Delayed closure of a full-thickness macular hole following pars plana vitrectomy with ILM flap.

PURPOSE: Our aim is to describe a patient with delayed closure of a stage 3 full thickness macular hole after pars plana vitrectomy. METHODS: A retrospective case report. Details of the case were obtained from the electronic patient record system, Medisoft. RESULTS: A 65-year-old male was referred with a left stage 3 full thickness macular hole measuring 720 microns and visual acuity of 6/36. He underwent phaco-vitrectomy, ILM peel with an inverted ILM flap and C3F8 gas tamponade. 7 weeks after surgery, the macular hole was smaller at 196 microns but remained open. The patient was listed for repeat surgery, however another 13 weeks later the full thickness macular hole demonstrated type 2 closure without further intervention. DISCUSSION/CONCLUSION: Delayed macular hole closure after pars plana vitrectomy is rare. In cases where there has been a substantial decrease in the size of a full thickness macular hole after surgery without full closure, a short period of observation to allow for further closure may be appropriate before reconsidering surgery.

Dimensionless squared jerk: An objective differential to assess experienced and novice probe movement in obstetric ultrasound.

OBJECTIVE: Widely accepted, validated and objective measures of ultrasound competency have not been established for clinical practice. Outcomes of training curricula are often based on arbitrary thresholds, such as the number of clinical cases completed. We aimed to define metrics against which competency could be measured. METHOD: We undertook a prospective, observational study of obstetric sonographers at a UK University Teaching Hospital. Participants were either experienced in fetal ultrasound (n = 10, >200 ultrasound examinations) or novice operators (n = 10, <25 ultrasound examinations). We recorded probe motion data during the performance of biometry on a commercially available mid-trimester phantom. RESULTS: We report that Dimensionless squared jerk, an assessment of deliberate hand movements, independent of movement duration, extent, spurious peaks and dimension differed significantly different between groups, 19.26 (SD 3.02) for experienced and 22.08 (SD 1.05, p = 0.01) for novice operators, respectively. Experienced operator performance, was associated with a shorter time to task completion of 176.46 s (SD 47.31) compared to 666.94 s (SD 490.36, p = 0.0004) for novice operators. Probe travel was also shorter for experienced operators 521.23 mm (SD 27.41) versus 2234.82 mm (SD 188.50, p = 0.007) when compared to novice operators. CONCLUSION: Our results represent progress toward an objective assessment of technical skill in obstetric ultrasound. Repeating this methodology in a clinical environment may develop insight into the generalisability of these findings into ultrasound education.

A study to assess knowledge and acceptability of foetal surgery for spina bifida amongst healthcare professionals in the UK.

Foetal surgery to repair open spina bifida before birth improves infant motor function and reduces ventriculoperitoneal shunt requirement. Alongside the development of the first UK foetal surgery service, we surveyed the knowledge and acceptability of this treatment to healthcare professionals in the UK and Ireland via an electronic questionnaire. Ninety-eight (98) responses were received: MFM clinicians (21), midwives (20), paediatric neurosurgeons (17), obstetricians (15), neonatologists (13), theatre nurses (11) and commissioners (1). Overall 70% of responders agreed with the concept that foetal surgery improved neonatal outcome in selected cases; although, only 41% of paediatric neurosurgeons agreed. A variety of concerns were expressed, the most common being the lack information regarding mid- to long-term effects on the child and mother.In offering this new service, it is important that we are cognisant of healthcare professional concerns and address them by applying internationally accepted criteria for foetal surgery, emphasising patient choice and collecting long-term data.Impact statementWhat is already known on this subject? Foetal surgery is a potentially controversial intervention, which is increasing in availability globally. Foetal surgery is now available in the UK on a charitable-funding basis. Prior to starting a UK foetal surgery service, we assessed the attitudes and knowledge of healthcare professionals in the UK towards this new surgery.What the results of this study add? Overall the majority of healthcare professionals agree with the concept that foetal surgery improves neonatal outcome in selected cases, but a variety of concerns exist, the most common being the lack of information regarding mid- to long-term effects on the child and mother. Other concerns included a lack of education, training and research; the specific risk of preterm birth following surgery; the evidence base for this procedure; effects on maternal choice and financial implications.What the implications are of these findings for clinical practice and/or further research? Those developing this new service should be mindful of the concerns expressed and address them by applying internationally accepted criteria for foetal surgery, emphasising patient choice and collecting long-term data.

Construct validity of cadaveric temporal bones for training and assessment in mastoidectomy.

OBJECTIVE: To determine the construct validity of cadaveric temporal bones in mastoidectomy training. STUDY DESIGN: A prospective observational study. METHODS: Trainees from the North London otolaryngology training program performed step-wise modified radical mastoidectomy on cadaveric temporal bones under faculty supervision. Performance was assessed using a validated mastoidectomy assessment tool. A longitudinal assessment of nine trainees was also carried out over two sessions separated by 12 months. The main outcomes measures were task-specific (TS) and global skills (GS). RESULTS: Twenty-six intermediate and eight novice trainees participated and were assessed by a minimum of two assessors each. Intermediate trainees performed significantly better than novices in TS and GS (P < 0.001). Performance correlated well with training level using Spearman rank correlation coefficient (r(s)) (TS r(s) 0.265 and GS r(s) 0.503). The number of otological procedures performed, and in particular mastoidectomies, correlated well with performance (TS r(s) 0.327 and GS r(s) 0.528). Longitudinal assessment showed significant improvement with iteration (TS P = 0.008 and GS P = 0.008). Attending otological courses also improved performance significantly (TS r(s) 0.345 and GS r(s) 0.469). CONCLUSIONS: The cadaveric temporal bone demonstrated construct validity and can be used to detect progress in performance of otolaryngology trainees. This is a keystone in moving toward a competency-based training system. LEVEL OF EVIDENCE: N/A.

Feasibility of a synthetic temporal bone for training in mastoidectomy: face, content, and concurrent validity.

OBJECTIVE: To investigate the face, content, and concurrent validity of the synthetic Pettigrew temporal bone (PTB) for mastoidectomy training as compared with cadaveric temporal bone (CTB). STUDY DESIGN: A prospective evaluation study. METHODS: Participants were invited to perform a step-by-step modified radical mastoidectomy using both bones and complete a 22-item, 5-point Likert scale questionnaire. The questionnaire is divided into 4 domains: face validity (FV), global content (GC), task-specific content (TSC), and curriculum recommendation (CR). RESULTS: Thirty-six experts and 89 trainees completed all tasks, 63 using CTB and 62 using PTB. The PTB median FV was 4 (IQR: 4-5), GC of 4 (IQR: 4-5), TSC of 4 (IQR: 3-4), and CR of 4 (IQR: 4-5). The CTB was rated significantly higher than PTB by both groups in all domains; CTB FV: 5 (IQR: 4-5), GC: 5 (IQR: 4-5), TSC: 5 (IQR: 4-5), and CR: 5 (IQR: 5-5), p < 0.001 for each. Trainees rated PTB significantly higher than experts in all domains. There was no statistically significant difference between experts and trainees in rating the CTB in all domains. PTB gives similar haptic feedback to CTB, allows the use of suction and irrigation, has the important landmarks painted for identification, and contains articulating ossicles. The facial nerve anatomy was found to be inaccurate around the region of the second genu. CONCLUSION: Participants found PTB to be valid for teaching some, yet not all, aspects of mastoid surgery, and experts agreed that it could improve global transferrable otologic skills. It is essential that the facial nerve anatomy is addressed before recommending this model.