Virtual reality simulation to enhance laparoscopic salpingectomy skills.

BACKGROUND: To assess skill enhancement and maintenance by virtual-reality simulation of laparoscopic salpingectomy in gynecologic surgery fellows. Skill acquisition by virtual-reality surgical simulation is an active field of research and technological development. Salpingectomy is one of the first gynecologic surgery techniques taught to fellows that requires accompanied learning. METHODS: A single-center prospective study was performed in the University of Lyon, France, including 26 junior fellows (≤ 3 semesters' internship) performing laparoscopic salpingectomy exercises on a LapSim® virtual reality simulator. Salpingectomy was performed and timed on 3 trials in session 1 and 3 trials in session 2, at a 3-month interval. Analysis was based on students' subjective assessments and a senior surgeon's objective assessment of skill. Progress between the 2 sessions was assessed on McNemar test and Wilcoxon test for matched series. RESULTS: 26 junior specialist trainees performed all trials. Most performed anterograde salpingectomy, both in session 1 (69 %) and session 2 (86 %). Mean procedure time was significantly shorter in session 2: 6.10min versus 7.82min (p=0.0003). There was a significant decrease in blood loss between the first trial in session 1 and the last trial in session 2: 167ml versus 70.3ml (p=0.02). Subjective assessment showed a significant decrease in anxiety and significant increase in perceived efficacy, eye-hand coordination and ergonomics. Efficacy, performance quality and speed of execution as assessed by the senior surgeon all improved significantly from trial to trial, while hesitation significantly decreased. CONCLUSIONS: The study showed that junior trainees improved their surgical skills on a short laparoscopic exercise using a virtual reality simulator. Virtual reality simulation is useful in the early learning curve, accelerating the acquisition of reflexes. Maintaining skill requires simulation sessions at shorter intervals.

What is the real impact of upper limb cast immobilisation on activity-related energy expenditure in children?

BACKGROUND: Upper limb fractures and subsequent cast immobilisation constitute a potential cause of reduction in childhood levels of physical activity (PA), with subsequent decrease of energy consumption. The main objective of this study was thus to quantify the decrease of activity-related energy expenditure (AEE) due to upper limb cast immobilisation. METHODS: We conducted a longitudinal matched case-control study that included 35 children and teenagers with a first episode of upper limb fracture and 35 healthy cases. PA was assessed during cast immobilisation by accelerometer. AEE was the calculated using an equation based on the total counts per day measured by accelerometers. RESULTS: AEE in children and teenagers with upper limb fractures was estimated to be 7.4 % lower than healthy controls. The mean difference corresponded to 1.35 kcal/kg per mean valid recorded time (750 min), that is, the waking hours. When converted in kcal per mean subjects' weight, the difference in AEE amounted 63.5 kcal/day, which corresponds approximately to 26 min of walking at a speed of 4 km/hours. In comparison with the mean AEE in healthy controls (18.2 kcal/kg), the noted decrease (1.35 kcal/kg) represents only 7.4 % of AEE. CONCLUSION: Reduction of AEE in children and teenagers with upper limb fractures may lead to a slight positive energy balance, as there is usually no compensatory reduction of energy intake. An increase of light PA has to be counselled in this situation or patients should be advised to reduce their energy intake during the immobilisation period. LEVEL OF EVIDENCE: Level I: high-quality prospective study (all patients were enrolled at the same point in their disease with ≥80 % follow-up of enrolled patients).

Activity-related energy expenditure during lower limb cast immobilization in children.

Physical inactivity, which may result from immobilization, is recognized as a risk factor for the development of obesity. We aimed to quantify the decrease in activity-related energy expenditure (AEE) because of lower limb cast immobilization. We carried out a longitudinal matched case-control study: 34 adolescents with a first episode of lower limb fracture and 34 healthy cases. Physical activity was assessed during cast immobilization by an accelerometer from which we calculated the decrease in AEE. AEE in adolescents with lower limb fractures was estimated to be 16.0% lower than healthy controls. When converted into kcal per mean participants' weight, the difference in AEE amounted to 125 kcal/day, which corresponds to 5.2 h of slow walking. A significant reduction of AEE in adolescents with lower limb fractures may lead to a significantly positive energy balance as there is usually no compensatory reduction of energy intake. An increase of walking seems unrealistic in this situation and patients should be advised at the emergency unit to reduce their energy intake during the immobilization period. LEVEL OF EVIDENCE: Level III, prospective case-control study.

Assessment of muscular performance in teenagers after a lower extremity fracture.

BACKGROUND: Deleterious effects of lower limb immobilization in adults have been well described and suggest that altered muscle strength was not fully recoverable after rehabilitation. In this study, we hypothesized that the same significant differences in strength and power performances between the injured and noninjured leg are foreseeable 18 months after a lower limb fracture in teenagers, and between injured adolescents and healthy controls. METHODS: The effects of cast immobilization on the strength and power performance were evaluated 18 months after a lower limb fracture in 39 injured teenagers who were paired with healthy controls. Strength and power performance were assessed during a single-leg vertical jump test using a force platform. RESULTS: At 18 months, strength performance in injured teenagers was similar in both lower limbs. A significant difference was found between injured and noninjured legs for maximal muscular power measurement. However, the limb symmetry index was superior to 85% for maximal muscular power, which should be considered as normal. Limb asymmetries greater than 15% for muscular strength and power were more frequent in injured teenagers than in noninjured children and adolescents, but the difference was statistically significant only for the mean muscle power (P=0.0003). CONCLUSIONS: These findings show that the recovery of muscular strength and power is foreseeable after a lower limb fracture in the pediatric population, even if a greater percentage of injured teenagers was found to have limb asymmetries greater than 15% for mean muscular power 18 months after trauma compared with the healthy controls. LEVEL OF EVIDENCE: Level III, case-control study.

French claims data as a source of information to describe cancer incidence: predictive values of two identification methods of incident prostate cancers.

Claims data from the "Programme de Médicalisation du Système d'Information" (PMSI) have been commonly used for several years to complement cancer registries and describe cancer incidence in France. It is less clear whether or not it is possible to use these data as an independent source of information to assess cancer incidence, in the absence of a regional cancer registry. Following a similar study on breast cancer, we present a study which aimed to evaluate two methods of identifying incident prostate cancer using claims data. These methods were developed using claims data from the Hospices Civils de Lyon (HCL) and their validity was tested against medical records. The first method (M1) identified incident patients as those who had at least one stay with a principal diagnosis of prostate cancer. The second method (M2) had a prostate cancer treatment code in addition to the criteria for the first method. Both methods of identification had similar results, indicating a low rate of false negatives (negative predictive values: M1 = 100 [CI95: 93.8-100], M2 = 98.6 [CI95: 90.1-99.6]) and a high rate of false positives (positive predictive values: M1 = 33.3 [CI95: 23.2-42.1], M2 = 33.7 [CI95: 24.2-43.2]). The sample size did not allow us to produce consistent estimates of sensitivity and specificity. Our results showed that an estimation of the number of incident cases of prostate cancer using both methods of identification would be biased because of the high rate of false positives. Statistical methods that correct identification errors should be used.