotor surgical decision making model was constructed. Face and content validities of the model were verified by experts in surgery and decision making. CONCLUSIONS: Dynamic surgical decision making is a multi-faceted and intricate process. We have used HTA to map this process and we present a model in surgical decision making. By understanding the mechanisms and factors which influence this process we may use it for effective, focused surgical training. We aim to use and test our model also on open major complex surgery.
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Tomada de Decisões , Técnicas de Apoio para a Decisão , Laparoscopia , Adaptação Fisiológica , Córtex Cerebral/fisiologia , Competência Clínica , Comunicação , Emoções , Ergonomia , Ambiente de Instituições de Saúde , Humanos , Memória , Motivação , Destreza Motora , Salas Cirúrgicas/organização & administração , Estudos Prospectivos , Reprodutibilidade dos Testes , Assunção de Riscos , Sono , Percepção Espacial , Estresse Psicológico/complicações , Equipamentos Cirúrgicos , Instrumentos Cirúrgicos , Análise e Desempenho de Tarefas , Percepção VisualRESUMO
OBJECTIVE: To explore pesticide regulation in Trinidad and Tobago, and to ascertain pesticide utilization and retailers' selling practices on Trinidad, which is the larger of twin islands that constitute the republic of Trinidad and Tobago. METHODS: Between February and June 2005, agrochemical retailers in Trinidad were surveyed about the most frequently sold pesticides and their knowledge and practices of pesticide sale. The Poisons and Toxic Chemicals Control Board of the Ministry of Health informed on legislature. RESULTS: Of 107 actively trading licensed pesticide outlets, 97 participated (91% response rate) in the survey. Currently only 2.9% (21) of 720 registered products from four chemical classes are frequently utilized. Paraquat, methomyl, and alpha-cypermethrin (respective trade names are Gramoxone, Lannate, and Fastac) from World Health Organization (WHO) Hazard Classes I and II, and glyphosate isopropylamine (Swiper, Class U) are the most frequently purchased pesticides. Pet shops constitute 39.2% (38) of retail shops selling pesticides. No regulations guide pesticide sale to agriculturists, and children may purchase them. Inadequate human and technical resources render legislative controls ineffective and disciplinary action against offenders is weak. Extensive governmental resources are employed in legislative procedures and product approval for the very low, 2.9% utilization rate, negatively impacting on monitoring pesticide sales. The Poisons Information Centre (PIC) does not liaise with the Poisons and Toxic Chemicals Control Board or provide educational interventions for the community. As a result of this survey, it was possible to develop the first database to include the chemical, brand, and colloquial names of pesticides used in Trinidad and Tobago; WHO classification of approved pesticides; manufacturers; packaging; and antidotes and their availability for use by the Board and health professionals in Trinidad. CONCLUSIONS: Urgent critical evaluation of legislation regarding pesticide imports and use, and partnership with the Rotterdam Convention are recommended for Trinidad and Tobago. A strengthened Poisons Information Centre can provide educational initiatives and information on early management of pesticide exposure.
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Agricultura/legislação & jurisprudência , Comércio/legislação & jurisprudência , Praguicidas , Antídotos , Criança , Coleta de Dados , Regulamentação Governamental , Humanos , Entrevistas como Assunto , Praguicidas/intoxicação , Praguicidas/provisão & distribuição , Centros de Controle de Intoxicações , Trinidad e TobagoRESUMO
OBJECTIVE: This approach provides the basis of our research program, which aims to expand operative assessment beyond patient factors and the technical skills of the surgeon; to extend assessment of surgical skills beyond bench models to the operating theater; to provide a basis for assessing interventions; and to provide a deeper understanding of surgical outcomes. SUMMARY BACKGROUND DATA: Research into surgical outcomes has primarily focused on the role of patient pathophysiological risk factors and on the skills of the individual surgeon. However, this approach neglects a wide range of factors that have been found to be of important in achieving safe, high-quality performance in other high-risk environments. The outcome of surgery is also dependent on the quality of care received throughout the patient's stay in hospital and the performance of a considerable number of health professionals, all of whom are influenced by the environment in which they work. METHODS: Drawing on the wider literature on safety and quality in healthcare, and recent papers on surgery, this article argues for a much wider assessment of factors that may be relevant to surgical outcome. In particular, we suggest the development of an "operation profile" to capture all the salient features of a surgical operation, including such factors as equipment design and use, communication, team coordination, factors affecting individual performance, and the working environment. Methods of assessing such factors are outlined, and ethical issues and other potential concerns are discussed.
Assuntos
Salas Cirúrgicas/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Gestão da Segurança/normas , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Análise de Sistemas , Gestão da Qualidade Total/métodos , Cirurgia Geral/normas , Humanos , Salas Cirúrgicas/organização & administração , Avaliação de Processos e Resultados em Cuidados de Saúde/organização & administração , Equipe de Assistência ao Paciente/normas , Indicadores de Qualidade em Assistência à Saúde , Gestão da Segurança/organização & administração , Procedimentos Cirúrgicos Operatórios/normas , Análise e Desempenho de TarefasRESUMO
OBJECTIVE: The assessment of surgical technical skills has become an important topic in recent years. This study presents the validation of a 6-task skills examination for junior surgical trainees (at the level of the Membership of the Royal College of Surgeons). SUMMARY BACKGROUND DATA: Six tasks were evaluated in a project that also examined the feasibility of this method of assessment. The tasks were knowledge of sutures and instruments; knowledge of surgical devices; knot formation; skin-pad suturing, closure of an enterotomy; excision of a skin lesion; and laparoscopic manipulation. Comparisons were made between a group of junior trainees (n = 13), and a group of seniors (n = 8). RESULTS: Each of the 6 tasks was able to be used to discriminate between the 2 groups. In all, there were 19 primary analyses across the 6 tasks, and 17 of these showed significant differences between the groups (P values ranging from 0.037 to < 0.001). There was generally a strong correlation between the analyses, and when a mean rank was calculated, the difference between groups was significant (P = 0.005 on Mann-Whitney U test; mean ranks 13.9 and 6.3 [of 21], for juniors and seniors respectively). Reliability of the 6-task assessment was very good at 0.70 (Cronbach's Alpha). CONCLUSIONS: A skills examination is a feasible and effective method of assessing the technical ability of basic surgical trainees.