Training value of laparoscopic colorectal videos on the World Wide Web: a pilot study on the educational quality of laparoscopic right hemicolectomy videos.

INTRODUCTION: Instructive laparoscopy videos with appropriate exposition could be ideal for initial training in laparoscopic surgery, but unfortunately there are no guidelines for annotating these videos or agreed methods to measure the educational content and the safety of the procedure presented. Aim of this study is to systematically search the World Wide Web to determine the availability of laparoscopic colorectal surgery videos and to objectively establish their potential training value. METHODS: A search for laparoscopic right hemicolectomy videos was performed on the three most used English language web search engines Google.com, Bing.com, and Yahoo.com; moreover, a survey among 25 local trainees was performed to identify additional websites for inclusion. All laparoscopic right hemicolectomy videos with an English language title were included. Videos of open surgery, single incision laparoscopic surgery, robotic, and hand-assisted surgery were excluded. The safety of the demonstrated procedure was assessed with a validated competency assessment tool specifically designed for laparoscopic colorectal surgery and data on the educational content of the video were extracted. RESULTS: Thirty-one websites were identified and 182 surgical videos were included. One hundred and seventy-three videos (95%) detailed the year of publication; this demonstrated a significant increase in the number of videos published per year from 2009. Characteristics of the patient were rarely presented, only 10 videos (5.4%) reported operating time and only 6 videos (3.2%) reported 30-day morbidity; 34 videos (18.6%) underwent a peer-review process prior to publication. Formal case presentation, the presence of audio narration, the use of diagrams, and snapshots and a step-by-step approach are all characteristics of peer-reviewed videos but no significant difference was found in the safety of the procedure. CONCLUSIONS: Laparoscopic videos can be a useful adjunct to operative training. There is a large and increasing amount of material available for free on the internet, but this is currently unregulated.

The straight to test endoscopy service for suspected colorectal cancer: meeting national targets but are we meeting our patients' expectations?

AIM: The NHS Cancer Plan describes initiatives to improve patient care in the UK, including the two-week rule cancer referral pathway. To meet this target a straight to test (STT) endoscopy service was devised to expedite diagnosis of suspected colorectal cancer. Our novel study aimed to determine patient satisfaction with this new approach to rapid access investigation. METHOD: An anonymized questionnaire was posted to 300 patients who had undergone STT endoscopy in our unit between January and June 2010. It assessed satisfaction with the service overall, time from referral to investigation, pre-test information, bowel preparation instructions and time to results as well as preference for a traditional pre-test or post-test outpatient appointment and awareness that the referral was for suspected bowel cancer. RESULTS: In all, 174 questionnaires were obtained (58% yield; mean age 68.8; 44.8% men). 82.2% of patients were 'very satisfied' with the service overall, 82.8% with time from referral to test, 75.2% with time from test to results, 73% with endoscopy information and 69.5% with bowel preparation instructions. Eight per cent would rather have seen a specialist prior to endoscopy, 31.6% would have preferred a post-test appointment and 68.4% of patients were aware that referral was for suspected bowel cancer. CONCLUSION: Straight to test is popular with patients. It offers a fast and cost effective service in the diagnosis of colorectal cancer and meets national targets whilst reducing the volume burden on outpatient clinics. However, its success heavily relies on accurate communication between general practitioner, patient and secondary care.

Patients' understanding of medical terminology used in the breast clinic.

This study evaluated patients' understanding of common terms used by breast surgeons in order to identify words which may need to be defined and explained during a clinic consultation. 95 patients completed the survey. 87% defined 'Surgeon' correctly whereas 'Radiographer' and 'Radiologist' were correctly defined by only 19% and 28% respectively. 26% correctly defined 'Pathologist' and 43% 'Oncologist'. Two-thirds of patients correctly defined 'Benign' (66%) and 'Malignant' (65%). 'Mammogram' and 'Ultrasound' were correctly defined by 39% and 8% respectively. 21% of patients correctly defined 'Multi-Disciplinary Team Meeting'. 1 in 5 patients correctly defined 'Chemotherapy' (20%) and 'Radiotherapy' (19%). This study has identified that many of the medical terms used in a consultation are not understood by patients. Education must be incorporated as a routine part of the consultation to enhance the patient experience and ensure they can actively participate in making informed decisions about their care.

Intravitreal injection of fibroblasts: the pathological effects on the ocular tissues of the rabbit following an intravitreal injection of autologous skin fibroblasts.

The intravitreal injection of autologous cultured fibroblasts has been used by many groups to study proliferative vitreoretinopathy. Ninety-five New Zealand white rabbits were used to study the pathological effects on the ocular tissues following such an injection over various time periods up to six months. The ocular tissues were studied by light microscopy, electron microscopy, immunohistochemistry, and autoradiography. The cells which contributed to the inflammatory response (initially neutrophils, then later macrophages and lymphocytes) were found to gain entry into the vitreous via the pars plana, pars plicata, and the vessels associated with the optic nerve head. In the experimental eyes the detached retinae had a reduced ability to incorporate 3H proline. Both epiretinal and subretinal membranes were found on the retinal surfaces. The majority of the glial cells within the membranes were identified as Müller cells. The retinal pigment epithelium beneath the detached retinae incorporated 3H thymidine and detached into the subretinal space. Clear evidence was obtained of both epithelial cell migration through the retina and involvement within epiretinal membranes.

Shape changes produced in detergent extracted bovine retinal pigment epithelium when exposed to ATP. A comparison with fibroblasts and smooth muscle cells.

The response of single detergent treated bovine retinal pigment epithelial cells in culture to ATP was measured with an image analyser. The most pronounced contraction was produced by 1.0 mM ATP with most change taking place in the first 10 min. At 1 h the area had decreased by about 33%, perimeter 22% and maximum length 25%. By way of comparison rabbit skin fibroblasts had a decreased area of approximately 40%, perimeter 25% and maximum length 22%. Bovine aortic smooth muscle cells on the other hand decreased in area by 55%, perimeter 40% and maximum length 36%. It is hoped that this assay may be used to evaluate drugs which could counteract contractile events in proliferative vitreoretinopathy.

Human retinal pigment epithelial cells in the vitreous of the owl monkey.

Cultured human retinal pigment epithelium was injected into the vitreous of owl monkeys. The epithelial cells were derived from either a foetal or an adult cell line. The five monkeys which were injected with cultured foetal cells developed substantial vitreal membranes and had retinal detachment by 2 weeks, whereas the five monkeys with cultured adult cells did not develop detachments within the period of investigation, and vitreal membranes were insubstantial. An electron-microscopic, immunohistochemical and autoradiographic study was conducted on these eyes to investigate in detail the behaviour and intraocular effects of the injected cells.

Investigations of cytoskeletal elements in cultured bovine meshwork cells.

An ultrastructural, immunohistochemical, and functional study was conducted on cultured bovine meshwork cells. Particular emphasis was placed on the organization of the cytoskeleton, and the cells were viewed either as whole cells or following detergent extraction. For ultrastructural examination, several modes of viewing were adopted, including a detector situated above the specimens collecting secondary electrons (SE), a detector situated beneath the specimen collecting transmitted electrons (STEM), and conventional transmission electron microscopy at 100 KV (TEM). In whole cell mounts, information was obtained about the organization of the cytoskeleton and its relationship to other cytoplasmic organelles. Extraction procedures removed much of the plasma membrane and most organelles. The nucleus and cytoskeleton remained and stress fibers were prominent. Immunohistochemistry showed that the actin content of the cytoskeleton could be preserved after detergent extraction. Detergent-extracted cells decreased their surface area when exposed to MgATP in a dose-dependent manner. The decrease in surface area was associated with disassembly of cytoskeletal stress fibers and was optimal with 1 mM MgATP. Whether or not the change in surface area could be considered a "contractile event" was discussed.

Contraction of scar tissue in the rabbit vitreous.

Sheets of vitreous membrane (scar tissue) and associated retinal detachment were produced in the right eye of 86 adult New Zealand white rabbits by intravitreal injection of cultured autologous skin fibroblasts. The membranes were examined by light and electron microscopy and time-lapse cinephotomicrography. Immunohistochemistry was used to demonstrate alterations in the distribution of cytoplasmic contractile proteins. While retinal detachment and membrane contraction were taking place, there was pronounced increase in the numbers of fibroblasts with an elongated spindle shape. These spindle-shaped cells had some similarities to myofibroblasts including the presence of 'stress cables'. However, the myofibroblast-like cells stained much less avidly for cytoplasmic (actin) microfilaments than migratory fibroblasts seen at early stages of membrane development. The significance of migrating fibroblasts and myofibroblasts in scar contraction is discussed.

Experimental scar membranes in the rabbit's vitreous. An autoradiographic and quantitative morphological study.

A morphological and autoradiographic assessment was made of scar tissue development in an experimental rabbit model of proliferative vitreoretinopathy which involves the intravitreal injection of cultured autologous skin fibroblasts. Within a few hours after injection as many as 40% of the cultured cells had autolysed. However, the remaining cells proliferated and formed membranes. The incorporation of [3H] thymidine was maximal at 1 week. Between 2 and 4 weeks spindle-shaped myofibroblasts were prominent, and this form of fibroblast has been considered to have an important role in scar tissue contraction. At the end of 4 weeks it was noted that all eyes had developed retinal detachments. Subsequently the membranes became progressively more fibrous and lipid-like material accumulated in the cytoplasm of many cells. The findings were discussed in relation to the use of this model to test the effectiveness of various drugs which may be of value in the treatment of proliferative vitreoretinopathy.

The effects of injections of cultured fibroblasts into the rabbit vitreous.

A comparison was made between rabbit's eyes which had an intravitreal injection of either 400,000 autologous or homologous skin fibroblasts. The follow-up period was up to 6 months with autologous and 10 weeks with homologous cells. The evaluation involved the clinical assessment of membrane formation, retinal detachment and anterior segment inflammation. In addition, a detailed histological, electron microscopic and autoradiographic study was made of membrane development and changes in the surrounding tissue. Clinical evaluations revealed little difference between the two models. However, on the basis of macroscopic and microscopic examination, homologous cells produced more extensive detachments and more pronounced retinal gliosis. Plasma cells were evident in the choroid 6 weeks after homologous fibroblast injection, but they were not associated to any appreciable extent with the autologous model. Fibrovascular proliferation from around the optic nerve head made a major contribution to the formation of membranes in the experiments with homologous fibroblasts but not those using the autologous cells.

Epiretinal membranes in vitro.

Monolayers of cells were grown from epiretinal membranes using standard tissue culture techniques. The growing cells were filmed by time-lapse cinephotomicrography to record their locomotory characteristics and cell-to-cell interactions. The established layers of cells were examined in the scanning electron microscope. In addition, the cultured cells were studied immunohistochemically to identify specific cell types and the distribution of contractile elements (e.g. actin). The locomotory patterns, the topography and the immunohistochemistry of cells from epiretinal membranes were compared to the movement, appearance and staining characteristics of a wide range of normal cells in culture. From the growth characteristics in tissue culture, early membranes appeared more hypercellular than longer standing membranes. Cell outgrowth was established more quickly and was more widespread in the young epiretinal membranes than in older, more fibrous, specimens. The locomotory and immunohistochemical studies demonstrated that a wide variety of cell types may contribute to epiretinal membranes. A remarkably wide range of cell forms were observed in cultures of individual membranes. Epithelial and glial cells were found in many of the monolayers. However, they did not constitute the majority of cells in the cultures. The predominating cell types had the morphological and locomotory characteristics of fibroblasts or macrophages.