Surgical Performance During Laparoscopic Radical Nephrectomy Is Improved With Training in a Porcine Model

Background and Purpose: Becoming proficient in laparoscopic surgery is dependent on the acquisition of specialized skills that can only be obtained from specific training. This training could be achieved in various ways using inanimate models, animal models, or live patient surgery-each with its own pros and cons. Currently, there are substantial data that support the benefits of animal model training in the initial learning of laparoscopy. Nevertheless, whether these benefits extent themselves to moderately experienced surgeons is uncertain. The purpose of this study was to determine if training using a porcine model results in a quantifiable gain in laparoscopic skills for moderately experienced laparoscopic surgeons. Materials and Methods: Six urologists with some laparoscopic experience were asked to perform a radical nephrectomy weekly for 10 weeks in a porcine model. The procedures were recorded, and surgical performance was assessed by two experienced laparoscopic surgeons using a previously published surgical performance assessment tool. The obtained data were then submitted to statistical analysis. Results: With training, blood loss was reduced approximately 45% when comparing the averages of the first and last surgical procedures (P = 0.006). Depth perception showed an improvement close to 35% (P = 0.041), and dexterity showed an improvement close to 25% (P = 0.011). Total operative time showed trends of improvement, although it was not significant (P = 0.158). Autonomy, efficiency, and tissue handling were the only aspects that did not show any noteworthy change (P = 0.202, P = 0.677, and P = 0.456, respectively). Conclusions: These findings suggest that there are quantifiable gains in laparoscopic skills obtained from training in an animal model. Our results suggest that these benefits also extend to more advanced stages of the learning curve, but it is unclear how far along the learning curve training with animal models provides a clear benefit for the performance of laparoscopic procedures. Future studies are necessary to confirm these findings and better understand the impact of this learning tool on surgical practice.

Implementing the Objective Structured Clinical Examination in a Geriatrics Fellowship Program-A 3-Year Experience

The Objective Structured Clinical Examination (OSCE) appears to be an effective alternative for assessing not only medical knowledge, but also clinical skills, including effective communication and physical examination skills. The purpose of the current study was to implement an OSCE model in a geriatrics fellowship program and to compare the instrument with traditional essay examination. Seventy first- and second-year geriatric fellows were initially submitted to a traditional essay examination and scored from 0 to 10 by a faculty member. The same fellows subsequently underwent an OSCE with eight 10-minute stations covering a wide range of essential aspects of geriatric knowledge. Each OSCE station had an examiner responsible for its evaluation according to a predefined checklist. Checklist items were classified for analysis purposes as clinical knowledge items (CKI) and communication skills items (CSI); fellow responses were scored from 0 to 10.Although essay examinations took from 30 to 45 minutes to complete, 180200 minutes were required to evaluate fellows using the proposed OSCE method. Fellows scored an average of 6.2 +/- 1.2 on the traditional essay examination and 6.6 +/- 1.0 on the OSCE (P < .001). Subanalyses of OSCE scores indicated that average performance on CKI was lower than the average on CSI (6.4 +/- 1.1 vs. 8.4 +/- 1.1; P < .001). Fellow performance on the essay examination was similar to their performance on CKI (P = .13). Second-year fellows performed better than first-year fellows on the essay examination (P < .001) and CKI (P = .05), but not on CSI (P = .25).The OSCE was successfully implemented as an educational strategy during a geriatrics fellowship program. Combining different testing modalities may provide the best assessment of competence for various domains of knowledge, skills, and behavior.

Stickiness in a bouncer model: A slowing mechanism for Fermi acceleration

Some phase space transport properties for a conservative bouncer model are studied. The dynamics of the model is described by using a two-dimensional measure preserving mapping for the variables' velocity and time. The system is characterized by a control parameter epsilon and experiences a transition from integrable (epsilon = 0) to nonintegrable (epsilon not equal 0). For small values of epsilon, the phase space shows a mixed structure where periodic islands, chaotic seas, and invariant tori coexist. As the parameter epsilon increases and reaches a critical value epsilon(c), all invariant tori are destroyed and the chaotic sea spreads over the phase space, leading the particle to diffuse in velocity and experience Fermi acceleration (unlimited energy growth). During the dynamics the particle can be temporarily trapped near periodic and stable regions. We use the finite time Lyapunov exponent to visualize this effect. The survival probability was used to obtain some of the transport properties in the phase space. For large epsilon, the survival probability decays exponentially when it turns into a slower decay as the control parameter epsilon is reduced. The slower decay is related to trapping dynamics, slowing the Fermi Acceleration, i.e., unbounded growth of the velocity.

Imaginative construction of care: the nursing professional experience in a remote care service

The direction of care delivery goes from the action to the being; a process built from professional experience, which gains special characteristics when the service is delivered by telephone. The goal of this research was to understand the interaction between professionals and users in a remote care service; to do so, a research is presented, using Grounded Theory and Symbolic Interactionism as theoretical references. Data were collected through eight interviews with professionals who deliver care by telephone. The theoretical understanding permitted the creation of the theoretical model of the Imaginative Construction of Care, which shows the interaction processes the professional experiences when delivering care by telephone. In this model, individual and social facts are added, showing the link between the concepts, with special emphasis on uncertainty, sensitivity and professional responsibility, as essential components of this experience.

Service Innovation: the state of the art and a proposal of a research agenda

The service sector has acquired a growing importance in every country economy, which has stimulated research in the field of service innovation, a new field in management studies. This text aimed to state a research agenda upon service innovation, based on an articulated discussion of the results of several articles that compose the state of the art of this concept. 73 empirical articles were analyzed, 33% of them exploring the innovation strategies and technology; 18% of the articles describe research on economic performance and enterprise productivity; 16% are related to antecedents and determinants of innovation; another 16% about network capacity development, alliances and collaboration among organizations; 9% of the articles explore service quality, innovation taxonomy, flexible systems and regional systems of innovation; and another 8% are related to themes such as intensive knowledge, research and development. The researches were concentrated in the Engineering & Technology and Hospitality Industries, which accounted for 31% and 24% of the texts, respectively. The remaining 45% of the articles referred to sectors such as Telecommunications, Health, Retail, Financial & Insurance and Public Services. The main gaps identified in these texts refer to the difficulties on measuring service innovation, besides the small number of researches on the public sector. At the end, a research agenda in the subject is presented, including the development of a scale for orientating the innovation and identifying the determining factors of the innovation in the public environment.

Childbirth experience according to a group of Brazilian primiparas

Objective: to understand the meaning of the childbirth experience for Brazilian primiparas in the postpartum period. Design: a qualitative approach using semi-structured interviews. Content analysis was used to derive the two themes that emerged from the discourses. Setting: participants were recruited at four primary-level health-care units in Ribeirao Preto, Brazil. After providing written informed consent, an appointment was made for an interview at the participants' homes. Participants: 20 primiparas in the postpartum period, aged 15-26 years old, who attended the health-care units to vaccinate their infants and test for phenylketonuria. Findings: two thematic categories emerged from the interviews: the meaning attributed to childbirth (with four subcategories) and perceptions of care. Among the participants, the childbirth experience was marked by the 'fear of death' and 'losing the child'. The pain of giving birth was expected, and the moment of childbirth was associated with pain of high intensity. Key conclusions: childbirth is considered synonymous with physical and emotional suffering, pain, fear and risk of death. Implications for practice: this research indicates the need to break the current mechanistic model of care on which health professionals' actions are based. Care during childbirth must be guided by the foundation that women are the subjects of childbirth actions, in an attempt to emphasise actions that grant them with the autonomy and empowerment needed to experience the situation. (C) 2011 Elsevier Ltd. All rights reserved.

Prognostic factors for survival in patients with colorectal liver metastases: experience of a single brazilian cancer center

CONTEXT: Liver metastases are a common event in the clinical outcome of patients with colorectal cancer and account for 2/3 of deaths from this disease. There is considerable controversy among the data in the literature regarding the results of surgical treatment and prognostic factors of survival, and no analysis have been done in a large cohort of patients in Brazil. OBJECTIVES: To characterize the results of surgical treatment of patients with colorectal liver metastases, and to establish prognostic factors of survival in a Brazilian population. METHOD: This was a retrospective study of patients undergoing liver resection for colorectal metastases in a tertiary cancer hospital from 1998 to 2009. We analyzed epidemiologic variables and the clinical characteristics of primary tumors, metastatic disease and its treatment, surgical procedures and follow-up, and survival results. Survival analyzes were done by the Kaplan-Meier method and the log-rank test was applied to determine the influence of variables on overall and disease-free survival. All variables associated with survival with P<0.20 in univariate analysis, were included in multivariate analysis using a Cox proportional hazard regression model. RESULTS: During the period analyzed, 209 procedures were performed on 170 patients. Postope-rative mortality in 90 days was 2.9% and 5-year overall survival was 64.9%. Its independent prognostic factors were the presence of extrahepatic disease at diagnosis of liver metastases, bilateral nodules and the occurrence of major complications after liver surgery. The estimated 5-year disease-free survival was 39.1% and its prognostic factors included R1 resection, extrahepatic disease, bilateral nodules, lymph node involvement in the primary tumor and primary tumors located in the rectum. CONCLUSION: Liver resection for colorectal metastases is safe and effective and the analysis of prognostic factors of survival in a large cohort of Brazilian patients showed similar results to those pointed in international series. The occurrence of major postoperative complications appears to be able to compromise overall survival and further investigation in needed in this topic.

A holistic approach to model-based testing of Web service compositions

The behavior of composed Web services depends on the results of the invoked services; unexpected behavior of one of the invoked services can threat the correct execution of an entire composition. This paper proposes an event-based approach to black-box testing of Web service compositions based on event sequence graphs, which are extended by facilities to deal not only with service behavior under regular circumstances (i.e., where cooperating services are working as expected) but also with their behavior in undesirable situations (i.e., where cooperating services are not working as expected). Furthermore, the approach can be used independently of artifacts (e.g., Business Process Execution Language) or type of composition (orchestration/choreography). A large case study, based on a commercial Web application, demonstrates the feasibility of the approach and analyzes its characteristics. Test generation and execution are supported by dedicated tools. Especially, the use of an enterprise service bus for test execution is noteworthy and differs from other approaches. The results of the case study encourage to suggest that the new approach has the power to detect faults systematically, performing properly even with complex and large compositions. Copyright © 2012 John Wiley & Sons, Ltd.