Simulation and Training of Gynaecological Skills.

In order to offer our patients, the "state of the art" treatment in gynaecology, we need a structured teaching program for trainees concerning the gynaecological skills. In recent years, training and education in endoscopic surgery has been critically reviewed. Clinicians, both surgeons as gynaecologists who perform endoscopic surgery without proper training of the specific psychomotor skills, are at higher risk to increased patient morbidity and mortality. The traditional apprentice-tutor model is no longer valid for developing all skills necessary in gynaecological surgery, particularly in endoscopy. Endoscopic training should happen at both the theoretical and the practical skill level. The acquisition of the correct knowledge regarding general laparoscopy, hysteroscopy and standard level procedures is as important as learning the necessary psychomotor skills to successfully perform endoscopic manipulations. Training in the operating room can only start when it is proven that knowledge and skills are present. To learn and train total abdominal hysterectomy by laparotomy there are inexpensive simple models that can be used, which are easy to reproduce. The development, construction, cost, and utility of a low-cost and anatomically representative vaginal hysterectomy simulator also has been described. The complexity of modern surgery has increased the demands and challenges to surgical education and the quality control.

Excess of exercise increases the risk of atrial fibrillation.

An interesting and still not well-understood example for old medical wisdom "Sola dosis facit venenum" is the increased prevalence of atrial fibrillation (AF) in athletes. Numerous studies have shown a fourfold to eightfold increased risk of AF in athletes compared to the normal population. Analysis of the existing data suggests a dose-dependent effect of exercise. Moderate exercise seems to have a protective effect and decreases the risk of AF, whereas excessive exercise seems to increase the risk of AF. The described cases illustrate clinical manifestations within the spectrum of AF in elderly athletes, that is, exercise-induced AF, vagal AF, chronic AF, and atrial flutter. As the arrhythmia worsened quality of life and exercise capacity in all patients, recovery of sinus rhythm was desired in all described cases. As the atrial disease was advanced on different levels, different treatment regimes were applied. Lifestyle modification and temporary anti-arrhythmic drug therapy could stabilize sinus rhythm in one patient, whereas others needed radiofrequency ablation to achieve a stable sinus rhythm. The patient with the most advanced atrial disease necessitated anti-arrhythmic drug therapy and another left atrial ablation. All described patients remained in sinus rhythm during the long-term follow-up.

Implementation of minimal invasive gynaecological surgery certification will challenge gynaecologists with new legal and ethical issues.

The introduction of a certification / diploma program in Minimal Invasive Surgery (MIS) is expected to improve surgical performance, patient's safety and outcome. The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA) and the ESHRE Certification for Reproductive Endoscopic Surgery (ECRES) provides a structured learning path, recognising different pillars of competence. In order to achieve a high level of competence a two steps validation is necessary: (a) the individual should be certified of having the appropriate theoretical knowledge and (b) the endoscopic psychomotor skills before entering in the diploma programme reflecting the surgical competence. The influence of such an educational and credentialing path could improve safety and offer financial benefits to the hospitals, physicians and healthcare authorities. Moreover the medicolegal consequences can be important when a significant amount of surgeons possess the different diplomas. As the programs are becoming universally accessible, recognised as the best scientific standard, included in the continuous medical education (CME) and continuous professional development (CPD), it is expected that a significant number of surgeons will soon accomplish the diploma path. The co-existence and practice of both non-certified and certified surgeons with different degrees of experience is unavoidable. However, it is expected that national health systems (NHS), hospitals and insurance companies will demand and hire doctors with high and specific proficiency to endoscopic surgery. When medico-legal cases are under investigation, the experts should be aware of the limitations that individual experience provides. The court first of all examines and then judges if there is negligence and decides accordingly. However, lack of certification may be considered as negligence by a surgeon operating a case that eventual faces litigation problems. Patients' safety and objective preoperative counselling are mandatory, directly connected to MIS certification while eliminating any dispute of surgeons' credibility.

The European Academy laparoscopic "Suturing Training and Testing'' (SUTT) significantly improves surgeons' performance.

UNLABELLED: The efficiency of suturing training and testing (SUTT) model by laparoscopy was evaluated, measuring the suturingskill acquisition of trainee gynecologists at the beginning and at the end of a teaching course. During a workshop organized by the European Academy of Gynecological Surgery (EAGS), 25 participants with three different experience levels in laparoscopy (minor, intermediate and major) performed the 4 exercises of the SUTT model (Ex 1: both hands stitching and continuous suturing, Ex 2: right hand stitching and intracorporeal knotting, Ex 3: left hand stitching and intracorporeal knotting, Ex 4: dominant hand stitching, tissue approximation and intracorporeal knotting). The time needed to perform the exercises is recorded for each trainee and group and statistical analysis used to note the differences. Overall, all trainees achieved significant improvement in suturing time (p < 0.005) as measured before and after completion of the training. Similar significantly improved suturing time differences (p < 0.005) were noted among the groups of trainees with different laparoscopic experience. In conclusion a short well-guided training course, using the SUTT model, improves significantly surgeon's laparoscopic suturing ability, independently of the level of experience in laparoscopic surgery. KEY WORDS: Endoscopy, laparoscopic suturing, psychomotor skills, surgery, teaching, training suturing model.

ICDs at higher age and clinical risk factors.

BACKGROUND: The implantable cardioverter defibrillator (ICD) is effective in preventing sudden cardiac death. However, in elderly patients (aged 75 years or older) the role of ICDs is still not well-defined and controversial. METHODS: We retrospectively analysed all clinical and survival data of all ICD patients who were ≥75 years at the date of implantation in the Erasmus MC, Rotterdam, the Netherlands and the University Hospital, Basel, Switzerland. Kaplan-Meier survival analysis was performed, and mortality predictors were identified. Mortality of the cohort was compared with a random sample of patients aged 60-70 years originating from the same database and to an age- and sex-matched cohort of Dutch persons. RESULTS: The study cohort consisted of 179 patients aged 75 years or older who were implanted between February 1999 and July 2008. The median follow-up time was 2.0 (IQR 2.8) years. Survival rates after 1, 2 and 3 years were 87, 82, 75 %, respectively. Survival was similar for primary and secondary prevention. Mortality in this study population could be predicted by combining four clinical risk factors: QRS duration >120 ms, NYHA class > II, renal failure and atrial fibrillation (AF). Survival was worse compared with the group of ICD patients aged 60-70 years and to the age- and sex-matched group of elderly persons. However, survival was not significantly worse when comparing elderly ICD patients without additional risk factors to the general population. CONCLUSIONS: Elderly patients still have an acceptable survival probability independent of prevention indication, certainly if there are no additional clinical risk factors. The presence or absence of additional clinical risk factors should be taken into account when making the decision for implantation, since they strongly correlate with survival.

We may not have it all together, but together we have it all. The importance of intra- and interdisciplinary collaboration.

The tremendous development of knowledge, the accumulation of clinical experience, and the enriching of everyday practice with the results of basic and clinical research created the need for splitting medicine in specialities and sub-specialities. Although this evolution is inevitable in order to meet the complex needs and demands of patients, we have to be aware of the risk of neglecting the holistic approach of a person in distress. Indeed, the organ-focused and pathology-centred approach of a patient may not exempt us of the rudiments of care such as the notion that a human being is more than the sum of its parts. This involves the absolute obligation for intra and inter-disciplinary cooperation. Recently, the European leading societies in Gynaecology, the European Board Obstetricians and Gynaecologists (EBCOG), the European Society of Human reproduction and Embryology (ESHRE), the European Society for Gynaecological Endoscopy (ESGE) and the European Academy for Gynaecological Surgery (+he Academy), have established some common impressive initiatives to improve women's health care. As a result of an intensive research programme coordinated by +he Academy with a multidisciplinary team of gynaecologists and surgeons a unique structured training and certification programme in endoscopic surgery is established. This project is a fine example making the dream of multidisciplinary approach reality and achieving some most impressive results. It is without any doubt a major step forwards in the improvement of the quality -assurance in endoscopic surgery in benefit of the patients care and has been accepted by our leading European and national societies. Recently, ESGE and ESHRE developed a new classification on female genital anomalies. An evidence-based -updated new classification published in the official journal of both societies was the ended result. THIS CREATIVE, SUCCESSFUL AND UNEVENTFUL COLLABORATION UNDERLINES THE NEED FOR RESPECTING SOME CRUCIAL POINTS: to clearly outline the topic of common action, to find the working platform, to define the method and to respect -independence of each society by clarifying the borders and the responsibilities. Keeping the window of the collaboration open is crucial for keeping the window to medicine of the future unlocked.

Adenosine testing after cryoballoon pulmonary vein isolation improves long-term clinical outcome.

BACKGROUND: Adenosine infusion after pulmonary vein isolation (PVI) with radiofrequency energy reveals dormant muscular sleeves and predicts atrial fibrillation (AF) recurrence. The aim of our study was to determine whether adenosine could reveal dormant PV sleeves after cryoballoon isolation and study its effect on long-term recurrence of AF. METHODS: Patients with paroxysmal AF underwent cryoballoon PVI. After PVI, adenosine 25 mg was infused to test for dormant muscular sleeves in each vein. If reconnection under adenosine was shown, further cryoballoon ablation was performed until no more reconnection occurred. Follow-up was performed with ECG, 24-h Holter recording, and a symptom questionnaire at three monthly intervals. Transtelephonic Holter monitoring was performed for 1 month before and 3 months after PVI. Patients who underwent cryoballoon PVI without adenosine administration were used as controls for comparison. RESULTS: In the study group (n = 34, 24 males), adenosine revealed dormant sleeves in 9/132 (8 %) veins, and 7/34 (21 %) patients. All but one vein was further treated until the dormant sleeves were isolated. During a mean follow-up of 520 ± 147 days, 23/34 (68 %) patients were free of AF without antiarrhythmic drugs (AADs). In the control group (n = 65, 46 males), 29/65 (46 %) were free of AF without AADs. There were significantly less AF recurrences in the study group (p = 0.04). CONCLUSIONS: Adenosine administration after cryoballoon PVI reveals dormant muscular sleeves in 21 % of patients. Clinical follow-up shows that adenosine testing is effective in reducing AF recurrence after cryoballoon ablation.

Migraine accompagnée after transseptal puncture.

Migraine has never been reported as a complication of transseptal puncture for ablation of atrial fibrillation. We studied its incidence before and after such procedures after observing some striking new migraine in several patients. A total of 8% of procedures for pulmonary vein isolation with a 15 Fr sheath used for transseptal puncture were associated with new headache with ocular symptoms or migraine within three months. Exacerbation of pre-existing migraine was reported in another 7% of procedures. More complaints were seen in redo procedures. The questionnaires were performed at three months after the intervention and there was no more evidence of persisting flow over the atrial septum at that time, when most complaints had already disappeared. This has important implications for follow-up after ablation for atrial fibrillation. (Neth Heart J 2010;18:374-5.).

The immunocytochemical versus cytosol measurement of the oestrogen receptor in invasive breast cancer tissue.

To compare two methods of measurement of oestrogen receptor (ER)-expression in invasive breast cancer tissue. Sections from 299 breast cancer cases were stained for the ER by immunocytochemical assay (ICA), using mouse monoclonal antibody (MAb) NCL-ER-6SF11, and by the dextran-coated charcoal assay (DCC). Concordant results were observed in 230 of the 299 cases (77%), 69 patients had discordant results (kappa=0.537). We found a moderate concordance between ICA and DCC for ER measurement in breast cancer tissue. If we change the golden standard from DCC to ICA, 23% of patients would receive a different therapeutic approach.

Office mini-hysteroscopy.

The technique of diagnostic hysteroscopy has not yet been accepted generally as an ambulatory, well-tolerated office procedure. Especially in the infertile patient the standard hysteroscopic procedure is poorly tolerated in an office environment. Our prospective registration of 530 diagnostic office mini-hysteroscopies in infertile patients demonstrates that using an atraumatic insertion technique, watery distention medium and the new generation of mini-hysteroscopic endoscopes, hysteroscopy can be performed in an office set-up without any form of anaesthesia and with a high patient compliance. The significant number of abnormal findings (28.5%), the absence of complications and the low failure rate (2.3%) indicate that diagnostic office mini-hysteroscopy should be a first-line diagnostic procedure. Those results are compared with the registration of 4204 consecutive conventional diagnostic hysteroscopies in a routine gynaecological population performed between 1982 and 1989. We conclude that the mini-hysteroscopic system offers a simple, safe and efficient diagnostic method in the office for the investigation of abnormal uterine bleeding, to evaluate the cervix and uterine cavity in the infertile patient, for screening of endometrial changes in patients under hormone replacement therapy or anti-oestrogens as (adjuvant) treatment and, lastly, it may be very helpful for the interpretation of uncertain findings in other diagnostic techniques such as ultrasound, magnetic resonance imaging, blind biopsy or hysterosalpingography.

Variability study of a non-invasive approach to the absolute quantification of cerebral blood flow with 99Tcm-ECD using aortic activity as the arterial input estimate.

The absolute measurement of regional cerebral blood flow can be made non-invasively if dynamic scanning is performed immediately following the intravenous injection of 99Tcm-labelled HMPAO or ECD. By application of an elementary one-step kinetic model in which the arterial input curve is estimated from a region of interest over the anterior aortic arch projection, a brain perfusion index (BPI) can be calculated which is correlated to the total hemispheric blood flow. The aim of this study was to assess the variability of the BPI approach as applied to the calculation of cerebral blood flow. For 46 patients (30 men, 16 women) aged 23.7-74.4 years (mean 60.3), we calculated hemispheric BPI factors. For two subgroups of 10 patients chosen at random, several data-processing parameters, including the number of noise suppression steps and the linear slope interval for the Patlak fit, were assessed. To determine the influence of region-of-interest selection and to estimate intra- and inter-observer differences, three independent observers conducted a repeat analysis of all 46 patients. From five patients who underwent the same injection procedure twice, an estimate of intra-subject reproducibility was calculated. Temporal noise reduction of the input data significantly decreased the intra-observer variability. Visual estimation of the linear interval in the Patlak curve is much less reproducible than automatic interval selection; very high interval borders in particular significantly decrease the calculated BPI. The intra-observer coefficients of variation for the BPI were 5.3, 5.6 and 7.9% respectively, corresponding to 2.8, 3.0 and 4.1% when converted to hemispheric CBF. The slight inter-observer differences found could be attributed to differing processing parameters. For the five patients in whom the procedure was repeated, the hemispheric BPI reproducibility index was on average 2.6%. Determination of absolute hemispheric blood flow can be performed in a precise manner by means of a dynamic scan during the first 2 min after tracer injection after careful optimization of the processing parameters.

Tubal ostium membranes and their relation to infertility.

OBJECTIVE: To define the clinical significance of tubal ostium membranes. DESIGN: Retrospective multivariate stepwise logistic regression analysis. SETTING: Algemene Kliniek Sint--Jan, Brussels, Belgium. PATIENTS: Three thousand forty-six hysteroscopies on 2979 patients, including 172 with infertility, over a 9-year period. MAIN OUTCOME MEASURES: Presence of tubal ostium membranes, age, infertility, endometrial thickness, and hormonal environment. RESULTS: Tubal ostial membranes were present in 74 (2.5%) patients: they were unilateral in 30 (42.1%) and bilateral in 44 (57.9%). Their presence was independent from hormonal state and from endometrial thickness. The incidence of ostial membranes was significantly higher (9.9%) in patients referred for infertility for unilateral (3.5%) as well as for bilateral presence (6.4%). Only the bilateral form was age dependent. CONCLUSIONS: Tubal ostium membranes may be one of the unknown limiting factors affecting female fertility and thus reducing the monthly fecundity rate. The present data suggest that bilateral and unilateral tubal ostium membranes may have a different clinical significance. The unilateral form is unrelated to age, hormonal state, or endometrial thickness and can be congenital. This form is most clearly related to infertility. The bilateral form is less related to infertility, is found in women of older age, and can be acquired. Further prospective analysis is needed to clarify the pathogenesis and pathophysiology of tubal ostium membranes. Tubal ostium membranes should routinely be looked for when performing a hysteroscopic examination in infertile women.

Hysteroscopic findings in patients with a cervical polyp.

OBJECTIVE: Our objective was to determine the presence of intrauterine lesions in patients with a cervical polyp. STUDY DESIGN: We performed a retrospective analysis to determine the influence of hormonal treatment and age on 165 patients with a cervical polyp and bleeding on admission. All 165 patients underwent a diagnostic hysteroscopy to rule out intrauterine lesions, including polyps, fibroids, hyperplasia, and adenocarcinoma. RESULTS: Endometrial polyps were found in up to 26.7% of patients who had a cervical polyp. In patients undergoing a combined pill treatment this incidence was much lower (8.3%). Menopausal patients had a 56.8% incidence of cervix-related endometrial polyps, and hormone replacement therapy did not significantly increase (45.7% vs 28.6%) the incidence of coexisting polyps. All cervical polyps present during tamoxifen treatment were associated with endometrial polyps. Abnormal vaginal bleeding was of no clinical significance in excluding concomitant endometrial polyps. CONCLUSIONS: All menopausal patients with a cervical polyp could benefit from a diagnostic hysteroscopy. Premenopausal patients receiving a combined pill treatment are the least likely to have coexistent endometrial polyps.