The changing landscape of brachytherapy for cervical cancer: a Canadian practice survey.

BACKGROUND: We documented changes in practice from 2009 to 2012 for cervical cancer brachytherapy in Canada. METHODS: Centres with gynecologic brachytherapy services were sent an e-mail questionnaire querying their 2012 practice. Responses are reported and compared with practice patterns identified in a similar survey for 2009. RESULTS: The response rate was 77% (24 of 31 centres). Almost all use high-dose-rate brachytherapy (92%); low-dose-rate brachytherapy has been completely phased out. Most continue to move patients from the site of applicator insertion to the radiation treatment simulation suite (75%) or to a diagnostic imaging department (29%), or both. In 2012, the imaging modalities used for dose specification were computed tomography [ct (75%)], magnetic resonance imaging [mri (38%)], plain radiography (21%), and cone-beam ct (8%). The number of institutions using mri guidance has markedly increased during the period of interest (9 vs. 1). Most respondents (58% vs. 14%) prescribed using guidelines from the Groupe Européen de Curiethérapie and the European Society for Therapeutic Radiology and Oncology, but they also used point A as a reference. Commonly used high-dose radiation regimens included 30 Gy in 5 fractions and 24 Gy in 3 fractions. CONCLUSIONS: In Canada, image-guided brachytherapy for cervical cancer continues to evolve. Although ct-based imaging remains the most commonly used modality, many centres have adopted mri for at least 1 brachytherapy treatment. More centres are using fewer fractions and a slightly lower biologically effective dose, but are still achieving EQD2 (2-Gy equivalent) doses of 80-90 Gy in combination with external-beam radiation therapy.

Learning needs in a medical curriculum in Hong Kong.

OBJECTIVE: To survey medical graduates from the University of Hong Kong on how well they perceived their learning needs had been fulfilled by the old (before 1997) and the new (after 1997) curricula. DESIGN: Retrospective questionnaire survey. SETTING: The University of Hong Kong, Hong Kong. PARTICIPANTS: Medical graduates from the University of Hong Kong who graduated between 1997 and 2006 were invited to complete a questionnaire online or in paper form; 1997-2001 graduates were trained under the old curriculum, and 2002-2006 graduates under the new curriculum. RESULTS: The response rate was 23%. The survey showed that the graduates of both curricula felt that research skills, population health, and ophthalmology were not emphasised enough in the medical programme. In addition, some graduates of the old curriculum mentioned interpersonal skills, ethics and professionalism, and language skills, which were pinpointed in the curriculum reform in 1997. Some graduates of the new curriculum mentioned anatomy, microbiology, and diagnostic radiology. Graduates of both the old and the new curricula perceived the same top five areas as being lacking in their respective curricula, in relationship to their clinical career and personal growth, namely: business administration, law, professional English, life coaching, and humanities. A small percentage of graduates also took courses in these areas after graduation. CONCLUSIONS: The survey showed that the curriculum reform in 1997 at the University of Hong Kong had correctly pinpointed some of the learning needs. The survey also identified educational needs in the existing curriculum that need to be dealt with in the forthcoming curriculum reform in 2012.

Medical students as observers in theatre: is an explicit consent necessary?

BACKGROUND: Obtaining consent before engaging patients in teaching activities is essential. The presence of medical students as observers in the operating theatre is sometimes overlooked as a form of teaching activity, in which patients could have become unwitting or unwilling participants. PURPOSE: To investigate patients' attitudes towards student observers in theatre. METHOD: A cross-sectional, voluntary, guided questionnaire survey on 225 general surgical patients at a teaching hospital. RESULTS: Over two-thirds of patients would accept student observers, and regard a prior consent process as essential. Gender, level of education, subjective state of health and the perceived risk of surgery were not found to influence their decisions. Younger patients were more likely to refuse observers. Close to 10 percent of patients who were happy to participate in bedside teaching would not accept theatre observers, whereas 25 percent who were not happy to participate in bedside teaching would accept theatre observers. CONCLUSION: An explicit consent process is essential for theatre-based teaching, even when students are simply acting as observers. Patients who are willing to participate in ward-based teaching should not be presumed to accept theatre observers.

Patient safety in the undergraduate curriculum: medical students' perception.

OBJECTIVE: Patient safety has emerged as a distinct health care discipline and an undergraduate programme on patient safety is being introduced at the authors' institution. The present study aimed to assess medical students' perceptions and knowledge on patient safety issues. DESIGN: A self-administered voluntary questionnaire survey. SETTING: Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong. PARTICIPANTS: A total of 130 fourth-year medical students. MAIN OUTCOME MEASURES: Students' baseline perceptions and knowledge on patient safety issues. RESULTS: The majority of students agreed that medical errors were inevitable but over 25% opined that "competent physicians do not make errors". The majority disapproved the practice of non-disclosure of error; whilst 6% would not address 'near-miss' events, and almost 10% did not support an active reporting system. Nearly half of the students were neutral on the notion that uncertainty should not be tolerated in patient care, and over 80% agreed that the most effective strategy to prevent error was "to work harder and be more careful". A knowledge gap in patient safety issues existed. Over 80% of students supported the introduction of our new undergraduate programme. CONCLUSION: Medical students were aware of medical errors being an inevitable barrier between intended 'best care' and what was actually provided to patients. Students appeared to lack the appreciation of non-physician-based causes of errors, and the importance of a multidisciplinary approach to the management of incidents. A formal curriculum on patient safety is urgently needed in this locality, and such an initiative was supported by the medical students who were surveyed.

Clinical undergraduate examination--voluntary patients' perspective.

AIM: Real patients are generally recruited to participate in assessment of medical students all over the world in their clinical examinations. In the past, such voluntary patients were taken for granted. However, this is no longer true nowadays. METHOD: A questionnaire survey was conducted on 72 patients who participated as volunteers in an undergraduate final MBBS clinical examination. Each patient underwent a total of three to four focused physical examinations, at the conclusion of which the survey was conducted. RESULTS: The majority of the subjects had little or no previous encounters with medical students. Most volunteers reported to have participated out of a willingness to help. Only a small number did so for financial rewards or more expeditious medical treatment. Positive experiences were reported by 82% of the volunteers and over 90% said they would encourage others to participate similarly. Fatigue is a common complaint which may be due to the long duration of the examination rather than the number of physical examinations performed. Volunteers expected to be better informed about the details of the examination including the numbers of times of physical examination, and the presence of observers. CONCLUSION: Printed information given during recruitment, and briefing sessions conducted immediately prior to the examination are recommended to improve patients' satisfaction.

Multimodality minimally invasive autopsy--a feasible and accurate approach to post-mortem examination.

BACKGROUND: Autopsy examination has been the bedrock of western medicine. With the decline in the autopsy rate secondary to the negative psychological impact to the deceased's relatives, the benefits of autopsy have been undermined. Minimally invasive autopsy has been introduced but has not been widely adopted as an alternative to the 'traditional' open approach. This technique not only provides information on the cause of death abut also minimizes the disfigurement induced to the deceased. Our study aims to explore the feasibility and evaluate the accuracy of this technique. METHODS: A series of coroner cases ordered for autopsy were examined by a group including an experienced forensic pathologist and two experienced laparoscopic surgeons using thoracoscopic, laparoscopic, endoluminal or endovascular approaches. The procedure was video-recorded and the provisional diagnoses and causes of death were made based on the findings. These findings were subsequently correlated with the full autopsy examination. A few limited clinical post-mortem examinations were also performed with consent from relatives. RESULTS: A total of 22 cases of minimally invasive autopsies were performed from November 2007 to March 2008. The median duration of the procedures was 78.3+/-20.7 min. Thoracoscopies and laparoscopies were performed in 18 patients while additional arterioscopic examination with endoscope was performed in two patients with suspected aortic diseases. Four consented limited clinical autopsies were also performed: two of them involved thoracoscopic biopsies of lung tissues, one was a para-mortem upper endoscopy for the investigation of pathology of the stomach and the other one was laparoscopy for a patient, who died of unexplained acidosis. Comparison with full autopsies showed that the accuracy of the diagnosis was 94.4%, the sensitivity was 90%, the specificity was 100%, the positive predictive value was 100% and the negative predictive value was 88.9%. CONCLUSION: Minimally invasive autopsy is a feasible approach, yielding accurate findings when compared with conventional autopsies. The former can be a valuable tool for obtaining more valuable information in situations when the next-of-kin of the deceased does not consent to a conventional autopsy.

Trunk muscle training, posture fatigue, and performance in laparoscopic surgery.

PURPOSE: To investigate the effect of trunk muscle endurance training on the perception of back postural fatigue and performance of a laparoscopic task. MATERIALS AND METHODS: Thirty-one medical students (28 men and 13 women) with no laparoscopic surgical experience were randomly assigned to either a training group or a control group. Participants in the training group underwent a 6-week, 18-session trunk (abdominal and back muscle) endurance training program, whereas participants in the control group did not. Performance by all participants was assessed on a simulated laparoscopic task under varying conditions of low back postural fatigue, both before and after the training program. RESULTS: Participants in the training group showed significant improvements in trunk endurance after the 6-week, trunk endurance training program (P<0.05), whereas those in the control group did not. The improvements in trunk endurance were accompanied by significantly reduced perceptions of discomfort (P< .001) and fewer errors during performance of the laparoscopic task. (P<0.02), whereas no significant changes occurred for the control group (P>0.05). CONCLUSION: Increasing trunk endurance can increase postural fatigue and discomfort during simulated laparoscopic tasks, which may assist in the management of errors during laparoscopy.

Implicit motor learning in surgery: implications for multi-tasking.

BACKGROUND: Implicitly learned motor skills are characterized by minimal conscious knowledge of the movements involved and stable performance despite stress, fatigue, or multi-tasking. In contrast, explicitly learned motor skills are characterized by conscious knowledge of the movements and performance that tends to be less stable under stress, fatigue, and multi-tasking. We examined the acquisition of a basic surgical skill in three observational learning treatment conditions designed to accomplish implicit or explicit motor learning. We then tested performance in conditions that emulated multi-tasking in the operating theater. Our intention was to elaborate current understanding of implicit and explicit processes that underpin observational learning in the surgical environment. METHODS: Thirty-six novice adults were assigned randomly to an observation-only, an instructed-observation, or a guided-observation treatment condition, in which they learned to perform a suturing and knot-tying task in a Learning Phase. Their performance during multi-tasking was then assessed objectively by motion analysis during a Test Phase. RESULTS: In the Learning Phase, performance improved equally in the treatment conditions throughout learning, with participants using fewer hand movements and completing the task more quickly. Participants in the observation-only and the guided-observation treatment condition, however, reported significantly less movement-related knowledge than participants in the instructed-observation condition. In the Test Phase, participants in the instructed-observation condition exhibited slower completion times and more hand movements when they were required to multi-task, whereas in the observation-only and the guided-observation treatment condition, participants showed stable performance. CONCLUSIONS: A surgical skill that is learned by observation alone or by observation accompanied by guidance to reduce the number of errors that are committed tends to be learned implicitly and to have stable performance during multi-tasking. The efficacy of observation for acquiring technical skills implies that, at least for some skills, verbal instructions may not be necessary.

Maggot debridement therapy in chronic wound care.

OBJECTIVE: To review the current evidence on the mechanism of actions and clinical applications of maggot debridement therapy. DATA SOURCES: Literature search of PubMed and Medline was performed up to January 2007. STUDY SELECTION: Original and major review articles related to maggot debridement therapy were reviewed. Key words used in the literature search were 'maggot debridement therapy', 'wound healing', and 'chronic wound management'. DATA EXTRACTION: All relevant English and Chinese articles. DATA SYNTHESIS: The mechanism of such maggot therapy was shown to be due to the debridement, disinfection, and wound healing enhancement actions of maggot excretions/secretions. The efficacy of maggot debridement therapy in chronic wound management has been demonstrated in chronic venous ulcers, pressure ulcers, and diabetic ulcers. There is also a new delivery system for the excretions/secretions, which has been shown to be as effective as using live maggots. CONCLUSIONS: Maggot debridement therapy has been shown to be a safe and effective means of chronic wound management. However, there are a number of limitations when considering its local applicability. Future development of the delivery system may help to overcome some of these limitations and improve its acceptability.

Management of herniated retroperitoneal adipose tissue during endoscopic extraperitoneal inguinal hernioplasty.

BACKGROUND: Herniation of retroperitoneal adipose tissue into the inguinal canal, traditionally called cord lipoma, is frequently encountered during endoscopic totally extraperitoneal inguinal hernioplasty (TEP). Failure to recognize and manage the cord lipoma accounted for 30%-50% of recurrent hernia after TEP. The present study was undertaken to evaluate the incidence, risk factors, and management of herniated retroperitoneal adipose tissue during TEP. METHODS: Between December 2002 and November 2005 all patients who underwent TEP were prospectively evaluated for the presence of cord lipoma. Clinical outcomes of patients who were treated for their cord lipoma were compared with those without cord lipoma. Risk factors for the occurrence of cord lipoma were also examined. RESULTS: A total of 498 patients underwent unilateral (n = 386) or bilateral (n = 112) TEP. The overall incidence of cord lipoma was 26.5% (n = 132). A higher body weight, a higher body mass index, and a larger hernial defect were significantly associated with the presence of cord lipoma. Most of the cord lipoma cases (n = 119) were reduced to pelvic peritoneal reflection line after division of the feeding vessels from surrounding structures, while the rest (n = 13) were resected. Early postoperative outcomes, including pain score, morbidities, and other recovery variables, showed no significant difference between the two groups. No recurrence occurred in the present series. CONCLUSIONS: Herniation of retroperitoneal adipose tissue into the inguinal canal occurred in more than one-fifth of the patients with inguinal hernia. Awareness and appropriate treatment of the cord lipoma helped to reduce the risk of recurrence. During TEP, the internal inguinal ring and inguinal canal should always be cleared of any herniated adipose tissue by either reduction or resection. This clearing posed no adverse effects on postoperative outcome.

Day-case endoscopic totally extraperitoneal inguinal hernioplasty versus open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males: a randomized trial.

BACKGROUND: Endoscopic totally extraperitoneal inguinal hernioplasty (TEP) is an accepted technique for the repair of recurrent and bilateral inguinal hernia, but its role in the management of unilateral primary inguinal hernia remains controversial. The current randomized trial was undertaken to compare the postoperative and 1-year outcomes of day-case TEP and open Lichtenstein hernioplasty for unilateral primary inguinal hernia in males. METHODS: From January 2002 to January 2004, a total of 200 male patients were randomized to undergo either day-case unilateral TEP or open Lichtenstein hernioplasty under general anesthesia. The primary outcome measures included postoperative pain score, time until return to work, incidence of chronic groin pain, and recurrence rate 1 year after the operation. RESULTS: All TEP procedures were successfully performed without conversion. The mean operation time for TEP (50 +/- 13.2 min) was significantly shorter than for open Lichtenstein hernioplasty (58 +/- 17.6 min) (p < 0.001). The pain score at rest was significantly lower in the TEP group than in the open group on postoperative days 0, 1, 4, 5, and 6. On the average, the patients returned to work 8.6 days after TEP and 14 days after Lichtenstein hernioplasty (p = 0.006). Postoperative recovery and morbidity rates were otherwise comparable between the two groups. The incidence of chronic groin pain 1 year after TEP (9.9%) was significantly lower than after open surgery (21.7%) (p = 0.032). None of the patients in either group showed recurrence at the last follow-up assessment. CONCLUSIONS: Day-case TEP was superior to open Lichtenstein hernioplasty for the repair of unilateral primary inguinal hernia in males. The benefits of day-case TEP included less postoperative pain, a faster return to work, and a lower incidence of chronic groin pain.

Early versus delayed-interval laparoscopic cholecystectomy for acute cholecystitis: a metaanalysis.

BACKGROUND: Early laparoscopic cholecystectomy has been advocated for the management of acute cholecystitis, but little evidence exists to support the superiority of this approach over delayed-interval operation. The current systematic review was undertaken to compare the outcomes and efficacy between early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis in an evidence-based approach using metaanalytical techniques. METHODS: A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1988 and June 2004. Only randomized or quasi-randomized prospective clinical trials in the English language comparing the outcomes of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were recruited. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio or weighted mean difference where feasible and appropriate. RESULTS: A total of four clinical trials comprising 504 patients met the inclusion criteria. Failure of conservative treatment requiring emergency cholecystectomy occurred for 43 patients (23%) in the delayed group. Metaanalyses demonstrated a significantly shortened total length of hospital stay in the early group (weighted mean difference, -1.12; 95% confidence interval [CI], -1.42 to -0.99; p < 0.001). Pooled estimates did not show any significant differences between the two approaches in terms of operation time, conversion rate, overall complication rate, incidence of bile leakage, and intraabdominal collection. CONCLUSIONS: The safety and efficacy of early and delayed-interval laparoscopic cholecystectomy for acute cholecystitis were comparable. Because evidence suggested that early laparoscopic cholecystectomy reduced the total length of hospital stay and the risk of readmissions attributable to recurrent acute cholecystitis, it is therefore a more cost-effective approach for the management of acute cholecystitis.

Is endoscopic totally extraperitoneal hernioplasty justified for the repair of groin hernia in female patients?

BACKGROUND: Groin hernia is an uncommon surgical pathology in females. The efficacy of the endoscopic approach for the repair of female groin hernia has yet to be examined. The current study was undertaken to compare the clinical outcomes of female patients who underwent open and endoscopic totally extraperitoneal inguinal or femoral hernioplasty (TEP). METHODS: From July 1998 to June 2004, 108 female patients who underwent elective repair of groin hernia were recruited. The patients were divided into TEP (n = 30) and open groups (n = 78) based on the type of operation. Clinical data and outcome parameters were compared between the two groups. RESULTS: The mean ages and hernia types were comparable between the two groups. All TEPs were successfully performed. The mean operative times were 52 min for unilateral TEP and 51 min for open repair. The difference was not statistically significant. Comparisons of the length of hospital stay, postoperative morbidity, pain score, and time taken to resume normal activities showed no significant differences between the two groups. A single patient in the TEP group experienced recurrence of hernia. CONCLUSIONS: The findings show equivalent postoperative outcomes after TEP and open repair of groin hernia in female patients. Because the wound scar after open repair is well concealed beneath the pubic hair and no superior clinical benefits are observed after TEP, open repair appears to be the technique of choice for the management of primary groin hernia in females. The TEP approach should be reserved for female patients with recurrent or multiple groin hernia.

Cultivating psychological well-being in Hong Kong's future doctors.

There has been much recent attention on psychological well-being and pastoral care for medical students. This study examines psychological morbidity (depression, anxiety and stress) in Hong Kong medical students, as well as their concerns, coping mechanisms and their help-seeking. Medical students in Hong Kong reported a higher level of psychological morbidity as compared with other tertiary education students. Their main concerns include examinations, stress, career, adjusting to the new medical curriculum and commitment to the course. The coping skills adopted were largely adaptive. Maladaptive coping skills like 'denial', 'self-blame' and 'behavioural disengagement' were highly correlated with depression, anxiety and stress scores. Most of the students concerned wanted support services that were specifically tailored to their needs and at least partly provided by people who had been through medical training themselves. The faculty at the University of Hong Kong is establishing a Programme for Effective Transition and Student Support (PETSS) to provide a multi-faceted support system for its medical students. The findings in this study help to ensure that the services provided will be relevant, accessible and acceptable to the students.

Acute pain after endoscopic totally extraperitoneal (TEP) inguinal hernioplasty: multivariate analysis of predictive factors.

BACKGROUND: Pain is the most common complaint after inguinal hernia surgery. The present study was undertaken to evaluate the significance of various perioperative clinical factors on the severity of postoperative pain following endoscopic totally extraperitoneal (TEP) inguinal hernioplasty. METHODS: Between November 1999 and December 2002, 509 patients who underwent unilateral ( n = 389) and bilateral ( n = 120) TEP were recruited for this study. There were 491 men and 18 women. Severity of postoperative pain at rest and on coughing was assessed by a linear analogue pain score (scale, 0-10) on a daily basis after operation. Univariate and multivariate analyses were performed to identify the significant independent factors affecting pain. RESULTS: By univariate analysis, pain scores at rest were significantly higher in young (< or =65 years) female patients, as well as patients who underwent unilateral and day case TEP. Clinical factors associated with a significantly higher pain score on coughing included mesh fixation by stapling, female sex, and age (< or =65 years). Other factors, including unilateral vs bilateral TEP, seroma formation, direct vs indirect hernia, primary vs recurrent hernia, and operative time, had no impact on postoperative pain. On multiple regression analysis, age and sex were found to be independent predictive factors for mean daily pain score at rest. Independent factors influencing mean pain score on coughing included age, sex, and prosthetic stapling. CONCLUSIONS: Patient age and sex are the most significant factors determining the degree of pain after TEP. Analgesic therapy should therefore be adjusted in accordance with the age of the patient. With regard to operative factors, avoidance of prosthetic stapling might help to reduce the severity of pain on coughing.

Umbilical hernia in adults.

BACKGROUND: There is no consensus on the best technique for the repair of umbilical hernia in adults. The role of laparoscopic hernioplasty of umbilical hernia remains controversial. This study was undertaken to compare the outcomes of open and laparoscopic onlay patch repair of umbilical hernia in adults. METHODS: From January 1996 to December 2002, 102 patients underwent elective repair of umbilical hernia. Operative techniques included Mayo repair ( n = 43), laparoscopic onlay Gore-Tex patch hernioplasty ( n = 26), suture herniorrhaphy ( n = 24), and mesh hernioplasty ( n = 9). RESULTS: Demographic features and risk factors were similar among the four groups. The operative time of laparoscopic hernioplasty (median, 66 min) was significantly longer than those for patients who underwent Mayo repair (60 min) or sutured herniorrhaphy (50 min) ( p < 0.05). None of the patients who underwent laparoscopic patch repairs required conversion to open repair. The median pain score at rest on postoperative day 1 was significantly lower in patients who underwent laparoscopic repair compared to those who had Mayo repair. A significantly shorter hospital stay and a lower wound morbidity rate were also observed in patients who underwent laparoscopic repair. With a mean follow-up of 2 years, suture herniorrhaphy had a relatively high recurrence rate (8.7%), whereas no recurrence was documented for the other techniques. CONCLUSIONS: Laparoscopic onlay patch hernioplasty is a safe and efficacious technique for the repair of umbilical hernia. Compared to Mayo repair, the laparoscopic approach confers the advantages of reduced postoperative pain, shorter hospital stay, and a diminished morbidity rate.

Prevalence and severity of chronic groin pain after endoscopic totally extraperitoneal inguinal hernioplasty.

BACKGROUND: Chronic groin pain after open inguinal hernia repair is a common long-term morbidity, but its incidence after endoscopic totally extraperitoneal inguinal hernioplasty (TEP) has not been studied in detail. The objective of this study was to evaluate the prevalence and severity of chronic groin pain after TEP. METHODS: Between June 1999 and September 2001, 313 consecutive patients who underwent TEP at our institution were recruited. To evaluate the incidence and severity of chronic pain, a cross-sectional telephone survey using a standardized questionnaire was conducted by a research assistant. Clinical data between the chronic pain group and the pain-free group were compared to identify any clinical factors that had a significant association with the subsequent development of chronic groin pain. RESULTS: The prevalence of chronic groin pain was 9.2% ( n = 24). The severity of the pain was mild ( n = 18), moderate ( n = 5), or severe ( n = 1). In more than half of the patients, the groin pain occurred less often than once a month and its duration did not exceed 1 min. Only one patient reported an impairment of functional activities as a result of the pain. Multivariate analyses identified a significant association between a high postoperative pain score on coughing on postoperative day 6 and the subsequent development of groin pain. CONCLUSIONS: The prevalence of chronic groin pain in patients after TEP was low. The pain was mostly mild and transient without associated sensory symptoms. The occurrence of pain had a negligible impact on daily activities.