Clinical efficacy and learning curve of robot-assisted thymectomy via subxiphoid approach / 中国胸心血管外科临床杂志

@#Objective     To explore the clinical efficacy and learning curve of robot-assisted thymectomy via subxiphoid approach. Methods    The clinical data of patients with robot-assisted thymectomy surgery via subxiphoid approach performed by the same surgical team in the Department of Thoracic Surgery of Shanghai Pulmonary Hospital from February 2021 to August 2022 were retrospectively analyzed. The cumulative sum (CUSUM) analysis and best fit curve were used to analyze the learning curve of this surgery. The general information and perioperative indicators of patients at different learning stages were compared to explore the impact of different learning stages on clinical efficacy of patients. Results    A total of 67 patients were enrolled, including 31 males and 36 females, aged 57.10 (54.60, 59.60) years. The operation time was 117.00 (87.00, 150.00) min. The best fitting equation of CUSUM learning curve was y=0.021 2x3–3.192 5x2 +120.17x–84.444 (x was the number of surgical cases), which had a high R2 value of 0.977 8, and the fitting curve reached the top at the 25th case. Based on this, the learning curve was divided into a learning period and a proficiency period. The operation time and intraoperative blood loss in the proficiency stage were significantly shorter or less than those in the learning stage (P<0.001), and there was no statistical difference in thoracic drainage time and volume between the two stages (P>0.05). Conclusion    The learning process of robot-assisted thymectomy via subxiphoid approach is safe, and this technique can be skillfully mastered after 25 cases.

Learning curve for ultrasound-guided external cephalic version without anesthesia in full-term and near-term pregnancies / 中华围产医学杂志

Objective:To evaluate the effects of physician skills on the success rate of the external cephalic version (ECV) and investigate the learning curve for ECV.Methods:A retrospective study of 97 pregnant women who underwent ECV at the First Affiliated Hospital of Nanjing Medical University from March 2019 to August 2021 was performed. Patients were divided into multipara and primipara groups. The success rate of ECV and morbidity were compared between the two groups, and the learning curve for ECV was evaluated using cumulative sum analysis (CUSUM).Results:(1) Patients in the multipara group were older than those in the primipara group [(33.0±3.4) vs (29.2±3.0) years, t=－5.57, P<0.001]. No significant difference was found in other baseline data between the two groups. (2) The overall ECV success rate was 61.9% (60/97), and a higher success rate was observed in the multipara group [93.3% (28/30) vs 47.8% (32/67), χ 2=18.24, P<0.001]. Fetal heart rate deceleration (5.2%, 5/97), vaginal bleeding (1.0%, 1/97), premature rupture of membranes (1.0%, 1/97), and fetal distress (1.0%, 1/97) were the main complications. (3) The CUSUM analysis showed that it needed 53 primiparas for a physician to obtain a 50% consistent success rate ( R2=0.91, H=－3.27, Y=52.16) and seven multiparas to achieve a 70% consistent success rate ( R2=0.99, H=－1.635, Y=6.60). Conclusions:Parity and operator skills have a significant influence on the success of ECV. A physician with standardized training will manage non-anesthesia ECV skillfully in full-term and near-term pregnancies after practice on 50 primiparae or approximately ten multiparae. It is recommended to start with the multiparae for learning ECV to build up confidence and promote the implementation of ECV.

Learning curve and key procedures analysis of modified rat models of orthotopic left lung transplantation / 器官移植

Objective To summarize and analyze the key procedures of the modified rat model of orthotopic left lung transplantation, aiming to provide more experience for the establishment of rat models of lung transplantation. Methods Two surgeons (A and B) performed complete transplantation in consecutive 15 rat models, and every 5 surgeries were divided into 1 practice stage. The operating time of each transplantation procedure was recorded. The differences of overall success rate and 1-week survival rate were calculated among different practice stages. The learning curve was delineated by the cumulative sum method. Results For surgeons A and B, the number of the first successful transplantation was the 5th and 6th time, the overall success rates of transplantation were 80% and 87% respectively, and the 1-week survival rates of rats both were 92%. Along with the increasing number of surgeries, the entire cardiopulmonary procurement, cannula preparation, cold ischemia, warm ischemia, transplantation and total operation time by two surgeons showed a significantly downward trend (all P < 0.05). For surgeons A and B, 3 and 2 rats died of heart failure due to overdose anesthesia, and 1 rat died of vein distortion at postoperative 1 d and 1 died of atelectasis at postoperative 7 d, respectively. The goodness of fit (R2) of cumulative sum method was 0.992 8 and 0.976 6. The turning point of learning curve was achieved in the 7th and 8th transplantation for surgeons A and B. Conclusions The modified rat model of orthotopic left lung transplantation yields high operability and repeatability both theoretically and technologically, and has multiple advantages of short learning curve, short operation time, high survival rate of the recipients and few complications, which is worthy of application in the basic research of lung transplantation.

Learning curve of Da Vinci robot-assisted radical gastrectomy for gastric cancer / 中华消化外科杂志

Objective To investigate the learning curve of Da Vinci robot-assisted laparoscopic radical gastrectomy for gastric cancer.Methods The retrospective cohort study was conducted.The clinicopathological data of 42 patients who underwent Da Vinci robot-assisted radical gastrectomy for gastric cancer in the First Affiliated Hospital of Xi'an Jiaotong University from October 2017 to August 2018 were collected.There were 30 males and 12 females,aged from 36 to 84 years,with an average age of 59 years.The learning curve was evaluated using the cumulative sum (CUSUM) analysis and the best fitting curve method.According to the minimum number of surgeries required to cross the learning curve,the patients were divided into learning stage group and mastery stage group.Then general data and surgical efficacy of the two groups were compared.Observation indicators:(1) surgical situations;(2) results of CUSUM analysis;(3) comparison of general data between the two groups;(4) comparison of surgical efficacy between the two groups;(5) follow-up.Patients were followed up by outpatient examination or telephone interview to detect the postoperative complications,tumor recurrence and metastasis up to February 2019.Measurement data with normal distribution were presented as Mean±SD,and comparison between groups was done using the independent sample t test.Count data were represented as absolute number,and comparison between groups was analyzed using the chi-square test or Fisher exact propability.Comparison of ordinal data between groups was analyzed using the Mann-Whitney U test.Results (1) Surgical situations:all the 42 patients underwent Da Vinci robot-assisted radical gastrectomy for gastric cancer successfully,without conversion to open surgery or perioperative death.Fourteen out of 42 patients underwent Da Vinci robot-assisted total radical gastrectomy and 28 underwent Da Vinci robot-assisted distal radical gastrectomy.The operation time and docking time were (213±31)minutes and (26± 11)minutes.The operation time and docking time had a tendency to decreasing as the surgical cases increasing.(2) Results of CUSUM analysis.The CUSUM learning curve were best modeled as a polynomial with equation:CUSUM (operation time)=0.016 9X3-1.913 3X2+ 50.985X-16.595,CUSUM (docking time) =0.012 8X3-1.070 7X2 + 22.189X-23.097 respectively (X means the surgical case).The P value of fitting test of models was ＜ 0.05,with goodness-of-fit (R2) as 0.960 and 0.985.The CUSUM learning curve of operation time reached its peak when the number of surgical cases accumulated to the 19th case.Nineteen cases were the minimum number of surgeries required to cross the learning curve.Similarly,The CUSUM learning curve of docking time reached its peak when the number of surgical cases accumulated to the 14th case,and 14 cases were the minimum number of surgeries required to skillfully master robot installation across the learning curve.(3) Comparison of general data between the two groups:patients were divided into learning stage group and mastery stage group with 19 cases as the cut-off point.Males,females,age,body mass index (BMI),cases in grade 1,2,3 of American society of anesthesiologists (ASA),cases with previous abdominal surgery history,cases with basic diseases,cases in T1,T2,T3,T4 stages of preoperative ultrasonic gastroscopic tumor T staging,maximum tumor diameter,cases in Ⅰ,Ⅱ,Ⅲ stages of postoperative clinical staging,cases with total gastrectomy and distal gastrectomy (surgical method) were 14,5,(60± 13)years,(23.7±2.9)kg/m2,1,16,2,3,8,5,3,3,8,(4.1±3.5)cm,6,7,6,10,9 in the learning stage group,and 16,7,(58±10)years,(23.7±1.3)kg/m2,1,17,5,2,14,3,6,9,5,(4.7±2.7)cm,8,9,6,18,5 in the mastery stage group,respectively.There was no significant difference in the sex,age,BMI,ASA score,basic diseases,preoperative ultrasonic gastroscopic tumor T staging,maximum tumor diameter,postoperative clinical staging,and surgical method between the two groups (x2 =0.086,t =0.475,-0.007,Z =-0.884,x2 =1.469,Z =-0.301,t =-0.651,Z =-0.079,-0.236,x2 =3.076,P ＞ 0.05).There was no significant difference in the previous abdominal surgery history between the two groups (P ＞ 0.05).(4) Comparison of surgical efficacy between the two groups:operation time,volume of intraoperative blood loss,number of lymph nodes harvested,time to first liquid food intake,cases with postoperative complications and duration of postoperative hospital stay were (230±25) minutes,(176± 103) mL,21±7,(5.1 ± 2.0) days,2,(9.3± 2.5)days in the learning stage group,and (191±18) minutes,(95±41)mL,21±6,(4.7±1.7)days,3,(8.4± 2.1)days in the mastery stage group,respectively.There were statistically significant differences in the operation time and volume of intraoperative blood loss between the two groups (t =5.951,-3.359,P＜0.05).There was no statistically significant difference in number of lymph nodes harvested,time to first liquid food intake,and duration of postoperative hospital stay between the two groups (t =-0.120,0.538,1.303,P＞0.05).There was no significant difference in the cases with postoperative complications between the two groups (P＞0.05).(5) Follow-up:all the 42 patients were followed up for 6-16 months,with a median time of 11 months.No serious long-term complications,tumor recurrence and metastasis or death occurred during the follow-up.Conclusions The CUSUM learning curve of Da Vinci robot-assisted radical gastrectomy for gastric cancer can be divided into the learning stage and the mastery stage.It is suggested that the surgeons need to finish 19 cases or more to master Da Vinci robot-assisted radical gastrectomy for gastric cancer.

Study on early warning threshold values for 7 common communicable diseases in Gansu province, 2016 / 中华流行病学杂志

Objective To optimize the warning threshold values of common communicable diseases in Gansu province,and improve the early warning effect.Method An early warning model was set up for influenza,scarlet fever,other infectious diarrheal diseases,dysentery,typhoid and paratyphoid,viral hepatitis type E and hand foot and mouth disease (HFMD) respectively in Gansu by using the moving percentile method and cumulative sum method.By calculating the sensitivity,specificity,predictive value of positive test,predictive value of negative test,Youden'index and receiver-operating characteristic curve,the optimum early warning threshold values for communicable diseases in Gansu were selected.Results The optimum early warning boundary values of influenza,scarlet fever,other infectious diarrheal diseases,dysentery,typhoid and paratyphoid,and viral hepatitis type E were P90,P80,P95,P90,P80 and P90 respectively.The optimum early warning parameters of HFMD were k =1.2,H=5σ.Under the optimum early warning boundary values/parameters,the early warning sensitivities of influenza,scarlet fever,other infectious diarrheal diseases,dysentery,typhoid and paratyphoid,viral hepatitis type E and HFMD were 86.67％,100.00％,91.67％,100.00％,100.00％,100.00％ and 100.00％,the specificities were 86.49％,62.22％,75.00％,100.00％,97.92％,89.13％ and 74.47％.The predictive values of positive test were 72.22％,29.17％,52.38％,100.00％,80.00％,54.55％ and 29.41％,and the predictive values of negative test were 94.12％,100.00％,96.77％,100.00％,100.00％,100.00％ and 100.00％,and the Youden'indexes were 0.73,0.62,0.67,1.00,0.98,0.89 and 0.74.Receiver-operating characteristic curve showed that the values/parameters of this warning boundary were the points closest to the upper left of the coordinate diagram.Conclusion The early warning thresholds of influenza,other infectious diarrheal diseases,dysentery and hepatitis E in Gansu may be raised appropriately and the early warning parameters of HFMD need to be adjusted to improve the effectiveness of early warning.

Study on early warning threshold values for 7 common communicable diseases in Gansu province, 2016 / 中华流行病学杂志

Objective To optimize the warning threshold values of common communicable diseases in Gansu province,and improve the early warning effect.Method An early warning model was set up for influenza,scarlet fever,other infectious diarrheal diseases,dysentery,typhoid and paratyphoid,viral hepatitis type E and hand foot and mouth disease (HFMD) respectively in Gansu by using the moving percentile method and cumulative sum method.By calculating the sensitivity,specificity,predictive value of positive test,predictive value of negative test,Youden'index and receiver-operating characteristic curve,the optimum early warning threshold values for communicable diseases in Gansu were selected.Results The optimum early warning boundary values of influenza,scarlet fever,other infectious diarrheal diseases,dysentery,typhoid and paratyphoid,and viral hepatitis type E were P90,P80,P95,P90,P80 and P90 respectively.The optimum early warning parameters of HFMD were k =1.2,H=5σ.Under the optimum early warning boundary values/parameters,the early warning sensitivities of influenza,scarlet fever,other infectious diarrheal diseases,dysentery,typhoid and paratyphoid,viral hepatitis type E and HFMD were 86.67％,100.00％,91.67％,100.00％,100.00％,100.00％ and 100.00％,the specificities were 86.49％,62.22％,75.00％,100.00％,97.92％,89.13％ and 74.47％.The predictive values of positive test were 72.22％,29.17％,52.38％,100.00％,80.00％,54.55％ and 29.41％,and the predictive values of negative test were 94.12％,100.00％,96.77％,100.00％,100.00％,100.00％ and 100.00％,and the Youden'indexes were 0.73,0.62,0.67,1.00,0.98,0.89 and 0.74.Receiver-operating characteristic curve showed that the values/parameters of this warning boundary were the points closest to the upper left of the coordinate diagram.Conclusion The early warning thresholds of influenza,other infectious diarrheal diseases,dysentery and hepatitis E in Gansu may be raised appropriately and the early warning parameters of HFMD need to be adjusted to improve the effectiveness of early warning.

Learning curves for three specific procedures by anesthesiology residents using the learning curve cumulative sum (LC-CUSUM) test / 대한마취과학회지

BACKGROUND: The learning curve cumulative sum (LC-CUSUM) test is an innovative tool that allows quantitative monitoring of individual medical performance during the learning process by determining when a predefined acceptable level of performance is reached. This study used the LC-CUSUM test to monitor the learning process and failure rate of anesthesia residents training for specific subspecialty anesthesia procedures. METHODS: The study included 490 tracheal punctures (TP) for jet ventilation, 340 thoracic epidural analgesia (TEA) procedures, and 246 fiberoptic nasal intubations (FONI) performed by 18 residents during their single 6-month rotation. RESULTS: Overall, 27 (14–52), 19 (5–41), and 14 (6–33) TP, TEA, and FONI procedures were performed, respectively, by each resident. In total, 2 of 18 residents achieved an acceptable failure rate for TEA according to the literature and 4 of 18 achieved an acceptable failure rate for FONI, while none of the residents attained an acceptable rate for TP. CONCLUSIONS: A single 6-month rotation in a reference teaching center may not be sufficient to train residents to perform specific or sub-specialty procedures as required. A regional learning network may be useful. More patient-based data are necessary to conduct a risk adjustment analysis for such specific procedures.

Learning curves for three specific procedures by anesthesiology residents using the learning curve cumulative sum (LC-CUSUM) test / 대한마취과학회지

BACKGROUND: The learning curve cumulative sum (LC-CUSUM) test is an innovative tool that allows quantitative monitoring of individual medical performance during the learning process by determining when a predefined acceptable level of performance is reached. This study used the LC-CUSUM test to monitor the learning process and failure rate of anesthesia residents training for specific subspecialty anesthesia procedures. METHODS: The study included 490 tracheal punctures (TP) for jet ventilation, 340 thoracic epidural analgesia (TEA) procedures, and 246 fiberoptic nasal intubations (FONI) performed by 18 residents during their single 6-month rotation. RESULTS: Overall, 27 (14–52), 19 (5–41), and 14 (6–33) TP, TEA, and FONI procedures were performed, respectively, by each resident. In total, 2 of 18 residents achieved an acceptable failure rate for TEA according to the literature and 4 of 18 achieved an acceptable failure rate for FONI, while none of the residents attained an acceptable rate for TP. CONCLUSIONS: A single 6-month rotation in a reference teaching center may not be sufficient to train residents to perform specific or sub-specialty procedures as required. A regional learning network may be useful. More patient-based data are necessary to conduct a risk adjustment analysis for such specific procedures.

Learning curve analysis of laparoscopic radical hysterectomy for gynecologic oncologists without open counterpart experience

OBJECTIVE: To evaluate the learning curve of laparoscopic radical hysterectomy (LRH) for gynecologic oncologists who underwent residency- and fellowship-training on laparoscopic surgery without previous experience in performing abdominal radical hysterectomy (ARH). METHODS: We retrospectively reviewed 84 patients with FIGO (International Federation of Gynecology and Obstetrics) stage IB cervical cancer who underwent LRH (Piver type III) between April 2006 and March 2014. The patients were divided into two groups (surgeon A group, 42 patients; surgeon B group, 42 patients) according to the surgeon with or without ARH experience. Clinico-pathologic data were analyzed between the 2 groups. Operating times were analyzed using the cumulative sum technique. RESULTS: The operating time in surgeon A started at 5 to 10 standard deviations of mean operating time and afterward steeply decreased with operative experience (Pearson correlation coefficient=-0.508, P=0.001). Surgeon B, however, showed a gentle slope of learning curve within 2 standard deviations of mean operating time (Pearson correlation coefficient=-0.225, P=0.152). Approximately 18 cases for both surgeons were required to achieve surgical proficiency for LRH. Multivariate analysis showed that tumor size (>4 cm) was significantly associated with increased operating time (P=0.027; odds ratio, 4.667; 95% confidence interval, 1.187 to 18.352). CONCLUSION: After completing the residency- and fellowship-training course on gynecologic laparoscopy, gynecologic oncologists, even without ARH experience, might reach an acceptable level of surgical proficiency in LRH after approximately 20 cases and showed a gentle slope of learning curve, taking less effort to initially perform LRH.

Application of CUSUM curve in cardiac surgery resident clinical training / 中华医学教育探索杂志

Objective To investigate the application of CUSUM (cumulative sum control chart) curve in cardiac clinical teaching of resident surgeon education.Methods We chose a surgeon of 10years work experience of attending the preparation operation of internal mammary artery as control reference (standard group,28 patients) and a resident engaged in professional clinical cardiac work no more than 5 years as group 1,a professional training physician engaged in cardiac surgery clinical work more than 5 years as group 2 and took 40 patients' data respectively from the two groups' preparation of internal mammary artery operation.And then we recorded the postoperative mammary artery flow,internal mammary artery preparation time and adverse events data and made statistics analysis with SPSS 19.0,and CUSUM curve with Matlab R2012b polynomial curve.Results When the density of operate interval and the operate numbers came to about 25 cases,the polynomial eurve's slope rate went up to 0,regardless the surgeons' experience,CUSUM value was accumulated from 66 to 76,and overcame the learning curve successfully.However,when the density of operate interval did no reach the standard,the surgeon's CUSUM ploynomial cmwe slope rate never reached to 0,and can't overcome the learning curve.Conclusion CUSUM curve gives a clear quantitative indicator to the cultivation of clinical physician,and makes teaching teachers can understand the young physicians' learning process,so as to change the teaching plan,help young physicians cross the learning curve as soon as possible.

Early detection on the onset of scarlet fever epidemics in Beijing, using the Cumulative Sum / 中华流行病学杂志

[Introduction] Based on data related to scarlet fever which was collected from the Disease Surveillance Information Reporting System in Beijing from 2005 to 2011,to explore the efficiency of Cumulative Sum (CUSUM) in detecting the onset of scarlet fever epidcmics.Models as C1-MILD (C1),C2-MEDIUM (C2) and C3-ULTRA (C3) were used.Tools for evaluation as Youden' s index and detection time were calculated to optimize the parameters and optimal model.Data on 2011 scarlet fever surveillance was used to verify the efficacy of these models.C1 (k=0.5,H=2σ),C2 (k=0.7,H=2σ),C3 (k=1.1,H=2σ) appeared to be the optimal parameters among these models.Youden' s index of C1 was 83.0％ and detection time being 0.64 weeks,Youden' s index of C2 was 85.4％ and detection time being 1.27 weeks,Youden' s index of C1 was 85.1％ and detection time being 1.36 weeks.Among the three early warning detection models,C1 had the highest efficacy.Three models all triggered the signals within 4 weeks after the onset of scarlet fever epidemics.The early warning detection model of CUSUM could be used to detect the onset of scarlet fever epidemics,with good efficacy.

Effect of magnitude and duration on the performance of Cumulative Sum / 中华流行病学杂志

To explore the effect of magnitude and duration on the performance of Cumulative Sum (CUSUM),with simulation method used on the subject after the insertion of 11 outbreak events into baseline data with Poisson distribution.Sensitivity fluctuated from 9.1％ to 100.0％ with specificities higher than 98.6％.Sensitivity was significantly correlated with magnitude,and increased along with the increase of magnitude.However,no significant correlation was observed between sensitivity and duration.A magnitude which was at least 2.6 times higher than that of the mean daily baseline could result in the sensitivity of 100.0％.Time-lag would be improved along with the increase of magnitude.Time between onset and detection of an outbreak was no longer than one day when magnitude was more than 1.8 of the mean daily baseline.In summary,the performance of CUSUM was influenced by magnitude,but not by duration.CUSUM had the advantage of good time-lag and high sensitivity when the outbreak magnitude was more than 2.4 time over the baseline data.

Application of cumulative sum control chart algorithm in the detection of infectious disease outbreaks / 中华流行病学杂志

In recent years, for improving the ability of early detection on infectious disease outbreak, many researchers study the disease outbreak detection algorithms, based on many disease surveillance data, expecting to detect the abnormal increasing and cluster of disease and symptom at an early stage by adopting appropriate algorithm. This paper introduces a cumulative sum control chart method, one of statistical process control algorithms widely used in foreign countries and describes its basic principle and characteristic, key points of design, typical examples in application of disease outbreak detection of cumulative sum method, with expect to provide reference for its application in studies of disease outbreak early warning in China.