Findings Favor Haptics Feedback in Virtual Simulation Surgical Education: An Updated Systematic and Scoping Review

BACKGROUND

Virtual simulations (VSs) enhance clinical competencies and skills. However, a previous systematic review of 9 RCT studies highlighted a paucity of literature on the effects of haptic feedback in surgical VSs. An updated systematic and scoping review was conducted to encompass more studies and a broader range of study methodologies.

METHODS

A systematic literature search was conducted on July 31, 2023, in MEDLINE, Embase, and Cochrane. English language studies comparing haptic vs non-haptic conditions and using VSs were included. Studies were evaluated and reported using PRISMA-ScR guidelines.

RESULTS

Out of 2782 initial studies, 51 were included in the review. Most studies used RCT (21) or crossover (23) methodologies with medical residents, students, and attending physicians. Most used post-intervention metrics, while some used pre- and post-intervention metrics. Overall, 34 performance results from studies favored haptics, 3 favored non-haptics, and the rest showed mixed or equal results.

CONCLUSION

This updated review highlights the diverse application of haptic technology in surgical VSs. Haptics generally enhances performance, complements traditional teaching methods, and offers personalized learning with adequate simulator validation. However, a sparsity of orienting to the simulator, pre-/post-study designs, and small sample sizes poses concerns with the validity of the results. We underscore the urgent need for standardized protocols, large-scale studies, and nuanced understanding of haptic feedback integration. We also accentuate the significance of simulator validation, personalized learning potential, and the need for researcher, educator, and manufacturer collaboration. This review is a guidepost for navigating the complexities and advancements in haptic-enhanced surgical VSs.

Improving Pediatric Trauma Education by Teaching Non-technical Skills: A Randomized Controlled Trial

BACKGROUND

Pediatric trauma is a significant cause of child mortality, and the absence of non-technical skills (NTS) among health providers is linked with errors in patients' care. In this study, we evaluate the effectiveness of a structured debriefing protocol in enhancing NTS during pediatric trauma simulation.

METHODS

A total of 45 medical students were successfully recruited from two medical schools, one in Brazil and one in Canada. Medical students were assigned to a control (N = 20) or intervention group (N = 25) in a randomized control trial. Following simulated scenarios, participants in the intervention group underwent NTS debriefing, while the control received standard debriefing based on the Advanced Trauma Life Support (ATLS) protocol. Students' confidence, NTS level, and performance were measured through self-assessment surveys, the Non-Technical Skills for Surgeons (NOTSS) score, and adherence to the trauma protocol, respectively. Baseline characteristics and outcomes were compared using t-tests, Mann-Whitney, Wilcoxon signed-rank Kruskal-Wallis, ANOVA, and a repeated-measures ANCOVA. A significance level was set at p < 0.05.

RESULTS

The workshop increased students' confidence in leading trauma resuscitation regardless of their assignment to condition. While controlling for covariates, students in the intervention group significantly improved their overall NOTSS compared to those in the control and in all categories: situational awareness, decision-making, communication and teamwork, and leadership. The intervention teams also demonstrated a significant increase in completing trauma protocol steps.

CONCLUSION

Implementing structured debriefing focusing on NTS enhanced these skills and improved adherence to protocol among medical students managing pediatric trauma-simulated scenarios. These findings support integrating NTS training in pediatric trauma education.

LEVEL OF EVIDENCE

I.

Clinical teaching self-efficacy positively predicts professional fulfillment and negatively predicts burnout amongst Thai physicians: a cross-sectional survey

BACKGROUND

Clinician teachers (physicians who teach in clinical settings) experience considerable psychological challenges in providing both educational training and patient care. This study aimed to determine the prevalence of physician burnout and professional fulfillment, and to identify internal and external factors associated with mental health outcomes among Thai clinician teachers working in non-university teaching hospitals.

METHOD

A one-time online questionnaire was completed by physicians at 37 governmental, non-university teaching hospitals in Thailand, with 227 respondents being assessed in the main analyses. Four outcomes were evaluated including burnout, professional fulfillment, quality of life, and intentions to quit.

RESULTS

The observed prevalence of professional fulfillment was 20%, and burnout was 30.7%. Hierarchical regression analysis showed a significant internal, psychological predictor (clinical teaching self-efficacy) and external, structural predictors (multiple roles at work, teaching support), controlling for the background variables of gender, years of teaching experience, family roles, and active chronic disease, with clinical teaching self-efficacy positively predicting professional fulfillment (b = 0.29, p ≤.001) and negatively predicting burnout (b = - 0.21, p =.003).

CONCLUSIONS

Results highlight the importance of faculty development initiatives to enhance clinical teaching self-efficacy and promote mental health among Thai physicians.

A scoping review of emotions and related constructs in simulation-based education research articles

BACKGROUND

While acknowledgement of emotions' importance in simulation-based education is emerging, there are concerns regarding how education researchers understand the concept of emotions for them to deliberately incorporate emotionally charged scenarios into simulation-based education. This concern is highlighted especially in the context of medical education often lacking strong theoretical integration. To map out how current simulation-based education literature conceptualises emotion, we conducted a scoping review on how emotions and closely related constructs (e.g. stress, and emotional intelligence) are conceptualised in simulation-based education articles that feature medical students, residents, and fellows.

METHODS

The scoping review was based on articles published in the last decade identified through database searches (EMBASE and Medline) and hand-searched articles. Data extraction included the constructs featured in the articles, their definitions, instruments used, and the types of emotions captured. Only empirical articles were included (e.g. no review or opinion articles). Data were charted via descriptive analyses.

RESULTS

A total of 141 articles were reviewed. Stress was featured in 88 of the articles, while emotions and emotional intelligence were highlighted in 45 and 34 articles respectively. Conceptualisations of emotions lacked integration of theory. Measurements of emotions mostly relied on self-reports while stress was often measured via physiological and self-report measurements. Negative emotions such as anxiety were sometimes seen as interchangeable with the term stress. No inferences were made about specific emotions of participants from their emotional intelligence.

CONCLUSIONS

Our scoping review illustrates that learners in simulation-based education are most often anxious and fearful. However, this is partially due to medical education prioritising measuring negative emotions. Further theoretical integration when examining emotions and stress may help broaden the scope towards other kinds of emotions and better conceptualisations of their impact. We call for simulation education researchers to reflect on how they understand emotions, and whether their understanding may neglect any specific aspect of affective experiences their simulation participants may have.

Identifying Royal College-accredited simulation centre research priorities across Canada

To advance the field of health sciences simulation, research must be of high quality and would benefit from multi-institutional collaboration where centres can leverage and share expertise as well as work together to overcome limits to the generalizability of research findings from single-institution studies. A needs assessment in emergency medicine simulation has illustrated the importance of identifying research priorities in Canada. The main purpose of this study was to identify simulation research priority directions for Canadian simulation centres. The current survey study drew on 16 research priorities developed through a two-round internal Delphi study at McGill University that 15 of 17 simulation centre advisory board members participated in. The final 16 research priorities were then rated by a total of 18 of 24 simulation centre directors and/or delegates contacted from 15 of 19 Royal College of Physicians and Surgeons of Canada-accredited simulation centres in Canada. Results revealed nine common research priorities that reached 70% or higher agreement for all respondents. We anticipate that our findings can contribute to building a shared vision of priorities, community, and collaboration to enhance health care simulation research quality amongst Canadian simulation centres.

Nursing Students Reported More Positive Emotions about Training during COVID-19 After Using a Virtual Simulation Paired with an In-person Simulation

Background

Virtual simulations (VS) are educational tools that can help overcome the limitations of in-person learning highlighted during the COVID-19 pandemic. Research has illustrated that VS can support learning, but little is known about the usability of VS as a distance learning tool. Research on students' emotions about VS is also scarce, despite the influence of emotions on learning.

Methods

A quantitative longitudinal study was conducted with undergraduate nursing students. 18 students participated in a hybrid learning experience involving a virtual simulation (VS) followed by an in-person simulation. Students completed questionnaires about their emotions, perceived success, and usability and received a performance score from the VS.

Results

Nursing students reported statistically significant improvements in their emotions about completing their program after completing both VS and in-person simulations compared to their emotions before the pair of simulations. Emotions directed toward the VS were weak-to-moderate in strength, but predominantly positive. Positive emotions were positively associated with nursing students' performance. Findings replicated "okay" approaching "good" usability ratings from a recent study with key methodological differences that used the same software.

Conclusions

VS can be an emotionally positive, effective, efficient, and satisfying distance learning supplement to traditional simulations.

Social-Historical Accounts of Hope and Resilience: Experiences of Prominent Sexual Orientation Minority Elders

Despite the challenges faced by sexual orientation minority (SOM) individuals, many SOM individuals are able to persist and develop resiliency over the course of their lives. The present study explored how prominent SOM elders perceived the LGBTQ+ community as developing hope and resiliency in relation to major events of lesbian, gay, bisexual, transgender, queer (LGBTQ+) rights development. Using a basic qualitative approach, we analyzed interview data and three categories emerged. More specifically, these categories were: (1) internalization of societal views; (2) fostering safety and acceptance by creating a sense of community; and (3) sources of inspiration for initiating change. The resulting categories show the complex interaction of social influences and resiliency during times of societal reformation. We discuss the implications of how group-based emotions and identity processes during times of societal reformation foster a life-long resilience.

A debriefing tool to acquire non-technical skills in trauma courses

Objective

The study reports the use of a nominal group technique (NGT) to evaluate the PEARLS Healthcare debriefing tool as a tool to foster non-technical skills in trauma simulation courses. Additionally, it introduces a debriefing card to be used in trauma courses.

Design

A nominal group technique was used to evaluate the main strategies for PEARLS. The experts had the opportunity to share their opinions in an online survey and online meeting.

Results

Seven participants participated in the nominal group. Based on the online survey results, the self-assessment debriefing strategy (from PEARLS) was rated 4.83/5 in relevance, the focused facilitation 5/5, and the provision of information 4.5/5. Participants felt that PEARLS was appropriate and useful for fostering non-technical skills: all the debriefing strategies contained in PEARLS were felt to be valid and worth using; and cue cards for the instructors were suggested to assist them in conducting structured formal debriefings. A specific debriefing tool for trauma scenarios was designed based on these suggestions, which is presented in this article.

Conclusion

A nominal group of experts in education, simulation, and trauma support PEARLS strategies for non-technical skills training in trauma courses.

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Surgical programs overlook non-technical skills, possibly due to uncertainty regarding their instruction.

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A structured debriefing tool can foster non-technical skills in trauma education.

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This study introduces a debriefing card for trauma scenarios generated by a group of experts.

The use of artificial intelligence and virtual reality in doctor-patient risk communication: A scoping review

OBJECTIVES

While the development of artificial intelligence (AI) and virtual reality (VR) technologies in medicine has been significant, their application to doctor-patient communication is limited. As communicating risk is a challenging, yet essential, component of shared decision-making (SDM) in surgery, this review aims to explore the current use of AI and VR in doctor-patient surgical risk communication.

METHODS

The search strategy was prepared by a medical librarian and run in 7 electronic databases. Articles were screened by a single reviewer. Included articles described the use of AI or VR applicable to surgical risk communication between patients, their families, and the surgical team.

RESULTS

From 4576 collected articles, 64 were included in this review. Identified applications included decision support tools (15, 23.4%), tailored patient information resources (13, 20.3%), treatment visualization tools (17, 26.6%) and communication training platforms (19, 29.7%). Overall, these technologies enhance risk communication and SDM, despite heterogeneity in evaluation methods. However, improvements in the usability and versatility of these interventions are needed.

CONCLUSIONS

There is emerging literature regarding applications of AI and VR to facilitate doctor-patient surgical risk communication.

PRACTICE IMPLICATIONS

AI and VR hold the potential to personalize doctor-patient surgical risk communication to individual patients and healthcare contexts.

Effect of Artificial Intelligence Tutoring vs Expert Instruction on Learning Simulated Surgical Skills Among Medical Students: A Randomized Clinical Trial

IMPORTANCE

To better understand the emerging role of artificial intelligence (AI) in surgical training, efficacy of AI tutoring systems, such as the Virtual Operative Assistant (VOA), must be tested and compared with conventional approaches.

OBJECTIVE

To determine how VOA and remote expert instruction compare in learners' skill acquisition, affective, and cognitive outcomes during surgical simulation training.

DESIGN, SETTING, AND PARTICIPANTS

This instructor-blinded randomized clinical trial included medical students (undergraduate years 0-2) from 4 institutions in Canada during a single simulation training at McGill Neurosurgical Simulation and Artificial Intelligence Learning Centre, Montreal, Canada. Cross-sectional data were collected from January to April 2021. Analysis was conducted based on intention-to-treat. Data were analyzed from April to June 2021.

INTERVENTIONS

The interventions included 5 feedback sessions, 5 minutes each, during a single 75-minute training, including 5 practice sessions followed by 1 realistic virtual reality brain tumor resection. The 3 intervention arms included 2 treatment groups, AI audiovisual metric-based feedback (VOA group) and synchronous verbal scripted debriefing and instruction from a remote expert (instructor group), and a control group that received no feedback.

MAIN OUTCOMES AND MEASURES

The coprimary outcomes were change in procedural performance, quantified as Expertise Score by a validated assessment algorithm (Intelligent Continuous Expertise Monitoring System [ICEMS]; range, -1.00 to 1.00) for each practice resection, and learning and retention, measured from performance in realistic resections by ICEMS and blinded Objective Structured Assessment of Technical Skills (OSATS; range 1-7). Secondary outcomes included strength of emotions before, during, and after the intervention and cognitive load after intervention, measured in self-reports.

RESULTS

A total of 70 medical students (41 [59%] women and 29 [41%] men; mean [SD] age, 21.8 [2.3] years) from 4 institutions were randomized, including 23 students in the VOA group, 24 students in the instructor group, and 23 students in the control group. All participants were included in the final analysis. ICEMS assessed 350 practice resections, and ICEMS and OSATS evaluated 70 realistic resections. VOA significantly improved practice Expertise Scores by 0.66 (95% CI, 0.55 to 0.77) points compared with the instructor group and by 0.65 (95% CI, 0.54 to 0.77) points compared with the control group (P < .001). Realistic Expertise Scores were significantly higher for the VOA group compared with instructor (mean difference, 0.53 [95% CI, 0.40 to 0.67] points; P < .001) and control (mean difference. 0.49 [95% CI, 0.34 to 0.61] points; P < .001) groups. Mean global OSATS ratings were not statistically significant among the VOA (4.63 [95% CI, 4.06 to 5.20] points), instructor (4.40 [95% CI, 3.88-4.91] points), and control (3.86 [95% CI, 3.44 to 4.27] points) groups. However, on the OSATS subscores, VOA significantly enhanced the mean OSATS overall subscore compared with the control group (mean difference, 1.04 [95% CI, 0.13 to 1.96] points; P = .02), whereas expert instruction significantly improved OSATS subscores for instrument handling vs control (mean difference, 1.18 [95% CI, 0.22 to 2.14]; P = .01). No significant differences in cognitive load, positive activating, and negative emotions were found.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, VOA feedback demonstrated superior performance outcome and skill transfer, with equivalent OSATS ratings and cognitive and emotional responses compared with remote expert instruction, indicating advantages for its use in simulation training.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04700384.

Nurses' and Physicians' Distress, Burnout, and Coping Strategies During COVID-19: Stress and Impact on Perceived Performance and Intentions to Quit

INTRODUCTION

Health care providers (HCPs) have experienced more stress and burnout during COVID-19 than before. We compared sources and levels of stress, distress, and approaches to coping between nurses and physicians, and examined whether coping strategies helped mitigate the negative impact of stress and intentions to quit.

METHODS

Using a cross-sectional study design, burnout was measured with the Maslach Burnout Inventory. Psychological distress was measured using the Depression, Anxiety, and Stress Scale. A self-reported survey was used to evaluate stressors, impact on perceived performance, and intentions to quit. The data were analyzed using t-tests and linear regression models.

RESULTS

Responses of 119 HCPs were analyzed. Findings suggest that (1) compared to physicians, nurses experienced a higher level of distress and burnout, and used more maladaptive coping strategies. (2) Both nurses and physicians experienced more distress and burnout during COVID-19 than before. (3) Adaptive coping strategies moderated the negative impact of stress on work performance (4) Adaptive coping strategies moderated the negative effect of stress on burnout, which in turn reduced intentions to quit. Stress negatively impacted work performance and burnout only for those with low, but not high, levels of adaptive coping strategies.

DISCUSSION

The current findings of HCPs' challenges, risks, and protective factors provide valuable information (1) on COVID-19's impact on HCPs, (2) to guide the distribution of institutional supportive efforts and recommend adaptive coping strategies, and (3) to inform medical education, such as resilience training, focusing on adaptive coping approaches.

Exploring the roles of artificial intelligence in surgical education: A scoping review

BACKGROUND

Technology-enhanced teaching and learning, including Artificial Intelligence (AI) applications, has started to evolve in surgical education. Hence, the purpose of this scoping review is to explore the current and future roles of AI in surgical education.

METHODS

Nine bibliographic databases were searched from January 2010 to January 2021. Full-text articles were included if they focused on AI in surgical education.

RESULTS

Out of 14,008 unique sources of evidence, 93 were included. Out of 93, 84 were conducted in the simulation setting, and 89 targeted technical skills. Fifty-six studies focused on skills assessment/classification, and 36 used multiple AI techniques. Also, increasing sample size, having balanced data, and using AI to provide feedback were major future directions mentioned by authors.

CONCLUSIONS

AI can help optimize the education of trainees and our results can help educators and researchers identify areas that need further investigation.

Evaluations of Healthcare Providers' Perceived Support From Personal, Hospital, and System Resources: Implications for Well-Being and Management in Healthcare in Montreal, Quebec, During COVID-19

Increased stressful experiences are pervasive among healthcare providers (HCPs) during the COVID-19 pandemic. Identifying resources that help mitigate stress is critical to maintaining HCPs' well-being. However, to our knowledge, no instrument has systematically examined how different levels of resources help HCPs cope with stress during COVID-19. This cross-sectional study involved 119 HCPs (64 nurses and 55 physicians) and evaluated the perceived availability, utilization, and helpfulness of a list of personal, hospital, and healthcare system resources. Participants also reported on their level of burnout, psychological distress, and intentions to quit. Results revealed that HCPs perceived the most useful personal resource to be family support; the most useful hospital resources were a safe environment, personal protective equipment, and support from colleagues; the most useful system resources were job protection, and clear communication and information about COVID. Moreover, HCPs who perceived having more available hospital resources also reported lower levels of psychological distress symptoms, burnout, and intentions to quit. Finally, although training and counseling services were perceived as useful to reduce stress, training was not perceived as widely available, and counseling services, though reported as being available, were underutilized. This instrument helps identify resources that support HCPs, providing implications for healthcare management.

A scoping review to identify competencies for transcatheter cardiovascular procedures

OBJECTIVES

Transcatheter procedures are increasingly being recognized as a priority for cardiac surgeons and cardiac surgery trainees. The optimal method of teaching these procedures during residency training has not been established. We used an evidence-based approach to systematically review the literature and identify competencies to inform future paradigms of transcatheter training in cardiac surgery.

METHODS

A scoping review was conducted to retrieve relevant literature on the performance of transcatheter cardiovascular procedures, identify competencies required by surgical residents learning to perform these procedures, and develop a preliminary list of competencies for consideration during transcatheter training. MEDLINE, Scopus, and ERIC were queried until April 1, 2020, using a systematic search strategy. No limitations were placed on publication date or type.

RESULTS

A total of 1456 sources of evidence were retrieved. After deduplication and screening, there remained 33 that were included in the scoping review, published between 2006 and 2020. The distribution of publication types included 10 comparative studies (30.3% of total), 8 societal statements (24.2% of total), 5 surveys and 5 opinion articles (each 15.2% of total), 2 editorials and 2 descriptions of a simulator (each 6.1% of total), and 1 narrative review (3.0% of total). From these, a total of 400 items were identified and organized into 97 competencies.

CONCLUSIONS

Evidence on the competencies required to perform transcatheter cardiovascular procedures is available from a variety of sources. The identified competencies may be a useful resource for developing curricula and teaching transcatheter procedures to cardiac surgery residents.

Toward a Feature-Driven Understanding of Students' Emotions during Interactions with Agent-Based Learning Environments

This selective review synthesizes and draws recommendations from the fields of affective computing, intelligent tutoring systems, and psychology to describe and discuss the emotions that learners report experiencing while interacting with agent-based learning environments (ABLEs). Theoretically driven explanations are provided that describe the relative effectiveness and ineffectiveness of different ABLE features to foster adaptive emotions (e.g., engagement, curiosity) vs. non-adaptive emotions (e.g., frustration, boredom) in six different environments. This review provides an analytical lens to evaluate and improve upon research with ABLEs by identifying specific system features and their relationship with learners' appraisals and emotions.

Anterior lumbar interbody fusion: does stable anterior fixation matter?

The purpose of this study was to compare the outcome of anterior lumbar interbody fusion without instrumentation (uninstrumented ALIF) against that with stable anterior cage fixation using Hartshill horseshoe instrumentation (ALIF-HH) for similar severity of disc disease. Between April 1994 and June 1998 the senior author N.R.B. performed 29 instrumented ALIF procedures with a Hartshill horseshoe cage (ALIF-HH). Between 1990 and 1998, the other senior author (J.M.H.), together with another senior consultant orthopaedic surgeon, performed 27 noninstrumented ALIF procedures using corticocancellous iliac crest autograft. All the patients in both groups had single-level fusion. An independent assessor (S.M.) performed the entire review. The mean follow-up was 4.7 years (2.3-7.9 years) in the uninstrumented ALIF group and 3.0 years (2.1-4.4 years) in the ALIF-HH group. There was subsidence of graft in four patients in the uninstrumented ALIF group. It is reasonable to assume that there was no pseudarthrosis in the ALIF-HH group. This difference was statistically significant (two-sided P-value =0.0425). On subjective score assessment, there was a satisfactory outcome (score0.05). On classification by the Oswestry Index into four categories, we found no difference in outcome between the two groups: 83.3% ( n=20) had a satisfactory outcome (defined as Excellent or Better) with ALIF and 77.8% ( n=21) had a satisfactory outcome with ALIF-HH using the Oswestry Disability Index for post-operative assessment ( P>0.05). The results of this study indicate that the Hartshill horseshoe cage does improve the fusion rate, but does not affect clinical outcome.

Circumferential and posterolateral fusion for lumbar disc disease

Clinical outcome of low back fusion is unpredictable. There are various reports discussing the merits and clinical outcome of these two procedures. The patients were selected from a population of patients who had chronic low back pain unresponsive to conservative treatment. Thirty-six instrumented posterolateral fusions and 35 instrumented circumferential fusions with posterior lumbar interbody fusions were done simultaneously. Preoperative radiographic assessment included plain radiographs, magnetic resonance imaging scans, and provocative discography in all the patients. Posterolateral fusion or anterior lumbar interbody fusion was done for internal disc disruption. The Oswestry disability index, subjective scoring, and assessment of fusion were done at a minimum followup of 2 years. On subjective scoring assessment there was a satisfactory outcome of 63.9% (23 patients) in the posterolateral fusion group and 82.8% (29 patients) in the posterior lumbar interbody fusion group. On assessment by the Oswestry index no difference was found in outcome between the two groups. The posterolateral fusion group had a 63.9% satisfactory outcome and the posterior lumbar interbody fusion group had an 80% satisfactory outcome using the Oswestry disability index for postoperative assessment. There was 61.1% improvement in working ability in the posterolateral fusion group and 77.1% improvement in the posterior lumbar interbody fusion group which was not statistically significant. The authors consider instrumented circumferential fusion with posterior lumbar interbody fusion better than instrumented posterolateral fusion for managing chronic disabling low back pain.

Does provocative discography screening of discogenic back pain improve surgical outcome?

The value of preoperative provocative discography in the setting of discogenic low back pain was investigated by evaluating surgical outcomes. Seventy-three consecutive patients who underwent posterolateral interbody and posterior spinal arthrodesis for discogenic low back pain refractory to nonoperative management were reviewed. Chronologically, the first 41 patients (group A) were indicated without discography, whereas the remaining 32 (group B) had been indicated only if their pain had been reproduced during disc injection. The two groups were similar in demographic, psychometric, and radiologic parameters. Average follow-up time in group A was 2.8 years and in group B it was 2.4 years, both with a 2-year minimum. Using modified Oswestry scoring, group A and group B patients had satisfactory outcomes of 75.6% and 81.2%, respectively. This difference was neither statistically significant nor suggestive. In this study, provocative discography screening did not improve surgical outcomes after circumferential fusion for lumbar discogenic back pain.

Fetal outcome in mothers with impaired glucose tolerance in pregnancy

A 75 g oral glucose tolerance test was carried out on 953 pregnant women who were identified on the basis of clinical risk factors. The tests were analysed by the WHO criteria: 826 were normal, 120 showed impaired glucose tolerance, and 7 identified diabetes. A number of obstetric and perinatal outcome measures were compared between the groups with normal and impaired glucose tolerance, and also with 135 women who had pre-existing Type 1 diabetes and delivered during the study period. There was no significant difference in the incidence of antenatal complications between mothers with normal and impaired glucose tolerance. There was a higher rate of induced labour (p < 0.05) and caesarean section (p < 0.01) in the impaired glucose tolerance group compared to the normal group, but no difference in fetal outcome or neonatal morbidity. All of these outcome measures were increased in the Type 1 diabetic pregnancies.

Cinderella had a champion

Images

Pure XY gonadal dysgenesis presenting as secondary amenorrhea. A case report

Secondary amenorrhea developed after two years of normal menstruation. On investigation, the patient's karyotype was 46,XY, the serum testosterone and free androgen index were elevated, and bilateral gonadoblastomas and dysgerminomas were found in the gonads. The uterus, fallopian tubes and vagina were normal. The gonads were removed and chemotherapy given because of lymphadenopathy.

Accelerated retinopathy and nephropathy in diabetic pregnancy

We report a case of severe deterioration in sight despite good metabolic control in a pregnant diabetic patient which has not recovered at two years post-delivery. This was accompanied by a deterioration in renal function which similarly has not improved.

Increased interleukin 2 receptor expression in post-gestational women: relationship to impaired glucose tolerance and islet cell antibodies in pregnancy

Fifteen women with positive islet cell antibodies were identified in a group of 115 consecutive patients found to have impaired glucose tolerance in pregnancy. These subjects were postulated to be at increased risk of later developing type 1 diabetes mellitus. They were examined post--partum for HLA types known to be associated with this disease and for any increase in Interleukin 2 receptor expression or alteration of T cell subsets of possible relevance to its pathogenesis. Fifteen women negative for islet antibodies and with normal glucose tolerance during previous pregnancy and 15 women with a normal fasting plasma glucose who had never been pregnant were studied as controls. Using flow cytometric techniques a significant increase in both the number and proportion of activated (Interleukin 2 receptor, CD25) lymphocytes in the peripheral blood of women who had islet cell antibodies and previous impaired glucose tolerance in pregnancy was found (0.14 +/- SE 0.03 x 10(9)/l; 7.1 +/- 1.1%) when compared with normal parous controls (0.09 +/- 0.01 x 10(9)/l; 4.2 +/- 0.6%), p less than 0.01 x 10(9)/l; showed significant increases when compared with nulliparous controls (0.04 +/- 0.01 x 10(9)/l; 2.1 +/- 0.2%), p less than 0.01. No differences were detected between the three groups with respect to total T-lymphocytes (CD3), helper T-lymphocytes (CD4), suppressor cytotoxic T-lymphocytes (CD8), or the inducer of suppressor (Leu 3+/Leu 8+) subset of T-lymphocytes. Three women persistently islet cell antibody positive, two of whom were HLA DR4, showed impaired glucose tolerance at the time of lymphocyte subset analysis, while two further patients, one DR3 and the other DR4, had developed type 1 (insulin-dependent) diabetes. No correlation between increased Interleukin 2 receptor expression and glucose intolerance was demonstrated. We conclude that islet cell antibody positive women with impaired glucose tolerance during pregnancy are at increased risk of later developing type 1 diabetes but that heightened immune activation present in these women is in part a post-pregnancy phenomenon.

Urinary albumin excretion in diabetic pregnancy

We have analysed the results of urinary albumin excretion in timed overnight urine samples once every two weeks during pregnancy and post-natally in 25 non-diabetic women and 14 women with Type 1 (insulin-dependent) diabetes who were Albustix negative and had urinary albumin excretion less than 15 micrograms.min-1 at conception. Urinary albumin excretion did not vary significantly in the first two trimesters in either group and at 28 weeks was 2.73 micrograms.min-1 (0.32-251.68) (median and range) in the diabetic women and 2.53 micrograms.min-1 (0.90-13.37) in control patients (not significant). During the third trimester urinary albumin excretion increased, and levels were significantly higher in diabetic patients from 36 weeks (9.37 (0.9-31.78) vs 3.52 (0.19-33.74) micrograms.min-1, p less than 0.01) until delivery. In both groups, urinary albumin excretion reached a peak within the week following delivery - diabetic 17.42 micrograms.min-1 (2.03-46.64), control subjects 16.29 micrograms.min-1 (1.53-35.56), but six weeks after delivery, levels were similar to those in early pregnancy. The effect of pregnancy on urinary albumin excretion in these diabetic women would appear to be an exaggeration of the normal pattern, with levels returning to normal post-delivery. It is not possible to know if this has significance for future renal function, but it would be important to investigate this phenomenon in patients who already have raised urinary albumin excretion at conception.

Hip replacement for adults with unreduced congenital dislocation. A new surgical technique

Total hip replacement for adults with unreduced congenital dislocation presents a difficult problem because soft-tissue contractures usually prevent sitting at the normal anatomical level. Extensive soft-tissue division or a high-level acetabulum leads to reduced function and poor fixation of the components. We describe a new technique for hip replacement in such cases. The shortened abductors and flexors are released proximally and excision of the upper third of the ilium allows them to be repaired without tension, while providing bone graft to reconstruct the acetabular roof. We report 12 such replacements in 10 patients with good results and few early complications.

Is centralized hospital care necessary for all insulin-dependent pregnant diabetics?

A retrospective population study in Northern Ireland examined the benefits of centralized care in insulin-dependent diabetic pregnancies. In the 5 years 1979-1983, there were 139, 250 deliveries in Northern Ireland and of these 221 pregnancies occurred in 187 insulin-dependent diabetic patients; 100 were managed entirely in peripheral maternity units, 61 were referred from a peripheral unit to the Royal Maternity Hospital, Belfast and 60 were managed entirely in this central referral hospital. The patients referred from the periphery had the worst past obstetric history with a combined perinatal mortality rate of 200 per 1000. During the study period the perinatal mortality rate was 107 for the referred pregnancies, 33 for those managed entirely in the peripheral units and 18 for those managed at the Royal Maternity Hospital. If those pregnancies terminated for fetal abnormality, and deaths beyond the perinatal period are included, the figures for total fetal loss were 15.5%, 5.5% and 7.1% respectively. Overall the major congenital malformation rate was 7.5%, and for the respective groups 6.5%, 3.0% and 13.0%. For the general population during the same period the perinatal mortality rate was 1.4% and the major congenital malformation rate was 2.5%. Thus it is suggested that only peripheral hospitals which can offer combined antenatal/endocrine care and with a neonatal intensive care unit should undertake the management of the pregnant diabetic.

A comparison of plating and traction in the treatment of tibial shaft fractures

A consecutive series of fractures of the tibial shaft was studied over a 4-year period. A total of 115 fractures in 115 patients were found to be unstable and therefore unsuitable for immediate treatment in a plaster cast. Sixty-three fractures were treated by internal fixation using AO dynamic compression plates and 52 patients were treated by calcaneal traction. The two treatment groups were compared and it was found that overall each spent a similar time in hospital but the surgically treated group required a minimum of two admissions. The surgically treated group healed 6 weeks sooner than the conservatively treated group but there was an overall complication rate of 30 per cent related to the internal fixation. One hundred and three patients were seen for clinical review, and the incidence of joint stiffness is discussed.

Acetabular cup failure after total hip replacement

Fracture of the polyethylene acetabular cup is a rare late complication of total hip replacement. Five cases are reported. In each one this followed a fall, and involved a Müller arthroplasty which had previously been symptomless. It is postulated that ridges or other irregularities of bone, produced by keying holes, could lead to areas of thin cement and potential weakness of support for the cup.

Physical and psychological health of children of Type 1 (insulin-dependent) diabetic mothers

No difference was found at paediatric assessment, or by a psychologically-based maternal and teacher questionnaire of the emotional state or academic achievement, between 123 children of Type 1 (insulin-dependent) diabetic mothers and 124 children of non-diabetic mothers. The groups were closely matched for maternal age, sex and position in sibship of the child, and age and home environment of the mother. The children of diabetic mothers had all been delivered before week 38 of gestation.

Diabetic retinopathy in pregnancy

The records of 23 insulin-dependent diabetics who had serial ophthalmological examinations during pregnancy and afterwards were reviewed. Fourteen pregnancies occurred in 10 patients with no retinopathy; 30% of these patients had obstetric complications. The mean birthweight was 3.5 kg. Ophthalmological status was unchanged in this group. In eight patients with background retinopathy during 10 pregnancies the obstetric complication rate was 70% and mean birthweight 3.3 kg. During pregnancy there was no evidence of progression of retinopathy. One patient developed proliferative retinopathy 4 years later. Five patients had proliferative retinopathy. The mean age (32 years) and duration of diabetes at index pregnancy (18 years) was greater than for the other groups. All patients developed pre-eclampsia and mean birthweight was 2.8 kg. Four of these patients required argon laser photocoagulation in association with pregnancy for progressive retinopathy; one died subsequently from end-stage diabetic nephropathy; the other four have maintained their pre-pregnancy visual acuity from 4 to 10 years.

The Royal Maternity Hospital, Belfast. Fifty glorious years 1933-1983. Presidential address to the Ulster Medical Society, 20th October 1983

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