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PubMed2006

New surgical consultants: is there a learning curve?

The purpose of this study was to determine whether newly established surgeons who have completed dedicated post-fellowship training are able to achieve surgical outcomes comparable to their more experienced peers. A cross-sectional study of consecutive patients undergoing total thyroidectomy (TT) or completion thyroidectomy was carried out. Outcomes measured included unplanned return to the operating theatre, postoperative infection, permanent recurrent laryngeal nerve (RLN) injury and permanent hypoparathyroidism. Outcomes were categorized according to whether surgery was carried out by an established surgeon (ES) or a newly appointed surgeon (NAS). Eight hundred and nine TT and completion thyroidectomy procedures were carried out in the period January 2002 to December 2004. Of these, 515 (64%) were carried out by ES and 294 (36%) were carried out by NAS. The overall rate of permanent hypoparathyroidism and RLN injury was 1.4% (12/809) and 0.6% (5/809), respectively. The rate of permanent hypoparathyroidism was not significantly different between the two categories of surgeon (ES 1.35% vs NAS 1.7%; P = 0.7). The incidence of permanent RLN injury was not different between the two groups (ES 0.8% vs NAS 0.3%; P = 0.4). For NAS, the rate of permanent RLN injury for the first two years of independent practice did not differ significantly from 3 to 4 years of practice (0/123 vs 1/171; P = 0.4). Indications for surgery between the two groups were similar, with ES carrying out TT for benign goitre in 42% and cancer in 28%, and NAS 44 and 32%, respectively. Surgical outcomes for the newly established endocrine surgeon following subspecialty training are equivalent to those achieved by more experienced surgeons.

Adult↗
PubMed2000

The long learning curve of gynaecological cancer surgery: an argument for centralisation.

OBJECTIVE: To study the development of surgical performance of an unchanging surgical team over 13 years. DESIGN: Prospective, observational study. SETTING: A university hospital, The Netherlands. PARTICIPANTS: Three hundred and eight women who underwent surgical treatment for early cervical cancer. INTERVENTIONS: Radical hysterectomy and pelvic lymphadenectomy between 1 January 1984 and 31 December 1996. RESULTS: The surgical procedure and indication for treatment remained unchanged during the study period. This applied also to the surgical team. The women's age increased significantly during the study years, as was the case with the number of nodes removed. The depth of infiltration by the tumour increased steadily throughout the study, but this failed to reach statistical significance. The distribution of FIGO stages, percentage of positive lymph nodes, radicality of the surgical margins and post-operative morbidity remained the same. Overall, the five year survival rate was 83%; for women with negative nodes 91%, and for women with positive nodes 53%. Survival tended to improve during the course of the study, but this was not statistically significant. Blood loss during surgery decreased consistently during the whole study period, from a mean of 1,515 mL at the beginning of the study to a mean of 1,071 mL at the end (P < 0.0001). The operating time also diminished significantly by 8 minutes per year (P < 0.0001). In 1985 the average operating time was 270 minutes, compared with 187 minutes in 1996. CONCLUSIONS: These findings indicate that it takes a long time to acquire skill in the surgical treatment of early cervical cancer. Centralisation of relatively infrequent operations for cancer should be encouraged.

Adult↗
PubMed1994

Laparoscopic management of ovarian masses: the initial experience and learning curve.

Fifty two consecutive patients undergoing laparoscopic surgery for ovarian masses were reviewed. The operative time depended on the experience of the surgeon and size of the tumour. It dropped progressively within the first 10 cases and then remained static until after 40 cases when there was a further decline. Postoperative pain was minimal and the median hospital stay was 2 days (range 1-7 days). The majority of patients returned to full activity within 2 weeks. The overall morbidity was 7.8% and was mild in nature without sequelae.

Adolescent↗
PubMed2004

Learning curve for hysteroscopic sterilisation: lessons from the first 80 cases.

The present report looks at the first 80 patients of Essure sterilisation performed by a surgeon with experience in operative hysteroscopy. The results show that the procedure is well tolerated under local anaesthesia with or without sedation, and that devices can be successfully placed in 90% of cases. Surgical time is reduced with increased experience, and successful placement increased by improving visibility within the endometrial cavity (cycle timing).

Adult↗
PubMedDate not supplied

Following the learning curve: the evolution of kinder, gentler neonatal respiratory technology.

Immense progress has been made in all aspects of neonatal critical care during the past 4 decades, particularly in the realm of respiratory support. A historical overview of the evolution of neonatal respiratory support illustrates how technological advances are improving survival and outcome for many sick newborns. Major milestones in this history include continuous positive airway pressure, conventional ventilation, exogenous surfactant, extracorporeal membrane oxygenation, and high frequency ventilation. Changes in clinical and nursing care highlight the significant impact of technological and practice advances on neonatal respiratory morbidity. Although bronchopulmonary dysplasia still occurs, the incidence and severity have decreased. The nature and outcome of the neonatal intensive-care experience has been redefined for many infants; however, great challenges remain in the care of infants on the edge of viability.

Bronchopulmonary Dysplasia↗
PubMed2002

An assessment of the learning curve for precut biliary sphincterotomy.

OBJECTIVE: Precut sphincterotomy is considered unsafe when used by inexperienced endoscopists. We sought to determine whether procedural experience with precut sphincterotomy predicted either successful cannulation or development of complications in these patients. METHODS: We describe the experience of 253 consecutive patients who underwent precut biliary sphincterotomy done by one endoscopist between September, 1993 and April, 2001. Data were prospectively collected on procedure indication and outcome. All patients were contacted by phone 30 days after the procedure to determine outcome. We also described precut utilization over time. RESULTS: All 253 precut procedures were divided chronologically into five groups of 50, with 53 in the final group. The rates of successful cannulation after precutting were 88%, 94%, 90%, 88%, and 98%, respectively (p = 0.05 for groups 1-4 vs group 5). Overall complication rates were similar in all groups (12%, 18%, 20%, 12%, and 14%), with no difference in complication severity. Female gender predicted successful cannulation (OR = 2.9 [p = 0.02]), whereas an indication of sphincter of Oddi dysfunction predicted development of complications (OR = 1.7 [p = 0.03]). The total number of ERCP procedures performed increased over time, whereas the proportion of precut sphincterotomies performed decreased. CONCLUSIONS: Although the success rate for precut sphincterotomy may increase with procedural experience, the complication rate does not seem to decrease. Precut sphincterotomy continues to carry an increased complication rate over standard sphincterotomy even when performed by an experienced biliary endoscopist. The need for precut sphincterotomy appears to decrease with increasing ERCP experience.

Clinical Competence↗
PubMed2004

Is routine ileoscopy useful? An observational study of procedure times, diagnostic yield, and learning curve.

BACKGROUND: IIeoscopy is not routinely attempted because of its perceived technical difficulty, time constraints, and the expectation of a low diagnostic yield. AIMS: To investigate the value of routine ileoscopy as an integral part of colonoscopy in terms of additional diagnostic information, extra time spent, and the relationship between ileoscopy rate and accumulation of colonoscopic experience. METHODS: We examined colonoscopy data from September 1995 to April 2004 of a gastroenterological firm. Crude and adjusted total colonoscopy rates (CTCR, ATCR) and ileoscopy rate (IR) were calculated. For calculation of ATCR and IR, 108 procedures in patients with previous colonic resection and 91 with unavoidable reasons for failure to reach cecum were excluded. Time trend in ileoscopy rate was analyzed with IR as a function of cumulative colonoscopy experience. Data on procedure times were collected for 1,222 consecutive colonoscopies between November 2000 and April 2004. Sixty-three procedures in patients with previous colonic resection, and 47 unavoidable and 14 avoidable failures to reach cecum were excluded from analysis of procedure times. RESULTS: Of 2,537 colonoscopies, 1,902 were performed by a single consultant and 635 by eight trainees with or without assistance from the consultant. The CTCR, ATCR, and IR were 94%, 97.5%, and 71.5% respectively. IR and ATCR rose progressively to plateau at 85% and 99% after 600 and 750 procedures respectively. The diagnostic yield from ileoscopy and ileal histology was 16.7% and 19% in patients with colonic inflammatory bowel disease, and 2.69% and 7.4% in other patients. Twenty six ileoscopies in 24 patients showed Crohn's ileitis with normal colon. The other diagnoses were NSAID related or nonspecific ileitis, ileal lipoma, ileal villous atrophy, and amyloidosis. The median anus to cecum and cecum to ileum times were 8.5 and 2 minutes (interquartile ranges=5.5 to 14 and 1 to 4 minutes) respectively. Procedure times for colonoscopies involving trainees were significantly longer compared with those by the consultant alone (median anus to cecum and cecum to ileum times=16.5 v 7 and 2.5 v 1.5 minutes; p<0.0001 and 95% CI for difference=7.5 to 9 and 0.5 to 1 minutes respectively). The median length of ileum examined was 15 cms (IR=10-20 cms). CONCLUSIONS: IIeoscopy is the gold standard in the documentation of completeness of colonoscopy. With practice, it can be achieved routinely in at least 85% of colonoscopies. In skilled hands, it adds only 3 minutes to the procedure time, and contributes significantly to quality assurance and diagnostic yield.

Adolescent↗
PubMed2006

Female sexuality and sexual dysfunction: are we stuck on the learning curve?

INTRODUCTION: Female sexual dysfunctions (FSDs) are very prevalent, multifaceted problems that continue to be under-recognized and undertreated. Improved recognition and management depend on physicians' inclination and ability to communicate with female patients about their sexual function. Many women hesitate to share sexual complaints due to concerns about physicians' time constraints or their interest in addressing it. Direct questioning by physicians about sexual function is often critical to patients' reporting of sexual concerns. AIM: To obtain pilot data on physicians' knowledge, perceptions, and practices regarding FSDs, which may help uncover means of facilitating future dialog between physicians and patients. METHODS: A self-reply questionnaire was used to survey physicians and other health professionals attending the 2004 annual meetings of four major specialty societies. MAIN OUTCOME MEASURES: Survey questions were included on the prevalence of FSDs; dialog on sexual function/activity; obstacles to appropriate evaluation and management of FSDs; effectiveness of current treatment options; and referral patterns. RESULTS: A total of 1,946 attendees completed the survey. Most respondents (60%) estimated that one- to three-quarters of their patients had FSDs. Low sexual desire was the most prevalent FSD observed. A total of 58% of participants reported initiating the first discussion of FSDs in one-quarter or less of patients. Obstacles to discussing sexual health included limited time and training, embarrassment, and absence of effective treatment options. Approximately 60% of participants rated both their knowledge of and comfort level with FSDs as only fair or poor. Eighty-six percent rated current treatment options as fair or poor. CONCLUSION: Healthcare professionals are aware of the high prevalence of FSDs but infrequently initiate a discussion of sexual function with their female patients or conduct a comprehensive evaluation for FSDs. Additional medical education and training are needed to improve the identification and management of FSDs in women.

Attitude of Health Personnel↗
PubMed2004

The learning curve.

Explore the source record for details and available documents.

Cardiac Surgical Procedures↗
PubMed1995

Staging of prostate cancer with endorectal MR imaging: lessons from a learning curve.

Endorectal magnetic resonance (MR) imaging is the most accurate noninvasive method of staging prostate cancer. However, inexperienced radiologists may lack the necessary technical and interpretative skills to use this technique, and both radiologists and referring urologists may become frustrated with this method because of its inaccuracy compared with analysis of the radical prostatectomy specimen. Meticulous pathologic correlation is necessary to evaluate endorectal MR imaging findings. The authors compare their initial experience using endorectal MR imaging for staging prostate cancer (25 cases) with their later experience (25 cases) to highlight the various diagnostic pitfalls and "pearls" one may encounter when using endorectal MR imaging. Knowledge of the pathways of tumor spread inside and outside the gland may be helpful in interpreting endorectal MR images. The authors achieved a substantial improvement in the overall staging accuracy of endorectal MR imaging by careful pathologic correlation and by considering the anatomic features of prostate cancer.

Case-Control Studies↗
PubMed1991

Cordocentesis (funipuncture) by maternal-fetal fellows: the learning curve.

One hundred cordocenteses were attempted at the University of Mississippi Medical Center between July 1, 1989, and June 1, 1991. There were 1.3 attempts for each successful umbilical blood sampling. The overall success rate was 94%. The first-year fellows-in-training attempted 61 procedures with a 90.2% success rate within two attempts and an overall success rate of 95.1%. Second-year fellows attempted 32 procedures with a 93.8% success rate within two attempts and an overall success rate of 93.8%. Procedure-related complications included five episodes of fetal bradycardia (one resulting in a stillbirth at 20 weeks) and a single case of chorioamnionitis. Of the three perinatal deaths, two were associated with severe congenital anomalies resulting in a corrected procedure-related mortality rate of 1%. The morbidity and mortality associated with cordocentesis appears to be relatively low and fellows-in-training can perform such procedures with no apparent increase in complications if appropriately supervised.

Blood Specimen Collection↗
PubMed2003

Passive marker computer-aided sinonasal and cranial base surgery: observations from a learning curve.

To assess the feasibility of passive marker computer-aided surgery in a single institution, we performed 22 procedures in 21 patients with disorders including sinonasal tumors (n = 9), fungal sinusitis (n = 4), recurrent polyps (n = 3), chronic sinusitis (n = 3), and cerebrospinal fluid rhinorrhea (n = 2). Passive marker computer-aided surgery was successful in 19 of the 21 patients. The accuracy was on the order of 1.35 mm. Probe conversion, rotation, and cordlessness were helpful in all 19 cases. The system helped with landmarks (n = 14), margins (n = 7), skull base (n = 6), orbit (n = 5), and approach (n = 4). Computer-aided surgery accurately confirmed the location of an instrument and demonstrated tumor-normal tissue interfaces. It aided the surgeon in procedures on the sinonasal area and cranial base. The potential advantages of a passive marker system as compared with other available technologies center around the ability to convert and/or rotate virtually any instrument to a cordless imaging probe on demand during the operation.

Angiofibroma↗
PubMed2004

Education and experience improve the performance of transbronchial needle aspiration: a learning curve at a cancer center.

STUDY OBJECTIVES: Transbronchial needle aspiration (TBNA) is an indispensable part of the pulmonologist's armamentarium, although it continues to be woefully underutilized despite its demonstrated safety and usefulness. We herein review our experience with the procedure. MATERIALS AND METHODS: All TBNAs were conducted according to standard techniques using 21-gauge cytology needles or 19-gauge histology needles connected to a flexible bronchovideoscope. All procedures were conducted at a 180-bed cancer center, and results were analyzed retrospectively. The mediastinum and hilar lymph node mapping system proposed by Wang was followed exclusively. RESULTS: From September 1999 to March 2003, inclusively, 90 of 549 patients undergoing diagnostic bronchoscopy were selected for TBNA: 66 patients for hilar-mediastinal lymphoadenopathies, and 24 patients for submucosal and/or peribronchial lesions. A total of 87 hilar-mediastinal lymph node stations were sampled, with a mean of 2.2 needle passes for each. Seventy-eight patients revealed a malignant diagnosis. TBNA provided positive results for malignancy for 59 patients. Sarcoidosis, mediastinal bronchogenic cyst, and mediastinal tuberculous adenitis were identified for another three patients, respectively. The diagnostic yield was 68.2% (45 of 66 patients) for hilar-mediastinal lesions, and 70.8% (17 of 24 patients) for submucosal and peribronchial lesions. The sensitivity was 75% (45 of 60 patients) for hilar-mediastinal lesions, and 80.9% (17 of 21 patients) for submucosal and peribronchial lesions. The overall accuracy of the procedure for returning a correct diagnosis was 75.9% (66 of 87 patients). Higher yields for patients featuring small-cell lung cancer were noted. Fifteen patients presenting mediastinal lesions attained to a specific pathologic diagnosis using TBNA despite normal-appearing airways. TBNA was the exclusive means of diagnostic sampling for 27 patients. Twenty-two patients had previously undergone a nondiagnostic bronchoscopy at other hospitals. Diagnosis and mediastinal staging was accomplished in one procedure for 19 patients exhibiting non-small cell lung cancer. The number of TBNA procedures performed per unit time rose steadily during the test period. The TBNA yield and sensitivity for the detection of hilar-mediastinal lymphoadenopathies increased significantly (p = 0.03) during the study period. The presence of the cytotechnologist during the TBNA procedure provided direct, immediate feedback pertaining to the quality of specimens acquired. With such rapid on-site examination of TBNA-derived specimens, there was a trend with borderline significance (p = 0.06) toward a decreasing frequency of inadequately acquired tissue specimens when using this technique. CONCLUSIONS: TBNA performance was able to be improved over time. Increased specimen yield and sampling sensitivity over a 43-month period suggested the impact of enhanced training interventions and experience. Rapid on-site examination was also indispensable for the promotion of diagnostic accuracy. The progressive acquisition of skills as regards the use of cytology needles for TBNA purposes should precede the use of a histology needle for such biopsy purposes. For selected cases, the use of the 19-gauge histology needle increased the diagnostic yield of TBNA. It is to be hoped that increased experience with the TBNA technique and focused education regarding its performance will enhance its utilization by bronchoscopists and the spread of its acceptance.

Adult↗
PubMed1992

Femoral neck fracture fixation with hook-pins. 2-year results and learning curve in 626 prospective cases.

We performed a prospective 2-year follow-up study of 626 consecutive femoral neck fractures treated with closed reduction and hook-pin fixation in all cases. The woman:man ratio was 2.9:1, the displaced:undisplaced fracture ratio 2.6:1. Mean patient age was 78 (18-100) years. The first 476 fractures were operated on by one of six surgeons with special interest in the technique, while the remaining operations were performed by any of the 35 surgeons in the department, all specialists in orthopedic surgery. Mortality within two years was 31 percent. Healing complications (redisplacement, nonunion or segmental femoral head collapse) in the total material/survivors only were for undisplaced fractures 5/7 percent, for displaced fractures 30/41 percent and for the total material 23/32 percent. According to life-table analysis, the complication rate in the total material at two years was 24 percent. The rate of secondary arthroplasty for healing complications was 13/19 percent. For displaced fractures, as well as for the total material, the group of specially interested surgeons had better results than the department as a whole.

Adolescent↗