Development and validation of a training and assessment tool for laparoscopic radical nephrectomy. / Desarrollo y validación de una herramienta de entrenamiento y evaluación para la nefrectomía radical laparoscópica.

INTRODUCTION: Laparoscopic radical nephrectomy(LRN) is a cornerstone in managing renal cancer and small renal masses. Twenty-first century surgical training faces challenges, thus must be efficient and safe so surgeons attain relevant skills, protecting patients and operative outcomes. This study aimed to systematically develop a tool for training and assessment in LRN and validate the developed tool for use by trainee urologists. METHODS: This prospective, longitudinal, multi-institutional study was undertaken from September 2014 - June 2015. Healthcare Failure Mode and Effect Analysis was utilised for development and followed by validation where the assessment tool was distributed to five specialists to increase content validity. Four experts were observed as a multi-institutional approach. Hand-assisted, transperitoneal and retroperitoneal approaches were considered. RESULTS: The LRN Assessment Tool comprised four phases, 17 processes, 41 sub-processes. Four surgeons and operating teams were observed across four hospitals for 19.5hours (5.75h hand-assisted, 8.75h trans-peritoneal, 5h retro-peritoneal). After hazard analysis, three checklists were constructed. Those for hand-assisted LRN and transperitoneal LRN contained four phases, 20 processes, 33 sub-processes and that for retroperitoneal LRN contained four phases, 20 processes, 30 sub-processes. These were merged to form one assessment tool. The final result was a four phase LRN Assessment Tool with 17 processes, 41 sub-processes. All participants agreed the final LRN Assessment Tool included pertinent steps. CONCLUSIONS: The LRN Assessment Tool was developed using Healthcare Failure Mode and Effect Analysis risk analysis to ensure hazardous procedural sub-steps were included. Validation ascertained important processes were not overlooked. Full application through a pilot study must be undertaken.

Variations in outcomes for Indigenous women with breast cancer in Australia: A systematic review.

This systematic review examines variations in outcomes along the breast cancer continuum for Australian women by Indigenous status. Multiple databases were systematically searched for peer-reviewed articles published from 1 January 1990 to 1 March 2015 focussing on adult female breast cancer patients in Australia and assessing survival, patient and tumour characteristics, diagnosis and treatment by Indigenous status. Sixteen quantitative studies were included with 12 rated high, 3 moderate and 1 as low quality. No eligible studies on referral, treatment choices, completion or follow-up were retrieved. Indigenous women had poorer survival most likely reflecting geographical isolation, advanced disease, patterns of care, comorbidities and disadvantage. They were also more likely to be diagnosed when younger, have advanced disease or comorbidities, reside in disadvantaged or remote areas, and less likely to undergo mammographic screening or surgery. Despite wide heterogeneity across studies, an overall pattern of poorer survival for Indigenous women and variations along the breast cancer continuum of care was evident. The predominance of state-specific studies and small numbers of included Indigenous women made forming a national perspective difficult. The review highlighted the need to improve Indigenous identification in cancer registries and administrative databases and identified key gaps notably the lack of qualitative studies in current literature.

A systematic review of inequalities in psychosocial outcomes for women with breast cancer according to residential location and Indigenous status in Australia.

BACKGROUND: The aim of this systematic review was to examine variations in psychosocial outcomes by residential location and Indigenous status in women diagnosed with breast cancer (BC) in Australia. METHODS: Systematic searches were undertaken using multiple databases covering articles between 1 January 1990 and 1 March 2015 focusing on adult women with BC in an Australian setting and measuring quality of life (QOL), psychological distress or psychosocial support. RESULTS: Thirteen quantitative and three qualitative articles were included. Two quantitative and one qualitative article were rated high quality, seven moderate and the remaining were low quality. No studies examining inequalities by Indigenous status were identified. Non-metropolitan women were more likely to record lower QOL relating to breast cancer-specific concerns and reported a lack of information and resources specific to their needs. Continuity of support, ongoing care and access to specialist and allied health professionals were major concerns for non-metropolitan women. Non-metropolitan women identified unmet needs in relation to travel, fear of cancer recurrence and lack of psychosocial support. CONCLUSIONS: Overall, there was a lack of evidence relating to variations in psychosocial outcomes for women with BC according to residential status or Indigenous status. While the review identified some specific concerns for non-metropolitan women with BC, it was limited by the lack of good quality studies using standardised measures. Copyright © 2016 John Wiley & Sons, Ltd.

Comfort and learnability assessment of a new soft robotic manipulator for minimally invasive surgery.

Laparoscopic surgeons perform precise and time consuming procedures while holding awkward poses in their upper body and arms. There is an ongoing effort to produce robotic tools for laparoscopic surgery that will simplify these tasks and reduce risk of errors to help both the surgeon and the patient. STIFF-FLOP is an ongoing EU FP7 project focusing on this by creating a stiffness controllable soft robotic manipulator. This paper reports on a study to test the soft manipulator's learnability and the effort associated with its use. The tests involved a limited prototype of the manipulator with a custom built test rig and EMG acquisition system. Task times and video recordings along with EMG waveforms from the forearm muscles of participants (n=25) were measured for objective assessment. A questionnaire was also provided to the participants for subjective assessment. The data shows that in average EMG levels were 25.9% less in RMS when using the STIFF-FLOP arm than when conventional laparoscopic tools were used. In terms of learnability, from the first to the second attempt on the STIFF-FLOP manipulator, elapsed time was reduced by an average of 32.1%. Further details and analysis of the EMG signals as well as time and questionnaire results is presented in the paper.

Geographic remoteness and risk of advanced colorectal cancer at diagnosis in Queensland: a multilevel study.

BACKGROUND: We examine the relationships between geographic remoteness, area disadvantage and risk of advanced colorectal cancer. METHODS: Multilevel models were used to assess the area- and individual-level contributions to the risk of advanced disease among people aged 20-79 years diagnosed with colorectal cancer in Queensland, Australia between 1997 and 2007 (n=18,561). RESULTS: Multilevel analysis showed that colorectal cancer patients living in inner regional (OR=1.09, 1.01-1.19) and outer regional (OR=1.11, 1.01-1.22) areas were significantly more likely to be diagnosed with advanced cancer than those in major cities (P=0.045) after adjusting for individual-level variables. The best-fitting final model did not include area disadvantage. Stratified analysis suggested this remoteness effect was limited to people diagnosed with colon cancer (P=0.048) and not significant for rectal cancer patients (P=0.873). CONCLUSION: Given the relationship between stage and survival outcomes, it is imperative that the reasons for these rurality inequities in advanced disease be identified and addressed.

Urine cytology: appropriate usage maximizes sensitivity and reduces cost.

OBJECTIVE: Urine cytology is costly because of the skilled manpower required for analysis. Inappropriate requests are a significant drain both financially and on the cytopathologist's time. The present study aimed at identifying the extent and cause of this misuse and reduce it. METHODS: An audit of urine cytology usage was undertaken using the hospital results reporting system to identify requests. Patient case notes were then obtained to gain further clinical information. Initially a 2-week period was analysed, following which departmental guidelines for requesting urine cytology were produced and circulated. The audit loop was then closed. RESULTS: Over the initial 2-week period, 117 urine cytology requests were received. Thirty-three per cent were inappropriate, either because they were from patients with benign disease or because of duplication. Following the education programme this number fell to 6%. Expenditure on unnecessary samples thus decreased from pounds 2418 to only pounds 310, giving an annual overall saving of pounds 55,000. CONCLUSION: Significant cost and time savings can be made if urine cytology is sent appropriately. Simple guidelines and staff education are the key to reducing inefficiency. Our findings have implications not just for cytopathology costs but for laboratory and radiology requests in general.

The cost effectiveness of a nurse-led shared-care prostate assessment clinic.

OBJECTIVE: Nurse-led prostate clinics (NPCs) have proved to be a highly effective method of assessing patients with lower urinary tract symptoms (LUTS) and most urology units now run such clinics. However, it was not known whether they are cost-effective and this analysis ansWers that question. PATIENTS AND METHODS: During one year, a trained urology nurse assessed 1,080 patients in our NPC following GP referral using a standard pro forma. Costs included those incurred for the salary of a grade D nurse at 30 min per patient, all investigations, indirect charges and overheads. This was compared to the cost of seeing all patients in clinic directly, either by a consultant, staff grade urologist or registrar. Of these 1,080 patients, 350 were sent back to their GPs after NPC assessment. RESULTS: The NPC cost of 44.25 pounds per patient compared favourably with an average medical out-patient clinic cost of 50.46 pounds per patient, yielding an actual annual saving of 6,706.80 pounds. Since a third of the patients assessed in the NPC were sent directly back to primary care, saving the cost of a medical follow-up appointment, the true savings in secondary care were 17,661.00 pounds (50.46 x 350pounds), giving a total annual saving of 24,367.80 pounds. CONCLUSIONS: A nurse-led shared-care prostate clinic is a cost effective, thorough and speedy method of assessing men presenting with suspected bladder outflow obstruction. The approach used has a wider generic, cost-benefit potential for the NHS.

Ecology. The value of nature and the nature of value.

Ecosystems are capital assets: When properly managed, they yield a flow of vital goods and services. Relative to other forms of capital, however, ecosystems are poorly understood, scarcely monitored, and--in many important cases--undergoing rapid degradation. The process of economic valuation could greatly improve stewardship. This potential is now being realized with innovative financial instruments and institutional arrangements.

The economics of poverty in poor countries.

PIP: This paper, which examines recently studied links between 1) poverty, high fertility, and undernourishment and 2) environmental degradation and civic disconnection in developing countries, opens by reviewing the limitations of orthodox discussions of economic institutions and property rights and the orthodox dichotomy that has located the cause of poverty in the suppression of markets. The introduction also notes that much of the analysis in this paper is based on data from sub-Saharan Africa and India. The next section of the paper summarizes evidence on the magnitude and extent of world poverty. Section 3 exposes the connection between undernourishment and a person's capacity to work as one of the pathways to the poverty trap. Sections 4 and 5 consider the dependence of impoverished rural populations on common-property resources and how the conventional process of economic growth can break down this system and make certain sections of the population especially vulnerable to economic shocks. The next two sections explore the possibility that links between poverty, high fertility, and environmental degradation may constitute another pathway to the poverty trap. The eighth section reviews the methodology of using net national product (which includes resource depletion and environmental deterioration) as an evaluation criterion and argues that mainstream development economists may have neglected environmental and population problems because they have been relying on the wrong economic indices. The final section concludes that a number of policies must be used to improve options for people.^ieng

Population, consumption and resources: ethical issues.

PIP: This article offers several models that test concepts of optimum population and consumption: classical or utilitarian models, contractual models, and generation-relative ethical models. This article is based on a lecture presented in August 1995, at a conference organized by the Swedish Collegium for Advanced Study in the Social Sciences. It is posited that classical utilitarianism casts the optimum population and consumption problem as a Genesis Problem. The authors argue that the Genesis problem is the wrong problem to study because there are no actual people. The Genesis problem asks how many people there ought to be ideally at what living standards. The unborn are not a class of people, just as mud on a river bank is not a mud hut. Actual persons and potential persons are categorically different. Actual persons have a claim that potential persons do not have. An overall ethical ordering over alternatives can only be conceived for each generation of actual people. The ethical point of view inevitably changes over time. For example, a generation in the first period consumes what they are given to consume by the older generation. In the second period, the younger generation is now the older generation who decide how many children to have and how to share nonstorable, all purpose consumption goods among themselves and future generations. Procreation is a means of making one's values durable. Human development is unfair. Those who live later benefit from the labor of their predecessors without paying the same price. Procreation and ecological preservation are a matter of ethics.^ieng

A cross-sectional growth study of trunk and limb segments of the Bengali boys of Calcutta.

This report deals with cross-sectional growth of sitting height (SH), subischial length (SL, estimated as height minus sitting height), height of the anterior superior iliac spine (HIS), and total arm length (TAL) of Bengali school boys (Calcutta), aged 7.0-16.0 years. Preece-Baines model 1 (PB1) fits to the cross-sectional means of the four traits estimate the average ages at maximum increment at 12.41 years for SL, at 12.43 years for HIS, at 12.97 for TAL, and at 13.74 years for SH. Maximum increment of the upper and lower segment of the body are reached at an earlier age in the present study than in a longitudinal analysis of semi-urban Bengali boys from the suburban area of Calcutta. Socioeconomic differences and secular trend might explain this shift towards earlier maturation.

On the concept of optimum population.

PIP: The economic welfare of a community is affected by policies that determine both the rate of capital accumulation and the rate of growth of population. The optimum size of population at any point is time will depend on the size of the existing capital stock and the optimum rate of savings will depend on the existing number of people. Consequently, in this sense, a population policy cannot be developed without a concurrent savings policy. The criterion of optimality that will be used is the ma ximization of the total discounted welfare of all generations from now to infinity. The problem will be to select that rate of savings and that size of population at every moment which will achieve this maximum welfare if, in fact, a maximum exists. An inquiry is made into the existence of an optimum policy under various circumstances. An attempt is made to evaluate the consequences of various ethical beliefs.^ieng