Actividades profesionales confiables en cirugía mínimamente invasiva: iniciando el camino para lograr competencias en el futuro graduado de medicina / Entrustable professional activities in minimally invasive surgery: starting the way to achieve competencies in the future medical graduate

Objetivos: El desarrollo de actividades profesionales confiables (APROC) para el graduado de medicina en Cirugía Mínimamente Invasiva (CMI) es una necesidad en Colombia. La evidencia disponible es limitada. Este estudio describe la experiencia preliminar con una intervención orientada a esta necesidad, en el marco de un modelo de educación basada en competencias (EBC). Materiales y Métodos: Se diseñó una intervención orientada al desarrollo de actitudes, conocimientos y habilidades prácticas en CMI para estudiantes de medicina, mediante un enfoque de aula invertida extendida. Se realizaron evaluaciones pre y posintervención mediante el cuestionario Team-STEPPS (actitudes), exámenes de conocimiento y OSATS (habilidades prácticas). Se realizaron comparaciones pre y posintervención (t-test (p < 0,05) y mediciones del tamaño del efecto de la intervención (prueba d Cohen). Finalmente se evaluó la satisfacción estudiantil. Resultados: Un total de 99 estudiantes participaron en el estudio. Se encontraron diferencias estadísticamente significativas (p < 0,05) entre las mediciones pre y posintervención, y gran efecto en las actitudes, conocimientos y habilidades prácticas (d > 0,80). Se evidenció alta satisfacción estudiantil. Discusión: El diseño instruccional a través de metodologías interactivas permite desarrollar APROC en CMI, desde el pregrado. Estos resultados son similares a los reportados en otras intervenciones en el marco de la EBC. Conclusión: Nuestra intervención demostró efectos positivos sobre competencias estudiantiles orientadas al desarrollo de APROC en CMI para el futuro graduado. Aun es necesario medir estas competencias en la práctica real y al finalizar la carrera, para determinar si estas actividades pueden ser totalmente confiables a los participantes en su futura práctica profesional.

Aims: The development of entrustable professional activities (EPAs) in minimally invasive surgery (MIS) for undergraduates is a need in Colombia. The available evidence is limited. This study aims to describe the preliminary experience with an intervention oriented to this need, embedded in the framework of a competence-based education model (CBE). Materials and Methods: An intervention was designed for the development of EPAs in MIS oriented to the development of attitudes, knowledge and practical skills in medical students. Intervention was delivered through an extended inverted classroom approach. Pre- and postintervention measures were performed by using the Team-STEPPS questionnaire (attitudes), knowledge assessments and OSATS (practical skills). Comparisons were performed by t-test tests (p < 0.05) and the effect size of the intervention was calculated by the Cohen d test. Finally, the student's satisfaction was evaluated. Results: A total of 99 students participated in the study. The intervention showed statistically significant differences (p < 0.05), and great effect on attitudes, knowledge and practical skills (d > 0.80). Likewise, high student satisfaction was evidenced. Discussion: Interactive instructional design fosters development of EPAs in MIS for medical undergraduates. These results are similar to those reported in other interventions under the CBE model. Conclusion: Our intervention showed positive effects on competences oriented to the development of EPAs in MIS for the future graduate. Still is necessary to assess these competencies in real practice and at the end of medical career, in order to evaluate if these activities can be totally reliable to the participants in their future professional practice.

[Challenges in inpatient ophthalmology for elderly patients]. / Herausforderungen in der stationären Augenheilkunde bei hoch- und höchstbetagten Patienten.

PURPOSE: The demographic changes will lead to an increase in elderly patients in the field of medicine and in particular ophthalmology. The purpose of this study was to assess ocular problems of inpatients in the clinical setting with a focus on patients over 60 years old, especially elderly patients over 80 years and very old patients over 90 years. METHODS: All consecutive inpatients were included in the study. Medical data were analyzed concerning the diagnosis, operative indications and comorbidities and the presence of dementia disorders was also considered. The effects of age or diseases on the inpatient course were investigated. RESULTS: At the eye clinic in Frankfurt (Oder) the mean age of patients was 69 years and was the highest of all medical and surgical disciplines. The age of patients of internal medicine was similarly with 67 years but orthopedic and urological patients were on average 64 years old. In the other departments the mean age of patients was clearly less than 60 years old. Of the patients 26% were aged 80 years or older. A total of 31 patients over 90 years old were treated as inpatients (2.0%) during the year 2012. The treatment-relevant diagnosis increased with age. Nearly 40% had a reduced mobility at an age of 80-89 years and 60% at an age over 90 years. In the age group over 90 years approximately 25% had dementia and 20% a visual disorder. CONCLUSION: Old and very old patients with ocular problems and more than 80-90 years of age had an increased comorbidity concerning the relevant treatment diagnostics. This has relevant implications and challenges for nursing and medical care in the clinical setting.

[How does central cornea thickness influence intraocular pressure during applanation and contour tonometry?]. / Wie beeinflusst die zentrale Hornhautdicke den intraokularen Druck bei der Applanations- und Konturtonometrie?

BACKGROUND: Golmann applanation tonometry represents a well-established procedure for measuring intraocular pressure (IOP). This implies the necessity of an accurate measurement of IOP with the reference tonometer. One example is the contour tonometer Pascal with a measuring probe, adapted to the cornea geometry, for measuring the IOP and the ocular pulse amplitude. There is controversy of how strongly corneal thickness affects the measurement of IOP. We thus analysed, for a number of eyes, the correlation of IOP, as measured by two types of applanation tonometers and one contour tonometer and the central corneal thickness. METHODS: In all 158 patient eyes were investigated in a clinical comparison of applanation tonometers AT 870 and Ocuton-A. The study was performed by a trained ophthalmologist and the comparison was in accordance with international standard ISO 8612. In addition, the corneal thickness in the vertex was repeatedly determined using an Oculus Pentacam. The potential effect of central corneal thickness on the IOP as measured by the mentioned tonometers was statistically evaluated by rank correlation analysis. RESULTS: We found that the measured IOP values for the three investigated tonometers were not normally distributed. The central corneal thickness values, in contrast, measured on 158 eyes by means of an ultrasound pachymeter and additionally on 235 eyes by the Pentacam, obeyed a Gaussian distribution. For the correlation analysis of both parameters the Spearman linear rank correlation coefficient (r) was considered. We found a very weak (|r| < 0.2) correlation between central corneal thickness and IOP for all 3 tonometers. The softness of the correlation is also illustrated by a large standard deviation of the regression line. A comparison of the different devices for corneal-thickness measurements shows less variance and a smaller variation coefficient when the ultrasoundpachymeter AL-1000 is used. CONCLUSIONS: The measured values for IOP are only very weakly correlated to the central corneal thickness. For the 3 tonometer types studied there is no need to correct the indicated pressure values according to the central corneal thickness of the investigated eye. Clinical comparisons according to the ISO 8612 standard between a tonometer under test and a reference Goldmann applanation tonometer are always a time-consuming procedure. Additional measures to determine the central corneal thickness of every investigated eyes are dispensable.

Prevalence of multifocal atherosclerosis and comorbidity on symptomatic Cypriot inpatients.

AIM: Multifocal atherosclerotic disease or multifocal ischemic pathology (MAD) is an issue gaining a lot of attention by clinicians in recent years, due to its high impact on the morbidity and mortality of vascular patients. The coexistence of coronary artery disease (CAD), peripheral arterial disease (PAD) and carotid disease (CS) is being investigated in this study. METHODS: The study included 556 consecutive inpatients who were admitted to the Nicosia General Hospital in Cyprus for carotid endarterectomy, peripheral arterial reconstruction or coronary artery bypass. All patients were subjected to color duplex examination of the carotid vessels and to lower extremity Doppler study. Cardiac risk screening was performed on patients with PAD and CS. Comorbidity was evaluated by using the Cumulative Illness Rating Scale (CIRS). RESULTS: The prevalence of MAD in atherosclerotic patients was found very high (60.3%). The most frequent comorbidity was the coexistence of PAD and CAD (41.8%). The comorbidity burden of MAD patients, in comparison to that of patients with unifocal atherosclerotic disease, was evaluated to conclude that the burden in the first group (MAD) is significantly higher, not only in relation to the number of clinically relevant diseases that co-exist, but also to the severity of these diseases. Furthermore, functional status is negatively affected by the existence of multifocal ischemic pathology. CONCLUSION: The high prevalence of MAD suggests the necessity of developing a systematic screening approach in the everyday practice. Apart from cardiovascular problems, other diseases affect the clinical situation of these patients. Therefore, it is important to investigate these problems pre- and postoperatively.

Inferior mesenteric artery aneurysm. Case report.

This paper reports a large inferior mesenteric artery aneurysm discovered incidentally during the work-up in a male patient with a thoracoabdominal aortic aneurysm. Aortography disclosed an aneurysm in the inferior mesenteric artery with a large marginal artery which filled the branches of the coeliac and superior mesenteric arteries retrogradely. The thoracoabdominal aortic aneurysm was reconstructed by a bifurcated aorto-biiliac Dacron graft while inferior mesenteric artery revascularisation was achieved with a PTFE graft, reconstruction being necessary because of its dominant blood supply to all of the viscera. This case highlights the importance of aneurysmal reconstruction when an anomalous arterial supply to the gastrointestinal tract from a dilated inferior mesenteric artery has been demonstrated on a preoperative angiogram.

Transposed basilic vein-brachial arteriovenous fistula: an alternative vascular access for hemodialysis.

Twenty-five brachial-basilic arteriovenous (AV) fistulas with transposed basilic vein for alternative vascular access were created in 22 chronic hemodialysis patients. This surgical procedure was performed under brachial block or general anesthesia. After a longitudinal skin incision that was made in the inner side of the arm, the basilic vein was exposed, transposed subcutaneously, and anastomosed end-to-side to the brachial artery. The follow-up was between 7 and 24 months. Early complications were hemorrhage, thrombosis, steal syndrome, and swelling of the arm. Among the late complications were failure of the fistula because of thrombosis and multiple stenosis at the site of venipuncture. The accumulated one-year patency rate of fistulas was 81%. The complications of high-output cardiac failure or local infection were not seen in our study. On the basis of our results, the brachial-basilic AV fistula with transposed basilic vein is a useful and safe second- or third-choice vascular procedure for hemodialysis patients, in particular for women without good quality of vessels.