Digital competence using the example of executives in residential care facilities in Germany-a comparison.

Background: Change and progress through digitalisation is also becoming increasingly important in the field of professional care and the associated increasing demands on the skills of nursing staff. The European Union considers digital skills to be one of the eight key competences for lifelong learning. At present, few reliable statements can be made about the status of digital skills in professional nursing care in Germany. The aim of this study was to map the current status of digital competences of executives in full inpatient care facilities in Germany and to identify possible differences to reference values of academics. Methodology: This survey is based on a Germany-wide cross-sectional survey in full inpatient care facilities (N = 8,727). The survey instrument Digital Competences Framework (DigComp 2.2) according to the European Union's reference framework was used as the basis for recording the digital competence characteristics. The statistical analysis was descriptive and inferential (t-test, two-sided, p < 0.05). Results: Out of 15 items across five dimensions, significant differences for nine items can be determined. The competence levels of the participating managers from the full inpatient care facilities were lower compared to the reference sample. Discussion: In order to be able to counter the skills discrepancy shown by the study in the future, it is of central importance to deepen knowledge and skills in the area of digitalisation in the care context.

Randomized Study Comparing a Reusable Morcellator with a Resectoscope in the Hysteroscopic Treatment of Uterine Polyps: The RESMO Study.

STUDY OBJECTIVE: To compare a reusable hysteroscopic morcellator and standard resectoscopes in the hysteroscopic management of uterine polyps. DESIGN: Single-center randomized prospective single-blind trial (resectoscope-morcellator study). SETTING: Centre Médico-chirurgical Obstétrique teaching hospital, Strasbourg University Hospitals, France. PATIENTS: All patients presenting with a single endometrial polyp of size 1 cm or larger. INTERVENTIONS: After consent, the patients were randomized into 2 groups: hysteroscopic morcellation (HM) group or standard resection (SR) group. Office-based review hysteroscopy was performed 6 weeks to 8 weeks after surgery. Primary end point: time of morcellation or resection. SECONDARY OUTCOMES: total operating time (minutes), volume of fluid used (mL), fluid deficit (mL), number of morcellator or resectoscope insertions, operator comfort (visual analog scale: 0 to 10) and quality of vision (0 to 5), perioperative complications, completeness of resection, need to convert to another technique, pain assessment (visual analog scale), and length of hospitalization. At review hysteroscopy, we noted whether the resection or morcellation had been effective and if synechiae were present or absent. Statistical analyses followed Bayesian methods. MEASUREMENTS AND MAIN RESULTS: Ninety patients were randomized: 45 in the HM group and 45 in the SR group. The average size of polyps at hysteroscopy was 13.3 mm. Morcellation time was lower than resection time (6.1 minutes vs 9 minutes; p [HM < SR] = .996). This also applied to total operating time (12.7 minutes vs 15.6 minutes; p [HM < SR] = .985), number of device insertions (1.50 vs 6; p [HM < SR] > .999), volume of fluid used (766.9 mL vs 1118.9 mL; p [HM < SR] = .994), and fluid deficit (60.2 mL vs 169.8 mL; p [HM < SR] = .989). Operator comfort was better in the HM group (8.4 vs 7.4; p [HM > SR] = .999) as was visualization (4 vs 3.7; p [HM > SR] = .911, highly probable). Operative complications were higher in the SR group (5 vs 0; p [HM < SR] = .989]. One patient in the SR group died after surgery owing to an anesthetic complication (anaphylactic shock complicated by pulmonary embolism). No differences were noted between the groups for pain assessment, length of hospitalization, and outcome on review hysteroscopy. CONCLUSION: The reusable morcellator is quicker, uses less fluid with less deficit and fewer introductory maneuvers, and offers better comfort and visualization than the resectoscope while being as effective for the hysteroscopic treatment of uterine polyps.

Surgical traps in laparoscopic sacrocolpopexy for vaginal vault prolapse.

OBJECTIVE: To describe the possible difficulties encountered in the event of laparoscopic sacrocolpopexy for vaginal vault prolapse and corresponding avoidance strategies. METHODS: Video recordings of different laparoscopic sacrocolpopexies for vaginal vault prolapse showing various situations and difficulties. University Teaching Hospital of Strasbourg. RESULTS: Although laparoscopic sacrocolpopexy for vaginal vault prolapse is becoming more common, achieving a good outcome remains challenging, especially with the vesicovaginal dissection. Bladder injuries are not rare and occur in about 2 to 6% of cases. Vaginal perforation is less common, but remains a risk. This video illustrates possible difficulties encountered and presents various strategies to avoid them. Several tips on exposing structures and following anatomical landmarks are described. CONCLUSION: Knowing how to avoid these surgical traps will help trainee urogynecologic surgeons to perform laparoscopic sacrocolpopexy for vaginal vault prolapse.

Risk of malignancy on suspicion of polyps in menopausal women.

Improved performances in gynaecological ultrasonography have enabled an increasing number of often asymptomatic endometrial polyps to be detected. Most of these polyps are removed surgically, as a precautionary measure, so as not to miss a case of endometrial cancer. Nonetheless, this management strategy is based solely on the sonographer's judgement and a number of these operations, which are probably of no benefit, could be avoided. In order to do so, risk factors for malignancy need to be identified. OBJECTIVE: Estimate the prevalence of lesions in menopausal patients with a pre-operative diagnosis of endometrial polyp. Establish risk factors for malignancy. STUDY DESIGN: This is a single-centre retrospective study. Enrolment criteria were menopausal patients aged over 45 who had undergone hysteroscopic resection of a polyp. Pre-op diagnosis was made either by ultrasonography or diagnostic hysteroscopy. Malignant lesions included cancers and atypical hyperplasia. Benign lesions consisted of simple polyps, non-atypical simple hyperplasia and non-atypical complex hyperplasia. Risk factors studied were existing abnormal uterine bleeding, endometrial thickness, personal or first-degree family history of gynaecological cancer (breast, cervix, endometrium, ovary) and age on diagnosis. RESULTS: 631 patients were enrolled of whom 30 presented a malignant disorder (4.75%); 579 patients (91.76%) presented a simple polyp, 11 a non-atypical simple hyperplasia (1.74%) and 11 a non-atypical complex hyperplasia (1.74%). On univariate analysis age alone proved to be statistically significant (OR 1.05; 95%CI=[1.02-1.09] p<0.01), with a threshold of 59 years of age on the ROC curve. On multivariate analysis, factors predictive of a malignant lesion were age (OR=1.06; 95%CI [1.02-1.10]), existence of AUB (OR=2.4; 95% CI [1.07-5.42]) and family history (OR=2.88; 95%CI [1.08-7.67]). Neither the univariate nor multivariate model was able to demonstrate a statistically significant relationship with respect to endometrial thickness. The risk of malignancy was 12.3% in patients aged over 59 presenting AUB. For all other subgroups, the risk varied between 2.31 and 3.78%. CONCLUSION: The risk of a malignant lesion appears to be high (12%) in menopausal patients aged over 59 presenting an endometrial polyp detected when there is pre-existing AUB. In this situation, hysteroscopic resection of endometrial polyps should therefore be routinely proposed. For other patients, the risk of a malignant lesion is low but not insignificant, standing at about 3%. Each patient record should therefore be discussed on an individual case basis, taking into consideration the patient's pre-existing conditions, after providing clear and appropriate information.

Does the Number of Neoadjuvant Chemotherapy Cycles before Interval Debulking Surgery Influence Survival in Advanced Ovarian Cancer?

OBJECTIVE: To evaluate the overall survival (OS) of patients with initially inoperable advanced ovarian cancer, tubal carcinoma, or primary peritoneal carcinoma of stages III or IV undergoing neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery, according to the number of cycles performed. METHODS: This retrospective study was conducted in three main oncology centres in the east of France, reviewing the charts of all patients who underwent NAC between January 1, 1998 and October 31, 2012. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analysed progression-free survival (PFS) as well as chemotherapy- and surgery-related morbidity. RESULTS: Of the 204 patients included, 75 (36.8%) underwent ≤4 NAC cycles and 129 (63.2%) ≥5 NAC cycles. Characteristic data were similar in the two groups. Five-year OS was 35.0 and 25.8%, respectively. This difference was non-significant [HR = 1.06 (0.70-1.59), p = 0.79]. We also found no differences in PFS or morbidity between the two groups. CONCLUSIONS: The number of NAC cycles does not seem to play a role in the OS of patients with advanced ovarian cancer. Further evidence and prospective data are needed to assess the value of a high/low number of NAC cycles among these patients.

Equipment failure: causes and consequences in endoscopic gynecologic surgery.

STUDY OBJECTIVE: To determine the incidence of equipment failure in gynecologic endoscopy and investigate causes and consequences. DESIGN: A prospective observational single-center study between January and April 2006. SETTING: Gynecologic surgery department of a university hospital. INTERVENTIONS: In all, 116 endoscopic interventions were included: 62 laparoscopies, 51 operative hysteroscopies, and 3 fertiloscopies. Emergency and equipment testing procedures were excluded. MEASUREMENTS AND MAIN RESULTS: Equipment malfunctions were divided into 4 categories with regard to imaging, transmission of fluids and light, the electric circuit, and surgical instruments. We also found cases with faulty connections between elements. Factors including human error, loss of time, and actual or potential consequences were analyzed. At least 1 equipment failure was noted in 38.8% of operative procedures, 41.9% of laparoscopies, and 37.3% of hysteroscopies. Fluid, gas, and light transmission was faulty in 36.2%, surgical instruments in 29.3%, the electric circuit in 22.4%, and imaging in 12.1%. Of malfunctions, 46.6% were a result of faulty connection between 2 elements. The most common cause for concern was bipolar forceps and cables in laparoscopy (42.3%) and the assembly of small parts in hysteroscopy (47.4%). Personnel were implicated in 43% of cases (nurses in 72%, surgeons in 12%, both in 16%). One equipment failure increased the total duration of laparoscopy by 7% and of hysteroscopy by 20%. The mean delay was 5.6+/-4.0minutes by equipment failure. Of the incidences, 19% could have led to serious complications for the patient; however, no morbidity or mortality actually occurred in this series. CONCLUSION: Equipment malfunction is common in endoscopic surgery and concerns both laparoscopy and hysteroscopy. Consequences are potentially serious. It is mandatory to identify and rectify causes of equipment failure so as to optimize the daily use of endoscopic instruments and improve patient safety. The implementation of systematic checklists is currently under evaluation.

Tubal perforation by ESSURE microinsert.

Female tubal sterilization remains the most widely used method of permanent contraception worldwide. Recent studies have shown the new sterilization technique by ESSURE microinsert to be an effective method with decided advantages for the patient in terms of morbidity associated to a quick recovery. We discuss the possible hysteroscopic signs of tubal perforation and the right measures to take if a perforation is suspected, with respect to the possible complications and contraceptive failure.

Sacro-spinous ligament fixation peri-operative complications in 195 cases: visual approach versus digital approach of the sacro-spinous ligament.

OBJECTIVE: To evaluate sacro-spinous ligament fixation (SLF) peri-operative complications. STUDY DESIGN: Monocentric, retrospective study. Department of Gynecology, SIHCUS-CMCO, University Hospital, Strasbourg, France. Between January 1990 and December 2000, 195 women, mean age 63.2 years old (40-90), underwent a vaginal SLF. Ninety point eight percent of women were post-menopaused and 27.9% of these had a hormonal substitution. About 24% of patients had prior hysterectomy, 20% vaginal prolapse repair and 22% urinary stress incontinence repair. SLF was performed in 1.5% of cases without any other procedures and it was combined with the following: rectocele and elytrocele repair in 89.2%, hysterectomy in 72.3%, cystocele repair in 52.8% and stress incontinence repair in 15.3% of cases. In 107 cases, the SLF attachment was placed under digital control and in 88 cases under visual control. RESULTS: The mean hospitalisation stay was of 8.5 +/- 2.6 days (4-26). About 41% of women presented a complication. Major complications were represented by 3.6% of bladder injury, 0.5% of uretero-vaginal fistula, 0.5% of vascular injuries, 0.5% of thromboembolic events. In 38% of cases patients had minor complications: urinary tract infections (29%), temporary urinary retention (5.6%), local complications (4.5%), and other complications (3%). The only specific SLF complication in this data was a vascular injury and in this case the SLF was performed under digital control. CONCLUSIONS: The global peri-operative complication frequency of SLF is high. It is mainly represented by non-specific complications, secondary to the combined procedures and not to the SLF itself. The specific complications due to SLF, all of which are major ones, can be avoided or diagnosed earlier, by using the visual approach technique.