[Evaluation of technical skills in surgical training]. / Evaluación objetiva de competencias técnicas en cirugía.

INTRODUCTION: technical skills acquisition is considered to be of paramount importance in surgical training. Yet, formal assessment of technical skills is the weakest and less developed area. Currently available resources to evaluate technical skills are largely subjective, and lack of validity and reliability. Direct observation, one of the most frequently used methods, is largely biased by interpersonal subjectivity and personality traits. We propose the creation and use of a new procedure-specific tool for objective assessment of technical skills in surgery to evaluate validity and reliability. MATERIALS AND METHODS: laparoscopic cholecystectomy and Lichstenstein's inguinal hernia repair were the chosen procedures. Three groups of comparison were defined according to surgical expertise: initial, intermediate, and experts. Surgeries were videorecorded in real time without identification of the patient or the surgeon. Tapes without any posterior edition were assigned to two expert surgeons in a blind and randomized sequence. A newly proposed procedure-specific rating scale was used for evaluation, as well as Reznick's OSATS global scale. Kruskal-Wallis non-parametric test was used to assess validity. p < 0,05 was considered statistically significant. Chronbach's? values> 0.8 granted reliability. RESULTS: from April 2010 to December 2012 36 laparoscopic cholecystectomies and 31 inguinal hernia repairs were recorded. Significant difference was found among groups of comparison for every item (p<0.05). Crhonbach's ? was largely over 0,80 for both procedures. There was no significant difference between the assessments of the two raters. There was no significant difference between our newly proposed procedure-specific instrument and Reznick's OSTATS. DISCUSSION: the objective assessment of technical skills in surgery is feasible and useful. The tool we proposed showed construct validity and reliability. Video recording of surgical procedures grants durability over time to an ephemeral phenomenon. The objectivity is based on the explicit statements and quantification of every step to be evaluated, and the blind randomization and anonymous treatment of the sample. Sharing the same quality criteria between evaluators is of paramount importance to reach satisfactory results. The process of evaluation always implies a shortened view of the reality.

Introducción: La adquisición de habilidades quirúrgicas constituye un factor central en la formación de todo cirujano. Sin embargo, la evaluación de las habilidades técnicas es uno de los factores más débiles y menos desarrollados. En la actualidad los recursos para evaluar las competencias técnicas adolecen de subjetividad, falta de confiabilidad y validez. La observación directa, método de evaluación más frecuentemente utilizado en nuestro medio, presenta inconvenientes instrumentales y está fuertemente influenciada por las relaciones intersubjetivas y los rasgos de personalidad. El objetivo de esta investigación es proponer creación y el uso de un instrumento objetivo para evaluar el desempeño técnico y determinar su confiabilidad y validez.Material y método: se seleccionaron dos procedimientos: colecistectomía laparoscópica y hernioplastia inguinal (técnica de Lichtenstein). Se constituyeron tres grupos de comparación según la experiencia quirúrgica: inicial, intermedio, y expertos. Se filmaron las cirugías en tiempo real, sin identificación del paciente ni del cirujano. Las filmaciones sin edición fueron asignadas a dos cirujanos expertos en forma aleatoria por sorteo y con sobres sin identificación. Para la evaluación se propuso el uso de un instrumento objetivo (explicitación de pasos a evaluar y cuantificación mediante escala de Likert) y específico para cada procedimiento. Así mismo se utilizó la escala global OSATS (R. Reznick). Se aplicó análisis de varianza no paramétrico para determinar validez. Valores de p menores a 0.05 fueron considerados estadísticamente significativos. Valores superiores a 0,80 del Coeficiente alfa de Cronbach aseguraron confiabilidad. Resultados: Desde Abril del 2010 hasta Diciembre del 2012 se filmaron 36 colecistectomías videolaparoscópicas y 31 hernioplastias inguinales. Se encontraron diferencias significativas entre los grupos en todos los ítems evaluados p<0.05. El coeficiente ? de Crohnbach fue mayor a 0,80 para ambas técnicas. No hubo diferencias significativas entre las calificaciones de ambos evaluadores. No hubo diferencias entre nuestro instrumento específico y la escala global OSATS. Discusión: Es posible y útil aplicar un instrumento objetivo de evaluación del desempeño técnico en cirugía. La herramienta presentó validez de constructo y confiabilidad aceptables. La filmación confiere perdurabilidad a un evento efímero: la cirugía. La objetividad se basa en la enunciación y cuantificación explícita de cada paso, y en la aleatorización y anonimato de la muestra. La uniformidad de criterios entre los evaluadores es fundamental para obtener resultados satisfactorios. Evaluarsiempreimplicaráunrecorte de la realidad.

Evaluación objetiva de competencias técnicas en cirugía / [Evaluation of technical skills in surgical training].

INTRODUCTION: technical skills acquisition is considered to be of paramount importance in surgical training. Yet, formal assessment of technical skills is the weakest and less developed area. Currently available resources to evaluate technical skills are largely subjective, and lack of validity and reliability. Direct observation, one of the most frequently used methods, is largely biased by interpersonal subjectivity and personality traits. We propose the creation and use of a new procedure-specific tool for objective assessment of technical skills in surgery to evaluate validity and reliability. MATERIALS AND METHODS: laparoscopic cholecystectomy and Lichstenstein’s inguinal hernia repair were the chosen procedures. Three groups of comparison were defined according to surgical expertise: initial, intermediate, and experts. Surgeries were videorecorded in real time without identification of the patient or the surgeon. Tapes without any posterior edition were assigned to two expert surgeons in a blind and randomized sequence. A newly proposed procedure-specific rating scale was used for evaluation, as well as Reznick’s OSATS global scale. Kruskal-Wallis non-parametric test was used to assess validity. p 0.8 granted reliability. RESULTS: from April 2010 to December 2012 36 laparoscopic cholecystectomies and 31 inguinal hernia repairs were recorded. Significant difference was found among groups of comparison for every item (p<0.05). Crhonbach’s ? was largely over 0,80 for both procedures. There was no significant difference between the assessments of the two raters. There was no significant difference between our newly proposed procedure-specific instrument and Reznick’s OSTATS. DISCUSSION: the objective assessment of technical skills in surgery is feasible and useful. The tool we proposed showed construct validity and reliability. Video recording of surgical procedures grants durability over time to an ephemeral phenomenon. The objectivity is based on the explicit statements and quantification of every step to be evaluated, and the blind randomization and anonymous treatment of the sample. Sharing the same quality criteria between evaluators is of paramount importance to reach satisfactory results. The process of evaluation always implies a shortened view of the reality.

Evaluación objetiva de competencias técnicas en cirugía. / [Evaluation of technical skills in surgical training].

INTRODUCTION: technical skills acquisition is considered to be of paramount importance in surgical training. Yet, formal assessment of technical skills is the weakest and less developed area. Currently available resources to evaluate technical skills are largely subjective, and lack of validity and reliability. Direct observation, one of the most frequently used methods, is largely biased by interpersonal subjectivity and personality traits. We propose the creation and use of a new procedure-specific tool for objective assessment of technical skills in surgery to evaluate validity and reliability. MATERIALS AND METHODS: laparoscopic cholecystectomy and Lichstensteins inguinal hernia repair were the chosen procedures. Three groups of comparison were defined according to surgical expertise: initial, intermediate, and experts. Surgeries were videorecorded in real time without identification of the patient or the surgeon. Tapes without any posterior edition were assigned to two expert surgeons in a blind and randomized sequence. A newly proposed procedure-specific rating scale was used for evaluation, as well as Reznicks OSATS global scale. Kruskal-Wallis non-parametric test was used to assess validity. p < 0,05 was considered statistically significant. Chronbachs? values> 0.8 granted reliability. RESULTS: from April 2010 to December 2012 36 laparoscopic cholecystectomies and 31 inguinal hernia repairs were recorded. Significant difference was found among groups of comparison for every item (p<0.05). Crhonbachs ? was largely over 0,80 for both procedures. There was no significant difference between the assessments of the two raters. There was no significant difference between our newly proposed procedure-specific instrument and Reznicks OSTATS. DISCUSSION: the objective assessment of technical skills in surgery is feasible and useful. The tool we proposed showed construct validity and reliability. Video recording of surgical procedures grants durability over time to an ephemeral phenomenon. The objectivity is based on the explicit statements and quantification of every step to be evaluated, and the blind randomization and anonymous treatment of the sample. Sharing the same quality criteria between evaluators is of paramount importance to reach satisfactory results. The process of evaluation always implies a shortened view of the reality.

Enfoque terapéutico de las neumonías en la infancia / General management of pneumonia in childhood

Los niños con neumonía y afectación media o moderada pueden ser cuidados en su domicilio con seguridad y reexaminados a las 48 horas del inicio del tratamiento. En los niños pequeños, una afectación más intensa –como tener una SaO2 <92%, cianosis, polipnea >70 rpm, esfuerzo respiratorio, apneas intermitentes, quejido, incapacidad para ingerir alimentos y limitación para observación o supervisión familiar– es indicación para su ingreso hospitalario. En los niños más mayores, estas indicaciones serían una SaO2 <92%, cianosis, polipnea >50 rpm, dificultad para ingerir líquidos o alimentos, quejido, signos de deshidratación o dificultad familiar para su observación o supervisión. Como los virus son la causa única de muchos casos de neumonía en la infancia no parece apropiado tratar a cada niño con antibióticos. Las decisiones terapéuticas en un niño concreto pueden ser difíciles, pues la mayoría de las pruebas no son útiles para diferenciar de modo adecuado las infecciones virales de las bacterianas. La resistencia antibacteriana se ha incrementado constantemente en los últimos años y está relacionada con su uso abusivo en situaciones en que la afectación viral es muy probable o la enfermedad es leve y limitada a vías superiores. Por esta razón, es preferible restringir los antibióticos tanto como sea posible y, si se usan, utilizar agentes de espectro estrecho siempre que sea posible, pues la menor presión antibiótica limita la emergencia de resistencia antibiótica. Finalmente, se comenta el enfoque terapéutico de las neumonías, de acuerdo con la edad, la repercusión sobre el estado general, el patrón radiológico, los datos de laboratorio y la epidemiología de estas infecciones en nuestro medio (AU)

Infants and children with moderate pneumonia can be safely cared for at home and should be re-examined within 48 hours of the beginning of treatment. An SaO2 of 92% or less, cyanosis, respiratory rate greater than70 breaths per minute, difficulty in breathing, intermittent apnea, grunting, inability to eat, and a family incapable of providing appropriate observation or supervision are indicators for hospital admission among infants. In the case of older children, theses indicators are an SaO2 of 92% or less, cyanosis, respiratory rate greater than 50 breaths per minute, difficulty in the intake of fluids or solids, grunting, signs of dehydration, or a family incapable of providing either appropriate observation or supervision. Since viruses are the sole cause of many cases of pneumonia in childhood, it is not appropriate to treat every child with antibiotics. However, therapeutic decisions can be difficult, because most tests do not adequately differentiate viral from bacterial infection in a given child. The problem of bacterial resistance to antibiotics has increased steadily in recent years, and it is certainly related to their overuse in situations in which viral involvement is quite probable or the illness is trivial and self-limiting, such as an upper respiratory infection. Hence, it is preferable to restrict antibiotics as much as possible and to use narrow-spectrum agents whenever appropriate, because less antibiotic pressure limits the emergence of bacterial resistance. Finally, we comment on the general management of pneumonias depending on the age, the impact on the general condition of the patient and the radiological pattern, laboratory data and the epidemiology of these infections in our general population (AU)

Defunctioning lateral colostomy or ileostomy.

A method of loop colostomy and ileostomy construction is described. The stoma provides complete diversion and can be either temporary or permanent.