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PubMed2003

The learning curve.

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Education, Graduate↗
PubMed1999

From the life-cycles of clinical evidence to the learning curve of clinical experience.

Treatments on offer to an individual with suspected disease are based on concepts which, like products, go through life-cycles (introduction, growth, maturity, decline). We argue that randomized controlled trials, meta-analyses, and guidelines have reached maturity and/or are already on the decline and note renewed interest in case reports and qualitative medicine. The latter emphasize individual rather than 'average' patients. Moreover, we point out that scientific evidence relates not only to variables that can be measured but also to categorical variables that are often neglected. An appropriate treatment strategy is probably one which is indicated by several methods based on different concepts rather than by a single standard method. The doctor's role is to use his critical judgement and experience to appraise evidence from formal trials and from analyses of observational data and to share his views with the patient.

Clinical Protocols↗
PubMed2002

Phased-array intracardiac echocardiography for guiding transseptal catheter placement: utility and learning curve.

The utility of a new intracardiac 64-element, phased-array, longitudinal ultrasound imaging system for guiding transseptal catheterization was assessed during 69 crossing attempts in 45 dogs because of the inherent limitations of fluoroscopy and mechanical ultrasound. Multifrequency (7.5-8.5 MHZ) imaging of the membranous fossa ovalis, posterior left atrium, and left atrial appendage was conducted from the right atrium. Contact of the Brockenbrough needle with the interatrial septum as reflected by membranous fossa ovalis "tenting" was uniformly identified. Transseptal crossing and advancement of the dilator and sheath were adequately imaged because of deeper ultrasound tissue penetration. Transseptal catheterization was successfully accomplished in 44 of 45 dogs: on the first attempt in 40 and with additional attempts in 4 and confirmed by direct far-field imaging of nonagitated saline injection via the sheath. Total transseptal catheterization time was 3.0 +/- 1.8 minutes. Unsuccessful first attempts and/or subsequent sheath pullback into the right atrium with catheter manipulation were also readily recognized. Insertion of the transseptal needle beyond the ultrasound imaging plane resulted in perforation of the posterior left atrial wall in three attempts. Accompanying effusions in these animals and three others related to subsequent intracardiac ablation catheter manipulation were readily identified and monitored echocardiographically. In conclusion, phased-array intracardiac imaging provides a highly reliable means of guiding transseptal access to the left atrium. In addition, inadvertent complications such as perforation and pericardial effusion development can be readily recognized.

Animals↗
PubMed1997

Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve.

OBJECTIVE: Although sonographic screening for blunt abdominal trauma is gaining acceptance, standards for implementation, training, credentialing, and quality control remain to be established. DESIGN: This prospective study examines a Level I trauma service experience with the de novo establishment of a trauma ultrasound (US) program credentialed through the Department of Surgery under the auspices of Continuous Quality Improvement. MATERIALS AND METHODS: All trauma surgeons attended a combined didactic and "hands on" 8-hour trauma US course. Abdominal sonography was subsequently performed on patients with potential blunt abdominal trauma followed by a standard diagnostic evaluation, which included computed tomographic scan, diagnostic peritoneal lavage, or observation. MEASUREMENTS AND MAIN RESULTS: Three hundred patients were studied over a 4-month period. They averaged 35 years of age with an average injury severity score of 12. The time required to perform the US examination averaged less than 3 minutes. Standard diagnostic evaluation included computed tomographic scan (21%), diagnostic peritoneal lavage (45%), and observation (34%). US examinations resulted in 277 true negatives, 17 true positives, two false positives, and four false negatives for a sensitivity of 81.0%, a specificity of 99.3%, and an accuracy of 98.0%. Annualized cost savings with the use of US evaluation versus standard diagnostic evaluation would amount to over $100,000.00. CONCLUSIONS: This experience with the de novo implementation of a trauma US program suggests that the training and credentialing requirements in this study are sufficient to provide surgeon ultrasonographers with acceptable competence in US diagnosis of blunt abdominal trauma.

Abdominal Injuries↗
PubMed1988

Learning curve for carotid endarterectomy.

It is generally accepted that training and experience are necessary to obtain acceptably low perioperative mortality and permanent neurologic morbidity for carotid endarterectomy. To test this hypothesis I analyzed the results of 600 consecutive primary carotid endarterectomies that I performed over a 13-year period beginning with my senior residency. The overall hospital mortality was 9/600 (1.5%), the permanent neurologic morbidity 11/600 (1.8%), and the combined mortality and permanent neurologic morbidity 20/600 (3.3%). The mortality for the first 300 operations was 6/300 (2%) (4/6 from stroke) and for the last 300, 3/300 (1%) (3/3 cardiac). All 11 nonfatal strokes occurred in the first 300 operations. Morbidity and mortality decreased with both cumulative experience and the number of operations done per year. While it is difficult to separate the effect of these two factors, the results suggest that both may be important in obtaining a combined perioperative mortality and permanent neurologic deficit below 3%.

Arteriosclerosis↗
PubMed2003

Percutaneous vasectomy: a simple modification eliminates the steep learning curve of no-scalpel vasectomy.

PURPOSE: We report a simplified method to avoid the most difficult step of no-scalpel vasectomy, while maintaining its minimally invasive advantages. MATERIALS AND METHODS: Using the no-scalpel vasectomy instruments in percutaneous fashion we perform vasectomy in the office setting without fixation of the vas to skin using the ring clamp. The sharp no-scalpel hemostat punctures the skin. The vas is then grasped with the ringed instrument instead of piercing the vas and performing the supination maneuver, as described for no-scalpel vasectomy. RESULTS: Percutaneous vasectomy was performed in 573 men by a single surgeon. In the 35 consecutive cases recently reviewed average operative time was 9.3 minutes with an additional 67 seconds added when a resident performed the procedure on 1 side in 15 cases. As determined by the knuckle of vas pulled through a puncture, average incisional length was 8.4 mm. Patients reported complete recovery in an average of 8.9 days. No major complications occurred. A single case of recanalization (0.17%) was successfully corrected by repeat percutaneous vasectomy. CONCLUSIONS: Percutaneous vasectomy is a minimally invasive option for permanent male sterilization that avoids the difficult aspects of no-scalpel vasectomy.

Ambulatory Surgical Procedures↗
PubMed2005

Perioperative complications of robotic radical prostatectomy after the learning curve.

PURPOSE: We assessed the incidence of and analyzed factors that contributed to perioperative complications in patients undergoing robotic radical prostatectomy, that is Vattikuti Institute prostatectomy (VIP), at our institution. MATERIALS AND METHODS: We recorded operative and postoperative data on 300 consecutive patients who underwent VIP at our institution during a 1-year period. All operations were performed by 1 of 2 surgeons (MM or JOP). We reviewed the complications seen in these patients. RESULTS: There was no operative mortality and no case was converted to open surgery. A total of 269 (89.7%) patients were considered to have an ideal postoperative course, ie they were discharged home within 48 hours with no unscheduled office visits or complications. There were 14 unscheduled postoperative visits (4.7%) for transient urinary retention after early catheter removal (13) or hematuria (1). There were 17 complications, of which 16 (5.3%) were related to surgery and 1 was related to anesthesia. A total of 11 complications (3.7%) were minor (grade I) and 5 (1.7%) were major (grade II). Of them 3 (1%) patients required reoperation. There were no grade III or IV complications. CONCLUSIONS: In our hands VIP is a safe operation with an overall complication rate of 5.3%, a major complication rate of less than 2% and a surgical re-intervention rate of 1%.

Adult↗
PubMedDate not supplied

Cardiopulmonary bypass in ewe's fetus: advances and setbacks in our learning curve.

Fetal cardiac surgery represents a surgical challenge and several centers are attempting to establish a suitable methodology in animals. We present our experience with extra-corporeal bypass procedures in preterm and term sheep fetuses. Twenty-two fetuses (103-139 days gestation, mean 115 days gestation) underwent a 1-hour period of right heart-to-pulmonary artery extracorporeal circulation followed by 1 hour of observation. Animals were divided into group 1 and group 2, according to gestational age (above and below 0.85). Three pumps were used: centrifugal without (group 1) reservoir, centrifugal with (group 2) reservoir, and roller with reservoir (group 2). Experiments were completed in 75% of fetuses in group 1 and in 37% of fetuses in group 2. Bleeding was the main cause of failure, especially for group 2. A slow deterioration of blood gas status was noted in group 1, while this trend could be partially reversed in group 2 with corrective measures. Complete heart bypass could not be achieved in either group, and residual fluctuations in arterial pressure were observed. During bypass, body temperature decreased more in group 2 than in group 1. We conclude that cardiac bypass is feasible over a short period in near-term fetuses. A successful outcome may also be obtained in younger fetuses, but better measures need to be implemented for the prevention of surgical bleeding.

Animals↗
PubMed2004

Risk-taking and health-seeking behavior in men with a history of urethritis: is there a learning curve?

BACKGROUND AND OBJECTIVES: Studies addressing how past experience with sexually transmitted diseases (STD) influence health-seeking behaviors among at-risk men are few. GOAL: The goal of this study was to determine whether health-seeking behaviors among men diagnosed with urethritis differ based on whether they report prior urethritis. STUDY DESIGN: Male STD clinic attendees answered a questionnaire regarding their demographic, sexual, and health-seeking characteristics. The men were stratified based on whether they reported prior urethritis. RESULTS: Of 466 men, 297 reported prior urethritis. Symptomatic men diagnosed with urethritis who reported prior urethritis did not recognize their symptoms as a possible STD earlier than those reporting no urethritis history; there was also no difference between the groups in their interval to presenting for care once symptoms were recognized as a possible STD. Furthermore, men with prior urethritis were as likely to engage in sex acts once they recognized their symptoms as a possible STD manifestation. CONCLUSION: Compared with men without prior urethritis, men with urethritis symptoms who reported prior urethritis did not recognize symptoms earlier, alter health-seeking behavior, or curtail sexual activity.

Adult↗
PubMed2004

On the learning curve: the emerging evidence supporting cognitive-behavioral therapies for adolescent substance abuse.

AIMS: Cognitive-behavioral therapy (CBT) approaches to intervention for adolescent substance use disorders has been limited and formal controlled clinical efficacy trials have been rare. Moreover, the early literature on the efficacy of CBT for adolescent substance abuse has been characterized by significant methodological limitations. Recent innovations in the treatment of adolescent substance abuse and the recent completion of several randomized clinical trials has brightened the picture with respect to establishing the empirical support for CBT. The aim of this review is to integrate the findings from controlled trials of CBT for adolescent substance abuse. METHOD: Studies representing randomized clinical trials were reviewed using criteria provided by Lonigan et al. and Nathan & Gorman as a guide. FINDINGS AND CONCLUSIONS: Despite some prominent differences in design and methodology, the studies reviewed provide consistent empirical evidence that group and individual CBT are associated with significant and clinically meaningful reductions in adolescent substance use. The evidence for the efficacy of group therapy is particularly important, countering the assertion that aggregating problem youths into group treatment settings is associated with iatrogenic effects. The findings from the randomized trials reviewed represent significant developments in treatment outcome research and lay the foundation for validating CBT for adolescent substance use disorders. Future research directions include improving short- and long-term outcomes, enhancing treatment motivation and engagement, and identifying mechanisms and processes associated with positive change, especially for youths with comorbid conditions.

Adolescent↗