Features that contribute to the usefulness of low-fidelity models for surgical skills training.

For practical, ethical and economic reasons, veterinary surgical education is becoming increasingly dependent on models for training. The limited availability and high cost of commercially produced surgical models has increased the need for useful, low-cost alternatives. For this reason, a number of models were developed to be used in a basic surgical skills course for veterinary students. The models were low fidelity, having limited resemblance to real animals. The aim of the present study was to describe the students' learning experience with the models and to report their perception of the usefulness of the models in applying the trained skills to live animal surgery. One hundred and forty-six veterinary fourth-year students evaluated the models on a four-point Likert scale. Of these, 26 additionally participated in individual semistructured interviews. The survey results showed that 75 per cent of the students rated the models 'useful'/'very useful'. Interviews revealed that tactile, dimensional, visual, situational and emotional features are important to students' perception of a successful translation of skills from models to live animal. In conclusion, low-fidelity models are useful educational tools in preparation for live animal surgery. However, there are specific features to take into account when developing models in order for students to perceive them as useful.

New pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners.

BACKGROUND: Cardiovascular status is a crucial determinant in the pre-operative assessment of patients for surgery as well as for the handling of patients with acute illness. We hypothesized that focus-assessed transthoracic echocardiography (FATE) could be performed with the subject in the semi-recumbent position. The aim was also to test whether the image quality of Vscan is interchangeable with a conventional high-quality portable echocardiography system. Furthermore, we evaluated the time needed to achieve an interpretable four-chamber view and to complete a full FATE examination. METHODS: Sixty-one subjects were included. All subjects were examined in accordance with the FATE protocol in the semi-recumbent position on two different systems: the novel Vscan pocket device and the high-quality portable Vivid i system. Two evaluations were performed. In group A (n=30), the focus was on image quality. In group B (n=31), the focus was on the time consumed. RESULTS: Group A: All patients (100%) had at least one image suitable for interpretation and no significant difference in image quality (P=0.32) was found between the two different systems. Group B: The mean value for the total time consumed for a full FATE was 69.3 s (59.8-78.8) on the Vscan and 63.7s (56.7-70.8) on the Vivid i, with no significant difference among the scanners (P=0.08). CONCLUSION: The Vscan displays image quality interchangeable with larger and more expensive systems. The apparatus is well suited for performing a FATE examination in a 1-day surgery setting and could very well also be applicable in almost any situation involving patients with acute illness.

The development of shared cognition in paediatric residents analysing a patient video versus a paper patient case.

In a previous study, we established that compared to a written case, a video case enhances observable cognitive processes in the verbal interaction in a postgraduate problem-based learning format. In a new study we examined non-observable cognitive processes using a stimulated recall procedure alongside a reanalysis of the data from the first study. We examined the development of shared cognition as reflected in collaborative concept link formation, an approach to connecting a series of concepts related to a particular topic. Eleven paediatric residents were randomly allocated to two groups. After both analysing the same written case vignette, one group watched a video of the case in the vignette and the other group read a written description of the video. Both groups then reanalysed the vignette. After the group sessions, time-logged transcripts were made of the verbal interaction in both groups and all residents individually took part in a stimulated recall procedure. Causal reasoning concept links were labelled as individual or collaborative depending on whether they originated from individual residents or were directly elicited by verbal utterances from others. The video led to a significantly increased frequency ratio (after intervention: before intervention) of collaborative concept links but did not affect the frequency of individual concept links. This novel process approach to chronological registration of concept link formation offered additional evidence that shared cognition by means of co-elaboration of concept formation is stimulated by the use of patient video recordings in small group learning.

Searching the core of emergency medicine.

BACKGROUND: The purpose of this study was to test whether focus groups involving medical students, house officers, senior doctors, and nurses could identify an undergraduate emergency medicine core curriculum. METHOD: From May 2001 to January 2002, we interviewed 12 homogeneous focus groups within all 88 participants. Three focus groups were composed of medical students; three of house officers, three of senior doctors, and three focus groups were composed of nurses. Each interview lasted 2 h. Interviews were recorded, transcribed, and analysed using qualitative methods. RESULTS: The focus groups suggested and discussed in all 196 objectives. Students, physicians, and nurses agreed that newly graduated physicians should master history taking, 21 clinical disorders, 15 practical skills, interpretation of two diagnostic tests, two general diagnostic skills, and two leadership skills. Apart from these 43 core objectives, disagreement was substantial. Participants gave very different priorities to communication, knowledge about clinical disorders, practical clinical skills, leadership, and "the art of medicine". CONCLUSION: In conclusion, focus groups could identify an emergency medicine core curriculum. However, participants had very different perspectives on the curriculum. Focus groups could be one very practicable part of seeking consensus on what is core and securing local roots and ownership to an undergraduate emergency medicine curriculum before and during implementation.

[Practical clinical skills in medical education 1--undergraduate education. A Delphi survey]. / Praktiske kliniske faerdigheder i den laegelige grunduddannelse 1--kandidatuddannelsen. En Delphi-undersøgelse.

INTRODUCTION: The necessity of defining standards in medical education is increasingly recognised. The aim of the present study was to adapt the Delphi method in establishing a consensus about competence levels of basic clinical skills in the undergraduate medical curriculum. METHOD: We used a Delphi design with two postal rounds. An expert panel of 52 physicians was selected on the criteria of knowledge and practical engagement in medical education. Questionnaires were set up with lists of 213 practical skills based on literature studies. Six levels of competence were identified. The task of the panel was to select the competence level for each skill. RESULTS: The panel reached a 75% level of consensus in 212 of the 213 skills. A core curriculum of basic clinical skills in the medical education of Danish undergraduates is proposed. DISCUSSION: The Delphi method was found applicable to qualify the process of identifying goals in a medical curriculum design.

[Practical clinical skills in medical education 2--internship. A Delphi survey]. / Praktiske kliniske faerdigheder i den laegelige grunduddannelse 2--turnusuddannelsen. En Delphi-undersøgelse.

INTRODUCTION: The aim of the present study was to use the Delphi technique to identify standards of quality for the curriculum of basic clinical skills in the pre-registration internship. METHOD: The Delphi method was used with a selected panel of 52 experts to set a level of competence for 213 practical clinical skills in a series of three questionnaires. RESULTS: For the pre-registration internship, the panel reached a 75% level of consensus for 80% of the basic clinical skills. A total of 47 basic clinical skills were identified (97% level of consensus) as core skills that should be mastered by the time of registration. DISCUSSION: The study suggests that further investigations should be performed to identify a core curriculum of basic clinical skills common to all pre-registration internists. In addition, a curriculum of electives should be based on the special characteristics of each training department.

[Early clinical exposure--an instant success. The new medical curriculum at the University of Aarhus]. / Tidlig klinik--en øjeblikkelig succes. Beskrivelse of en ny studieordning på Aarhus Universitet.

INTRODUCTION: In the new medical curriculum at the University of Aarhus, a third term, 20-week course focussing on early patient contact was launched. MATERIAL AND METHODS: Nine prototypical and clinically important disease entities each formed the basis of one-week courses covering an introductory clinical lecture, presentation of "paper" cases, and formalised training of pertinent clinical skills. This was integrated with plenaries and group work in physiology pertaining to the disease and the patient cases. In addition, seminars were held in patient-doctor relationships, and environmental and social medicine. Introductory lectures were given on topics, such as medical ethics, taxonomy of diseases, the organisation of hospital-based health care. At the end of the term, the students resided for eight weeks at county hospitals, which do not traditionally participate in pregraduate teaching. Each student followed one particular patient, which formed the basis of a written essay. RESULTS: Early clinical lectures (87 +/- 8%, mean +/- SD) and use of clinical cases (73 +/- 8%) were well received by third term students, and 87% found that the "paper" cases facilitated their understanding of physiology. The evaluation of the hospital training was very positive (rated excellent or good by > 95%). DISCUSSION: We conclude that early introduction to clinical practice is feasible and well received by the students.

Regional differences exist in elastic wall properties in the ureter.

According to classical mechanical theory, the passive elastic properties of a distensible tube are important for the resistance to flow. The aim was to study luminal dimensions under pressure loading and the tension-strain distribution of the ureter in anaesthetized pigs by means of impedance planimetry. Stepwise inflation of an intraluminal balloon in which the cross-sectional area (CSA) and pressure were measured provided the distension stimulus in the ureteropelvine junction, in the midureter and in the intramural part of the ureter at the ureterovesical junction. The circumferential tension-strain distributions were computed from steady state values of these measurements. The CSA always reached equilibrium within the two-minute distension period. The steady state pressure-CSA curves were nonlinear and differed between the three measuring points (p < 0.001). The most pronounced difference was found between the ureteropelvine junction and the two other measuring points. At the lowest applied pressure of 1 kPa the steady state CSA was 15.4 +/- 1.1, 16.6 +/- 1.1, and 19.9 +/- 19.9 mm2 in the intramural part, middle part and ureteropelvine junction, respectively. At the maximum pressure the figures were 41.9 +/- 2.9, 47.0 +/- 2.7, and 73.1 +/- 8.2 mm2 for the three locations, respectively. The circumferential tension-strain distributions were nonlinear with an exponential-like behaviour. The tension-strain curve obtained from the ureteropelvine junction was translated to the right compared to the curves obtained from the two other measuring points (p < 0.05) indicating that the ureteropelvine junction was more compliant than the two other locations.

[The impact of clean intermittent catheterization on bladder capacity and residual urine]. / Virkningen af ren intermitterende kateterisation på blaerekapacitet og residualurin.

Clean intermittent catheterization (CIC) is a well-established method for treatment of bladder emptying failure. There have been many reports on the therapeutical benefits of CIC as well as on its complications. However, no reports have appeared on the impact of CIC on urodynamic parameters. We therefore investigated 18 women with urinary retention on the basis of a hypocontractile detrusor muscle and performed uroflowmetry and cystometry and recorded residual urine. The women were treated with CIC for an average of 26 months (1-62 months). At the time of investigation five had stopped because residual urine was reduced to below 50 ml. These patients were young and infrequent voiders. Two had stopped because of complications. In 11 patients there were still significant amounts of residual urine. When bladder capacity was measured cystometrically, there was a reduction in bladder capacity in ten patients but an increment in 8 cases. Patient compliance was high despite a high frequency of symptomatic urinary infections (16/18). On the basis of this study we suggest that CIC is efficient in normalizing mild cases of large bladders with emptying failure only.

Epidermal growth factor attenuates the sclerotherapy-induced biomechanical properties of the oesophagus. An experimental study in minipigs.

BACKGROUND: The effect of epidermal growth factor (EGF) on the biomechanical properties of the oesophagus subjected to sclerotherapy was studied in Goettingen minipigs by means of impedance planimetry. METHODS: Seventeen animals underwent three sessions of weekly endoscopic sclerotherapy. During these 3 weeks and for the subsequent 2 weeks they were treated with either EGF or placebo. After another 3 weeks an impedance planimetric study was done. Ten healthy non-sclerosed pigs were studied as controls. Impedance planimetry was performed by stepwise pressure-induced balloon inflation for analysis of oesophageal cross-sectional area 5 and 10 cm above the gastro-oesophageal junction (GEJ). RESULTS: Systemic treatment with EGF (total daily dose of 30 micrograms/kg/day, administered subcutaneously) for 3 to 7 days per week combined with a weekly paravenous injection of 20-40 micrograms/kg attenuated the oesophageal damage caused by sclerotherapy, implying less pronounced narrowing 5 cm above and less dilation 10 cm above the GEJ. CONCLUSION: These observations suggest a potential therapeutic role for EGF in attenuating sclerotherapy-induced oesophageal injury.

Effects of diuresis on micturition.

Micturition can be characterized experimentally by monitoring both the frequency and volume of micturition. Previous studies demonstrated that the functional capacity of the rat and rabbit bladder, as determined by cystometry, is approximately equal to the maximal single micturition volume as recorded over a 24 hour period. Studies in many laboratories have demonstrated that chronic increases in diuresis induce increases in micturition frequency and capacity, and an increase in bladder mass. The current study compares the temporal relationship among these parameters in three models of diuresis: streptozotocin-induced diabetes in rats, sucrose-induced diuresis in rats, and furosemide-induced diuresis in rabbits. In both sucrose diuresis in rats and furosemide diuresis in rabbits there were immediate increases in both the frequency and volume of micturition. The magnitude of the increases in micturition frequency and micturition volume paralleled the increase in the total volume of urine excreted. Bladder mass increased progressively over the time course of the study. Streptozotocin-induced diabetes resulted in a more gradual (but parallel) increase in micturition frequency and volume, and again a more gradual increase in bladder mass. These studies demonstrate that functional bladder capacity is increased immediately upon the initiation of diuresis with sucrose or furosemide, as is the frequency of micturition. This indicates that functional bladder capacity is probably under neuronal regulation and the change in capacity is not a function of the increased bladder mass which occurs at a later time period.(ABSTRACT TRUNCATED AT 250 WORDS)

Modulation of urinary bladder function by sex hormones in streptozotocin-diabetic rats.

The modulation of urinary bladder function by sex hormones was examined in castrated and sham-operated male and female streptozotocin-diabetic rats. Male and female diabetic rats weighed less than age-matched controls and had significantly greater serum glucose levels and bladder weights. Castration had no effect on bladder mass and did not alter the diabetes-induced changes in rat or bladder mass. Protein concentrations were significantly increased and collagen concentrations were significantly decreased in bladders from diabetic rats compared with non-diabetics. Sex or castration had no effects on protein or collagen concentration of bladders from nondiabetic and diabetic rats. There were no differences in water consumption and urine excretion between male and female nondiabetic rats, and no effects of castration were observed on micturition in nondiabetic rats. Ovariectomy followed by diabetes caused a significant increase in urine excretion compared with diabetes alone. Ovariectomized diabetic rats had increased mean and maximal micturition volumes when compared with other female rats. Orchiectomy had no effects on the expected increases in micturition associated with diabetes. Diabetes in male rats caused significant increases in contractile responses of bladder strips to field stimulation, carbachol, KCl and high concentrations of ATP. In both nondiabetic and diabetic groups, orchiectomy had no effects on the contractile responses compared with sham operation. Similarly, in bladder strips from diabetic females, contractile responses to carbachol, KCl and high concentrations of ATP were significantly increased compared with those of nondiabetics, and were unchanged by ovariectomy. However, ovariectomy in nondiabetic rats caused significant decreases in contractile responsiveness to nerve stimulation, effects which were only partially prevented by diabetes. The data suggest that there are few differences between male and female rats in their sensitivity to streptozotocin and the effects of diabetes on micturition, bladder collagen and protein concentration, and the responsiveness of bladder strips to contractile agents. The changes in bladder function observed after induction of diabetes do not appear to be related to changes in sex hormone levels. The major differences noted between males and females were the decreased responsiveness of bladders from nondiabetic ovariectomized female rats to field stimulation. In conjunction with previous data obtained in this laboratory, the study suggests that the responses to field stimulation are more sensitive to the effects of ovariectomy than are the responses to contractile agonists.

Comparison of urinary bladder function in rats with hereditary diabetes insipidus, streptozotocin-induced diabetes mellitus, and nondiabetic osmotic diuresis.

In vivo and in vitro bladder function were studied in three different models of increased diuresis: 1) Brattleboro rats with hereditary diabetes insipidus (di/di), 2) Sprague-Dawley rats with streptozotocin-induced diabetes mellitus (STZ), and 3) Sprague-Dawley rats with increased diuresis due to 5% sucrose added to the drinking water. When compared with controls, all three models showed bladder mass, increased water consumption and urine output, higher mean and maximal increased micturition volumes, and greater bladder capacity and compliance by in vitro cystometry. The changes were more extensive in di/di rats than in the STZ and sucrose-drinking rats. The concentration of bladder collagen decreased in all three rat models when compared with controls. However, the collagen concentration of STZ bladders was significantly lower than the collagen concentration of di/di and sucrose bladders, suggesting that the decrease in bladder collagen concentration associated with experimental diabetes mellitus is only partly related to the increased diuresis. Contractile function was studied using a whole bladder model. Responses of whole bladders from control and diabetic rats to electrical field stimulation, carbachol and KCl were identical. Volume-pressure relations of the isolated whole bladder showed that the magnitude of the contractile response to KCl is constant at intravesical volumes ranging from about 10 to 95% of cytometrical bladder capacity. Bladders from Brattleboro di/di rats and STZ rats showed a rightward shift of volume-passive pressure curves when compared with appropriate controls. Bladders from sucrose-drinking rats had volume-passive pressure curves similar to the bladders from controls. This study suggests that while contractile function remains intact with increased diuresis, the passive function changes, with the bladder becoming more distensible.

Elastic wall properties and collagen content in the ureter: an experimental study in pigs.

We used an impedance planimetric method to look at elastic wall properties of ureter in ten anaesthetized pigs. A balloon was stepwise inflated and deflated in the ureteropelvine junction, in the mid-ureter, and in the intramural part of the ureter at the ureterovesical junction with pressures up to 70 cmH2O, while the pressure and balloon cross-sectional area (Bcsa) were measured simultaneously. The elastic wall parameters were calculated from these measurements. At sacrifice, tissue samples were collected for analysis of collagen content of the ureteral wall. A non-linear clockwise relation (hysteresis loops) between Bcsa and balloon pressure was demonstrated. At maximal inflation of the balloon, the Bcsa, wall tension, and compliance were 35.28 +/- 3.52, 38.44 +/- 3.23, and 61.36 +/- 8.09 mm2, 230.71 +/- 12.82, 242.38 +/- 10.49, and 302.17 +/- 20.03 cmH2O x m, and 0.167 +/- 0.047, 0.124 +/- 0.002, and 0.182 +/- 0.040 mm2 x cmH2O-1 in the intramural part of the ureter, middle part, and ureteropelvine junction, respectively. The collagen content was 0.3249 +/- 0.0077, 0.3301 +/- 0.0066, and 0.3457 +/- 0.0060 mg x mg-1 dry defatted weight in the intramural part, in the middle, and in the ureteropelvine junction, respectively. The collagen content of the ureteropelvine junction was significantly higher than that of the middle of ureter (P < 0.02) and than that of the intramural part (P < 0.05). No significant correlations were found between the elastic parameters at maximal inflation of the balloon and the collagen content (P < 0.10). In conclusion the elastic wall properties were significantly different in the three ureteral segments and the collagen content of the ureteropelvine junction differed from that of the two distal locations. However, no relationship between the wall properties and the collagen content was found.

Stimulation of DNA synthesis in rabbit bladder wall after partial outlet obstruction and acute overdistension.

Partial outlet obstruction of the rabbit urethrovesical junction (UVJ) has been used to induce pathology in the urinary bladder characteristic of obstructive damage observed in humans. The purpose of the experiments reported here was to compare the 3H-thymidine (3H-TdR) labelling of DNA in urinary bladders of male New Zealand White (NZW) rabbits subjected to partial outlet obstruction or overdistension. A total of 18 animals was used. Two normal controls, and 12 partially obstructed animals (at 1 day [D], 3D, 5D, 7D, 14D, and 21D) were injected (i.v.) with 3H-TdR at a dose of 0.5 microCi/g body weight. An additional 4 were overdistended to volumes 120% of maximum intravesical pressure, immediately emptied via the catheter, and injected with 3H-TdR 24 hr (1D) later. All animals were sacrificed up to 3.5 hr after injection of the label. DNA-associated radioactivity reached a peak at 3D after obstruction and was reduced substantially by 5D, although the level of incorporation remained well above control levels out to 21D. Levels of 3H-TdR incorporation 1D after overdistension bladders were about half of that found 1D following partial obstruction. The distribution of 3H-TdR labelled DNA in tissues was demonstrated by radioautography of histologic sections. One day following obstruction, 3H-Tdr incorporation was localized in the urothelium. Labelling of urothelium subsequent to 1D was reduced but remained above control levels until 21D. Labelled smooth muscle nuclei were observed only in control and 3D bladders, and they were measured at similar frequencies. Labelling of both intrinsic connective tissue (ICT) (mucosal, submucosal, and mural) and extrinsic connective tissue (ECT) (serosal) peaked at 3D after obstruction and declined thereafter but not to control levels. Labelling of ECT was, of course, limited to those bladders in which ECT was present (i.e., 3-21D). While the distribution of labelled cells in radioautograms was more variable 1D after obstruction than 1D after overdistension, the general cellular and biochemical responses to overdistension, as measured by DNA synthesis, are similar to those observed after partial outlet obstruction. Since the first sequela of obstruction is acute distension, these data support the assertion that the initial overdistension of the bladder initiates the cellular response to obstruction.