Development of a valid, cost-effective laparoscopic training program.

BACKGROUND: Practical programs for training and evaluating surgeons in laparoscopy are needed to keep pace with demand for minimally invasive surgery. METHODS: At the University of Kentucky five inexpensive simulations have been developed to train and assess surgical residents. Residents are videotaped performing laparoscopic procedures on models. Five surgeons assess the taped performances on 4 global skills. RESULTS: Creating mechanical models reduces training costs. Trainees agreed procedures were well represented by the simulations. Blinded assessment of performances showed high interrater agreement and correlated with the trainees' level of experience. Nonclinician evaluations on checklists correlated with evaluations by surgeons. CONCLUSIONS: Inexpensive simulations of laparoscopic appendectomy, cholecystectomy, inguinal herniorrhaphy, bowel enterotomy, and splenectomy enable surgical residents to practice laparoscopic skills safely. Obtaining masked, objective, and independent evaluations of basic skills in laparoscopic surgery can assist in reliable assessment of surgical trainees. The simulations described can anchor an innovative educational program during residency for training and assessment.

Determinants of competency judgments by experienced laparoscopic surgeons.

BACKGROUND: The definitive criteria for assessing competence remain elusive. In our study, we aimed to identify the determinants of competence assessment used by individual laparoscopic surgeons. METHODS: In a blinded fashion, five laparoscopic surgeons rated 27 subjects on three laparoscopic simulations in four skill categories: clinical judgment, dexterity, serial/simultaneous complexity, and spatial orientation. The raters then assessed overall subject competence for each procedure. Point-biserial correlational analyses and cluster analyses were performed to ascertain the relationships among the various scales. RESULTS: All of the correlations between the skills' ratings and competence judgments were statistically significant ( p <.05). No skill rating was consistently more highly correlated with the competence rating. There were no distinct patterns of correlations for each rater or each procedure. One factor emerged from each cluster analysis of the skills measures. CONCLUSIONS: The results suggest that the four skills scored in the study are highly correlated with each other and are important in determining competence. The cluster analyses revealed that the surgeon raters shared a common perception of competence.

Using immersive VR as a tool for preoperative planning for minimally invasive donor nephrectomy.

For surgeons approaching minimally invasive donor nephrectomy it is important to identify variant anatomy preoperatively since this anatomy can vary significantly from patient to patient. The goal of this operation is to preserve the architecture and function of the organ so it can be transplanted and function successfully. The ability of the surgeon to navigate through an individual patient's anatomy in a virtual three-dimensional (3D) immersive environment augments understanding of anatomical relationships particular to that individual patient and facilitates conveying that information to other physicians and students. Utilizing automated 3D reconstruction of high contrast computed tomography (CT) scan files viewed in this way, surgeons reported a better preoperative understanding of the anatomical variations and encountered fewer surprises at the time of surgery.

Immersive virtual reality used as a platform for perioperative training for surgical residents.

Perioperative preparations such as operating room setup, patient and equipment positioning, and operating port placement are essential to operative success in minimally invasive surgery. We developed an immersive virtual reality-based training system (REMIS) to provide residents (and other health professionals) with training and evaluation in these perioperative skills. Our program uses the qualities of immersive VR that are available today for inclusion in an ongoing training curriculum for surgical residents. The current application consists of a primary platform for patient positioning for a laparoscopic cholecystectomy. Having completed this module we can create many different simulated problems for other procedures. As a part of the simulation, we have devised a computer-driven real-time data collection system to help us in evaluating trainees and providing feedback during the simulation. The REMIS program trains and evaluates surgical residents and obviates the need to use expensive operating room and surgeon time. It also allows residents to train based on their schedule and does not put patients at increased risk. The method is standardized, allows for repetition if needed, evaluates individual performance, provides the possible complications of incorrect choices, provides training in 3-D environment, and has the capability of being used for various scenarios and professions.

Pediatric health care and management.

Pediatric health care is an integral part of providing for the general health needs of puppies and kittens from birth to 6 months of age. Successful rearing of puppies and kittens requires providing them with a suitable environment; the correct quantities and quality of nutrients for growth; a regular schedule of feeding, sleeping, grooming, and exercise; and the stimulus that provokes micturation and defecation. The intestinal parasites, such as hookworms, roundworms, whipworms, tapeworms, Giardia, and Cryptosporidium, occur commonly in puppies and kittens. The advantages of early-age spay/neuter far outweight the risks.

Feline respiratory diseases.

Respiratory diseases in kittens can quickly result in life-threatening emergencies if not identified and managed early. Congenital anomalies of young cats are extremely uncommon. Viral respiratory infections in the cat are primarily caused by feline herpesvirus type 1 and feline calicivirus. Primary bacterial respiratory infections occur sporadically in cats. Bordetella bronchiseptica may cause severe respiratory signs in young kittens.

Isolation and characterization of Bordetella bronchiseptica from cats in southern Louisiana.

The role of Bordetella bronchiseptica in respiratory disease of domestic cats is currently being explored. Clinical and experimental studies in the United Kingdom have shown Bordetella bronchiseptica to be a primary respiratory pathogen in cats; similar studies in the United States are limited. The purpose of this study is to report on the isolation, seroprevalence, and partial characterization of Bordetella bronchiseptica from shelter cats in southern Louisiana. A total of 614 cats from four local shelters were studied. All cats appeared to be asymptomatic for signs of respiratory disease. Bordetella bronchiseptica was isolated in 19/614 (3.1%) cats by oropharyngeal swab and in 6/614 cats by bronchial lavage. Using an antibody capture ELISA method, 148/614 (24.1%) cats were seropositive for Bordetella bronchiseptica. The 25 isolates of Bordetella bronchiseptica were further characterized by ribotype analysis, and a total of 17 different ribotypes were identified. Specific pathogen-free kittens were experimentally infected with five of the isolates, and four of the five isolates induced clinical signs typical of feline bordetellosis. It is concluded that Bordetella bronchiseptica is present in the cat population in southern Louisiana, the organism can be isolated from asymptomatic cats, some of these isolates can produce disease in specific pathogen-free kittens, and that Bordetella bronchiseptica isolates from cats in a relatively small geographic area are genetically diverse. This and other studies indicate that Bordetella bronchiseptica should be considered in cases of feline respiratory disease.

Geriatric care in the late 1990s.

Geriatric health care remains a virtually untapped area in spite of changing public views and scientific knowledge on aging. The number of older dogs and cats will continue to grow into the next century. Owners of older dogs and cats are willing to invest in quality health care services. A geriatric health care program can expand veterinary services in a practice and is a natural extension of pediatric and adult maintenance programs.

Musculoskeletal system. Joint and vertebral column diseases.

Owner complaints that refer to the musculoskeletal system are common in older dogs and cats. When the veterinarian is presented with these types of complaints, the differential lists include chronic intervertebral disk disease, diskospondylitis, degenerative joint disease, spondylosis with nerve root compression, joint/ ligament instability, and/or cancer. The diagnosis and management of some of these conditions is presented in detail with the general goal in mind that the older dog or cat is provided the best quality of life possible through good mobility along with being pain free.

Feline neonatal sepsis.

When bacterial infections exceed or overcome the ability of a kitten's immune system to provide protection, life-threatening illnesses such as neonatal sepsis often occur. Many kittens with neonatal sepsis show unusual presentations or a wide variety of clinical presentations that may not be immediately recognized as being associated with sepsis. Because neonatal sepsis causes unexpected sudden death, kittens suspected of having sepsis should be treated immediately. In most instances, initial antimicrobial therapy is selected empirically. Kittens are treated by giving intravenous or intraosseous fluids for dehydration, oxygen to counter tissue hypoxemia, and glucose if hypoglycemia is present. The beta-lactam antimicrobial agents such as the penicillins, cephalosporins, and the combination of beta-lactam antimicrobials and beta-lactamase inhibitors are considered to be the first choice in the treatment of any septicemic kittens.

Coronavirus infection in cats.

Cats are susceptible to natural infection with several strains of feline coronavirus that may result in either effusive and noneffusive FIP disease or in subclinical to severe enteritis. Investigators are still unsure of the routes by which strains of coronavirus are transmitted between cats. Excretion of coronavirus by infected cats into the environment occurs by way of feces, oronasal secretions, and, possibly, urine. FIP coronavirus remains stable outside the host for as long as 3 to 7 weeks and is rapidly inactivated by most household disinfectants. Clinical diagnosis of coronavirus infection is made by evaluating the presenting history, physical findings, laboratory results, coronavirus antibody titers, and by excluding analogous disease. The presence of coronavirus antibodies can be used to screen cats for the presence of coronavirus infection and as an adjunct in diagnosing clinical coronavirus infection. A intranasal TS-FIPV vaccine that protects against natural coronavirus challenge is available for healthy cats 16 weeks of age or older.

Germfree technique for the rearing of kittens--a research tool.

Techniques to derive and rear germfree kittens (Felis catus) for biomedical research were explored and refined. The isolator units, equipment, sterilization procedures, husbandry techniques, and safety issues are discussed. This method proved to be successful for the surgical derivation and hand-rearing of germfree kittens.

Tick-borne zoonoses: Lyme disease, ehrlichiosis, and Rocky Mountain spotted fever.

The primary health risk for veterinary staff and companion pet owners is exposure to ticks in the wooded/pasture areas or to ticks brought indoors by their pets. There are no proven cases of direct animal to human transmission for Lyme disease, ehrlichiosis, or Rocky Mountain spotted fever. Direct inoculation of blood from a bacteremic animal, eg, by needle stick is a theoretical, but, so far, undocumented health risk. However, veterinarians should record needle sticks or other inoculation-type injuries that occur in their practices. Prevention of Lyme disease, ehrlichiosis, Rocky Mountain spotted fever, and other tick-borne diseases depends on the avoidance of tick-infested areas and proper use of repellents and acaricides.

Quantitative urinalysis in kittens from four to thirty weeks after birth.

To evaluate renal function and obtain reference values for measurements of urinary excretion of various substances, quantitative urinalysis was performed in healthy, growing kittens from 4 to 30 weeks after birth. Endogenous creatinine clearance, 24-hour urine protein excretion, and urine protein-to-creatinine ratio were determined. Additionally, fractional excretion to creatinine clearance was calculated for calcium, inorganic phosphorus, sodium, potassium, and chloride. Mean +/- SD endogenous creatinine clearance values (range, 3.80 +/- 0.48 to 4.74 +/- 0.61 ml/min/kg) were significantly (P less than 0.0001) higher in kittens 9 to 19 weeks old, compared with younger (range, 1.39 +/- 0.85 to 3.59 +/- 0.86 ml/min/kg) and older kittens (range, 2.69 +/- 0.40 to 3.46 +/- 0.37 ml/min/kg). Mean values for all kittens for 24-hour urine protein excretion (range, 2.54 +/- 1.81 mg/kg at 4 weeks to 11.39 +/- 7.61 mg/kg at 14 weeks) and for urine protein-to-creatinine ratio (range, 0.14 +/- 0.03 to 0.34 +/- 0.18) varied from week to week of age. The urine protein-to-creatinine ratio in kittens greater than or equal to 9 weeks old correlated well (R2 = 0.861) with 24-hour urine protein excretion. Urinary fractional excretion of calcium, inorganic phosphorus, sodium, potassium, and chloride in kittens varied among age groups, being significantly (P less than 0.01) different for potassium and calcium in young kittens (4 to 6 weeks) and older kittens (greater than or equal to 7 weeks).

Disseminated infection with Neospora caninum in a ten-year-old dog.

Naturally-occurring neosporosis with multiple organ involvement was identified in a 10-year-old neutered male Basset hound dog. Clinical signs were first noticed 3 weeks prior to referral and consisted of crouched stance and mild pelvic limb ataxia. Dexamethasone administration had provided transient improvement. On presentation to the teaching hospital, clinical signs included depression, pelvic limb ataxia, inability to stand without assistance, and pain on deep palpation of the cervical and lumbar vertebral column. Lesions were found in the myocardium, liver, spleen, adrenal glands, brain, and spinal cord. Tachyzoites of Neospora caninum were found in the myocardium and adrenal glands. Organisms stained with anti-Neospora caninum, but not to anti-Toxoplasma gondii serum in an immunohistochemical test.

Canine haemobartonellosis, canine hepatozoonosis, and feline cytauxzoonosis.

Although Lyme borreliosis (Lyme disease), ehrlichiosis, Rocky Mountain spotted fever, and babesiosis occur more frequently in dogs or cats, from a clinical standpoint, other tick-borne diseases such as canine haemobartonellosis, canine hepatozoonosis, and feline cytauxzoonosis are just as important to recognize. Information concerning these less common tick-borne diseases are discussed, including their causative agents and their relationship to disease pathogenesis, diagnosis, treatment, and prevention.

Ixodid and argasid ticks. Keys to their identification.

Ticks of the Ixodidae family are important ectoparasites of humans and animals. Of the 80 or so species found in the United States, about 20 are of veterinary importance. Ticks are second only to mosquitoes as carriers of human pathogens. The ixodid (or hard) ticks are the most common and are represented by the genera Ixodes, Haemaphysalis, Boophilus, Rhipicephalus, Amblyomma, and Dermacentor. Accurate identification of the species of ixodid ticks within an area is a prerequisite to control and eradication. Therefore, veterinarians should have a working knowledge of the biology and identity of the more common mammalian-parasitizing ticks in the United States. In the United States, the argasid (or soft) ticks are less common than the ixodid (or hard) ticks. Argasids are represented by the genera Argas, Ornithodoros, and Otobius. Although the overall anatomy of the various species of argasids is similar, their functional approaches to feeding, reproduction, host finding and preference, tick-host behavior, tick relationship to their environment, and disease association vary among species. Accurate identification of the species of argasid ticks within an area is useful in their control.

Ehrlichial diseases of dogs.

Ehrlichial diseases of dogs currently are recognized to be caused by Ehrlichia canis, Ehrlichia platys, Ehrlichia equi, and Ehrlichia risticii. Information on each disease's history, transmission, pathogenesis, clinicopathologic findings, diagnosis, therapy, and prevention is presented in this article. Ehrlichia canis is the most common cause of clinical illness. Case reports are included to illustrate common presentations of Ehrlichia canis infections.

Temporal study of staphylococcal species on healthy dogs.

During a 1-year period, specimens were obtained monthly from 5 hair coat and 7 mucous membrane sites of 11 healthy dogs. Among 804 isolates of staphylococci, 13 species were identified. Staphylococcus intermedius was the most frequently isolated (40.2% of total isolates) coagulase-positive species, and S xylosus was the most frequently isolated (17.3%) coagulase-negative species. Moreover, S intermedius was the most frequently isolated species from the 12 sites evaluated and was isolated persistently from 8 of the 9 dogs that completed the 1-year study. On the basis of a commercial identification system, 14 profile numbers were identified for isolates of S intermedius. However, 2 profile numbers accounted for a majority (70.9%) of the isolates. Specific S intermedius biotypes identified on the basis of hemolysis, coagulase production, beta-lactamase activity, and antimicrobial susceptibility patterns were found repeatedly in 3 dogs. Seemingly, S intermedius was a resident of the normal bacterial microflora of these dogs; however, the inability to isolate S intermedius from 1 dog during the study year indicated that not all dogs harbor S intermedius as a resident microorganism.