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Perez-Estrada BA, Acevedo-Gallegos S, Lumbreras-Marquez MI, Gardner R, Gallardo-Gaona JM. Cumulative sum learning curve for cordocentesis among maternal-fetal medicine fellows in a low-cost simulation model. Int J Gynaecol Obstet 2024. [PMID: 38736305 DOI: 10.1002/ijgo.15611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/30/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVE To determine the individual learning curves for cordocentesis in a low-cost simulator for maternal-fetal medicine (MFM) fellows. METHODS This observational, descriptive, educational, and prospective study was performed from July through November 2022. After an introductory course based on a standardized technique for cordocentesis, each second-year MFM fellow who accepted to participate in the study performed this procedure using a low-cost simulation model, and experienced operators supervised the cordocenteses. Learning curves were then created using cumulative sum analysis (CUSUM). RESULTS Seven second-year MFM fellows with no previous experience in cordocentesis accepted to participate in the study. A total of 2676 procedures were assessed. On average, residents performed 382 ± 70 procedures. The mean number of procedures to achieve proficiency was 369 ± 70, the overall success rate was 84.16%, and the corresponding failure rate was 15.84%. At the end of the study, all fellows were considered competent in cordocentesis. One fellow required 466 attempts to achieve competency, performing a total of 478 procedures, but the resident with the fewest attempts to reach competency required 219 procedures, completing 232 procedures. Some of the most frequent reasons for failed attempts included not reaching the indicated point for vascular access (20.99%) and being unable to retrieve the sample (69.10%). CONCLUSION CUSUM analysis to assess learning curves, in addition to using low-cost simulation models, helped to appraise individualized learning, allowing an objective demonstration of competency for cordocentesis among MFM fellows.
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Affiliation(s)
- Bibiana A Perez-Estrada
- Department of Maternal and Fetal Medicine, Instituto Nacional de Perinatologia, Mexico City, Mexico
| | - Sandra Acevedo-Gallegos
- Department of Maternal and Fetal Medicine, Instituto Nacional de Perinatologia, Mexico City, Mexico
| | - Mario I Lumbreras-Marquez
- Department of Maternal and Fetal Medicine, Instituto Nacional de Perinatologia, Mexico City, Mexico
- Epidemiology and Public Health Division, Universidad Panamericana School of Medicine, Mexico City, Mexico
| | - Roxane Gardner
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Center for Medical Simulation, Boston, Massachusetts, USA
| | - Juan M Gallardo-Gaona
- Department of Maternal and Fetal Medicine, Instituto Nacional de Perinatologia, Mexico City, Mexico
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Wang P, Xin Y, Zhou S, Duan S, Bai D, Li B, Xu W. Efficacy of computer-assisted robotic based clinical training program for spinal oncology education on pedicle screw placement. J Robot Surg 2024; 18:150. [PMID: 38564025 PMCID: PMC10987351 DOI: 10.1007/s11701-023-01804-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 04/04/2024]
Abstract
Pedicle screw placement (PSP) is the fundamental surgical technique that requires high accuracy for novice orthopedists studying spinal oncology education. Therefore, we set forth to establish a computer-assisted robotic navigation training program for novice spinal oncology education. Novice orthopedists were involved in this study to evaluate the feasibility and safety of the computer-assisted robotic navigation (CARN) training program. In this research, trainees were randomly taught by the CARN training program and the traditional training program. We prospectively collected the clinical data of patients with spinal tumors from 1st May 2021 to 1st March 2022. The ability of PSP was evaluated by cumulative sum (CUSUM) analysis, learning curve, and accuracy of pedicle screws. The patients included in both groups had similar baseline characteristics. In the CUSUM analysis of the learning curve for accurate PSP, the turning point in the CARN group was lower than that in the traditional group (70th vs. 92nd pedicle screw). The LC-CUSUM test indicated competency for PSP at the 121st pedicle screw in the CARN group and the 138th pedicle screw in the traditional group. The accuracy of PSP was also significantly higher in the CARN group than in the traditional group (88.17% and 79.55%, P = 0.03 < 0.05). Furthermore, no major complications occurred in either group. We first described CARN in spinal oncology education and indicated the CARN training program as a novel, efficient and safe training program for surgeons.
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Affiliation(s)
- Pengru Wang
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Yingye Xin
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China
| | - Shangbin Zhou
- Department of Orthopedics, Naval Medical Center, Naval Military Medical University, Shanghai, China
| | - Shujie Duan
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Danyang Bai
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China
| | - Bo Li
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
| | - Wei Xu
- Department of Orthopedic Oncology, Changzheng Hospital, Naval Military Medical University, 415 Fengyang Road, Shanghai, 200003, China.
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, China.
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Moldenhauer JS, Johnson A, Van Mieghem T. International Society for Prenatal Diagnosis 2022 DEBATE: There should be formal accreditation and ongoing quality assurance/review for units offering fetal therapy that includes public reporting of outcomes. Prenat Diagn 2022; 43:411-420. [PMID: 36522853 DOI: 10.1002/pd.6286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/23/2022]
Abstract
The field of fetal therapy has so far escaped from formal accreditation and quality control. Despite that, current published evidence shows that outcomes of interventions in younger fetal therapy centers are similar to what is achieved in more experienced centers and outcomes of interventions have improved over time. The question however remains what is not being published and what should be the standard of care, given the lack of level 1 evidence from randomized controlled trials for many interventions. Formal collaborative networks such as NAFTnet and others allow for anonymized benchmarking of center outcomes, without publicly shaming (and financially punishing) underperforming centers. Large registries also allow for tracking of rare complications and may result in improved patient outcomes over time. Core outcome sets, which could serve as a basis for outcome reporting, are available for some conditions, but certainly not for all, resulting in communication difficulties between centers. Formal accreditation, quality control, and outcome reporting are hard to implement, expensive, and may result in decreasing access to care by pushing smaller centers out of the market. Despite the existing difficulties, international societies have committed to quality improvement, and fetal therapy programs are strongly recommended to participate in voluntary outcome tracking.
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Affiliation(s)
| | - Anthony Johnson
- The Fetal Center Department of Obstetrics and Gynecology and Reproductive Sciences Division of Fetal Intervention McGovern Medical School at The University of Texas Health Science Center Houston Texas USA
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology Fetal Medicine Unit and Ontario Fetal Centre Mount Sinai Hospital and University of Toronto Toronto Ontario Canada
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Philip CA, Sandré A, de Saint-Hilaire P, Cortet M, Dubernard G. Learning Curve for the Detection of Deep Infiltrating Endometriosis and Adenomyosis with 3-D Transvaginal Water Contrast Sonography. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:1328-1335. [PMID: 35469632 DOI: 10.1016/j.ultrasmedbio.2022.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 03/03/2022] [Accepted: 03/07/2022] [Indexed: 06/14/2023]
Abstract
Three-dimensional rectosonography (RSG) is a transvaginal sonography technique using rectal water contrast and 3-D acquisitions. The main points of interest of 3-D RSG could be its easy accessibility and its quick learning curve, especially with respect to rectosigmoid lesions. The objective of this prospective observational study was to assess the learning curve of 3-D RSG for the diagnosis of rectosigmoid lesions and for various other locations of deep endometriosis (DE), endometriomas and adenomyosis. From April 2017 to November 2017, 116 patients with suspected pelvic endometriosis were referred to the Croix-Rousse University Hospital, and those who underwent 3-D RSG were included in our study. After a short training period, four residents were asked to perform 3-D RSG by themselves. Each procedure was systematically controlled immediately afterward by a single expert sonographer. The success of the procedure involved the correct identification of various locations of endometriosis (rectosigmoid, uterosacral ligament, retrocervical space, vagina, bladder and ovaries) and adenomyosis, using the expert sonographer's examination as the reference technique. The learning curve was generated using these data and assessed using the Learning Curve Cumulative Summation Test (LC-CUSUM) method. The pooled LC-CUSUM revealed that the required level of achievement was reached after 24 3-D RSGs were performed for the diagnosis of rectosigmoid lesions. All four residents were significantly competent in diagnosing rectosigmoid lesions at the end of their training period, with an α risk <0.05 (T1, p = 0.03; T2, p = 0.0002; T3, p = 0.05; T4, p = 0.02). The LC-CUSUM analysis confirmed that competency was achieved for vaginal DE, torus uterinum DE, US DE, bladder DE, endometriomas and adenomyosis within 17, 27, 38, 19, 17 and 33 scans, respectively. This study provides evidence that the skills required to diagnose endometriosis lesions and adenomyosis with 3-D RSG can be acquired after a brief learning period in an expert center.
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Affiliation(s)
- Charles-André Philip
- Obstetrics and Gynecology Department, Croix-Rousse University Hospital of Lyon (Hospices Civils de Lyon), Lyon, France; Claude Bernard Lyon 1 University, Lyon, France.
| | - Amélie Sandré
- Obstetrics and Gynecology Department, Croix-Rousse University Hospital of Lyon (Hospices Civils de Lyon), Lyon, France; Claude Bernard Lyon 1 University, Lyon, France
| | - Pierre de Saint-Hilaire
- Obstetrics and Gynecology Department, Croix-Rousse University Hospital of Lyon (Hospices Civils de Lyon), Lyon, France
| | - Marion Cortet
- Obstetrics and Gynecology Department, Croix-Rousse University Hospital of Lyon (Hospices Civils de Lyon), Lyon, France; Claude Bernard Lyon 1 University, Lyon, France
| | - Gil Dubernard
- Obstetrics and Gynecology Department, Croix-Rousse University Hospital of Lyon (Hospices Civils de Lyon), Lyon, France; Claude Bernard Lyon 1 University, Lyon, France
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Ascertaining the Effects of Tissue Sealers on Minor Laparoscopic Procedures between Obstetrics and Gynecology Residents: A Prospective Cohort Study. Medicina (B Aires) 2022; 58:medicina58050578. [PMID: 35629995 PMCID: PMC9147952 DOI: 10.3390/medicina58050578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/17/2022] [Accepted: 04/21/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Objectives: The type of instrumentation used during laparoscopic surgery might impact on the learning curve of resident surgeons. The aim of this study was to investigate differences in operator satisfaction and surgical outcomes between tissue sealers and classic bipolar instruments during gynecological laparoscopies performed by residents. Materials and Methods: A prospective cohort study conducted at two tertiary university hospitals between March 2019 and March 2021, on consecutive procedures: salpingo-oophorectomies (Group 1) and salpingectomies (Group 2), subdivided according to the utilized device: radiofrequency tissue sealers (Groups A1 and A2) or bipolar forceps (Groups B1 and B2). Results: 80 procedures were included. Concerning salpingo-oophorectomies, better visibility (8.4 ± 0.8 vs. 7.3 ± 0.9; p = 0.03), reduced difficulty (5.4 ± 1.2 vs. 7.0 ± 1.4; p = 0.02), improved overall satisfaction (9.2 ± 0.4 vs. 7.6 ± 1.0; p = 0.02) and reduced procedure time (7.8 ± 3.4 vs. 12.6 ± 3.1; p = 0.01) were reported by residents using tissue sealers. Intraoperative blood loss (12.2 ± 4.7 mL vs. 33.2 ± 9.7 mL; p = 0.01) and 24 h postoperative pain (4.5 ± 1.1 vs. 5.7 ± 1.8; p = 0.03) were lower in group A1 than B1. For salpingectomies, a significant reduction in duration was found in A2 compared to B2 (7.2 ± 3.4 min vs. 13.8 ± 2.2 min; p = 0.02). Tissue sealers enhanced visibility (8.1 ± 1.1 vs. 6.7 ± 1.4; p = 0.01), difficulty (6.5 ± 1.1 vs. 7.5 ± 0.9; p = 0.04) and improved satisfaction (9.3 ± 0.5 vs. 7.5 ± 0.6; p = 0.01). Moreover, hemoglobin loss and postoperative pain were reduced in A2 relative to B2 [(8.1 ± 4.2 % vs. 4.5 ± 1.1%; p = 0.02) and (5.1 ± 0.9 vs. 4.1 ± 0.8; p = 0.03), respectively] Conclusions: The use of sealing devices by residents was related to reduced difficulty as well improved visibility and overall satisfaction, with improved surgical outcomes.
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Tankul R, Halilamien P, Tangwiwat S, Dejarkom S, Pangthipampai P. Qualitative and quantitative gastric ultrasound assessment in highly skilled regional anesthesiologists. BMC Anesthesiol 2022; 22:5. [PMID: 34979932 PMCID: PMC8722139 DOI: 10.1186/s12871-021-01550-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 11/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary aspiration is a major complication in anesthesia, and various studies have shown that gastric sonography can reliably provide valuable information relative to both the qualitative and quantitative aspects of gastric content. This study aimed to determine the accuracy of ultrasound assessment of gastric content compared between two novice anesthesiologist gastric sonographers. METHODS This prospective cohort study of two anesthesiologists learning to perform qualitative and quantitative ultrasound assessment of gastric content on healthy volunteers was conducted at Siriraj Hospital (Bangkok, Thailand). This trial was registered with ClinicalTrials.gov (reg. no. NCT04760106). RESULTS Of the 50 enrolled participants, three were excluded due to study protocol violation. Each anesthesiologist performed a qualitative assessment on 47 participants for an overall total of 94 scans. There were 15 males and 32 females (age 42 ± 11.7 years, weight 61.2 ± 13.1 kg, height 160.7 ± 7.3 cm, and BMI 23.6 ± 4.3 kg/m2). The overall success rate for all gastric content categories was approximately 96%. From antral cross-sectional area measurement, as the ingested volume increased, there was a tendency toward increased deviation from the actual ingested volume. Interrater agreement between anesthesiologists was analyzed using intraclass correlation coefficients (ICCs). A larger fluid volume was found to be associated with a lower level of agreement between the two anesthesiologists. The ICCs were 0.706 (95% CI: -0.125 to 0.931), 0.669 (95% CI: -0.254 to 0.920), 0.362 (95% CI: -0.498 to 0.807) for the 100 ml, 200 ml, and 300 ml fluid volumes, respectively. The mean duration to perform an ultrasound examination for each gastric content category and for the entire examination did not differ significantly between anesthesiologists (p > 0.05). CONCLUSION Our results indicate that qualitative ultrasound assessment of gastric content is highly accurate and can be easily learned. In contrast, quantification of gastric volume by novice gastric sonographers is more complex and requires more training. TRIAL REGISTRATION ClinicalTrials.gov no. NCT04760106 Date registered on Feb 11, 2021. Prospectively registered.
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Affiliation(s)
- Rattanaporn Tankul
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Pathom Halilamien
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Suwimon Tangwiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Sukanya Dejarkom
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand
| | - Pawinee Pangthipampai
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand.
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Kim R, Lee MY, Won HS, Kim JM, Lee YJ, Jeong BD, Kim HJ. Perinatal outcomes and factors affecting the survival rate of fetuses with twin-to-twin transfusion syndrome treated with fetoscopic laser coagulation: a single-center seven-year experience. J Matern Fetal Neonatal Med 2021; 35:5595-5606. [PMID: 33879028 DOI: 10.1080/14767058.2021.1888286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This single-center study aimed to assess the perinatal outcomes and its associated factors in fetuses with twin-to-twin transfusion syndrome (TTTS) treated by fetoscopic laser coagulation (FLC). METHODS In this retrospective study, we included fetuses prenatally diagnosed with TTTS at Asan Medical Center, Seoul, Korea, between October 2011 and December 2018. All patients with TTTS stage II or higher and those with stage I TTTS coupled with symptomatic polyhydramnios or cardiac dysfunction were eligible for FLC. RESULTS A total of 172 cases of monochorionic diamniotic twins and one case of dichorionic triamniotic triplets were prenatally diagnosed with TTTS and treated with FLC. The median gestational ages (GAs) at diagnosis and FLC were 20.3 and 20.5 weeks, respectively. The median GA of survivors at delivery was 32.5 weeks. The overall at least one twin- and double-survival rates within 28 days after birth were 82.1% and 55.5%, respectively. The GAs at diagnosis and FLC, Quintero stage, inter-twin weight discordance, associated selective intrauterine growth restriction (sIUGR), procedure time, volume of amnioreduction, preterm prelabor rupture of membranes (PPROM) within one week after FLC, intraoperative intrauterine bleeding, and chorioamnionitis were significant predictive factors of perinatal death. Associated sIUGR, absent end-diastolic flow of umbilical artery, and abnormal cord insertion were significantly associated with donor demise in utero, whereas lower GA at diagnosis and FLC, smaller twins at FLC, pulsatile umbilical vein, and presence of mitral regurgitation were significantly associated with recipient demise in utero. Since the application of the Solomon technique, the survival rate has improved from 75.4% to 88.8%. The FLC before 17 weeks was associated with PPROM within one week after FLC and lower survival rate, whereas that after 24 weeks was associated with twin anemia-polycythemia sequence and higher survival rate. We reached a survival rate of 82% for at least one survival with only 12 procedures. CONCLUSIONS FLC is an effective treatment for TTTS. The learning curve reached the acceptable target faster than in previous studies. Several prenatal parameters are identified as predictive factors of fetal survival in TTTS treated with FLC.
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Affiliation(s)
- Rina Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jung-Min Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yoo-Jin Lee
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Ba-Da Jeong
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Hwa-Jung Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Republic of Korea
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Akuchie C, Renaud EJ, Watson-Smith D, Carr SR, Luks FI. Minimizing Individual Learning Curves in a Mature Endoscopic Fetal Surgery Program. Fetal Diagn Ther 2020; 47:918-926. [PMID: 32906121 DOI: 10.1159/000509246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 06/06/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Twin-to-twin transfusion syndrome affects monochorionic twin pregnancies and can result in fetal death. Endoscopic laser treatment remains a relatively infrequent procedure for this condition. This presents difficulties for maintaining proficiency and for training new personnel. OBJECTIVE The dual mentoring program at our institution allows for continuous mentoring of new providers. We hypothesize that this approach stabilizes program proficiency despite the addition of new practitioners. METHODS Query of the fetal treatment program database returned 146 cases of laser ablation between 2000 and 2019. Patient and pregnancy characteristics as well as operative time and outcomes were recorded. The learning curve-cumulative summation method and rolling averages were used to analyze outcomes. RESULTS Overall survival was 69%, and survival of at least 1 twin was 89%. Mean operative time was 53.6 ± 20.9 min. Overall twin survival stabilized after the first 40 cases. Rolling averages for operative time decreased from 71 to 49 min for the most recent cases. These results were not affected by the introduction of new surgeons. CONCLUSIONS Creative mentoring can maintain stable overall program outcomes despite changes in team composition. This training approach may be applicable to other rare procedures in fetal surgery.
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Affiliation(s)
| | - Elizabeth J Renaud
- Brown University, Providence, Rhode Island, USA, .,The Fetal Treatment Program of New England, Providence, Rhode Island, USA, .,Division of Pediatric Surgery, Alpert Medical School of Brown University, Hasbro Children's Hospital, Rhode Island Hospital, Providence, Rhode Island, USA,
| | - Debra Watson-Smith
- The Fetal Treatment Program of New England, Providence, Rhode Island, USA
| | - Stephen R Carr
- Brown University, Providence, Rhode Island, USA.,Division of Maternal-Fetal Medicine, Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island, USA
| | - Francois I Luks
- Brown University, Providence, Rhode Island, USA.,The Fetal Treatment Program of New England, Providence, Rhode Island, USA.,Division of Pediatric Surgery, Alpert Medical School of Brown University, Hasbro Children's Hospital, Rhode Island Hospital, Providence, Rhode Island, USA
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9
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Joyeux L, De Bie F, Danzer E, Russo FM, Javaux A, Peralta CFA, De Salles AAF, Pastuszka A, Olejek A, Van Mieghem T, De Coppi P, Moldenhauer J, Whitehead WE, Belfort MA, Lapa DA, Acacio GL, Devlieger R, Hirose S, Farmer DL, Van Calenbergh F, Adzick NS, Johnson MP, Deprest J. Learning curves of open and endoscopic fetal spina bifida closure: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:730-739. [PMID: 31273862 DOI: 10.1002/uog.20389] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 06/18/2019] [Accepted: 06/24/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The Management of Myelomeningocele Study (MOMS) trial demonstrated the safety and efficacy of open fetal surgery for spina bifida aperta (SBA). Recently developed alternative techniques may reduce maternal risks without compromising the fetal neuroprotective effects. The aim of this systematic review was to assess the learning curve (LC) of different fetal SBA closure techniques. METHODS MEDLINE, Web of Science, EMBASE, Scopus and Cochrane databases and the gray literature were searched to identify relevant articles on fetal surgery for SBA, without language restriction, published between January 1980 and October 2018. Identified studies were reviewed systematically and those reporting all consecutive procedures and with postnatal follow-up ≥ 12 months were selected. Studies were included only if they reported outcome variables necessary to measure the LC, as defined by fetal safety and efficacy. Two authors independently retrieved data, assessed the quality of the studies and categorized observations into blocks of 30 patients. For meta-analysis, data were pooled using a random-effects model when heterogeneous. To measure the LC, we used two complementary methods. In the group-splitting method, competency was defined when the procedure provided results comparable to those in the MOMS trial for 12 outcome variables representing the immediate surgical outcome, short-term neonatal neuroprotection and long-term neuroprotection at ≥ 12 months of age. Then, when raw patient data were available, we performed cumulative sum analysis based on a composite binary outcome defining successful surgery. The composite outcome combined four clinically relevant variables for safety (absence of extreme preterm delivery < 30 weeks, absence of fetal death ≤ 7 days after surgery) and efficacy (reversal of hindbrain herniation and absence of any neonatal treatment of dehiscence or cerebrospinal fluid leakage at the closure site). RESULTS Of 6024 search results, 17 (0.3%) studies were included, all of which had low, moderate or unclear risk of bias. Fetal SBA closure was performed using standard hysterotomy (11 studies), mini-hysterotomy (one study) or fetoscopy by either exteriorized-uterus single-layer closure (one study), percutaneous single-layer closure (three studies) or percutaneous two-layer closure (one study). Only outcomes for standard hysterotomy could be meta-analyzed. Overall, outcomes improved significantly with experience. Competency was reached after 35 consecutive cases for standard hysterotomy and was predicted to be achieved after ≥ 57 cases for mini-hysterotomy and ≥ 56 for percutaneous two-layer fetoscopy. For percutaneous and exteriorized-uterus single-layer fetoscopy, competency was not reached in the 81 and 28 cases available for analysis, respectively, and LC prediction analysis could not be performed. CONCLUSIONS The number of cases operated is correlated with the outcome of fetal SBA closure, and the number of operated cases required to reach competency ranges from 35 for standard hysterotomy to ≥ 56-57 for minimally invasive modifications. Our observations provide important information for institutions looking to establish a new fetal center, develop a new fetal surgery technique or train their team, and inform referring clinicians, potential patients and third parties. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L Joyeux
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - F De Bie
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - E Danzer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - F M Russo
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - A Javaux
- Department of Mechanical Engineering, KU Leuven, Leuven, Belgium
| | - C F A Peralta
- Department of Fetal Medicine, The Heart Hospital, University of São Paulo, São Paulo, Brazil
- Department of Fetal Medicine, Pro Matre Hospital, São Paulo, Brazil
| | - A A F De Salles
- Neuroscience Institute, The Heart Hospital, University of São Paulo, São Paulo, Brazil
| | - A Pastuszka
- Department of Descriptive and Topografic Anatomy, Medical University of Silesia, Katowice, Poland
- Division of Dentistry, School of Medicine, Zabrze, Poland
| | - A Olejek
- Department of Gynecology, Obstetrics and Gynecologic Oncology, Medical University of Silesia, Bytom, Poland
| | - T Van Mieghem
- Department of Obstetrics and Gynecology, Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - P De Coppi
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Specialist Neonatal and Paediatric Surgery Unit, Great Ormond Street Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Moldenhauer
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - W E Whitehead
- Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Texas Children's Fetal Center, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - D A Lapa
- Fetal Therapy Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - G L Acacio
- Department of Obstetrics and Gynecology, Taubate University, São Paulo, Brazil
| | - R Devlieger
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
| | - S Hirose
- Fetal Care and Treatment Center, UC Davis Children's Hospital, Sacramento, CA, USA
| | - D L Farmer
- Fetal Care and Treatment Center, UC Davis Children's Hospital, Sacramento, CA, USA
| | - F Van Calenbergh
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - N S Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - M P Johnson
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J Deprest
- MyFetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Center for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Women and Child, Fetal Medicine Unit, University Hospitals Leuven, Leuven, Belgium
- Institute of Women's Health, University College London Hospitals, London, UK
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10
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The learning curve in transcatheter aortic valve implantation clinical studies: A systematic review. Int J Technol Assess Health Care 2020; 36:152-161. [DOI: 10.1017/s0266462320000100] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BackgroundTranscatheter aortic-valve implantation (TAVI) has become an essential alternative to surgical aortic-valve replacement in the treatment of symptomatic severe aortic stenosis, and this procedure requires technical expertise. The aim of this study was to identify prospective studies on TAVI from the past 10 years, and then to analyze the quality of information reported about the learning curve.Materials and methodsA systematic review of articles published between 2007 and 2017 was performed using PubMed and the EMBASE database. Prospective studies regarding TAVI were included. The quality of information reported about the learning curve was evaluated using the following criteria: mention of the learning curve, the description of a roll-in phase, the involvement of a proctor, and the number of patients suggested to maintain skills.ResultsA total of sixty-eight studies met the selection criteria and were suitable for analysis. The learning curve was addressed in approximately half of the articles (n = 37, 54 percent). However, the roll-in period was mentioned by only eight studies (12 percent) and with very few details. Furthermore, a proctorship was disclosed in three articles (4 percent) whereas twenty-five studies (37 percent) included authors that were proctors for manufacturers of TAVI.ConclusionMany prospective studies on TAVI over the past 10 years mention learning curves as a core component of successful TAVI procedures. However, the quality of information reported about the learning curve is relatively poor, and uniform guidance on how to properly assess the learning curve is still missing.
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Abstract
In recent years there has been a growing trend for physician groups to develop guidelines to establish levels of hospital care based on health care team expertise and physical resources. A growing number of fetal centers have been established as the field of fetal medicine continues to evolve. In 2015, the state of Texas began an initiative to develop guidelines for the certification of fetal centers. After significant input from clinicians, a series of rules was developed by the Department of Health and Human Services. Site visits for certification are expected to begin in the near future. Specific leadership, personnel, and facility requirements were developed. Maternal as well as fetal and neonatal outcomes were mandated to be transparent to the public through websites. A commitment to ongoing research and the education of future fetal interventionists was included. Lessons learned from this process should be considered when a national fetal center certification process is developed. Although the Texas legislation defined only a single level of fetal center, a multi-tier designation system, much like that used to define levels of neonatal and maternity care, would be a more acceptable approach. A level I center would offer diagnostic and needle-based procedures, and a level III center would offer all evidence-based fetal procedures. Because the field of fetal medicine and intervention continues to advance rapidly, a national certification process for fetal centers should be considered.
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12
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Abbasi N, Cortes MS, Ruano R, Johnson A, Morgan T, Coleman B, Baschat A, Zaretsky M, Lim FY, Bulas D, Benachi A, Ryan G. Variability in antenatal prognostication of fetal diaphragmatic hernia across the North American Fetal Therapy Network (NAFTNet). Prenat Diagn 2019; 40:342-350. [PMID: 31600412 DOI: 10.1002/pd.5560] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 08/22/2019] [Accepted: 09/07/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate variability in antenatal sonographic prognostication of congenital diaphragmatic hernia (CDH) within the North American Fetal Therapy Network (NAFTNet). METHODS NAFTNet centre were invited to complete a questionnaire and participate in videoconference calls, during which participants were observed while measuring lung area by ultrasound using the anteroposterior (AP) method, longest method, and trace method. Each center identified 1-2 experienced fetal medicine specialist(s) or medical imaging specialists locally to participate in the study. Practices were compared among NAFTNet centre within and without the fetal endoscopic tracheal occlusion (FETO) consortium. RESULTS Nineteen participants from 9 FETO center and 30 participants from 17 non-FETO center completed the survey and 31 participants were interviewed and observed while measuring sonographic lung area. All Centres measured observed-to-expected lung-to-head ratio (o/e LHR) or LHR for CDH prognostication. Image selection criteria for lung area measurement were consistent, including an axial section of the chest with clear lung borders and a 4-chamber cardiac view. Lung area measurement methods varied across NAFTNet, with most centre using longest (4/9 FETO vs. 13/29 non-FETO) or trace (3/9 FETO vs. 11/29 non-FETO) method. Centres differed in expected reference ranges for o/e LHR determination and whether the lowest, highest or average o/e LHR was utilized. CONCLUSION Variability in antenatal sonographic prognostication of CDH was identified across NAFTNet, indicating a need for consensus-based standardization.
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Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Magda Sanz Cortes
- Department of Obstetrics & Gynecology, Texas Children's Fetal Center. Baylor College of Medicine, Houston, Texas, USA
| | - Rodrigo Ruano
- Division of Maternal-Fetal Medicine, Dept. of Obstetrics & Gynecology, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anthony Johnson
- The Fetal Center, Children's Memorial Hermann Hospital, University of Texas Health Science Centre, Houston, Texas
| | - Tara Morgan
- The Fetal Treatment Center, Department of Radiology, University of California, San Francisco, San Francisco, California
| | - Beverly Coleman
- Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ahmet Baschat
- Center for Fetal Therapy, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael Zaretsky
- Colorado Fetal Care Center, Colorado Children's Hospital, University of Colorado, Aurora, Colorado
| | - Foong Yen Lim
- Fetal Care Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dorothy Bulas
- Children's National Medical System, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alexandra Benachi
- Centre Maladie Rare: Hernie de Coupole Diaphragmatique, Hôpital Antoine-Béclère, Clamart, France.,Service de Gynécologie-Obstétrique, AP-HP, Hôpital Antoine Béclère, Université Paris-Sud, Clamart, France
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Phithakwatchara N, Nawapun K, Viboonchart S, Jaingam S, Wataganara T. Simulation‐based fetal shunting training. Prenat Diagn 2019; 39:1291-1297. [DOI: 10.1002/pd.5599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/18/2019] [Accepted: 10/19/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Nisarat Phithakwatchara
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Katika Nawapun
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Sommai Viboonchart
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Suparat Jaingam
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
| | - Tuangsit Wataganara
- Division of Maternal‐Fetal Medicine, Department of Obstetrics and GynecologyFaculty of Medicine Siriraj Hospital Bangkok Thailand
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Using Simulation to Define the Learning Curve for the Digital Cervical Examination. Obstet Gynecol 2019; 134 Suppl 1:1S-8S. [PMID: 31568034 DOI: 10.1097/aog.0000000000003433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION To assess how skill in the digital cervical examination is acquired in medical students. METHODS In a longitudinal study, medical students completed 200 simulated cervical examinations. We performed regressions of each student's cumulative accuracy using the linear, power, and sigmoidal models to determine best fit. We also constructed multilevel models to determine the influence of dilation and effacement on accuracy and to determine whether the starting level and rate of learning varied between individuals. To assess skill decay, we assessed accuracy at 1, 2, and 5 months after training. We defined the amount of sustained accuracy needed to achieve competence using cumulative summation analyses and determined the amount of practice needed to reach this level of skill. RESULTS Twenty-five medical students participated. The median (interquartile range) of cumulative accuracy at the end of the study was 69% (65-78) for dilation and 80% (76-91) for effacement. The sigmoidal model had the best fit. All students achieved competence during the study. The multilevel models showed that accuracy decreased with higher dilation and lower effacement and found that starting level and rate of learning varied between individuals. Maximal accuracy in both dilation and effacement was seen after 150 repetitions. Accuracy of the medical students persisted for 1 month for dilation and 2 months for effacement. The average±SD number of repetitions needed to achieve competence was 89±46 (range 35-195) for dilation and 48±38 (range 11-174) for effacement. DISCUSSION Based on the variability in skill between individuals and the rate of skill acquisition and decay, we feel that a competence-based rather than time-based approach is most appropriate, that trainee performance should be monitored both during and after training, and that 150 repetitions, or more, should be included in any digital cervical examination simulation regimen.
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15
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Loh M, Bhatia A, Tan KL, Thia E, Yeo GSH. Outcomes following selective fetoscopic laser ablation for twin-to-twin transfusion syndrome: a single-centre experience. Singapore Med J 2019; 61:523-531. [PMID: 31489429 DOI: 10.11622/smedj.2019107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Fetoscopic laser photocoagulation (FLP), a treatment option for twin-to-twin transfusion syndrome (TTTS) in monochorionic twin pregnancies, is currently the treatment of choice at our centre. We previously reported on our experience of FLP from June 2011 to March 2014. This paper audits our fetal surgery performance since then. METHODS 15 consecutive patients who underwent FLP for Stage II-III TTTS before 26 weeks of gestation from June 2011 to January 2017 were retrospectively reviewed, consisting of five cases from our initial experience and ten subsequent cases. Perioperative, perinatal and neonatal outcomes were analysed. RESULTS Of 15 pregnancies, 10 (66.7%) and 5 (33.3%) were for Stage II and III TTTS respectively, with FLP performed at an earlier Quintero stage in the later cohort. Overall mean gestational ages at presentation, laser and delivery were comparable between the cohorts at 19.7 (15.4-24.3) weeks, 20.3 (16.3-25.0) weeks and 31.2 (27.6-37.0) weeks, respectively. 2 (13.3%) cases had intra-amniotic bleeding and 1 (6.7%) had iatrogenic septostomy. 1 (6.7%) case had persistent TTTS requiring repeat FLP, and another (6.7%) had preterm premature rupture of membranes at seven weeks post procedure. The overall perinatal survival rate was 21 (75.0%) out of 28 infants. One mother underwent termination of pregnancy for social reasons at 1.4 weeks post procedure. Double survival occurred in 8 (57.1%) out of 14 pregnancies, while 13 (92.9%) had at least one survivor. CONCLUSION FLP requires a highly specialised team and tertiary neonatal facility. Continual training improves maternal and perinatal outcomes, ensuring comparable standards with international centres.
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Affiliation(s)
- Michelle Loh
- Department of Obstetrics and Gynaecology, KK Women's and Children's Hospital, Singapore
| | - Anju Bhatia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Kai Lit Tan
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - Edwin Thia
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
| | - George Seow Heong Yeo
- Department of Maternal Fetal Medicine, KK Women's and Children's Hospital, Singapore
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16
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Bergh EP, Donepudi R, Bell CS, Moise KJ, Johnson A, Papanna R. Distance Traveled to a Fetal Center and Pregnancy Outcomes in Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2019; 47:451-456. [PMID: 31487738 DOI: 10.1159/000501774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/26/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Fetoscopic laser photocoagulation (FLP) is the definitive treatment for twin-twin transfusion syndrome (TTTS). Due to variability in geographic proximity to high-volume fetal centers, many patients travel great distances to receive experienced care. We sought to determine whether distance traveled (DT) is associated with gestational age (GA) at delivery and neonatal survival. METHODS A prospective cohort study of patients within the continental United States referred to our center between September 23, 2011 and July 25, 2018 undergoing planned FLP for TTTS (n = 393; GA 20.6 ± 2.5 weeks; stage I: n = 50; stage II: n = 118; stage III: n = 208; stage IV: n = 17) was performed. The great-circle distance to our center was calculated using patients' home zip codes. DT was stratified into groups containing equal patient numbers and pregnancy outcomes assessed. RESULTS A total of 393 patients met the inclusion criteria. The threshold distance from our center was <250 miles (n = 181), 250-499 miles (n= 119), and ≥500 miles (n = 93). There was no significant difference between any of the preoperative variables among the three groups, with the exception of race and rural status. Furthermore, there was no significant association between DT and GA at delivery (p = 0.34), time interval from procedure to delivery (p = 0.37), and the number of neonatal survivors (p= 0.21). Preterm premature rupture of membranes (PPROM) at <34 weeks was highest (47.9%, p = 0.04) in the group traveling 250-499 miles. CONCLUSION To our knowledge, this is the largest study to show that in TTTS, DT is not associated with GA at delivery, time interval from procedure to delivery, or neonatal survival. Although PPROM at <34 weeks was higher in the group traveling 250-499 miles, there was no significant difference in GA at delivery. While patients with advanced disease may choose to seek treatment based on proximity, traveling long distances does not adversely affect pregnancy outcomes.
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Affiliation(s)
- Eric P Bergh
- The Fetal Center, Department of Obstetrics, Children's Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UTHealth, McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Roopali Donepudi
- Texas Children's Fetal Center, Departments of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Cynthia S Bell
- McGovern Medical School at UTHealth, Center for Clinical Research and Evidence-Based Medicine, Houston, Texas, USA
| | - Kenneth J Moise
- The Fetal Center, Department of Obstetrics, Children's Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UTHealth, McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Anthony Johnson
- The Fetal Center, Department of Obstetrics, Children's Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UTHealth, McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Ramesha Papanna
- The Fetal Center, Department of Obstetrics, Children's Memorial Hermann Hospital, Gynecology and Reproductive Sciences, UTHealth, McGovern Medical School, University of Texas, Houston, Texas, USA,
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Spruijt MS, Lopriore E, Tan RNGB, Slaghekke F, Klumper FJCM, Middeldorp JM, Haak MC, Oepkes D, Rijken M, van Klink JMM. Long-Term Neurodevelopmental Outcome in Twin-to-Twin Transfusion Syndrome: Is there still Room for Improvement? J Clin Med 2019; 8:jcm8081226. [PMID: 31443258 PMCID: PMC6723379 DOI: 10.3390/jcm8081226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/02/2019] [Accepted: 08/12/2019] [Indexed: 12/23/2022] Open
Abstract
Despite many developments in its management, twin-to-twin transfusion syndrome (TTTS) remains an important risk factor for long-term neurodevelopmental impairment (NDI). Our objective was to compare the incidence of severe NDI in a recent cohort of TTTS survivors, treated with laser surgery from 2011 to 2014, with a previous cohort treated from 2008 to 2010. Neurological, cognitive, and motor development were assessed at two years of age. We determined risk factors associated with Bayley-III scores. Severe NDI occurred in 7/241 (3%) survivors in the new cohort compared to 10/169 (6%) in the previous cohort (p = 0.189). Disease-free survival (survival without severe impairment) did not significantly differ. Low birth weight and being small for gestational age (SGA) were independently associated with lower cognitive scores (both p < 0.01). Severe cerebral injury was related to decreased motor scores (B = −14.10; 95% CI −3.16, −25.04; p = 0.012). Children with severe NDI were born ≥32 weeks’ gestation in 53% of cases and had no evidence of cerebral injury on cranial ultrasound in 59% of cases. Our results suggest that improvement in outcome of TTTS has reached a plateau. Low birth weight, SGA, and cerebral injury are risk factors for poor neurodevelopmental outcome. Neither gestational age above 32 weeks nor the absence of cerebral injury preclude severe NDI.
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Affiliation(s)
- Marjolijn S Spruijt
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Ratna N G B Tan
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Femke Slaghekke
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Frans J C M Klumper
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Johanna M Middeldorp
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Monique C Haak
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Dick Oepkes
- Department of Obstetrics, Division of Fetal Therapy, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Monique Rijken
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Jeanine M M van Klink
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, J7-48, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Ding D, Jiang H, Nie J, Liu X, Guo SW. Concurrent Learning Curves of 3-Dimensional and Robotic-Assisted Laparoscopic Radical Hysterectomy for Early-Stage Cervical Cancer Using 2-Dimensional Laparoscopic Radical Hysterectomy as a Benchmark: A Single Surgeon's Experience. Med Sci Monit 2019; 25:5903-5919. [PMID: 31392971 PMCID: PMC6698092 DOI: 10.12659/msm.914952] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background For early-stage cervical cancers, radical hysterectomy (RH) with pelvic lymphadenectomy has been the standard care. This study compared the learning curves and intra-, peri-, and post-operative outcomes for 3-dimensional laparoscopic RH (3D-LRH) and robotic-assisted (RA)-LRH by a surgeon highly skilled in 2-dimensional (2D)-LRH for treatment of early-stage cervical cancer. Material/Methods Two hundred and thirty-nine patients with early-stage cervical cancer (FIGO stage: Ia2–IIa2) admitted to Shanghai Obstetrics and Gynecology Hospital, Fudan University were recruited into this prospective study: 54, 85, and 100 patients underwent 2D-, 3D-, and RA-LRH, respectively and were followed up. Patients’ demographic, clinical, and operative information was retrieved and compared. CUSUM (cumulative summation) analysis using a benchmark derived from previously performed 2D-LRHs. Results Both 3D- and RA-LRH had a steep learning curve. 3D-LRH was superior to 2D- and RA-LRH in terms of significantly shorter operating time. For all approaches, the operating time was associated with the uterus size of the patient and was not affected by other parameters. All approaches of LRH yielded comparable radicality and operative results other than operative time. Conclusions Both 3D- and RA-LRH approaches had similar radicality, and intra-operative and post-operative complication rates, however, 3D-LRH had the shortest operating time and lowest amount of blood loss. After reaching proficiency, RA-LRH had comparable operating time with that of 2D-LRH, and might be even shorter in cases where surgeon has acquired more experience. In countries where labor costs are low; 3D-LRH might be preferable to 2D- and RA-LRH for early-stage cervical cancer.
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Affiliation(s)
- Ding Ding
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland)
| | - Hongyuan Jiang
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland)
| | - Jichan Nie
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland)
| | - Xishi Liu
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland).,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China (mainland)
| | - Sun-Wei Guo
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China (mainland).,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China (mainland)
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Fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome treatment: initial experience in tertiary reference center in Brazil. Obstet Gynecol Sci 2018; 61:461-467. [PMID: 30018900 PMCID: PMC6046365 DOI: 10.5468/ogs.2018.61.4.461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/06/2018] [Accepted: 01/15/2018] [Indexed: 11/08/2022] Open
Abstract
Objective To evaluate the initial maternal and perinatal outcomes of fetoscopic laser photocoagulation for the treatment of twin-to-twin transfusion syndrome (TTTS) in a referral center in Brazil. Methods This prospective observational study analyzed 24 fetoscopic laser photocoagulation procedures at 18–26 weeks of gestation. TTTS severity was determined using the Quintero classification. Blood vessels that crossed the interamniotic membrane were nonselectively photocoagulated. The χ2 test and Mann-Whitney U test were used for the statistical analysis. Results The mean (±standard deviation) age of pregnant women, gestational age at surgery, surgical time, gestational age at birth, and newborn weight were 32.2±4.1 years, 20.7±2.9 weeks, 51.8±16.7 minutes, 30.5±4.1 weeks, and 1,531.0±773.1 g, respectively. Using the Quintero classification, there was a higher percentage of cases in stage III (54.2%), followed by stages IV (20.8%), II (16.7%), and I (8.3%). Ten (41.7%) donor fetuses died and 14 (58.3%) donor fetuses survived until the end of gestation. Placental insertion location (anterior vs. posterior) did not affect the incidence of iatrogenic septostomy, surface bleeding, and premature rupture of membranes until the end of gestation. The death rate of donor and recipient fetuses before 24th gestational week increased with severity of TTTS. Conclusion The maternal and perinatal outcomes resulting from the implementation of a new minimally invasive surgical technique are in line with those obtained in major centers worldwide, considering the learning curves and infrastructures.
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Diehl W, Diemert A, Grasso D, Sehner S, Wegscheider K, Hecher K. Fetoscopic laser coagulation in 1020 pregnancies with twin-twin transfusion syndrome demonstrates improvement in double-twin survival rate. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:728-735. [PMID: 28477345 DOI: 10.1002/uog.17520] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 04/08/2017] [Accepted: 04/27/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the growing experience and learning curve of fetoscopic laser coagulation of the placental vascular anastomoses in severe mid-trimester twin-twin transfusion syndrome (TTTS) and its influence on perinatal outcome in a single-center setting. METHODS Between January 1995 and March 2013 we performed laser therapy in 1020 consecutive pregnancies with TTTS between 15.1 and 27.4 weeks' gestation. We compared perinatal outcome in blocks of five sequential groups of 200 cases, taking into account several covariates in order to adjust for case mix and to demonstrate learning curves and success rates. RESULTS The percentage of pregnancies with survival of both fetuses increased from 50.0% (n = 100) in the first 200 cases to 69.5% (n = 153) in the last 220 cases (P = 0.018 for trend) and the overall survival rate for both fetuses in the complete series of 1019 cases with known outcome was 63.3% (n = 645). The survival rate of at least one fetus increased from 80.5% (161/200) in the first group to 91.8% (202/220) in the last group (P = 0.072 for trend) and the overall survival rate of at least one fetus in the complete series was 86.7% (883/1019). In the total population, the mean gestational age at delivery of pregnancies with at least one liveborn neonate was 33.7 ± 3.2 weeks, with a mean interval of 12.9 ± 4.0 weeks between intervention and delivery. Among the first two groups, 124 pregnancies had anterior placentae and were treated with a 0° fetoscope. These cases had the poorest overall outcome, with a double-twin survival rate of 44.4% (55/124), which increased to 65.1% (207/318; P = 0.001) after the introduction of a 30° fetoscope for cases with anterior placenta. The success rate for double-twin survival reached a plateau of 69% at 600 procedures, a rate equalled by a new operator who was trained hands-on and performed 174 of the last 400 procedures. CONCLUSIONS We report the largest single-center experience of laser coagulation in TTTS. We observed a continuous increase in double-twin survival rate owing to the growing experience based on the learning curve and refinements in fetoscopic instruments and techniques. These data provide strong arguments for the centralization of minimally invasive intrauterine surgery in specialized high-volume centers. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- W Diehl
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - D Grasso
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Sehner
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Segna E, Caruhel JB, Corre P, Picard A, Biau D, Khonsari RH. Quantitative assessment of the learning curve for cleft lip repair using LC-CUSUM. Int J Oral Maxillofac Surg 2017; 47:366-373. [PMID: 29111102 DOI: 10.1016/j.ijom.2017.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 08/20/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
The first step in cleft lip repair is the precise positioning of anatomical landmarks and tracing of the incisions on the patient's lip at the beginning of the procedure. The aim of this study was to evaluate progress made in learning cleft lip repair tracing using a quantitative assessment of learning curves: LC-CUSUM (learning curve - cumulative sum). Eight surgical residents were enrolled and asked to trace lip repair incisions on five cases of unilateral left cleft lip over 5 consecutive weeks. Results were compared to a reference tracing based on the positioning of nine anatomical landmarks and assessed using LC-CUSUM. Competence was defined as the accurate positioning of the nine landmarks (less than 1.4mm deviation from the reference positions, with an accepted 15% failure rate). After five tracing sessions, competence was not achieved evenly for all trainees, or for all landmarks, underlining differences in inter-individual learning ability even with similar training. However, despite an initial marked lack of theoretical and practical training in lip repair techniques, repeated drawings of cleft lip incisions allowed a satisfactory level of competence to be reached for most landmarks and most trainees. Nevertheless it was found that not all landmarks are understood by students with similar ease, and that landmark positioning reveals significant inter-individual differences. This approach allowed a global assessment of the teaching of cleft repair and will help to focus training on specific problematic points for which competence was not obtained according to the LC-CUSUM test.
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Affiliation(s)
- E Segna
- Ospedale Maggiore Policlinico di Milano, Unità Operativa di Chirurgia Maxillo-facciale e Odontostomatologia, Università di Milano-Bicocca, Milan, Italy
| | - J-B Caruhel
- Assistance Publique - Hôpitaux de Paris, Service de Chirurgie Maxillofaciale, Hôpital Universitaire Pitié-Salpêtrière, Université Paris-Descartes, Paris, France
| | - P Corre
- Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - A Picard
- Assistance Publique - Hôpitaux de Paris, Service de Chirurgie Maxillofaciale et Plastique, Hôpital Necker Enfants-Malades, Université Paris-Descartes, Paris, France
| | - D Biau
- Assistance Publique - Hôpitaux de Paris, Service de Chirurgie Orthopédique, Hôpital Cochin Port-Royal, Université Paris-Descartes, Paris, France
| | - R H Khonsari
- Assistance Publique - Hôpitaux de Paris, Service de Chirurgie Maxillofaciale et Plastique, Hôpital Necker Enfants-Malades, Université Paris-Descartes, Paris, France.
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22
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Linsk AM, Monden KR, Sankaranarayanan G, Ahn W, Jones DB, De S, Schwaitzberg SD, Cao CGL. Validation of the VBLaST pattern cutting task: a learning curve study. Surg Endosc 2017; 32:1990-2002. [PMID: 29052071 DOI: 10.1007/s00464-017-5895-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 09/16/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Mastery of laparoscopic skills is essential in surgical practice and requires considerable time and effort to achieve. The Virtual Basic Laparoscopic Skill Trainer (VBLaST-PC©) is a virtual simulator that was developed as a computerized version of the pattern cutting (PC) task in the Fundamentals of Laparoscopic Surgery (FLS) system. To establish convergent validity for the VBLaST-PC©, we assessed trainees' learning curves using the cumulative summation (CUSUM) method and compared them with those on the FLS. METHODS Twenty-four medical students were randomly assigned to an FLS training group, a VBLaST training group, or a control group. Fifteen training sessions, 30 min in duration per session per day, were conducted over 3 weeks. All subjects completed pretest, posttest, and retention test (2 weeks after posttest) on both the FLS and VBLaST© simulators. Performance data, including time, error, FLS score, learning rate, learning plateau, and CUSUM score, were analyzed. RESULTS The learning curve for all trained subjects demonstrated increasing performance and a performance plateau. CUSUM analyses showed that five of the seven subjects reached the intermediate proficiency level but none reached the expert proficiency level after 150 practice trials. Performance was significantly improved after simulation training, but only in the assigned simulator. No significant decay of skills after 2 weeks of disuse was observed. Control subjects did not show any learning on the FLS simulator, but improved continually in the VBLaST simulator. CONCLUSIONS Although VBLaST©- and FLS-trained subjects demonstrated similar learning rates and plateaus, the majority of subjects required more than 150 trials to achieve proficiency. Trained subjects demonstrated improved performance in only the assigned simulator, indicating specificity of training. The virtual simulator may provide better opportunities for learning, especially with limited training exposure.
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Affiliation(s)
- Ali M Linsk
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | - Woojin Ahn
- Rensselaer Polytechnic Institute, Troy, NY, USA
| | | | - Suvranu De
- Rensselaer Polytechnic Institute, Troy, NY, USA
| | | | - Caroline G L Cao
- Wright State University, 207 Russ Engineering Center, 3640 Colonel Glenn Hwy, Dayton, OH, 45435, USA.
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Snowise S, Mann LK, Moise KJ, Johnson A, Bebbington MW, Papanna R. Preterm prelabor rupture of membranes after fetoscopic laser surgery for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:607-611. [PMID: 27153404 DOI: 10.1002/uog.15958] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/24/2016] [Accepted: 04/29/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To assess the incidence, clinical course, risk factors and outcomes of preterm prelabor rupture of membranes (PPROM) after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS). METHODS This was a prospective observational cohort study of 154 consecutive cases of TTTS. PPROM was defined as rupture of membranes before 34 weeks' gestation. Procedure-to-PPROM and PPROM-to-delivery intervals were determined. Relevant preoperative and intraoperative variables were analyzed by univariate and multivariate logistic regression to determine their impact on PPROM after FLS. RESULTS The incidence of PPROM was 39% (n = 60), occurring at a mean gestational age of 27.2 ± 4.6 weeks. Median procedure-to-PPROM interval was 46 (range, 1-105; interquartile range (IQR), 13-66) days and median PPROM-to-delivery interval was 1 (range, 0-93; IQR, 0-13) day. Mean gestational age at delivery in cases with PPROM was 29.0 ± 4.5 weeks compared with 32.6 ± 3.9 weeks in cases without PPROM (P < 0.0001). Insertion of a collagen plug was the only significant factor found on both univariate and multivariate analysis to be associated with an increased rate of PPROM (odds ratio, 3.1 (95% CI, 1.2-8.0); P = 0.006). There was no statistically significant difference in fetal (P = 0.07) or neonatal (P = 0.08) survival between those with and those without PPROM. CONCLUSIONS PPROM after FLS increases prematurity by 3.6 weeks. The latency period after PPROM was 2 weeks; 50% of patients delivered within 24 h. No variable thought to be associated with PPROM after FLS was found to be significantly associated with this complication. Other etiologies and mechanisms for PPROM after FLS should be explored. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S Snowise
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - L K Mann
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - K J Moise
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - M W Bebbington
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Papanna
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, UT Health-University of Texas Medical School at Houston and The Fetal Center at Children's Memorial Hermann Hospital, Houston, TX, USA
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Malshe A, Snowise S, Mann LK, Boring N, Johnson A, Bebbington MW, Moise KJ, Papanna R. Preterm delivery after fetoscopic laser surgery for twin-twin transfusion syndrome: etiology and risk factors. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:612-616. [PMID: 27222097 DOI: 10.1002/uog.15972] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/23/2016] [Accepted: 05/16/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Preterm delivery after fetoscopic laser surgery (FLS) for twin-twin transfusion syndrome (TTTS) is a major complication. The causative factors leading to preterm delivery continue to be elusive and a better understanding of the risk factors could reduce complications. The objective of this study was to determine the etiology of preterm delivery after FLS for TTTS and its associated risk factors. METHODS This was a secondary analysis of a prospective study of 203 patients with TTTS who underwent FLS at a single center between September 2011 and December 2014. Preoperative, operative, postoperative, delivery and neonatal data were reviewed. Preterm delivery was categorized according to etiology into three groups: spontaneous (SPT), indicated (IND) and elective (ELC). Comparisons between groups were performed by ANOVA. Kaplan-Meier survival analysis was performed to compare the procedure-to-delivery interval between groups. To identify risk factors for preterm delivery, logistic regression, with calculation of relative risks (RR), was performed, with P < 0.05 considered statistically significant. RESULTS Mean gestational age at time of FLS was 20.6 ± 2.4 weeks and mean gestational age at delivery was 30.9 ± 4.7 weeks. Iatrogenic preterm prelabor rupture of membranes (iPPROM) occurred in 39% of cases. SPT preterm delivery occurred in 97 (48%) patients, IND preterm delivery in 65 (32%) and ELC preterm delivery in 41 (20%). In the IND group, 30 (46%) patients delivered for fetal indications, 31 (48%) for maternal indications and four (6%) for combined fetal and maternal indications. The overall chorioamnionitis rate was 6.4%; of these, nine (9%) were in the SPT group and four (6%) were in the IND group, with no case occurring in the ELC group. There was a significant difference in procedure-to-delivery interval between groups (P < 0.0001). Using variables from the ELC group as a baseline, significant risk factors for SPT preterm delivery were iPPROM (RR, 16.2 (95% CI, 4.5-57.7)), preoperative cervical length (RR, 0.96 (95% CI, 0.92-0.998)) and number of anastomoses (RR, 1.14 (95% CI, 1.02-1.27)). Significant risk factors for IND preterm delivery were iPPROM (RR, 9.6 (95% CI, 2.6-35.0)) and number of ablated anastomoses (RR, 1.13 (95% CI, 1.02-1.30)). CONCLUSION iPPROM and an increased number of ablated placental anastomoses were associated independently with SPT and IND preterm deliveries. A shorter preoperative cervical length was associated with SPT preterm delivery. Strategies to prevent iPPROM and for management of cervical length shortening are needed urgently in these pregnancies. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Malshe
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
| | - S Snowise
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - L K Mann
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - N Boring
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - A Johnson
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - M W Bebbington
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - K J Moise
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - R Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, UTHealth Medical School, Houston, TX, USA
- The Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
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Lecointre L, Sananès N, Weingertner AS, Gaudineau A, Akladios C, Cavillon V, Langer B, Favre R. [Fetoscopic laser coagulation in 200 consecutive monochorionic pregnancies with twin-twin transfusion syndrome]. J Gynecol Obstet Hum Reprod 2017; 46:175-181. [PMID: 28403975 DOI: 10.1016/j.jogoh.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 10/09/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To report preoperative data, surgical characteristics, complications and perinatal outcome of twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery, to analyze predictors of neonatal survival and to compare the 100 most recent cases with the older 100. MATERIALS AND METHODS Observational cohort moncentric study of 200 cases of TTTS consecutively treated with fetoscopic laser coagulation between January 2004 and December 2014. RESULTS There were 49 stage I, 88 stage II, 55 stage III and eight stage IV. Median gestation at time of laser was 20.1±3.0 weeks' gestation (WG) whereas median gestation at delivery was 31.6±5.4 WG. Overall perinatal survival rate was 68.0% and 84.0% have one or more surviving twins. Preterm premature rupture of membranes occurred in 39 cases with and the median gestational age for this complication was 28.8±4.6 SA. Predictive factors to have at least one living birth were Quintero stage and gestational age at delivery. In the most recent period, there were significantly more TTTS Quintero stage I treated with laser, more coagulation by the Solomon technique and a larger number of coagulated vessels. CONCLUSION The neonatal survival of TTTS is improved by fetoscopic laser coagulation, preferely by using Solomon tecnhique. The use of active management of stage I is currently on research.
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Affiliation(s)
- L Lecointre
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France.
| | - N Sananès
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France; Inserm, UMR-S 1121, « Biomatériaux et Bioingénierie », 11, rue Humann, 67085 Strasbourg cedex, France
| | - A S Weingertner
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
| | - A Gaudineau
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France; Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - C Akladios
- Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - V Cavillon
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
| | - B Langer
- Pôle de gynécologie-obstétrique, département d'obstétrique, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 1, avenue Molière, 67098 Strasbourg cedex, France
| | - R Favre
- Pôle de gynécologie-obstétrique, département d'échographie et de médecine fœtale, CMCO-HUS, 19, rue Louis-Pasteur, 67300 Schiltigheim/Strasbourg, France
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Yuk JS, Kim YJ, Yi KW, Hur JY, Shin JH. Surgical proficiency decreases the rate of healing abnormalities using anterior transobturator mesh in cystocele women. F1000Res 2016; 5:2662. [PMID: 28003880 PMCID: PMC5166588 DOI: 10.12688/f1000research.10012.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2016] [Indexed: 11/20/2022] Open
Abstract
Aims: The objective of this study is to report the outcomes of cystocele repair with anterior transobutrator mesh kits. Methods: 119 consecutive women with cystoceles were treated between January 2006 and November 2010 by a single surgeon at a university hospital using the anterior transobturator mesh kit procedure. Postoperative follow-up visits were scheduled at 1, 6, and 12 months after surgery. Results: A total of 114 women who were operated on with the anterior transobturator mesh kit completed 12 months of follow-up. The population had a mean age of 65.8 ± 7.0, a body mass index of 25.1 ± 3.0, and a parity average of 4.0 ± 1.7. An overall anatomic cure was reported for 108 patients (94.7%). The Ba point of the POP-Q exam used for grading cystoceles decreased significantly from 2.5 ± 1.6 cm to -2.8 ± 0.8 cm after 12 months (P < 0.01). One patient (0.9%) presented with bladder perforation, and five patients (4.4%) showed with healing abnormalities. Surgical case volume was negatively correlated with healing abnormalities after adjusting for age, body mass index, operation time, and parity (P = 0.15). Conclusion: The surgeon's experience decreases the incidence of healing abnormalities using anterior transobturator mesh in cystocele women. The anatomical cure rate of anterior transobturator mesh is quite good.
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Affiliation(s)
- Jin-Sung Yuk
- Department of Obstetrics and Gynecology, College of Medicine, Gyeongsang National University, Gyeongsang National University Changwon Hospital, Changwon, Korea, South
| | - Yong Jin Kim
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea, South
| | - Kyong Wook Yi
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea, South
| | - Jun-Young Hur
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea, South
| | - Jung-Ho Shin
- Department of Obstetrics and Gynecology, Korea University College of Medicine, Seoul, Korea, South
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Pascual MA, Alcazar JL, Graupera B, Rodriguez I, Guerriero S, Mallafre A, de Lorenzo C, Hereter L. Training Performance in Diagnosis of Congenital Uterine Anomalies With 3-Dimensional Sonography: A Learning Curve Cumulative Summation Analysis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2589-2594. [PMID: 27872415 DOI: 10.7863/ultra.16.02003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/06/2016] [Accepted: 03/11/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES We evaluated learning curve cumulative summation (CUSUM) of 3-dimensional (3D) sonography for diagnosis of congenital uterine anomalies and the deviations of the level of trainees' performance at the control-stage CUSUM. METHODS First-year (R1), second-year (R2), and third-year (R3) residents in obstetrics and gynecology received a training program to learn how to analyze 3D sonographic volumes and to classify congenital uterine anomalies. Each trainee worked on 155 3D sonographic volumes from preselected patients. Their results were evaluated by learning curve CUSUM and standard CUSUM. The time for each volume analysis was calculated for the expert examiner and the trainees. RESULTS Trainees R1, R2, and R3 reached competence at the 85th, 58th, and 40th evaluations, respectively, with success rates of 80%, 81%, and 85%, and kept the process under control with error levels of less than 4.5% until the end of the test. The trainees significantly reduced the average time of the evaluation per volume (P < .001). CONCLUSIONS Learning curve CUSUM provided quantitative indicators of the learning evolution of 3D sonography for diagnosis of congenital uterine anomalies by obstetrics and gynecology residents. The training received by the residents was adequate for diagnosis of congenital uterine anomalies using 3D sonography.
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Affiliation(s)
- M Angela Pascual
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Juan Luís Alcazar
- Department of Obstetrics and Gynaecology, Medical School, University of Navarra, Pamplona, Spain
| | - Betlem Graupera
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Ignacio Rodriguez
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Stefano Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy
| | - Anna Mallafre
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Cristina de Lorenzo
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
| | - Lourdes Hereter
- Department of Obstetrics, Gynecology, and Reproduction, Institut Universitari Dexeus, Barcelona, Spain
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Abstract
Twin-to-twin transfusion syndrome (TTTS) is the major complication of monochorionic (MC) pregnancy. The outcomes of this condition have been significantly improved after the introduction and widespread uptake of fetoscopic laser ablation over the last decade. However, there is still a significant fetal loss rate and morbidity associated with this condition. Improvements in the management of TTTS will require improvements in many areas. They are likely to involve refinements in the prediction of the disease and clarification of the optimum frequency of surveillance and monitoring. Improvements in training for fetoscopic surgery as well as in the technique of fetoscopic laser ablation may lead to better outcomes. New technologies as well as a better understanding of the pathophysiology of TTTS may lead to adjuvant medical therapies that may also improve short- and long-term results.
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Balancing Patient Access to Fetoscopic Laser Photocoagulation for Twin-to-Twin Transfusion Syndrome With Maintaining Procedural Competence: Are Collaborative Services Part of the Solution? Twin Res Hum Genet 2016; 19:276-84. [PMID: 27087260 DOI: 10.1017/thg.2016.24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The benefits of fetoscopic laser photocoagulation (FLP) for treatment of twin-to-twin transfusion syndrome (TTTS) have been recognized for over a decade, yet access to FLP remains limited in many settings. This means at a population level, the potential benefits of FLP for TTTS are far from being fully realized. In part, this is because there are many centers where the case volume is relatively low. This creates an inevitable tension; on one hand, wanting FLP to be readily accessible to all women who may need it, yet on the other, needing to ensure that a high degree of procedural competence is maintained. Some of the solutions to these apparently competing priorities may be found in novel training solutions to achieve, and maintain, procedural proficiency, and with the increased utilization of 'competence based' assessment and credentialing frameworks. We suggest an under-utilized approach is the development of collaborative surgical services, where pooling of personnel and resources can improve timely access to surgery, improve standardized assessment and management of TTTS, minimize the impact of the surgical learning curve, and facilitate audit, education, and research. When deciding which centers should offer laser for TTTS and how we decide, we propose some solutions from a collaborative model.
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Peeters SHP, Akkermans J, Bustraan J, Middeldorp JM, Lopriore E, Devlieger R, Lewi L, Deprest J, Oepkes D. Operator competence in fetoscopic laser surgery for twin-twin transfusion syndrome: validation of a procedure-specific evaluation tool. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:350-355. [PMID: 26307171 DOI: 10.1002/uog.15734] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 07/29/2015] [Accepted: 08/14/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Fetoscopic laser surgery for twin-twin transfusion syndrome is a procedure for which no objective tools exist to assess technical skills. To ensure that future fetal surgeons reach competence prior to performing the procedure unsupervised, we developed a performance assessment tool. The aim of this study was to validate this assessment tool for reliability and construct validity. METHODS We made use of a procedure-specific evaluation instrument containing all essential steps of the fetoscopic laser procedure, which was previously created using Delphi methodology. Eleven experts and 13 novices from three fetal medicine centers performed the procedure on the same simulator. Two independent observers assessed each surgery using the instrument (maximum score: 52). Interobserver reliability was assessed using Spearman correlation. We compared the performance of novices and experts to assess construct validity. RESULTS The interobserver reliability was high (Rs = 0.974, P < 0.001). Checklist scores for experts and novices were significantly different; the median score for novices was 28/52 (54%), whereas that for experts was 47.5/52 (91%) (P < 0.001). The procedure time and fetoscopy time were significantly shorter (P < 0.001) for experts. Residual anastomoses were found in 1/11 (9%) procedures performed by experts and in 9/13 (69%) procedures performed by novices (P = 0.005). Multivariable analysis showed that the checklist score, independent of age and gender, predicted competence. CONCLUSIONS The procedure-specific assessment tool for fetoscopic laser surgery shows good interobserver reliability and discriminates experts from novices. This instrument may therefore be a useful tool in the training curriculum for fetal surgeons. Further intervention studies with reassessment before and after training may increase the construct validity of the tool. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - J Bustraan
- PLATO, Center for Research and Development in Education and Training, Faculty of Social Sciences, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, The Netherlands
| | - R Devlieger
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - L Lewi
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - J Deprest
- Department of Obstetrics, Division of Fetal Medicine, University Hospitals Leuven, Department of Development and Regeneration, KU Leuven, Belgium
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, The Netherlands
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Associations of Genetic Variants at Nongenic Susceptibility Loci with Breast Cancer Risk and Heterogeneity by Tumor Subtype in Southern Han Chinese Women. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3065493. [PMID: 27022606 PMCID: PMC4789034 DOI: 10.1155/2016/3065493] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 01/06/2016] [Accepted: 02/04/2016] [Indexed: 12/05/2022]
Abstract
Current understanding of cancer genomes is mainly “gene centric.” However, GWAS have identified some nongenic breast cancer susceptibility loci. Validation studies showed inconsistent results among different populations. To further explore this inconsistency and to investigate associations by intrinsic subtype (Luminal-A, Luminal-B, ER−&PR−&HER2+, and triple negative) among Southern Han Chinese women, we genotyped five nongenic polymorphisms (2q35: rs13387042, 5p12: rs981782 and rs4415084, and 8q24: rs1562430 and rs13281615) using MassARRAY IPLEX platform in 609 patients and 882 controls. Significant associations with breast cancer were observed for rs13387042 and rs4415084 with OR (95% CI) per-allele 1.29 (1.00–1.66) and 0.83 (0.71–0.97), respectively. In subtype specific analysis, rs13387042 (per-allele adjusted OR = 1.36, 95% CI = 1.00–1.87) and rs4415084 (per-allele adjusted OR = 0.82, 95% CI = 0.66–1.00) showed slightly significant association with Luminal-A subtype; however, only rs13387042 was associated with ER−&PR−&HER2+ tumors (per-allele adjusted OR = 1.55, 95% CI = 1.00–2.40), and none of them were linked to Luminal-B and triple negative subtype. Collectively, nongenic SNPs were heterogeneous according to the intrinsic subtype. Further studies with larger datasets along with intrinsic subtype categorization should explore and confirm the role of these variants in increasing breast cancer risk.
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Hui L, Tabor A, Walker SP, Kilby MD. How to safeguard competency and training in invasive prenatal diagnosis: 'the elephant in the room'. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:8-13. [PMID: 26643796 DOI: 10.1002/uog.15806] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 10/21/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
Affiliation(s)
- L Hui
- Perinatal Medicine, Mercy Hospital for Women, Heidelberg, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
- Public Health Genetics, Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - A Tabor
- Center of Fetal Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Medicine and Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S P Walker
- Perinatal Medicine, Mercy Hospital for Women, Heidelberg, VIC, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, Australia
| | - M D Kilby
- Fetal Medicine Centre, Birmingham Women's Foundation Trust, and University of Birmingham, Birmingham, UK
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Kim SH, Jung E, Lee MY, Lee BS, Won HS, Kim EAR, Kim KS. The Impact of Introduction of Fetoscopic Laser Surgery on Twin-to-Twin Transfusion Syndrome. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.4.203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Soo Hyun Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Euiseok Jung
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mi-Young Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Sop Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Sung Won
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ellen Ai-Rhan Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Soo Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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The North American Fetal Therapy Network Consensus Statement: Management of Complicated Monochorionic Gestations. Obstet Gynecol 2015; 126:575-584. [PMID: 26244534 DOI: 10.1097/aog.0000000000000994] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The North American Fetal Therapy Network is a consortium of 30 medical institutions in the United States and Canada with established expertise in fetal therapy and other forms of multidisciplinary care for complex fetal disorders. This publication is the third in a series of articles written by NAFTNet about monochorionic pregnancies. In this article, we provide the general obstetric practitioner with information regarding management options available for complications of monochorionic gestations. This information may be useful for a better understanding of the pathophysiology of the various conditions, for better patient counseling, for timely referral to a regional treatment center, and for ongoing comanagement after treatment.
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Peeters SHP, Akkermans J, Slaghekke F, Bustraan J, Lopriore E, Haak MC, Middeldorp JM, Klumper FJ, Lewi L, Devlieger R, De Catte L, Deprest J, Ek S, Kublickas M, Lindgren P, Tiblad E, Oepkes D. Simulator training in fetoscopic laser surgery for twin-twin transfusion syndrome: a pilot randomized controlled trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:319-326. [PMID: 26036333 DOI: 10.1002/uog.14916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 05/17/2015] [Accepted: 05/22/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the effect of a newly developed training curriculum on the performance of fetoscopic laser surgery for twin-twin transfusion syndrome (TTTS) using an advanced high-fidelity simulator model. METHODS Ten novices were randomized to receive verbal instructions and either skills training using the simulator (study group; n = 5) or no training (control group; n = 5). Both groups were evaluated with a pre-training and post-training test on the simulator. Performance was assessed by two independent observers and comprised a 52-item checklist for surgical performance (SP) score, measurement of procedure time and number of anastomoses missed. Eleven experts set the benchmark level of performance. Face validity and educational value of the simulator were assessed using a questionnaire. RESULTS Both groups showed an improvement in SP score at the post-training test compared with the pre-training test. The simulator-trained group significantly outperformed the control group, with a median SP score of 28 (54%) in the pre-test and 46 (88%) in the post-test vs 25 (48%) and 36 (69%), respectively (P = 0.008). Procedure time decreased by 11 min (from 44 to 33 min) in the study group vs 1 min (from 39 to 38 min) in the control group (P = 0.69). There was no significant difference in the number of missed anastomoses at the post-training test between the two groups (1 vs 0). Subsequent feedback provided by the participants indicated that training on the simulator was perceived as a useful educational activity. CONCLUSIONS Proficiency-based simulator training improves performance, indicated by SP score, for fetoscopic laser therapy. Despite the small sample size of this study, practice on a simulator is recommended before trainees carry out laser therapy for TTTS in pregnant women.
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Affiliation(s)
- S H P Peeters
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J Akkermans
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - F Slaghekke
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J Bustraan
- PLATO, Center for Research and Development in Education and Training, Faculty of Social Sciences, Leiden, The Netherlands
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - R Devlieger
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - L De Catte
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynecology, Division of Fetal Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - S Ek
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - M Kublickas
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - P Lindgren
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - E Tiblad
- Center for Fetal Medicine, Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm, Sweden
| | - D Oepkes
- Department of Obstetrics, Division of Fetal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Akkermans J, Peeters SHP, Middeldorp JM, Klumper FJ, Lopriore E, Ryan G, Oepkes D. A worldwide survey of laser surgery for twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:168-174. [PMID: 25251913 DOI: 10.1002/uog.14670] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/01/2014] [Accepted: 09/04/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To evaluate differences between international fetal centers in their treatment of twin-twin transfusion syndrome (TTTS) by fetoscopic placental laser coagulation. METHODS Fetal therapy centers worldwide were sent a web-based questionnaire. Participants were identified through networks and through scientific presentations and papers. Questions included physician and center demographics, treatment criteria, operative technique and instrumentation. Laser treatment was compared between low-volume (< 20 procedures/year) and high-volume (≥ 20 procedures/year) centers. Data were analyzed using descriptive statistics. RESULTS Of 106 fetal therapy specialists approached, 76 (72%) from 64 centers in 25 countries responded. Of these, 48% (31/64) of centers and 63% (48/76) of operators performed fewer than 20 laser procedures annually. Comparison of low- and high-volume centers showed differences in technique, gestational age limits for treatment and geography. High-volume centers more often used the Solomon technique and applied wider gestational age limits for treatment. Europe and Asia had more high-volume centers, whereas South America, the Middle East and Australia had mainly low-volume centers. CONCLUSION This survey revealed significant differences between fetal centers in several aspects of fetoscopic placental laser therapy for TTTS. Increasing awareness of TTTS, and of laser coagulation as its preferred treatment, will lead to an increase in centers offering this modality, especially in Asia, Africa, South America and the Middle East. Considering the rarity of TTTS and the relative complexity of the procedure, developing international guidelines for techniques, instrumentation and suggested minimum volumes per center may aid in optimizing perinatal outcome.
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Affiliation(s)
- J Akkermans
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Piessens S, Healey M, Maher P, Tsaltas J, Rombauts L. Can anyone screen for deep infiltrating endometriosis with transvaginal ultrasound? Aust N Z J Obstet Gynaecol 2014; 54:462-8. [DOI: 10.1111/ajo.12242] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 06/26/2014] [Indexed: 01/01/2023]
Affiliation(s)
- Sofie Piessens
- Women's and Children's Program; Monash Health; Clayton Victoria Australia
| | - Martin Healey
- Department of Obstetrics and Gynaecology; University of Melbourne; Parkville Victoria Australia
- Department of Gynaecology; Royal Women's Hospital; Parkville Victoria Australia
| | - Peter Maher
- Department of Obstetrics and Gynaecology; University of Melbourne; Parkville Victoria Australia
- Department Gynaecology; Mercy Hospital for Women; Heidelberg Victoria Australia
| | - Jim Tsaltas
- Women's and Children's Program; Monash Health; Clayton Victoria Australia
| | - Luk Rombauts
- Women's and Children's Program; Monash Health; Clayton Victoria Australia
- Department of Obstetrics and Gynaecology; Monash University; Clayton Victoria Australia
- Monash IVF; Clayton Victoria Australia
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Eichelberger KY, Bengtson AM, Tolleson-Rinehart S, Menard MK. Training needs in operative obstetrics for maternal-fetal medicine fellows. J Matern Fetal Neonatal Med 2014; 28:1467-70. [DOI: 10.3109/14767058.2014.957669] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Dessolle L. Quality control of training and performance in embryo transfer: time to broadcast LC CUSUM and CUSUM tests. Hum Reprod 2014; 29:2353-4. [PMID: 25035433 DOI: 10.1093/humrep/deu181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lionel Dessolle
- CHU Brest, service de gynécologie obstétrique et médecine de la reproduction, Hôpital Morvan, Brest 29200, France
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Curvas de aprendizaje de sumatoria acumulada (CUSUM) en procedimientos básicos de anestesia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rca.2014.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Aguirre Ospina OD, Ríos Medina ÁM, Calderón Marulanda M, Gómez Buitrago LM. Cumulative Sum learning curves (CUSUM) in basic anaesthesia procedures. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2014. [DOI: 10.1016/j.rcae.2014.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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van Klink JM, Koopman HM, van Zwet EW, Middeldorp JM, Walther FJ, Oepkes D, Lopriore E. Improvement in neurodevelopmental outcome in survivors of twin-twin transfusion syndrome treated with laser surgery. Am J Obstet Gynecol 2014; 210:540.e1-7. [PMID: 24412743 DOI: 10.1016/j.ajog.2014.01.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 11/04/2013] [Accepted: 01/02/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare the incidence of neurodevelopmental impairment in surviving children from pregnancies with twin-twin transfusion syndrome (TTTS) treated with laser surgery between 2 time periods. STUDY DESIGN We compared the neurodevelopmental outcome between the first consecutive cohort of TTTS pregnancies treated with laser surgery from 2000 to 2005, with a cohort treated between 2008 and 2010. Neurologic, cognitive, and motor development was evaluated using Bayley scales at 2 years of age corrected for prematurity. RESULTS A total of 229 twin pregnancies were treated with laser surgery, 113 in the first cohort and 106 in the recent cohort. Overall survival increased from 70% (158/226) to 80% (170/212) (P = .014). The incidence of neurodevelopmental impairment decreased from 18% (28/152) to 6% (10/155) (P < .01). In multivariate analysis, severe cerebral injury at birth was independently associated with neurodevelopmental impairment (odds ratio, 34.86; 95% confidence interval, 11.83-102.75; P < .01). CONCLUSION Overall survival in TTTS has improved over time, with a concomitant reduction in the incidence of neurodevelopmental impairment. Research focused on prevention of cerebral injury is needed to further improve outcomes of these complicated twin pregnancies.
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Peeters SHP, Van Zwet EW, Oepkes D, Lopriore E, Klumper FJ, Middeldorp JM. Learning curve for fetoscopic laser surgery using cumulative sum analysis. Acta Obstet Gynecol Scand 2014; 93:705-11. [PMID: 24773155 DOI: 10.1111/aogs.12402] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 04/17/2014] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To identify a learning curve and monitor operator performance for fetoscopic laser surgery for twin-to-twin transfusion syndrome using cumulative sum analysis. DESIGN Retrospective cohort study. SETTING National tertiary referral center for invasive fetal therapy. POPULATION A total of 340 consecutive monochorionic pregnancies with twin-to-twin transfusion syndrome treated with fetoscopic laser coagulation between August 2000 and December 2010. METHODS A learning curve was generated using learning curve cumulative sum analysis and cumulative sum methodology to assess changes in double survival across the case sequence. Laser surgery was initially performed by two operators, joined by a third and fourth operator after 1 and 2 years, respectively. MAIN OUTCOME MEASURES Individual operator performance, double perinatal survival at 4 weeks. RESULTS Overall survival of both twins occurred in 59% (201/340), median gestational age at birth was 32.0 weeks. Cumulative sum graphs showed that level of competence for double survival for the operators was reached after 26, 25, 26, and 35 procedures, respectively. Two operators kept their competence level and continued to improve after completing the initial learning process; two others went out of control at one point in time, according to the cumulative sum boundaries. A difference in learning effect was associated with number of procedures performed annually and previous experience with other ultrasound-guided invasive procedures. CONCLUSIONS This study shows that all operators reached a level of competence after at least 25 fetoscopic laser procedures and confirms the value of using the cumulative sum method both for learning curve assessment and for ongoing quality control.
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Affiliation(s)
- Suzanne H P Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, the Netherlands
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Hodgins JL, Veillette C, Biau D, Sonnadara R. The knee arthroscopy learning curve: quantitative assessment of surgical skills. Arthroscopy 2014; 30:613-21. [PMID: 24725315 DOI: 10.1016/j.arthro.2014.02.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 02/09/2014] [Accepted: 02/13/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess orthopaedic trainees performing diagnostic knee arthroscopies and evaluate procedural competence using a novel statistical method, the Cumulative Summation Test for Learning Curve (LC-CUSUM). METHODS Twenty orthopaedic trainees in postgraduate year (PGY) 1 through 5 performed diagnostic knee arthroscopy and were evaluated intraoperatively with a validated 10-point knee task-specific checklist (TSCL) and 50-point global rating scale (GRS). A score of 40 points or greater (of 50 points) for the GRS and 8 points or greater (of 10 points) for the knee TSCL was considered to indicate a successful procedure. For the LC-CUSUM analysis, adequate performance was defined as a 10% failure rate, inadequate performance was defined as a 30% failure rate, and an acceptable deviation from adequate performance was defined as 10%. A limit h equal to 1.6 was selected to give a true-discovery rate of 90% and a false-discovery rate of 10% over 50 procedures. RESULTS A total of 340 consecutive procedures were performed by 20 trainees during the 12-month study period. The cumulative number of arthroscopic procedures performed by trainees before study start increased with increasing PGY. The median number of arthroscopic procedures performed per trainee was 16.5 (interquartile range, 14 to 21.75). Competency in knee arthroscopy for the TSCL was achieved by 8 trainees (40%), after a median of 16 procedures (interquartile range, 13 to 20), and for the GRS by only a single trainee (5%), after 14 procedures. Threshold-adjusted curves stratified by PGY level enabled multiple trainees to achieve competency for both the TSCL and GRS. CONCLUSIONS The LC-CUSUM can be successfully applied to knee arthroscopy to provide an individualized assessment of performance and quantitatively demonstrate competency for basic arthroscopic tasks. CLINICAL RELEVANCE The LC-CUSUM is an effective method to evaluate procedure competence in arthroscopic training and can provide objective feedback and benchmarks in the learning phase.
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Affiliation(s)
- Justin L Hodgins
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.
| | | | - David Biau
- Département de Chirurgie Orthopédique, Hôpital Cochin, Paris, France
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Dessolle L, Leperlier F, Biau DJ, Fréour T, Barrière P. Proficiency in oocyte retrieval assessed by the learning curve cumulative summation test. Reprod Biomed Online 2014; 29:187-92. [PMID: 24832373 DOI: 10.1016/j.rbmo.2014.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 03/13/2014] [Accepted: 03/19/2014] [Indexed: 11/26/2022]
Abstract
The number of procedures required for a trainee to reach proficiency in oocyte retrieval and the criteria applied to define performance are not well defined. To evaluate the learning curve of oocyte retrieval, this study prospectively evaluated three trainees over 6 months. Oocyte retrieval was monitored by the learning curve-cumulative summation test (LC-CUSUM), a specific statistical tool designed to indicate when a predefined level of performance is reached. Oocytes were retrieved from one ovary by the trainee and from the second ovary by a senior operator in a randomized manner. The main outcome measure was the ratio of oocytes collected and follicles aspirated. A trainee's ratio of ≥ 80% of the senior operator's defined success. From 17 to >50 procedures were necessary for the trainees to reach the predefined level of performance. Cumulative summation tests implemented after the learning phase confirmed that performance was maintained. The present study confirms the large variability in acquiring proficiency for surgical procedures. It provides an exportable model for a quantitative tailored monitoring of the learning curve and for continuous monitoring of performance in oocyte retrieval.
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Affiliation(s)
- Lionel Dessolle
- Service de Biologie et Médecine de la Reproduction, Centre Hospitalier Universitaire de Nantes, 38, Bd Jean Monnet, 44093 Nantes Cedex 1, France.
| | - Florence Leperlier
- Service de Biologie et Médecine de la Reproduction, Centre Hospitalier Universitaire de Nantes, 38, Bd Jean Monnet, 44093 Nantes Cedex 1, France
| | - David J Biau
- Département de Chirurgie Orthopédique, APHP - Hôpital Cochin, Université René Descartes, Paris, France
| | - Thomas Fréour
- Service de Biologie et Médecine de la Reproduction, Centre Hospitalier Universitaire de Nantes, 38, Bd Jean Monnet, 44093 Nantes Cedex 1, France
| | - Paul Barrière
- Service de Biologie et Médecine de la Reproduction, Centre Hospitalier Universitaire de Nantes, 38, Bd Jean Monnet, 44093 Nantes Cedex 1, France
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Campbell RD, Hecker KG, Biau DJ, Pang DSJ. Student attainment of proficiency in a clinical skill: the assessment of individual learning curves. PLoS One 2014; 9:e88526. [PMID: 24586337 PMCID: PMC3930528 DOI: 10.1371/journal.pone.0088526] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 01/08/2014] [Indexed: 11/29/2022] Open
Abstract
The aims of this study were to determine if the learning curve cumulative summation test (LC-CUSUM) can differentiate proficiency in placing intravenous catheters by novice learners, and identify the cause of failure when it occurred. In a prospective, observational study design 6 undergraduate students with no previous experience of placing intravenous catheters received standardized training by a board certified veterinary anesthesiologist in intravenous catheter placement technique. Immediately following training, each student attempted 60 intravenous catheterizations in a dog mannequin thoracic limb model. Results were scored as a success or failure based upon completion of four specific criteria, and where catheter placement failure occurred, the cause was recorded according to pre-defined criteria. Initial acceptable and unacceptable failure rates were set by the study team and the LC-CUSUM was used to generate a learning curve for each student. Using 10% and 25% acceptable and unacceptable failure rates, 3 out of 6 students attained proficiency, requiring between 26 to 48 attempts. Applying 25% and 50% acceptable and unacceptable failure rates, 5 of 6 students obtained proficiency, requiring between 18 and 55 attempts. Wide inter-individual variability was observed and the majority of failed catheterisation attempts were limited to two of the four pre-defined criteria. These data indicate that the LC-CUSUM can be used to generate individual learning curves, inter-individual variability in catheter placement ability is wide, and that specific steps in catheter placement are responsible for the majority of failures. These findings may have profound implications for how we teach and assess technical skills.
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Affiliation(s)
- Robert D. Campbell
- Calgary Animal Referral and Emergency Centre, Calgary, Alberta and the Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kent G. Hecker
- Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David J. Biau
- Département de Biostatistique et Informatique Médicale, Hôpital Saint-Louis, AP-HP Paris, France
| | - Daniel S. J. Pang
- Veterinary Clinical and Diagnostic Sciences, Faculty of Veterinary Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
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Moise KJ, Johnson A, Bebbington MW, Papanna R. The 'Solomon method'. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:238-239. [PMID: 24497423 DOI: 10.1002/uog.13280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 12/10/2013] [Indexed: 06/03/2023]
Affiliation(s)
- K J Moise
- Department of Obstetrics, Gynecology and Reproductive Medicine, UT Health - School of Medicine, Texas Fetal Center, Children's Memorial Hermann Hospital, Houston, TX, USA
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Ruano R, Rodo C, Peiro JL, Shamshirsaz AA, Haeri S, Nomura ML, Salustiano EMA, De Andrade KK, Sangi-Haghpeykar H, Carreras E, Belfort MA. Reply: To PMID 23616360. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:239-240. [PMID: 24497424 DOI: 10.1002/uog.13281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- R Ruano
- Baylor College of Medicine and Texas Children's Hospital, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Houston, TX, USA
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Selective reduction in multiple gestations. Best Pract Res Clin Obstet Gynaecol 2014; 28:239-47. [DOI: 10.1016/j.bpobgyn.2013.12.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 11/13/2013] [Accepted: 12/10/2013] [Indexed: 11/23/2022]
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50
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Cerebral Injury and Neurodevelopmental Outcome in Twin-Twin Transfusion Syndrome. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2013. [DOI: 10.1007/s13669-013-0054-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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