The importance of non-technical skills in robot-assisted surgery in gynaecology.

Robot-assisted surgery (RAS) in gynaecology has undergone exponential growth in recent decades, with utility in treating both benign and malignant gynaecological conditions. The technological complexities and amended theatre dynamics that RAS demands mean that effective non-technical skills (NTS) are vitally important to overcome these unique challenges. However, NTS have been neglected in RAS-training programmes with focus placed instead on the exclusive acquisition of technical skills (TS). NTS include teamwork, communication, leadership, situational awareness, decision-making and stress management. Communication is the most frequently cited NTS impacted during RAS, as the physical limitations imposed by the robotic hardware make communication exchange difficult. The full immersion that RAS enables can contribute to situational awareness deficits. However, RAS can complement communication and teamwork when multidisciplinary (MDT) surgeries (such as complex endometriosis excisions) are undertaken; dual-console capabilities facilitate the involvement of specialties such as general surgery and urology. The development of NTS in RAS cannot be achieved with in-situ experience alone, and current training is poorly standardised. RAS-training programmes and curricula for gynaecology do exist, however the integration of NTS remain limited. Simulation is a viable tool to facilitate enhanced-NTS integration, yet cost implications form a barrier to its wider implementation. However, given that RAS will continue to occupy a greater proportion of the gynaecological caseload, integration of NTS within gynaecological RAS training curricula is necessary. Patients undergoing gynaecological RAS would benefit from the improved safety standards and enhanced surgical outcomes that would result.

Hyperbaric oxygen therapy in preventing mechanical ventilation in COVID-19 patients: a retrospective case series.

OBJECTIVE: A pandemic afflicts the entire world. The highly contagious SARS-CoV-2 virus originated in Wuhan, China in late 2019 and rapidly spread across the entire globe. According to the World Health Organization (WHO), the novel Coronavirus (COVID-19)has infected more than two million people worldwide, causing over 160,000 deaths. Patients with COVID-19 disease present with a wide array of symptoms, ranging from mild flu-like complaints to life threatening pulmonary and cardiac complications. Older people and patients with underlying disease have an increased risk of developing severe acute respiratory syndrome (SARS) requiring mechanical ventilation. Once intubated, mortality increases exponentially. A number of pharmacologic regimens, including hydroxychloroquine-azithromycin, antiviral therapy (eg, remdesevir), and anti-IL-6 agents (e.g., toclizumab), have been highlighted by investigators over the course of the pandemic, based on the therapy's potential to interrupt the viral life-cycle of SARS-CoV-2 or preventing cytokine storm. At present, there have been no conclusive series of reproducible randomised clinical trials demonstrating the efficacy of any one drug or therapy for COVID-19. CASES: COVID-19 positive patients (n=5) at a single institution received hyperbaric oxygen therapy (HBOT) between 13 and 20 April 2020. All the patients had tachypnoea and low oxygen saturation despite receiving high FiO2. HBOT was added to prevent the need for mechanical ventilation. A standard dive profile of 2.0ATA for 90 minutes was employed. Patients received between one and six treatments in one of two dedicated monoplace hyperbaric chambers. RESULTS: All the patients recovered without the need for mechanical ventilation. Following HBOT, oxygen saturation increased, tachypnoea resolved and inflammatory markers fell. At the time of writing, three of the five patients have been discharged from the hospital and two remain in stable condition. CONCLUSION: This small sample of patients exhibited dramatic improvement with HBOT. Most importantly, HBOT potentially prevented the need for mechanical ventilation. Larger studies are likely to define the role of HBOT in the treatment of this novel disease.

Small cell lung cancer: time to diagnosis and treatment.

OBJECTIVES: Small cell lung cancer (SCLC) is the most rapidly progressive form of lung cancer, and delays in treatment may increase the tumor burden. We determined the time from abnormal radiograph to diagnosis and treatment for patients with SCLC and investigated the effect of emergent presentation, stage, radiographic findings, and race on these measures and survival. METHODS: Retrospective analysis of clinical data for 45 consecutive evaluable patients at a single institution diagnosed as having SCLC. RESULTS: Median time from first abnormal radiograph to tissue diagnosis was 10 days and time from first abnormal radiograph to initiation of treatment was 35 days. Emergency department presentation led to earlier diagnosis compared with the clinic (3 vs 21 days), with a trend toward earlier treatment (15 vs 39 days; P = 0.057). No significant effect of radiographic findings, disease stage, or race was observed from time to diagnosis or treatment. Forty-three patients (96%) died, with a median survival time from initial abnormal radiograph to death of 375 days. Survival was longer for patients with limited stage disease (619 vs 230 days), but it was not significantly affected by emergent presentation, radiographic findings, or race. Consistent with the aggressive behavior of SCLC, 10 patients (22%) had a normal radiograph within 6 months prediagnosis, and 7 of these had extensive disease. CONCLUSIONS: The median time from abnormal radiograph to initiation of treatment for SCLC in our single-center study overlapped with the expected doubling time for this malignancy and likely allowed a preventable increase in tumor burden.

Psychological therapies for chronic pelvic pain: systematic review of randomized controlled trials.

Chronic pelvic pain (CPP), a common cause of disability in women, is a condition best viewed in the biopsychosocial framework. Psychological interventions are frequently considered alongside medical and surgical treatments. Our objective was to evaluate the effectiveness of psychological therapies for the treatment of CPP. Electronic literature searches were conducted in Medline, Embase, PsycInfo and DARE databases from database inception to April 2010. Reference lists of selected articles were searched for further articles. The studies selected were randomized controlled trials of psychological therapies in patients with CPP compared with no treatment, standard gynecological treatment or another form of psychological therapy. Two reviewers independently selected articles without language restrictions and extracted data covering study characteristics, study quality and results. Reduction in pain, measured using visual analog scales or other measurements, was the main outcome measure. Of the 107 citations identified, four studies satisfied the inclusion criteria. Compared with no psychological intervention, therapy produced a standardized mean pain score of -3.27 [95% confidence interval (CI) -4.52 to -2.02] and 1.11 (95% CI -0.05 to 2.27) at 3 months and -3.95 (95% CI -5.35 to -2.55) and 0.54 (95% CI -0.78 to 1.86) at 6 months and greater, based on a visual analog scale score of 0-10. The current evidence does not allow us to conclude whether psychological interventions have an effect on self-reported pain scores in women with CPP.

Increasing the effectiveness of referral of ovarian masses from cancer unit to cancer center by using a higher referral value of the risk of malignancy index.

HYPOTHESIS: Higher risk of malignancy index (RMI) with multidisciplinary approach will reduce the number of referrals of ovarian masses, thus reducing the stress for patients and workload at the cancer center. METHODS: Prospective observational study in which all patients with pelvic masses and an RMI lower than 450 were treated at the local hospital after discussion at multidisciplinary input. Patients with an RMI higher than 450 were referred to tertiary cancer centers. Records of multidisciplinary meetings, operative details, and histologic examination results were evaluated. Data were analyzed to calculate the predictive values and the sensitivity of this approach. RESULTS: If the RMI cutoff of 450 alone is considered, 1 woman with invasive cancer would not have been referred. The sensitivity for invasive epithelial ovarian cancer was 96.2% or 25 of 26 patients (95% confidence interval [CI], 80.4-99.9) with a positive predictive value of 96.3% or 26 of 27 patients (95% CI, 81.0-99.9). The specificity was 98.7% or 77 of 78 patients (95% CI, 93.1-100.0). The negative predictive value was 98.7% or 76 of 77 patients (95% CI, 93.0-100.0). CONCLUSIONS: A higher RMI with multidisciplinary approach to refer patients with pelvic masses has the potential to reduce the numbers of benign cases, thus reducing stress for patients and reducing workload at centers.

Best evidence continuous medical education.

Health care professionals need to approach their profession with a view to life long learning. They need to develop a strategy to meet their learning needs in a reflective and effective manner. Continuous medical educational (CME) is the traditional tool for learning and updating knowledge. Most of them are in the forms of courses, conferences, journal clubs and workshops. They are mostly didactic sessions and evidence suggests that they are not effective to improve the clinical skills and attitude. Systematic review of teaching evidence-based medicine shows that interactive and clinically integrated learning is the most effective form of learning. It enhances knowledge and skills. Professionals should view CME in a holistic manner in the context of continuous professional development (CPD) and even in the wider concept of knowledge translation, which encompasses both CME and CPD. e Learning is one of the most important forms of non-traditional CME. It provides an efficient and increasingly interactive delivery system that can handle complex and layered information. More work needs to be done to see its effectiveness for practising clinicians.