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A novel drill set for the enhancement and assessment of robotic surgical performance.

BACKGROUND: There currently exist several training modules to improve performance during video-assisted surgery. The unique characteristics of robotic surgery make these platforms an inadequate environment for the development and assessment of robotic surgical performance. METHODS: Expert surgeons (n=4) (>50 clinical robotic procedures and >2 years of clinical robotic experience) were compared to novice surgeons (n=17) (<5 clinical cases and limited laboratory experience) using the da Vinci Surgical System. Seven drills were designed to simulate clinical robotic surgical tasks. Performance score was calculated by the equation Time to Completion + (minor error) x 5 + (major error) x 10. The Robotic Learning Curve (RLC) was expressed as a trend line of the performance scores corresponding to each repeated drill. RESULTS: Performance scores for experts were better than novices in all 7 drills (p<0.05). The RLC for novices reflected an improvement in scores (p<0.05). In contrast, experts demonstrated a flat RLC for 6 drills and an improvement in one drill (p=0.027). CONCLUSION: This new drill set provides a framework for performance assessment during robotic surgery. The inclusion of particular drills and their role in training robotic surgeons of the future awaits larger validation studies.

Clinical Competence↗

Challenges of teaching surgery: ethical framework.

Surgeons, trainees, and patients may be uncomfortable with the secrecy that surrounds the process of teaching and learning surgical procedures. Well structured training programs use a system of graded responsibility, supervision, and evaluation to ensure skill development and patient safety. Patient outcomes are generally excellent in training institutions. Disclosure of the role of trainees and their contribution to care enhances trust.

Clinical Competence↗

The structure of child and adolescent psychopathology: generating new hypotheses.

To begin to resolve conflicts among current competing taxonomies of child and adolescent psychopathology, the authors developed an interview covering the symptoms of anxiety, depression, inattention, and disruptive behavior used in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994), the International Statistical Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992), and several implicit taxonomies. This interview will be used in the future to compare the internal and external validity of alternative taxonomies. To provide an informative framework for future hypothesis-testing studies, the authors used principal factor analysis to induce new testable hypotheses regarding the structure of this item pool in a representative sample of 1,358 children and adolescents ranging in age from 4 to 17 years. The resulting hypotheses differed from the DSM-IV, particularly in suggesting that some anxiety symptoms are part of the same syndrome as depression, whereas separation anxiety, fears, and compulsions constitute a separate anxiety dimension.

Adolescent↗

Training and accreditation in radiation protection for interventional radiology.

Training in radiation protection is a basic aspect of the optimisation of medical exposures. Council Directive 97/43/EURATOM establishes the need for an adequate theoretical and practical training of the staff working in radiological practices, and competence in radiation, for which Member States shall ensure the establishment of appropriate curricula. Keeping in mind the different specialities and professional responsibilities, training curricula must be proposed and endorsed to achieve a common core of knowledge in radiation protection throughout Europe, for different groups of health workers. In interventional radiology, previous initiatives led to the definition of a syllabus of educational objectives and to its testing in a specific course. The present paper presents educational objectives for interventional radiology, developed in the framework of the DIMOND European concerted action.

Accreditation↗

Accreditation processes in the Slovak Republic.

This article provides a conceptual framework for understanding changes occurring in the accreditation process for institutions of higher learning in the Slovak Republic. Health sector transformation is occurring rapidly throughout the Central and Eastern European region as former socialist states are experimenting with market-oriented approaches. Educators and universities are playing an important role in the development of knowledge, skills and abilities of current and future health practitioners. Accreditation is viewed as an important process in the continuing development of quality health service management curricula and preparing competent practitioners for the health care field. Historical considerations are examined as well as future directions for accreditation in the Slovak Republic.

Accreditation↗

A molecular basis for integrin alphaMbeta 2 ligand binding promiscuity.

The leukocyte integrin alpha(M)beta(2) is a highly promiscuous leukocyte receptor capable of binding a multitude of unrelated ligands. To understand the molecular basis for the broad ligand recognition of alpha(M)beta(2), the inter-integrin chimera was created. In the chimeric integrin, the betad-alpha5 loop-alpha5 helix segment comprised of residues Lys(245)-Arg(261) from the alpha(M)I domain of alpha(M)beta(2) was inserted into the framework of alpha(L)beta(2). The construct was expressed in HEK 293 cells, and the ability of generated cells to adhere to fibrinogen and its derivatives was characterized first. Grafting the alpha(M)(Lys(245)-Arg(261)) sequence converted alpha(L)beta(2) into a fibrinogen-binding protein capable of mediating efficient and specific adhesion similar to that of wild-type alpha(M)beta(2). Verifying a switch in the binding specificity of alpha(L)beta(2), the chimeric receptor became competent to support cell migration to fibrinogen. Mutations at positions Phe(246), Asp(254), and Pro(257) within Lys(245)-Arg(261) of alpha(M)beta(2) produced significant decreases in cell adhesion, illustrating the critical role of these residues in ligand binding. The insertion of alpha(M)(Lys(245)-Arg(261)) imparted to the chimeric integrin the ability to recognize many typical alpha(M)beta(2) protein ligands. Furthermore, cells expressing the chimeric receptor, but not alpha(L)beta(2), were able to stick to uncoated plastic, which represents the hallmark of wild-type alpha(M)beta(2). These results suggest that alpha(M)(Lys(245)-Arg(261)) serves as a consensus binding site for interaction with a variety of distinct molecules and, thus, may define the degenerate recognition properties inherent to alpha(M)beta(2).

Amino Acid Sequence↗

A clinical ladder program based on Carper's Fundamental Patterns of Knowing in Nursing.

Clinical and career ladder programs were popular adjuncts to recruitment and retention during the nursing shortage of the 1980s. Programs commonly used Benner's work as an organizing framework and typically used activities such as continuing education credit, committee participation, work experience, certifications, academic degrees, community service, and performance appraisal scores as criteria for advancement. The authors present a unique clinical ladder program based on Carper's Fundamental Patterns of Knowing in Nursing. This philosophical work has been debated in the literature for many years, yet to the authors' knowledge, this work has never been used as the conceptual basis for program development. The four patterns of knowing in nursing were found to be consistent with the definition of professional nursing, and provided a meaningful organizing framework that was well received by staff registered nurses. An overall history of clinical ladders is presented, followed by the organization's prior experience with these programs, and finally the details of development and implementation of the program with plans for evaluation.

Attitude of Health Personnel↗

Re-defining nursing expertise in the United kingdom.

There is now international recognition of the importance of practice expertise in modern and effective health services. The Expertise in Practice Project in the United Kingdom began in May 1998 and continued to 2004. It included nurses working in all four countries of the United Kingdom, and it covered clinical specialists from pediatrics to palliative care. The project added to the current understanding of what nursing practice expertise is, through the identification and verification of attributes and factors which enable expert practice. The proposed framework offers a language for sharing what constitutes practice expertise and offers insight into what occurs between the expert practitioner and the people that experience their care. The Expertise in Practice Project demonstrates that nurses affect change and facilitate performance and organizational development.

Attitude of Health Personnel↗

Using a nursing framework to establish a nurse-managed Senior Health Clinic.

This article describes the organizing framework and evaluation component of a newly initiated nurse-managed Senior Health Clinic that is being collaboratively run by a school of nursing and a senior service agency in Central Florida. Background is provided on choosing a partner agency; negotiations; developing a mission statement, goals, and operation plans; determining the target audience; and marketing strategies. The clinic targets residents who are 55 years old and older and who do not currently have a primary care provider. Cox's (1982) Interactional model for Client Health Behavior provides the framework for care delivery and all process and outcome evaluation activities. As such, the model provides an innovative nursing focus to the delivery of primary care services. Client characteristics are used to form the components of the client data collection tool, which was developed to provide baseline information on seniors who are using the clinic. Three elements of client professional interaction are included in the Health Care Form, which documents the nurse practitioner services that were provided: health information, affective support, and professional technical competencies. The Client Satisfaction Tool measures the client's satisfaction with each of the elements of client-professional interaction that are theorized to influence health outcomes. Information management is facilitated by a computer program that enables staff to enter the information directly into the computer. Data collection is ongoing and will quantify the type and extensiveness of services provided and the quality of care at the Senior Health Clinic.

Aged↗

The influence of an organizational pain management policy on nurses' pain management practices.

PURPOSE/OBJECTIVES: To examine the influence of a formal organizational pain management policy on nurses' pain management practices. DESIGN: Descriptive correlational. SETTING: Tertiary-care medical center. SAMPLE: 91 nurses providing direct patient care on five study units during a 72-hour study period. METHODS: Off-going nurses completed three self-administered questionnaires one-half hour before the end of each eight-hour work shift. Opioid administration data also were collected. Data were analyzed using correlational, t test, chi-square, and analysis of variance analyses and descriptive statistics. MAIN RESEARCH VARIABLES: Nurses' knowledge of the healthcare organization's chronic pain management policy; nurses' knowledge of pain and pain management; nurses' perceived accountability for pain management activities; the ratio of actual amounts of opioid analgesics administered compared with maximum amounts ordered. FINDINGS: Nurses' knowledge of pain management and their perceived accountability for pain management were significantly related to knowledge of the organization's chronic pain management policy. Correlations were lower than expected, based on theoretical relationships proposed in the open system study framework. CONCLUSIONS: Further research is needed to explore the influence of a high-quality pain management policy on nursing practice and clinical pain management. IMPLICATIONS FOR NURSING PRACTICE: Better understanding of the influence of organizational policy could lead to much needed improvements in pain management.

Adult↗

Transforming growth factor beta1 stimulates contrasting responses in metastatic versus primary mouse prostate cancer-derived cell lines in vitro.

Tumor progression to the stage of metastasis may result in part from the selection of certain primary tumor cell clones which are phenotypically competent for survival, invasion, and growth at secondary sites. Selection for traits such as loss of growth inhibitory responses, acquisition of increased adhesiveness, increased local immunosuppression, and enhanced motility and collagenase activities likely contribute to cancer progression and may be regulated through the action of growth factors. The transforming growth factors (TGF-beta) family of growth factors has often been associated with these traits and tumor progression; therefore, elimination or subversion of TGF-beta-responsive pathways should be considered as a mechanistic framework for metastatic events. In this report, we have compared growth and extracellular matrix responses to TGF-beta in six metastatic and six primary tumor-derived cell lines in a mouse model of prostate cancer. We have found that tumor cell lines derived from focal pulmonary metastasis secreted relatively greater quantities of total TGF-betas, lost most or all TGF-beta1 growth inhibition, but responded to TGF-beta1 through induction of the type IV collagenase matrix metalloproteinase-9, whereas cell lines derived from tumors which proliferated at the primary site retained the growth inhibition but lacked collagenase activity. Synthesis of another extracellular matrix protein, plasminogen activator inhibitor 1, was stimulated by TGF-beta1 in both primary as well as metastatic tumors. These results suggest that acquisition of differential responses to the TGF-beta family could result in phenotypic traits which facilitate tumor metastasis from certain primary site clones.

Animals↗

Analysis of a survey of 36 French research committees on intracytoplasmic sperm injection.

BACKGROUND: In France, when a new medical technology is to be applied experimentally to human beings, it must adhere to the principles stipulated by the Huriet-Sérusclat law on biomedical research. This law requires that the validation of a protocol applicable to human beings, with its corollary protection and information dimensions, is first submitted to a research committee, known as a Consultative Committee Protecting Persons in Biomedical Research (CCPPRB). We aimed to survey the competence of these committees in biotechnology, and whether or not intracytoplasmic sperm injection (ICSI) had been considered by the committees as being an innovative treatment. METHODS: We presented each of France's 48 CCPPRBs with a questionnaire to assess the choices and criteria for making decisions that arose at the time ICSI was implemented in the different centres in each region. FINDINGS: 36 committees took part. We found that ICSI had been largely introduced in settings outside the scope of the CCPPRBs and of the framework fixed by the law on biomedical research. Only three centres for medically assisted reproduction had submitted applications to a CCPPRB, although ICSI has been implemented in over 20 centres. 21 (58%) committees were of the opinion that the implementation of ICSI could have come under their supervision. 24 (67%) committees believed that, independently of their own involvement, evaluation procedures for ICSI should have been specified before centres decided to introduce it. INTERPRETATION: We observed important differences in the way CCPPRBs handled ICSI as being within or outside the medical research field. The status of the research committees is legally and identically defined. However, committees did not agree on the definition of the limits of their action, and, therefore, their handling of the same issue differed. An inquiry is needed to define how, now that ICSI is done in many centres, it should adhere to principles of evaluation and safety already in existence for other medical technologies.

Ethical Review↗

Relative testis size and sperm morphometry across mammals: no evidence for an association between sperm competition and sperm length.

Understanding why there is extensive variation in sperm form and function across taxa has been a challenge because sperm are specialized cells operating at a microscopic level in a complex environment. This comparative study collates published data to determine whether the evolution of sperm morphometry (sperm total length and separate component dimensions) is associated with sperm competition (when different males' sperm mix and compete for a female's ova) across 83 mammalian species. We use relative testes mass as an indicator of the intensity of sperm competition across taxa: relative investment into testes is widely accepted to predict the level of sperm competition that a species or population endures. Although we found evidence for positive associations between relative testes mass (controlling for allometry) and sperm morphometry across 83 mammalian species, these relationships were phylogenetically dependent. When we appropriately controlled for phylogenetic association using multiple regression within a phylogenetic framework, there was no relationship between relative testes mass and sperm length across mammals. Furthermore, we found no evidence for associations between relative testes mass and sperm head, mid-piece or flagellar lengths, nor was there a relationship with mid-piece or mitochondrial volumes. Results, therefore, indicate that sperm competition does not select for longer or shorter sperm across mammals, and alternative forces selecting on sperm form and function are discussed.

Animals↗

Periphyton function in lake ecosystems.

Periphyton communities have received relatively little attention in lake ecosystems. However, evidence is increasing that they play a key role in primary productivity, nutrient cycling, and food web interactions. This review summarizes those findings and places them in a conceptual framework to evaluate the functional importance of periphyton in lakes. The role of periphyton is conceptualized based on a spatial hierarchy. At the coarsest scale, landscape properties such as lake morphometry, influence the amount of available habitat for periphyton growth. Watershed-related properties, such as loading of dissolved organic matter, nutrients, and sediments influence light availability and hence periphyton productivity. At the finer scale of within the lake, both habitat availability and habitat type affect periphyton growth and abundance. In addition, periphyton and phytoplankton compete for available resources at the within-lake scale. Our review indicates that periphyton plays an important functional role in lake nutrient cycles and food webs, especially under such conditions as relatively shallow depths, nutrient-poor conditions, or high water-column transparency. We recommend more studies assessing periphyton function across a spectrum of lake morphometry and trophic conditions.

Ecosystem↗

The catalytic mechanism of tryptophan synthase from Escherichia coli. Kinetics of the reaction of indole with the enzyme--L-serine complexes.

The mechanism by which indole condenses with L-serine in the active site of tryptophan synthase was studied by the stopped-flow technique. The single turnover occurs by rapid binding of indole to the pre-formed enzyme--L-serine complex, followed by C--C bond formation, reprotonation of the alpha carbon carbanion of L-tryptophan, and its final release. The effects of isotopic substitution at C-3 of indole, of pH, and of the presence of indolepropanol phosphate on these processes were also studied. The mechanism of binding of indole complements the known mechanisms of binding of L-serine and L-tryptophan to give a detailed picture of the mechanism of catalysis. It invokes two competent species of enzyme--L-serine complexes, leading to a branched pathway for the central condensation process. The rates of dehydration of L-serine and reprotonation of the carbanion of L-tryptophan are probably limited by rearrangements at the active site. Analysis of absorption, fluorescence and circular dichroic spectra, as well as of published data on the stereoisomers obtained by reduction with borohydride, suggests that the rearrangement includes a reorientation of the pyridoxal phosphate C-4' atom. The mechanism provides a detailed framework for explaining all available information, including the activating effect of the alpha subunit on the reaction catalyzed by the beta 2 subunit.

Catalysis↗

The consilia attributed to Arnau de Vilanova.

Four of the works attributed to Arnau de Vilanova may be considered consilia, which is the name of the genre of texts that expound medical treatments for illnesses suffered by specific individuals. In this paper, I first address the problem of their autheticity within the framework of the so-called "Arnaldian question". The evidence presented here confirms that Arnau de Vilanova was the author of the Regimen podagre and the Epistola ad Bremundum Montisferrarii, while the question regarding the authorship of the Regimen quartane and the Cura febris ethice remains unresolved. This article furthermore documents the degree to which the actual cures prescribed by the physician in the consilia agreed with the doctrinal works of the Galenic tradition. It is explained how medieval university-trained physician had to compete with other practitioners and how they tried to outrival them by applying the doctrines of learned medicine to the individual cases at hand.

Drug Prescriptions↗

Resource document for curriculum development in cancer genetics education. American Society of Clinical Oncology.

PURPOSE: The rapid growth in the use of genetic testing for heritable cancers and other diseases has led to the establishment of many committees to assess the status and future implications of such testing. The American Society of Clinical Oncology (ASCO) published a statement on genetic testing for cancer susceptibility in May 1996. In that statement, ASCO recognized the need for a major initiative to develop courses and other educational materials for ASCO members and other health care professionals that were pertinent to cancer genetics and the role of cancer predisposition testing in clinical oncology. These curriculum guidelines represent an effort to promote formal instruction on the assessment and management of familial cancer risks in training programs and continuing education courses. DESIGN AND RESULTS: An Ad hoc Task Force was created from the ASCO membership and other professional organizations. Goals of ASCO's cancer genetics education initiative, curriculum guidelines, and plans for implementation of the curriculum have been developed. To gain understanding and competency in cancer genetics and cancer predisposition testing, the curriculum emphasizes formal instruction in: (1) basic concepts and principles of genetics; (2) an understanding of the role of genetics in the etiology, diagnosis, and management of different malignancies; (3) an understanding of the ethical, legal, and social issues that surround predisposition testing; and (4) long-term management plans for individuals at high risk for cancer. This document is broad in scope and applicable to all types of malignancies. It should be considered as the framework around which cancer genetics education is developed. It is expected that implementation of training activities over the next few years will allow ASCO to fulfill its obligations to the membership. CONCLUSION: This curriculum should prove a valuable guide to those who wish further education on cancer genetics and the appropriate use of cancer predisposition testing.

Curriculum↗

The history of the Laboratory of Pathology of the Cluj-Napoca Oncological Institute.

The Laboratory of Pathology of the actual "Professor Ion Chiricută" Oncological Institute of Cluj-Napoca, former "Iuliu Maniu" Institute for Cancer Study and Prophylaxis, had the privilege that in its framework carry on an important part of their activity professors Titu Vasiliu and Rubin Popa, who are forming, beside Victor Babeş, the golden trinity of the Romanian pathology. The Cancer Institute of Cluj, one of the first in the World, was founded in 1929, especially by the clear-sightedness and the efforts of Professor Iuliu Moldovan, the master of the modern Romanian school of hygiene. The clinic division was assisted by a Laboratory of Pathology, whose chief was appointed the young pathologist of high competence, Rubin Popa, associate Professor of this department of the Cluj School of Medicine. In 1942' he became director of the Institute, function accomplished until his premature disappearance in 1958. Titu Vasiliu worked in the Oncological Institute from 1949, a year after his forced retreat from the chair of pathology, up to 1958. Fortunately, his premature disappearance did not interrupt the activity of the laboratory, because the management of the Oncological Institute was committed to Ion Chiricută, an experimented and modern surgeon of Bucharest. From 1960, the Laboratory of Pathology has been led by Professor Augustin Mureşan, an experimented, rigorous and prudent pathologist, who has imprinted these indispensable qualities to his disciples learning under his leadership. The activity of the laboratory has been very favorably influenced by the presence of Professor Gheorghe Badenski from the Department of Microbiology. The collaboration with Professor Eugen Pora from Babeş-Bolyai Department of Animal Physiology and his disciples, Virgil Toma, Draga Nestor, Sena Roşculet, Carmen Stugren and Georgette Buga has carried on the performance of interesting works concerning the thymus involution in tumor-bearing hosts and its signification for the depressed immunity in the advanced stages of cancer. In the same direction, the behavior of mast cells has been studied in collaboration with Professor George Csaba from the Budapest Medical University, Department of Biology. The observations brought about were remarked by the Canadian scientist Hans Selye. Most of these works have been included in the book "Immunity and cancer", distinguished with "Victor Babeş" Prize of the Romanian Academy. The arrival in the Institute of Professor Ion Macavei, disciple of Iuliu Hatieganu and founder of the Clinical Hematology in Cluj, expert in blood and bone marrow cytology, has given a strong impulse to the studies of malignant hemopoietic diseases. The current use of cytologic and histopathologic examinations in this field of pathology and, especially, the introduction by him, for the first time in Romania, of the osteomedullary biopsy has permitted the elaboration of an appreciated work about the cytologic and histologic diagnosis of lymphadenopathies. In the histochemical-histoenzymatic period of the microscopic diagnosis, between the years 1960-1990, the laboratory has enjoyed by the advices and the material help of Professor Raymond Wegmann from the Paris University, Institute of Histochemistry, the founder-editor of the International Review of Histochemistry, from 1976, of Cellular and Molecular Biology, who visited our laboratory in 1992. From 1965, in an adjacent Laboratory of Cytogenetics, Corneliu D. Olinici has performed the first karyotypes in Cluj and has teached the method to several other specialists. Despite the technical difficulties, the works performed in the Laboratory of Pathology have succeeded sometimes to reach the quality required by Professor Chiricută to a valuable scientific work in cancerology. This performance has been obtained by a study concerning Crabtree effect variations in tumoral metastases or about lactic-dehydrogenase behavior in breast carcinomas.

Cancer Care Facilities↗