Fosfomycin Trometamol for the Prevention of Infectious Complications After Prostate Biopsy: A Consensus Statement by an International Multidisciplinary Group

CONTEXT

Transrectal ultrasound-guided prostate biopsy (TRPB) has been a standard of care for diagnosing prostate cancer but is associated with a high incidence of infectious complications.

OBJECTIVE

To achieve an expert consensus on whether fosfomycin trometamol provides adequate prophylaxis in TRPB and discuss its role as prophylaxis in transperineal prostate biopsy (TPPB).

EVIDENCE ACQUISITION

An international multidisciplinary group of experts convened remotely to discuss how to best use fosfomycin in various clinical settings and patient situations. Six statements related to prostate biopsy and the role of fosfomycin were developed, based on literature searches and relevant clinical experience.

EVIDENCE SYNTHESIS

Consensus was reached for all six statements. The group of experts was unanimous regarding fosfomycin as a preferred candidate for antimicrobial prophylaxis in TRPB. Fosfomycin potentially also meets the requirements for empiric prophylaxis in TPPB, although further clinical studies are needed to confirm or refute its utility in this setting. There is a risk of bias due to sponsorship by a pharmaceutical company.

CONCLUSIONS

Antimicrobial prophylaxis is mandatory in TRPB, and fosfomycin trometamol is an appropriate candidate due to low rates of resistance, a good safety profile, sufficient prostate concentrations, and demonstrated efficacy in reducing the risk of infectious complications following TRPB.

PATIENT SUMMARY

Patients undergoing transrectal ultrasound-guided prostate biopsy (TRPB) have a high risk of infectious complications, and antimicrobial prophylaxis is mandatory. However, increasing antimicrobial resistance, as well as safety concerns with fluoroquinolones, has restricted the number of antimicrobial options. Fosfomycin trometamol meets the requirements for a preferred antimicrobial in the prophylaxis of TRPB.

A pro-inflammatory CD8+ T-cell subset patrols the cervicovaginal tract

The immune system of the cervicovaginal tract (CVT) must balance immunosurveillance and active immunity against pathogens with maintenance of tolerance to resident microbiota and to fetal and partner antigens for reproductive purposes. Thus, we predicted that CVT immunity is characterized by distinctive features compared to blood and other tissue compartments. Indeed, we found that CVT CD8+ T-cells had unique transcriptional profiles, particularly in their cytokine signature, compared to that reported for CD8+ T-cells in other tissue sites. Among these CVT CD8+ T-cells, we identified a CD69- CD103- subset that was characterized by reduced migration in response to tissue-exit signals and higher pro-inflammatory potential as compared to their blood counterpart. These inflammatory mucosal CD8+ T-cells (Tim) were increased in frequency in the CVT of individuals with chronic infection, pointing to a potential role in perpetuating inflammation. Our findings highlight the specialized nature of immunity within the CVT and identify Tim cells as potential therapeutic targets to tame tissue inflammation upon chronic infection.

Training surgical residents: the current Canadian perspective

BACKGROUND

Numerous constraints may limit the practical experience of surgical residents. Current research supports a need for structured curricula, skills acquisition, and feedback outside the operating room (OR) and formal assessment of technical skills. We examined the current state of surgical skill teaching and evaluation for Canadian residents across surgical specialties.

METHODS

One hundred twenty-three surveys were mailed to surgical residency program directors of all 17 Canadian medical schools. Nine surgical specialties were identified. Program demographics, details of surgical skill teaching methods, and several surgical skill assessment modalities used from admission to graduation were surveyed. Obstetrics and Gynecology (ObGyn) survey results were compared with other surgical specialties.

RESULTS

Seventy surveys (57%) from 15 medical schools (88%) were returned. All specialties were represented in responses. ObGyn residents had fewer surgical training months per year than other residents (4.9 versus 8.5 months; p = 0.001). The most common teaching method was didactic lectures (86%; 95% confidence interval [CI], 75%-93%) for all programs. Inanimate and/or animate skills laboratories and didactic lectures were equally used by 90% (95% CI, 55%-100%) of ObGyn programs. Virtual reality simulators for procedure-specific surgical skills ranked low at 30% (95% CI, 7%-65%) use in ObGyn programs. Most programs had a dedicated space to teach and practice skills outside the OR. Assessment, feedback, and determination of surgical competence were most commonly performed via subjective evaluation by surgical mentors. Forty percent of ObGyn programs versus 76% of other programs used a local program-specific surgical training curriculum (p = 0.054). Most program directors who did not have access to a standard training curriculum wished to have one implemented.

CONCLUSIONS

Lectures and subjective evaluations are the most common educational tools in Canadian surgical residencies. Despite the availability of validated surgical teaching and evaluation tools remote from the OR, standard training curricula are not the norm in Canadian ObGyn residency programs.

Vaginal Langerhans cells resist genomic integration of HIV-1 but transmit endocytosed virions to susceptible target cells (39.27)

B: Vaginal Langerhans cells (LCs) efficiently endocytose HIV-1 (Immunity 2007, 26:257-70), but the ability of LCs to become productively infected or to transmit HIV to mucosal CD4+ T cells is unclear.

M: Epithelial sheets isolated from healthy vaginal mucosa were challenged with HIV-1. After 3 days, isolated cells were sorted by FACS into single LCs (>99% purity) and T cell (TC)-LC conjugates. Integrated HIV-1 was tested in DNA isolated from these cell populations using real-time PCR. LCs and LC-TC conjugates from HIV-challenged tissues were also co-cultured with uninfected T cells and transmission of HIV was evaluated by HIV-1 Gag p24 content in the co-culture supernatants.

R: We detected integrated HIV-1 DNA in 100% (4/4 donors) of the LC-TC conjugates while HIV-1 genomic integration could not be detected in single LCs (0/4 donors). Nevertheless, single LCs transmitted HIV-1 to T cells, which were productively infected (2/3 donors). LC-TC conjugates transmitted HIV-1 to T cells in 3/3 donors.

C: Vaginal LCs resist genomic integration of HIV-1 and are not susceptible to productive infection. However, vaginal LCs are capable of transmitting stored virions to T cells. Thus, in contrast to reports on HIV endocytosis in skin-derived LCs, HIV-1 endocytosis into vaginal LCs is not a dead end for the virus. This infection pathway needs to be considered when designing preventive strategies. Supported by R01 NIH-HD-51455

A psychoeducational intervention for sexual dysfunction in women with gynecologic cancer

Treatment of early-stage cervical and endometrial cancer has been associated with significant sexual difficulties in at least half of women following hysterectomy. Despite the fact that women report such sexual side effects to be the most distressing aspect of their cancer treatment, evidence-based treatments for Female Sexual Arousal Disorder (FSAD), the most common sexual symptom in this group, do not exist. We developed and pilot tested a brief, three session psychoeducational intervention (PED) targeting FSAD in 22 women with early-stage gynecologic cancer. The PED consisted of three, 1-h sessions that combined elements of cognitive and behavioral therapy with education and mindfulness training. Women completed questionnaires and had a physiological measurement of genital arousal at pre- and post-PED (sessions 1 and 4) and participated in a semi-structured interview (session 4) during which their feedback on the PED was elicited. There was a significant positive effect of the PED on sexual desire, arousal, orgasm, satisfaction, sexual distress, depression, and overall well-being, and a trend towards significantly improved physiological genital arousal and perceived genital arousal. Qualitative feedback indicated that the PED materials were very user-friendly, clear, and helpful. In particular, women reported the mindfulness component to be most helpful. These findings suggest that a brief 3-session PED can significantly improve aspects of sexual response, mood, and quality of life in gynecologic cancer patients, and has implications for establishing the components of a psychological treatment program for FSAD.

Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence

The objective of our study was to estimate the age-specific incidence and lifetime risk of surgically managed pelvic organ prolapse (POP) and urinary incontinence (UI). Women aged 20 and older who underwent primary surgical management of POP or UI in 1993 were identified from the database of a health maintenance organization using ICD-9 codes and confirmed through chart abstraction. From a population of 147,719 women, 135 were identified who underwent prolapse surgery only, 82 incontinence only, and 34 surgery for both conditions. From the age-specific incidence, we estimated the lifetime risk of undergoing an operation by age 80 to be 11.8%. Our findings agree with a previous estimate that approximately 11% of women will undergo surgery for POP or UI by age 80. POP and UI appear to be common problems, undoubtedly affecting an even larger proportion of the women than suggested by this high cumulative incidence of surgery.

A comprehensive women's health care center: are gynecologists offering primary care?

OBJECTIVE

The purpose of this study was to compare patient characteristics and diagnoses in a comprehensive Women's Health Care Clinic between gynecologists and internal medicine physicians.

STUDY DESIGN

This retrospective cohort study evaluated International Classification of Diseases, 9th Revision, codes that were recorded between January 1, 2001, and January 4, 2004, at the Women's Health Care Clinic. We compared demographics and prevalence of diagnosis codes for patients who were seen by obstetricians/gynecologists and internal medicine physicians and compared these data with national survey statistics. A sampling of charts was reviewed for coding verification.

RESULTS

We analyzed 13,462 visits at the Women's Health Care Clinic. Patients who were seen by internists were older, had greater racial diversity, and had more gender-nonspecific medical disorders (hypertension, depression). Gynecologists saw more specific women's health problems (P < .05). The diagnoses of menstrual disorders, menopause, pelvic pain, and abnormal cytologic findings within the Women's Health Care Clinic follow closely with the national ambulatory survey data.

CONCLUSION

Within this multispecialty Women's Health Care Clinic, internal medicine physicians are practicing primary care and obstetricians/gynecologists are providing specialty care.

A six-year study of surgical teaching and skills evaluation for obstetric/gynecologic residents in porcine and inanimate surgical models

OBJECTIVE

This study was undertaken to evaluate an ongoing teaching and objective surgical skills testing program for obstetric/gynecologic residents in a laboratory setting, and assess the impact on residents of having 4 years of a surgical laboratory curriculum.

STUDY DESIGN

From 1997 through 2002, we conducted surgical skills training sessions for all obstetric/gynecologic residents, using both inanimate and animal (porcine) models. Once a year we tested each resident on 12 structured surgical bench tasks. At the end of each year, we conducted formal objective structured assessment of technical skills (OSATS) with all residents attempting multiple surgical procedures. We compared residents who had 4 years of laboratory training with those who started residency earlier and had only 1 or 2 years of the new curriculum. We also compared residents' own performance from year to year and cohort performance by resident year.

RESULTS

PGY3 and PGY4s who had 4 years of surgical laboratory training did significantly better on bench laboratory skills than PGY3 and PGY4s with fewer years of training sessions (total scores of 48.8 vs 30.3, P < .001). However, no significant improvement in surgical procedures as measured by global OSATS was found. When comparing residents' own performance between the beginning and the end of 1 year, global OSATS scores improved significantly on laparoscopic salpingotomy (P < .001) and open oophorectomy (P < .001). For the cohort of PGY4s completing 4 years of laboratory training, average global OSATS scores showed statistically significant improvement (PGY1, PGY2 < PGY3 < PGY4, P < .001).

CONCLUSION

Residents who completed the 4-year curriculum showed significantly better technical skills on bench tasks but not on OSATS compared with those with less training. Resident surgical skills evaluated by OSATS significantly improve over time both individually and as a cohort by resident year.

Self-assessment of resident surgical skills: is it feasible?

OBJECTIVE

The purpose of this study was to examine obstetrics and gynecology residents' self-assessment of proficiency on a variety of surgical bench procedures and to compare their ratings with those ratings of trained faculty observers who used instruments that have been shown to be reliable and valid.

STUDY DESIGN

As part of a 6-station Objective Structured Assessment of Technical Skills, 74 residents at 5 institutions estimated their overall open and laparoscopic skill level before the testing. After completing each station, residents evaluated their overall and global skills performance.

RESULTS

Residents rated their proficiency higher on open skills than on laparoscopic skills. Task-specific, overall, and global assessments were correlated significantly with the faculty ratings (P < .001). Residents tended to rate themselves lower than did faculty on almost all measures; even those residents with poor skills indicated that they were aware of their deficiencies. Overall and global self-assessments increased with each resident level, which indicated good construct validity.

CONCLUSION

Residents can rate their overall open and laparoscopic skills, task-specific performance, and global skills with good reliability and validity. Although they tended to score themselves lower than did faculty observers, the correlations are high (ie, residents who give themselves a higher score tended to receive a higher score from faculty, and vice versa). One of the concerns about self-assessment is that residents with poor skills might not be aware of their deficiencies. We did not find that to be the case. Therefore, when residents work on self-directed exercises, task-specific and global checklists can be used for both learning and self-assessment.

Most DC-SIGNR transcripts at mucosal HIV transmission sites are alternatively spliced isoforms

The repeat region of DC-SIGNR (CD209L) is polymorphic on the genomic level, and, in a separate study, we observed a correlation between the DC-SIGNR genotype and HIV-1 susceptibility during sexual contact. However, previous investigations using immunohistochemistry failed to detect membrane-bound DC-SIGNR on cells in the genital and rectal mucosa. We therefore explored the presence of DC-SIGNR in these compartments with a more sensitive limiting dilution RT-PCR, which also allowed for quantification of alternatively spliced mRNA isoforms. DC-SIGN (CD209) and DC-SIGNR mRNA transcript isoforms were found in all 12 vaginal and two rectal biopsies obtained from 14 healthy individuals. For DC-SIGNR, we detected significantly more isoform than full-length transcripts (mean copy numbers/mug RNA: 602 vs 26; P=0.0009). Four mucosal samples lacked full-length DC-SIGNR transcripts entirely. Cloning and sequencing of DC-SIGNR mRNA in three additional individuals revealed a diverse repertoire of DC-SIGNR isoforms, many of which encoded for proteins predicted to be soluble and secreted. Indeed, in one vaginal sample, we detected only soluble isoforms. In conjunction with our prior observation that the DC-SIGNR genotype has an effect on HIV-1 transmission in vivo, these findings emphasize that DC-SIGNR, in addition to DC-SIGN, should be considered as a cofactor in sexual HIV-1 transmission. Soluble isoforms, in particular, may modulate the efficiency of viral transmission and dissemination.

Complications from transvaginal pubovaginal slings using bone anchor fixation

OBJECTIVES

To evaluate the history and management of complications from transvaginally placed pubovaginal slings using bone anchor fixation.

METHODS

During a 3-year period, 10 patients were referred to us for complications related to transvaginally placed pubovaginal slings using bone anchor fixation.

RESULTS

The patient age ranged from 42 to 73 years. All women had a vaginally introduced bone anchor sling for stress urinary incontinence. The presenting symptoms after surgery included fever, pain, and difficulty ambulating in 1; pain and/or vaginal dyspareunia with discharge in 5; pain or dyspareunia alone in 2; and vaginal discharge alone in 2 patients. Two patients ultimately developed bone lesions on radiologic studies consistent with osteomyelitis. Six patients developed sinus drainage tracts associated with granulation tissue from at least one bone anchor that was unresponsive to outpatient management. One of the patients with pain alone had a permanent suture extending into the bladder neck. Nine patients underwent surgery, of whom five had resolution of their presenting complaint. Four of these patients were continent at last follow-up.

CONCLUSIONS

Transvaginally placed pubovaginal slings using bone anchors can be associated with serious complications that may be intractable to common therapies. This knowledge may enable practitioners who use this technique to better counsel their patients regarding these significant complications.

Relationship between patient report and physician assessment of urinary incontinence severity

OBJECTIVE

The purpose of this study was to determine the relationship between patient report and physician assessment of urinary incontinence severity and to compare these assessments to a validated severity instrument.

STUDY DESIGN

A sequential sample of 153 women with urinary incontinence was enrolled over 12 months. Patients completed a detailed health questionnaire that included a medical comorbidity scale, 12-item short-form health survey (SF-12) the incontinence quality of life instrument, the PRIME-MD patient health questionnaire, and a patient incontinence severity assessment. The patient incontinence severity assessment is a single question that asks the patient to rate the severity of her incontinence symptoms on a 5-point Likert scale (range: 1 [mild] to 5 [severe]). After the physicians completed a detailed history, a physical examination, and a review of a 3-day voiding diary, they assigned a physician incontinence severity assessment score. The physician incontinence severity assessment is a physician rating of the severity of the patient's incontinence on a 5-point Likert scale (range: 1 [mild] to 5 [severe]). A validated severity index was computed and used for comparison. This is a multiplicative index that is based on frequency (4 levels) and amount of leakage (2 levels), which yields an index value of 1 to 8. Spearman correlation coefficients were calculated for patient incontinence severity assessment, the physician incontinence severity assessment scores, and the severity index values. Chi-square tests were used to determine differences between patient incontinence severity assessment and physician incontinence severity assessment ratings.

RESULTS

Spearman correlation coefficients for patient incontinence severity assessment and physician incontinence severity assessment were 0.62 (P <.001), for patient incontinence severity assessment and the severity index was 0.61 (P <.001), and for physician incontinence severity assessment and the severity index was 0.66 (P <.001). Agreement between patient assessment and physician assessment for different severity levels on the patient incontinence severity assessment and physician incontinence severity assessment are provided.

CONCLUSION

There is a high correlation between patient report and physician assessment of urinary incontinence severity. Both patient reports (patient incontinence severity assessment) and physician assessments (physician incontinence severity assessment) correlate well with a validated severity index. The agreement between patient and physician ratings is very high for mild incontinence but decreases as incontinence severity progresses.

The functional and psychosocial impact of fecal incontinence on women with urinary incontinence

OBJECTIVES

The study was undertaken to determine the impact of fecal incontinence (FI) on functional status and quality of life in women with urinary incontinence (UI).

STUDY DESIGN

In 24 months 732 women completed a standardized assessment and questionnaire, including the Short Form (SF)-12 and Incontinence Quality of Life (I-QOL) scores. Analysis of variance was used to compare SF-12 scores between groups defined as having UI, FI, or both UI and FI. I-QOL scores in patients with UI or UI and FI were compared by using the Student t test.

RESULTS

Of the 732 patients enrolled, 425 patients had either UI (n = 342, 80%), FI (n = 18, 4%), or both (n = 65, 15%). Greater impairment in physical functioning was seen in the group with UI and FI (38.6; P =.027) compared with the group with UI (42.4). Significant decreases in I-QOL scores were seen for the group with UI and FI compared with those with UI (P <.005).

CONCLUSION

Fecal incontinence further reduces the functional status and quality of life of women with urinary incontinence.

Posterior vaginal wall defects and their relation to measures of pelvic floor neuromuscular function and posterior compartment symptoms

OBJECTIVE

The purpose of this study was to describe the pelvic floor neuromuscular function and posterior compartment symptoms in patients with posterior vaginal wall prolapse.

STUDY DESIGN

Two hundred twenty-seven women who were referred to a urogynecology and urology clinic were enrolled prospectively. Each patient completed a health history questionnaire and standardized physical examination that specifically graded uterovaginal prolapse according to the pelvic organ prolapse quantification system.

RESULTS

Sixty-nine women had a pelvic organ prolapse quantification system point (most dependent portion of the posterior vaginal wall during straining as measured from the hymeneal ring) of < or =-1. Older age, a history of hysterectomy, a genital hiatus of >3 cm (48% vs 24%; P =.002), and perineal descent of > or =2 cm (14% vs 5%; P =.042) were significantly more common in women with posterior vaginal prolapse. When women with posterior prolapse and symptomatic complaints were compared with asymptomatic women with prolapse, a perineal descent of > or =2 cm (21% vs 0%; P =.004) was significantly more common in the symptomatic group.

CONCLUSION

Pelvic floor neuromuscular function should be related to posterior vaginal prolapse and symptoms; however, only perineal descent appears associated strongly with both symptoms and prolapse in this population.

Hormonal manipulation in women with chronic, cyclic irritable bladder symptoms and pelvic pain

OBJECTIVE

Chronic, painful bladder symptoms are diagnostic and therapeutic challenges for urologists and gynecologists. The aims of this study were to evaluate women with menstrual cycle-related changes in their interstitial cystitis symptoms, to treat them with hormonal manipulation, and to follow them long term.

STUDY DESIGN

The cases of women who were referred to a tertiary care center with interstitial cystitis and menstrual cycle exacerbation of symptoms were evaluated in a retrospective study. Fifteen women had undergone laparoscopy that was followed immediately by cystoscopy and bladder hydrodistension. Patients were then treated with leuprolide acetate or oral contraceptive pills.

RESULTS

Patient age ranged from 23 to 48 years. The duration of symptoms ranged from 1 to 26 years. Ten patients (67%) had findings of both interstitial cystitis and peritoneal endometriosis. Five of 15 patients (33%) had interstitial cystitis, but no endometriosis was found. Symptoms improved for 8 of 9 women who were treated with leuprolide acetate and for 5 of 6 women who were treated with oral contraceptive pills. Patients were followed up for an average of 55 months.

CONCLUSION

Diagnostic laparoscopy should be considered together with hydrodistension of the bladder for women with pelvic pain and irritative bladder symptoms that are exacerbated premenstrually. Endometriosis is often present in patients with these complex symptoms. This is the first report of hormonal treatment for chronic, cyclic irritative bladder symptoms; improvement appears to occur even when endometriosis is not identified by laparoscopy.

Surgical skills assessment: a blinded examination of obstetrics and gynecology residents

OBJECTIVE

We have previously shown that objective structured assessment of technical skills (OSATS) is an innovative, reliable, and valid method of assessing surgical skills. Our goal was to establish the feasibility, reliability, and validity of our surgical skills assessment instrument when administered in a blinded fashion.

STUDY DESIGN

A 7-station OSATS was administered to 16 obstetric and gynecology residents from Madigan Army Medical Center. The test included laparoscopic (salpingostomy, intracorporeal knot, and ligation of vessels with clips) and open abdominal procedures (subcuticular closure, bladder neck suspension, enterotomy repair, and abdominal wall closure). All tasks were performed with lifelike surgical models. Residents were timed and assessed at each station with 3 methods of scoring: task-specific checklist, global rating scale, and pass/fail grade. Each resident was evaluated by one examiner blinded as to the postgraduate year level and one examiner who had previously worked with the resident.

RESULTS

Assessment of construct validity (the ability to distinguish between resident levels) found significant differences on the checklist, global rating scale, and pass/fail grade by residency level for both blinded and unblinded examiners. Reliability indices calculated with Cronbach's alpha were.82 for the checklists and.93 for the global rating scale. Overall interrater reliability between blinded and unblinded examiners was 0.95 for global rating scale and ranged from 0.74 to 0.97 for the checklists. The cost to administer the exam for the 16 residents was approximately $1000.

CONCLUSIONS

OSATS administered in either a blinded or unblinded fashion can assess residents' surgical skills with a high degree of reliability and validity. This study provides further evidence that OSATS can be used to establish surgical competence.

Development of a bench station objective structured assessment of technical skills

OBJECTIVE

We have previously shown that objective structured assessment of technical skills performed in an animal model was an innovative, reliable, and valid method of assessing surgical skills. Our goal was to develop a less costly bench station objective structured assessment of technical skills and to evaluate the feasibility, reliability, and validity of this exam.

METHODS

A seven-station examination was administered to 24 residents. The tests included laparoscopic procedures (salpingostomy, intracorporeal knot tying, closure of port sites) and open abdominal procedures (subcuticular closure, bladder neck suspension, repair of enterotomy, abdominal wall closure). All tasks were performed using life-like surgical models. Residents were timed and assessed at each station using three methods of scoring: a task-specific checklist, a global rating scale, and a pass/fail grade.

RESULTS

Assessment of construct validity, the ability of the test to discriminate among residency levels, found significant differences on the checklist, global rating scale, time for procedures, and pass/fail grade by level of training. Reliability indices calculated with Cronbach's alpha were 0.77 for the checklists and 0.94 for the global rating scale. Overall interrater reliability indices were 0.91 for the global rating scale and 0.92 for the checklists. Total cost for replaceable parts and facilities was $1900.

CONCLUSION

The less costly and more portable bench station objective structured assessment of technical skills can reliably and validly assess the surgical skills of gynecology residents. This type of examination can be a useful tool to identify residents who need additional surgical instruction, provide remediation, and may become a mechanism to certify surgical skill competence.

Testing surgical skills of obstetric and gynecologic residents in a bench laboratory setting: validity and reliability

OBJECTIVE

Resident surgical skills are acquired mainly through observing and later performing procedures in the operating room. Evaluation of surgical skills has traditionally been done through subjective faculty evaluation, a technique that has poor reliability and unknown validity. Our goal was to develop specific surgical tasks, both laparoscopic and open abdominal, that could be objectively and reliably evaluated in a bench laboratory setting.

STUDY DESIGN

The prospective development of a reliable and valid resident surgical skills test in a bench laboratory setting was our goal. A written test of surgical knowledge and 12 skills tests were administered to 36 residents. Laparoscopic bench tasks were simulated with the use of a box and camera with a video display. Six laparoscopic tasks were assessed, including placing pegs on a board, running the bowel simulation, and other tasks that involve hand-eye coordination and manual dexterity. Open abdominal skills simulated incision closure, suturing a vaginal cuff, knot tying, and using a tie on a passer. Residents were timed at each given station and were given a rating score by 2 examiners.

RESULTS

Knowledge scores showed a significant improvement by residency level. Assessment of construct validity (the ability to discriminate among residency levels) demonstrated significant differences on the rating of overall performance and individual tasks by level (determined by 1-way analysis of variance). Interrater reliability (agreement between 2 raters) with the use of intraclass correlation was 0.79 for the total score. The cost to administer the bench laboratory test was less than $50 and required 30 hours of faculty time.

CONCLUSION

The results of this study suggest that surgical bench laboratory tasks can assess residents' surgical skills with good reliability and validity on most tasks. Our previous study, which used an animal laboratory, was expensive, and the bench laboratory model may provide an alternative means to assess surgical skills.

Development of an objective structured assessment of technical skills for obstetric and gynecology residents

OBJECTIVE

To develop an objective structured assessment for evaluating surgical skills of obstetrics and gynecology residents and to evaluate the reliability and validity of the assessment.

METHODS

A seven-station, objective, structured assessment of technical skills was administered to 24 residents. The test included laparoscopic procedures (port placement, salpingostomy, suturing, vessel ligation) and open abdominal procedures (hypogastric ligation, repair of enterotomy, salpingo-oophorectomy.) All surgical tasks were done on pigs. Residents were timed and assessed at each station using three methods of scoring, a task-specific checklist, global rating scale, and pass-fail grade.

RESULTS

Assessment of construct validity (the ability of the test to discriminate among residency levels) found significant differences on the checklist and the global rating scale by residency level. Reliability indices calculated with Cronbach's alpha were 0.89 for the global rating scale and 0.89-0.95 for the individual skills checklists. Interrater reliability was 0.87 for the global rating scale and 0.78-0.98 for the checklists.

CONCLUSION

Objective, structured assessment of technical skills can assess residents' surgical skills with high reliability and validity. These assessments have possible application for identifying residents who need additional training and might provide a mechanism to ensure competence of surgical skills.

Teaching and evaluating surgical skills

OBJECTIVE

To examine how surgical skills are taught and evaluated in obstetrics-gynecology residency programs in the United States.

METHODS

A questionnaire was mailed to the directors of all 266 residency programs in the United States and to second contact names at 51 sites. Directors were asked to evaluate how surgical skills are taught and evaluated and to rate the importance of specific techniques and procedures for residents at given points in resident training.

RESULTS

Two hundred twenty-three surveys were returned (70%), representing 203 of 266 programs (76%). Among responding programs, 99% reported teaching surgical skills in operating rooms, 88% in lectures, 68% with bench procedures, and 54% with animal surgery. Twenty-nine percent indicated they had formal surgical skills curricula. A significantly higher percentage of those programs with formal curricula used animal surgery laboratories (81% versus 42%, P <.001) and were more likely to conduct formal skills assessments (88% versus 69%, P =.005) than programs without formal curricula. Overall, 74% of programs evaluated surgical skills. Of those, 56% reported using subjective faculty evaluations, 12% written evaluations (eg, checklists), 4% written and oral assessments, and 1% a test. Regardless of formal curricula, there was much agreement in respondents' ratings of 60 different skills and procedures as "essential," "important," "nice to know," or "unimportant.

CONCLUSION

Most programs teach surgical skills in the operating room and through lectures. Only 29% of reporting programs provide formal surgical curricula. Evaluation of surgical skills is usually done by subjective evaluation, a technique with unknown validity and poor reliability.

Periurethral collagen injection: a long-term follow-up study

OBJECTIVE

To determine the long-term success of the periurethral injection of collagen (Contigen(R), Bard UK) in women with genuine stress incontinence.

PATIENTS AND METHODS

Sixty-one women with genuine stress incontinence were enrolled in a trial of periurethral collagen injections between 1 September 1990 and 31 August 1992. They were assessed at 1, 3, 6, 12 and 24 months after the last collagen injection. In 1998, their notes were reviewed, and a standardized questionnaire was sent to 46 women who were still alive and had undergone no further anti-incontinence surgery.

RESULTS

Of the 53 women who were either known failures or who had follow-up information beyond 5 years, 26% were subjectively improved. Women who had a maximum urethral closure pressure of >20 cmH2O and those who had urinary incontinence for <10 years before their first injection were more likely to have had long-term success. There was no correlation between long-term success and the number of previous operations, body mass index, age or preoperative pad loss. Neither the number of injection sessions, total volume of collagen injected nor perceived bulking at the time of surgery affected long-term success rates. Of the 14 women who considered themselves subjectively improved, seven had daily incontinence and only one was completely dry. Urinary retention and urinary tract infection were the most common complications. In addition, one woman reported a flare-up of her skin test and transient 'flu-like symptoms 2 weeks after the injection, and one woman developed a right upper lobe pneumonia 2 weeks after the collagen injection.

CONCLUSION

The long-term results of periurethral collagen injections are disappointing. We found no evidence to support the use of periurethral collagen injections in women with intrinsic sphincter deficiency, who had a higher failure rate than those with hypermobility. Further research is essential to develop agents that are not immunogenic, produce minimal inflammatory response and yet are durable.

Formal teaching of surgical skills in an obstetric-gynecologic residency

OBJECTIVE

To describe a formal teaching program of basic surgical skills in an obstetric-gynecologic residency program and evaluate its effectiveness.

METHODS

A surgical skills program was developed for all residents. Using bench and animal laboratory sessions, residents were given instruction and performed both laparoscopic and open abdominal procedures. All were given a pretest and were tested again 6 months later. Residents also evaluated their experiences.

RESULTS

To date, the formal teaching sessions have been given to 24 residents, all of whom believed their confidence and technical skills improved as a result of the sessions. On a scale of 1 to 5, the median rating of the bench laboratory experience was 5 (range 4-5), and the pig laboratory was 5 (range 4-5). All residents believed the surgery sessions should be continued and the number of sessions increased. Preliminary evaluation indicated that time to suture a 10-inch incision decreased by 28%, from an average of 225 (standard deviation [SD] 51) seconds to 171 (SD 43) seconds (P < .001), and evaluation of surgical technique significantly improved at the second pretest (P = .013). Laparoscopic placement of pegs on a board in 2 minutes increased from an average of 5 (SD 2.5) to 7.3 (SD 2.6; P = .001). The cost of the bench laboratory sessions was minimal. Each pig was approximately $100, and the facility charge for each 4-hour laboratory session was $1500.

CONCLUSION

When formal surgical training was given to obstetric-gynecologic residents, their surgical skills improved subjectively and objectively.

Parent characteristics, perceived health risk, and smokeless tobacco use among white adolescent males

The results of this study indicate that father education, father use of smokeless tobacco, and adolescent risk perception contribute to the use of smokeless tobacco by white males 12 to 14 years of age. However, risk perception does not account for the correlation between parent characteristics and child behavior. Father education and child smokeless tobacco use are inversely related if the father does not use it, and they are directly related if the father does; this finding is consistent with theories of modeling but is contrary to the common observation that the use of some abusive substances is relatively low among adolescents in higher social and economic levels. We concluded that father characteristics should be considered in research and in programs pertaining to the use of smokeless tobacco by white adolescent males.