Web-connected surgery: using the internet for teaching and proctoring of live robotic surgeries.

The purpose of this study was to assess the feasibility of using live teleconferencing for teaching of new robotic-assisted surgical techniques. This was a prospective study with review of outcomes (Canadian Task Force classification II-3) in a community hospital. In 2009, our community hospital acquired the da Vinci Connect™ System, a technology which allows for live surgeon-to-surgeon interaction during robotic surgery via a secure internet connection. We utilized this technology from March 2009 through March 2011 to perform 28 live robotic surgeries that were observed by surgeons and hospital staff in 14 different US states as well as in France. We also had 14 episodes where new robotic surgeons in our facilities were mentored by experienced robotic surgeons in other geographic locations live through the da Vinci Connect internet connection. We performed two live surgeries for continuing medical education courses with live interactions between the course attendees and the console surgeon. Finally, one surgeon in our hospital proctored new surgeons remotely in distant sites on challenging cases. Utilizing computers that allow an experienced mentor surgeon to interact with less experienced surgeons on a live case is invaluable and presages the way we will train surgeons in the future. This feasibility study validates the need to pursue this technology for future education and training as well as for real-time collaboration.

Bronchodilators for bronchiolitis.

BACKGROUND: Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and often treated with bronchodilators. OBJECTIVES: To assess the effects of bronchodilators on clinical outcomes in infants with acute bronchiolitis. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 1) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to March week 2 2010) and EMBASE (2003 to March 2010). SELECTION CRITERIA: Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis. DATA COLLECTION AND ANALYSIS: Two authors assessed trial quality and extracted data. Unpublished data were obtained from trial authors. MAIN RESULTS: We included 28 trials (1912 infants) with bronchiolitis. In 10 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.45, 95% confidence interval (CI) -0.96 to 0.05, n = 1182). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (12% in bronchodilator group versus 16% in placebo, odds ratio (OR) 0.78, 95% CI 0.47 to 1.29, n = 650). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349). In seven inpatient and eight outpatient studies, average clinical score decreased slightly with bronchodilators (standardized mean difference (SMD) -0.37, 95% CI -0.62 to -0.13, n = 1006).Oximetry and clinical score outcomes showed significant heterogeneity. Including only studies at low risk of bias significantly reduced heterogeneity measures for oximetry (I(2) statistic = 17%) and average clinical score (I(2) statistic = 26%), while having little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00, P = 0.05) and average clinical score (SMD -0.26, 95% CI -0.44 to -0.08, P = 0.005).Effect estimates for outpatients were slightly larger than for inpatients for oximetry (outpatients MD -0.57, 95% CI -1.13 to 0.00 versus inpatients MD -0.29, 95% CI -1.10 to 0.51) and average clinical score (outpatients SMD -0.49, 95% CI -0.86 to -0.11 versus inpatients SMD -0.20, 95% CI -0.43 to 0.03). Adverse effects included tachycardia and tremors. AUTHORS' CONCLUSIONS: Bronchodilators do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. The small improvements in clinical scores for outpatients must be weighed against the costs and adverse effects of bronchodilators.

Community collaborations for farmworker health in New York and Maine: process analysis of two successful interventions.

We conducted a process evaluation of 2 successful farmworker community-based participatory research intervention development projects (in Maine and New York State). Participant surveys measured satisfaction with the program process. We used qualitative methods to analyze free-text responses. Respondents indicated high satisfaction levels overall. The main concern was long-distance project coordination. Community-based participatory research programs in which (1) the work team defines the target health issue, (2) agricultural employers are meaningfully included, and (3) interventions are carried through to completion, warrant further study.

Occupational injury and treatment patterns of migrant and seasonal farmworkers.

Migrant and seasonal farmworkers are thought to be at increased risk for occupational injury and illness. Past surveillance efforts that employed medical chart review may not be representative of all farmworkers, since the proportion of farmworkers using migrant health centers (MHCs) and area hospital emergency rooms (ERs) was unknown. The purpose of the current study was to determine the proportion of workers using MHCs versus other sources of occupational health care, and to use these data to correct previous occupational injury and illness rate estimates. Researchers conducted a survey of migrant and seasonal farmworkers in two sites: the Finger Lakes Region of New York and the apple, broccoli, and blueberry regions of Maine. Researchers also conducted MHC and ER medical chart reviews in these regions for comparison purposes. Proportions of occupational morbidity by treatment location were calculated from the survey, and a correction factor was computed to adjust chart review morbidity estimates for Maine and New York State. Among 1103 subjects, 56 work-related injuries were reported: 30 (53.6%) were treated at a MHC, 8 (14.3%) at an ER, 9 (16.1%) at some other location (e.g., home, relative, chiropractor), and 9 (16.1%) were untreated. Mechanisms of injuries treated at MHCs versus all other sources did not differ significantly. The survey-based multiplier (1.87) was applied to previous statewide MHC chart review injury counts from Maine and New York. The corrected injury rates were 7.9 per 100 full-time equivalents (FTE) per year in Maine, and 11.7 per 100 FTE in New York. A chart-review based surveillance system, combined with a correction factor, may provide an effective method of estimating occupational illness and injury rates in this population.

County lung cancer mortality: a decision tree model for control and prevention.

OBJECTIVE: It is widely accepted that smoking prevalence and poverty predict the occurrence of lung cancer mortality. The question asked in the study was: What are the important factors for counties that are useful to public health professionals? We sought to provide an answer, using a recursive partitioning approach applied to county-level indicators. METHODS: Classification and regression tree analysis is relatively unexplored for its utility in public health. Using available ecologic data, county lung cancer mortality was modeled by several predictor variables from a larger set of candidates. We constructed a tree on the basis of statistical software, R. RESULTS: Seven groupings were defined. Not surprisingly, smoking prevalence was a major determiner of tree nodes, as were prior coronary heart disease mortality, poverty, and National Air Toxics Assessment excess cancer deaths estimates. Lung cancer mortality groupings ranged from 47 per 100000 in the best 2 groupings (leaves) to 85 per 100000 in the worst grouping of 52 local jurisdictions. CONCLUSIONS: Ecologic data portrayed in a classification and regression tree have utility for spurring etiologic investigation, tracking county outcomes, developing policy at any governmental level, and guiding program design and management. Community by community, improvements are not yet at Healthy People 2010 targets. Individual communities may benefit through efforts to focus attention on aspects such as smoking levels, poverty, air quality, or region, highlighted by this analysis.

Estimating the occupational morbidity for migrant and seasonal farmworkers in New York state: a comparison of two methods.

PURPOSE: Compare occupational morbidity estimates for migrant and seasonal farmworkers obtained from survey methods versus chart review methods and estimate the proportion of morbidity treated at federally recognized migrant health centers (MHCs) in a highly agricultural region of New York. METHODS: We simultaneously conducted 1) an occupational injury and illness survey among agricultural workers, 2) MHC chart reviews, and 3) hospital emergency room (ER) chart reviews. RESULTS: Of the 24 injuries reported by 550 survey subjects, 54.2% received treatment at MHCs, 16.7% at ERs, 16.7% at some other facility, and 12.5% were untreated. For injuries treated at MHCs or ERs, the incidence density based on survey methods was 29.3 injuries per 10,000 worker-weeks versus 27.4 by chart review. The standardized morbidity ratio for this comparison was 1.07 (95% confidence intervals = 0.65-1.77). CONCLUSIONS: Survey data indicated that 71% of agricultural injury and illness can be captured with MHC and ER chart review. MHC and ER incidence density estimates show strong correspondence between the two methods. A chart review-based surveillance system, in conjunction with a correction factor based on periodic worker surveys, would provide a cost-effective estimate of the occupational illness and injury rate in this population.

YKL-40 is a differential diagnostic marker for histologic subtypes of high-grade gliomas.

PURPOSE AND EXPERIMENTAL DESIGN: In modern neuro-oncology, no variable affects therapeutic decisions and prognostic estimation more than tumor classification. We showed recently that class prediction models, based on gene expression profiles, classify diagnostically challenging malignant gliomas in a manner that better correlates with clinical outcome than standard pathology. In the present study, we used immunohistochemistry to investigate YKL-40 protein expression in independent sets of glioblastomas and anaplastic oligodendrogliomas to determine whether this single marker can aid classification of these high-grade gliomas. RESULTS AND CONCLUSIONS: Glioblastomas show strikingly more YKL-40 expression than anaplastic oligodendrogliomas. Only 2 of 37 glioblastomas showed completely negative YKL-40 staining in both tumor cells and extracellular matrix, whereas 18 of 29 anaplastic oligodendrogliomas were completely negative in non-microgemistocytic tumor cells and extracellular matrix. Tumor cell staining intensity was also markedly different: 84% of glioblastomas showed strong staining intensities of 2+ or 3+ whereas 76% of anaplastic oligodendrogliomas either did not stain or stained at only 1+. YKL-40 staining provided a better class distinction of glioblastoma versus anaplastic oligodendroglioma than glial fibrillary acidic protein, the current standard immunohistochemical marker used to distinguish diagnostically challenging gliomas. Moreover, a combination of YKL-40 and glial fibrillary acidic protein immunohistochemistry afforded even greater diagnostic accuracy in anaplastic oligodendrogliomas.

Selection pressures of TP53 mutation and microenvironmental location influence epidermal growth factor receptor gene amplification in human glioblastomas.

Epidermal growth factor receptor (EGFR) gene amplification occurs in glioblastomas as so-called double minutes. Because double minutes are extrachromosomal fragments, selection pressures must operate to maintain high EGFR copy number over multiple cell divisions. In analyses of glioblastoma lysates, EGFR amplification has been observed almost exclusively in glioblastomas harboring wild-type TP53 genes, which raises the alternative hypotheses that TP53 mutation either prevents amplification or selects against maintenance of EGFR-amplified cells. To address these possibilities at the cellular level, we studied 14 glioblastomas for TP53 mutation and EGFR gene amplification status, using fluorescence in situ hybridization (FISH) for the latter. Remarkably, four of the six cases with TP53 mutation had isolated EGFR-amplified cells in different regions, demonstrating that EGFR amplification occurs frequently at the cellular level in TP53-mutant glioblastomas. Thus, TP53 mutation does not prevent EGFR amplification but does not facilitate selection of EGFR-amplified cells. Of the eight cases without TP53 mutation, five had widespread EGFR amplification. In four of these five cases, multiple regions of the tumor were available for examination; FISH demonstrated a gradation of EGFR amplification, with highly amplified cells, primarily at the invading edges rather than the relatively solid tumor centers, suggesting that EGFR overexpression, when selected for in vivo, may be related to tumor invasion.