Construct validation of a novel hybrid surgical simulator.

BACKGROUND: Simulated minimal access surgery has improved recently as both a learning and assessment tool. The construct validation of a novel simulator, ProMis, is described for use by residents in training. METHODS: ProMis is a surgical simulator that can design tasks in both virtual and actual reality. A pilot group of surgical residents ranging from novice to expert completed three standardized tasks: orientation, dissection, and basic suturing. The tasks were tested for construct validity. Two experienced surgeons examined the recorded tasks in a blinded fashion using an objective structured assessment of technical skills format (OSATS: task-specific checklist and global rating score) as well as metrics delivered by the simulator. RESULTS: The findings showed excellent interrater reliability (Cronbach's alpha of 0.88 for the checklist and 0.93 for the global rating). The median scores in the experience groups were statistically different in both the global rating and the task-specific checklists (p < 0.05). The scores for the orientation task alone did not reach significance (p = 0.1), suggesting that modification is required before ProMis could be used in isolation as an assessment tool. CONCLUSIONS: The three simulated tasks in combination are construct valid for differentiating experience levels among surgeons in training. This hybrid simulator has potential added benefits of marrying the virtual with actual, and of combining simple box traits and advanced virtual reality simulation.

Splenic preserving distal pancreatectomy of a solid pseudopapillary pancreatic tumour.

BACKGROUND: Solid pseudopapillary tumours are rare primary lesions of the pancreas. They occur most commonly in young female patients. They are traditionally regarded as benign tumours with malignant potential. AIM: We describe the incidental finding of this rare pancreatic lesion in a healthy 37-year-old female which was treated with splenic preserving distal pancreatectomy. RESULTS: The patient underwent curative resection with an uncomplicated postoperative course. Histology revealed the tumour origin with clear resection margins. The patient did not require adjunct therapy. Follow-up computed tomography (CT) scanning has demonstrated no evidence of local recurrence. CONCLUSION: The authors conclude that splenic preservation is safe and desirable where no compromise in oncological principles exists. Despite improvements in histological characteristics of solid pseudopapillary tumours, no prognostic features exist and each case must be followed-up on an individual basis.

The role of academic medical centers in delivery of primary care: an urban study.

BACKGROUND: Washington Heights-Inwood is a multiethnic community in northern Manhattan served by an academic medical center, the Columbia-Presbyterian Medical Center. METHOD: Two random, stratified household surveys were carried out in 1989-1990 and 1992. Results were compared with institutional utilization data to identify major changes in patterns of utilization of primary care since 1989. RESULTS: A total of 629 households completed interviews for the first survey, and 544 completed interviews for the second survey; respectively, 33% and 14.5% of the dwellings contacted did not complete interviews. During 1989-1990 the last physician visit for most people in this community was not provided at the academic medical center. Off-site, community-based services reached far fewer patients than did private doctors without local affiliations and out-of-area hospitals. Changes in utilization in the early 1990s considerably altered this picture. Many people who previously had received care outside the area either shifted to care in the area or went without care by 1992. CONCLUSION: Despite a rapid rise in services provided at community-based facilities associated with the Columbia-Presbyterian Medical Center, unmet needs continue to be great. A model for provision of service by academic medical centers in underserved urban communities is examined.

Patient outcomes and regional planning of coronary care services: a location-allocation approach.

We explore the use of patient outcome criteria in planning the locations of critical care health services. Two attributes of the regional distribution of health services which influence health outcomes are: (1) the geographical accessibility of services and (2) the number of patients served by each facility (the patient volume). A model incorporating both factors is developed to determine the number, sizes, and locations of coronary care services in a region in order to maximize patient outcomes. We examine the implications and use of the model in an investigation of the location of coronary care units in rural upstate New York. The results indicate that a system consisting of fewer, well-located coronary care units would be superior for patient survival than the existing system of many dispersed units. Disparities in access to services between urban and rural areas are discussed.

Characteristics of the distribution of emigrant Indian radiologists, pathologists and anesthesiologists in the United States.

We present the results of a questionnaire sent in the autumn of 1981 to all board certified specialists practicing radiology, pathology and anesthesiology who are graduates of Indian medical schools and now reside in the United States. Respondents were asked to indicate their Indian state of birth, the size of the community in which they were born. The location of their medical school, the size of the city in which they now reside and their reasons for emigrating to the United States. The respondents tended to settle in the larger cities of the Northeast and Midwest, filling, to some degree, positions provided by the movement of American trained physicians to the West and South. Most came from urban areas and from the more urbanized Indian states. Rajasthan, Madhya Pradesh and the East Indian states were underrepresented. The limited opportunities for specialty practice at home and the perception of an unmet physician demand in the United States were the twomost important reasons for emigration. Job availability largely determined locational choice in the United States. The distribution of emigrants arriving from 1965 to 1975 were similar to that of a much smaller group of early emigrants. Restrictions on entry of foreign born, foreign trained physicians as prescribed by the Health Professionals Assistance Act of 1976 (Public Law 94-284) mandates that the cohort of young specialists will not be supplemented to a significant extent by future arrivals from the Indian sub-continent. This will create an encapsulated minority of highly trained Asian-Americans. As they grow older their locational choices and integration into American society bears watching.

Cocaine abuse sharply reduced in an effective methadone maintenance program.

A comprehensive study of an urban methadone clinic with supervised urine analyses for illicit drugs was conducted over an 18 month period for a 133 patient cohort as they entered or remained in methadone maintenance for narcotic addiction. Overall retention during the study was 85%, with significantly (p < .05) higher daily methadone doses (mean 67.1 mg +/- 2.1) in those patients still in treatment at the end of the study. Predictably, illicit opioid use was dramatically reduced, to 10% as measured by urine toxicology in the last month of treatment. Moreover, significantly more patients stopped regular cocaine abuse (69%) than started using cocaine (10%, Fisher's exact test, p = .02). Thus, with effective methadone maintenance using adequate dosages, the majority of patients remain in treatment and reduce cocaine abuse as well as illicit opioid use, with implications for public health by reducing the spread of infectious diseases including hepatitis B, C, D and human immunodeficiency virus (HIV-1).

Transvaginal aspiration of ovarian cysts: long-term follow-up.

BACKGROUND AND PURPOSE: Transvaginal aspiration of ovarian cysts has been advocated as a viable alternative to surgery in patients who are high-risk surgical candidates. We describe a retrospective study evaluating the results of transvaginal aspirations of benign ovarian cysts in patients at increased surgical risk, focusing on long-term follow-up for recurrence of the cyst and/or development of malignancy. METHODS: Twenty-four women with ovarian cysts underwent 34 transvaginal drainages between October 1998 and December 2004. All patients were referred following diagnosis of a persistent ovarian cyst with a benign appearance on ultrasound. All patients were unsuitable candidates for surgery (history of previous pelvic surgery, n = 21; high risk for anesthesia, n = 1; and unsuitable for laparoscopy due to obesity, n = 2). Patients with a history of pregnancy, acute abdominal symptoms, or previous gynecologic malignancy were excluded. A 20G x 20 cm Chiba needle was used for transvaginal aspiration using an endocavity probe (Acuson XP, Mountain View, CA, USA; Siemens Sololine, Erlangen, Germany) and intravenous sedoanalgesia. Cysts were aspirated to dryness. RESULTS: Long-term follow-up of patients was performed and revealed a recurrence rate of 75%. Eighty-three percent of cysts on the left and 42% of those on the right recurred. Nine of 15 (60%) patients with recurrence required further intervention. Two of 9 underwent surgical intervention only, 4 of 9 had repeat transvaginal aspiration(s) performed, and 3 of 9 had a combination of both transvaginal aspiration and surgery. No patient developed ovarian malignancy. CONCLUSION: Transvaginal cyst aspiration has many advantages including short hospital stay, rapid recovery, excellent patient tolerance, and a low rate of procedure-related complications. Our study demonstrates that ovarian cyst recurrence following transvaginal drainage is a more significant problem than previously documented, especially if the cyst is on the left side. However, when recurrences do occur, repeat transvaginal aspirations may be considered in the symptomatic patient.