Do soft skills predict surgical performance?: a single-center randomized controlled trial evaluating predictors of skill acquisition in virtual reality laparoscopy.

BACKGROUND: Virtual reality (VR) training in minimal invasive surgery (MIS) is feasible in surgical residency and beneficial for the performance of MIS by surgical trainees. Research on stress-coping of surgical trainees indicates the additional impact of soft skills on VR performance in the surgical curriculum. The aim of this study was to evaluate the impact of structured VR training and soft skills on VR performance of trainees. METHOD: The study was designed as a single-center randomized controlled trial. Fifty first-year surgical residents with limited experience in MIS ("camera navigation" in laparoscopic cholecystectomy only) were randomized for either 3 months of VR training or no training. Basic VR performance and defined soft skills (self-efficacy, stress-coping, and motivation) were assessed prior to randomization using basic modules of the VR simulator LapSim(®) and standardized psychological questionnaires. Three months after randomization VR performance was reassessed. Outcome measurement was based on the results derived from the most complex of the basic VR modules ("diathermy cutting") as the primary end point. A correlation analysis of the VR end-point performance and the psychological scores was done in both groups. RESULTS: Structured VR training enhanced VR performance of surgical trainees. An additional correlation to high motivational states (P < 0.05) was found. Low levels of self-efficacy and negative stress-coping were related to poor VR performance in the untrained control group (P < 0.05). This correlation was absent in the trained intervention group (P > 0.05). CONCLUSION: Low self-efficacy and negative stress-coping strategies seem to predict poor VR performance. However, structured training along with high motivational states is likely to balance out this impairment.

Ventricular assistance after tricuspid valve replacement for carcinoid heart disease.

We report a case of a 71-year-old woman with carcinoid heart disease admitted in ICU after tricuspid valve replacement. She quickly developed a acute heart right failure. Optimal medical treatment failed and we implanted ventricular assistance. After 10 days of support, patient improved and the right ventricle recovered. Temporary devices can provide a successful bridge to cardiac recovery. However, the risk of infection that is a major prognosis factor should be carefully considered particularly when temporary assistance implanted on immunosuppressed patients.

Patients' needs during hospitalization in a cardiac surgery unit before and after coronary artery bypass graft surgery.

BACKGROUND: The aim of this study was to explore patients' needs and changes to these needs during a hospital stay for coronary artery bypass graft (CABG) surgery. METHODS: 70 patients (60 males; mean age = 64.1; SD = 8.9) reported their needs two days before and ten days after CABG surgery using a specifically developed 15-item questionnaire. Student's T-test was used to detect significant differences. RESULTS: Before CABG, patients rated the need for "preparation for surgery", and after CABG the need for "information about the correct handling of drugs", as the most important. The rating of "information about the correct handling of drugs" showed a significant increase after CABG surgery ( T(69) = - 3.46; P < 0.001) and the need for a "letter with the latest scientific information on heart disease" was significantly reduced during this period ( T(69) = 2.07; P = 0.04). CONCLUSIONS: The results indicate that preparation for surgery should be conducted very carefully without time pressure. Patients should receive more detailed information on prescribed drugs.

[The short- and long-term motivational effects of a patient education programme for patients with coronary artery bypass grafting]. / Die kurz- und langfristigen motivationalen Effekte eines Patientenschulungsprogramms für Herzbypasspatienten.

PURPOSE: An important rehabilitation aim following coronary artery bypass graft (CABG) surgery is to modify cardiovascular risk factors positively. Among the most potent possibilities for improvement of these factors is a lifestyle change in terms of increasing sports exercise, changing diet patterns, stress reduction, etc. An indispensable condition for these changes is the motivation to implement the necessary changes. In our working group a patient education programme was developed aimed at enhancing the motivation for lifestyle change, which was already applied in a cardiac surgery hospital. In evaluating the programme, we could observe that various cognitive factors of motivation for lifestyle change had dropped in untreated patients and risen in patients participating in the programme. Based on these preliminary findings we examined the motivation for lifestyle change one year after CABG surgery. METHOD: Each patient was evaluated for his/her value in motivation for lifestyle change using a 30-item questionnaire which measures the six factors Vulnerability, Intention, Social Expectations, Outcome Expectation, Self-Efficacy Expectation, and Perceived Severity two days before CABG surgery as well as ten days and one year after CABG surgery. Between January and May 2002 patients in usual care were investigated as control group (n=70). From January to May 2003, n=70 patients had the opportunity to take part in a comprehensive patient education programme that was provided by a specifically trained psychologist. Data from 108 patients could be evaluated one year after CABG surgery (response rate=77.1%). The programme had comprised individualized units, as well as a group lecture. If partners were available they were included in the process. RESULTS: One year after CABG surgery no significant differences between the control group and the intervention group could be found. CONCLUSION: The positive effects of the patient education programme measured ten days after surgery were found to have vanished one year after the operation. A possible reason is the short duration of the programme. Long-term, structured aftercare programmes should help stabilize the positive effects obtained in the short term.

The impact of self-belief on laparoscopic performance of novices and experienced surgeons.

BACKGROUND: In many professions, nontechnical aspects such as motivation or coping with stress are known to influence performance, success, and outcome. These qualities are assessed and trained in novices for quality and safety reasons. This study explored the impact of self-belief of surgeons on laparoscopic performance using a virtual reality simulator (LapSim). METHODS: Eighteen inexperienced surgical residents (with less than ten laparoscopic procedures performed) and 22 advanced residents (with more than 50 laparoscopic procedures performed) filled out a ten-item questionnaire used for the assessment of the individual sense of general self-efficacy (GSE). Afterward the participants were asked to perform three defined tasks on the LapSim, each at two different levels of difficulty. The tasks consisted of coordination, dissection, and application of clips. To assess laparoscopic performance, the total time to complete the tasks, economy of motion, and damage parameters were analyzed and correlated with the GSE score by means of Bravis-Pearson correlation analysis. RESULTS: In novices, high GSE scores correlated with more errors and poor economy of motion, while in advanced residents, laparoscopic performance was independent of the level of assessed self-efficacy. CONCLUSION: In a small sample, high self-belief does not predict success. In novices it negatively correlates with laparoscopic skills, while in advanced residents it is independent of laparoscopic performance. Thus, training aspects seem to be of greater importance for laparoscopic skills. Nevertheless, nontechnical aspects like self-belief, motivation, stress-coping strategies, judgment, decision-making, and leadership should be included in the surgical curriculum.

Health-related quality of life two days before, ten days and one year after coronary artery bypass graft surgery.

BACKGROUND: Health-related quality of life (HRQL) is one of the most important outcome criteria of nearly all medical procedures. Only the patients themselves can provide detailed and true information on their quality of life. The measurement of HRQL can be used to assess the expected benefit of coronary artery bypass graft (CABG) surgery. METHODS: 142 patients were included in the study and completed the German version of the SF-36 health survey questionnaire (SF-36) [1]. The SF-36 was administered 2 days before, 10 days and one year after CABG surgery. Additionally, data produced by our patients was compared to the summary data of three populations displayed in the SF-36 handbook (standard population, patients with myocardial infarction and with angina pectoris). RESULTS: While HRQL is slightly reduced 10 days after CABG surgery, the improvement one year later is highly significant compared to two days before CABG surgery. One year after CABG surgery, the HRQL of our patients is much closer to that of the standard population of the SF-36. CONCLUSIONS: According to HRQL, patients benefit from CABG surgery.

Association of glucose levels and glucose variability with mood in type 1 diabetic patients.

AIMS/HYPOTHESIS: The aim of this study was to investigate the association of glucose levels and variability of glucose, assessed by continuous glucose monitoring, with mood in type 1 diabetic patients. MATERIALS AND METHODS: Thirty-six type 1 diabetic patients (77.8% male, age: 31.1 +/- 10.0 years; disease duration: 14.7 +/- 7.1 years, BMI: 26.7 +/- 5.1 kg/m2, HbA1c 8.4 +/-1.8%, 27.8% with continuous subcutaneous insulin infusion [CSII] therapy) used a continuous glucose monitoring system for 48.8 h. During this time the patients rated their current mood states 14.6 times on average, using the University of Wales Institute of Science and Technology Mood Adjective Checklist and hand-held computers. RESULTS: Sensor performance was satisfactory, with a mean absolute difference from reference laboratory glucose measurement of 13.7%. Current glucose values were significantly associated with ratings of 'tension' (z = 2.40), 'hedonic tone' (z = -2.63) and 'energetic arousal' (z = -2.09). 'Anger' (z = 1.64) was not significantly associated with glucose values. The glucose AUC during the 60 min prior to the mood rating showed similar associations. The two parameters of glucose variability-coefficient of variation and absolute glucose change during the 60 min prior to the mood ratings-did not show any significant association with the mood ratings. The magnitude of association was significantly higher for glucose level than for glucose variability in the scales 'tension' and 'hedonic tone'. CONCLUSIONS/INTERPRETATION: High glucose values had a negative impact on mood; positive mood ratings decreased, whereas negative mood ratings increased. The association between mood and glucose variability seemed to be less important than that between glucose level and mood.

Negative stress-coping strategies among novices in surgery correlate with poor virtual laparoscopic performance.

BACKGROUND: This study explored the impact of habitual stress-coping strategies on the laparoscopic performance of novices in surgery using a virtual reality simulator. METHODS: The SVF78 stress-coping questionnaire was administered to 12 medical students in their final year of medical school (camera holders) and to 12 inexperienced surgical residents (postgraduate years 1-3). The questionnaire included devaluation during stressful situations, distractions from stressful situations, control over stressful reactions and negative coping strategies such as stress avoidance and need for social support. Assessment of laparoscopic dexterity was based on the results of performance on a virtual reality simulator. The variables of time taken to complete the task, errors and economy of motion were analysed, with a higher score indicating poor performance. Pearson and non-parametric Spearman correlations were used to compare the subjects' results on the SVF78 with those on the LapSim. RESULTS: Time taken to complete the task correlated with high values in distractive stress-coping strategies (P = 0.002) and high values in negative stress-coping strategies (P = 0.042). CONCLUSION: Ineffective stress-coping strategies correlate with poor virtual laparoscopic performance. The need for effective intraoperative stress-coping strategies is evident.

Locomotor activity and defecation of rats observed alone and in pairs in repeated open-field sessions.

Several experiments with independent groups have shown social effects on open-field defecation and locomotor activity in male rats. In this experiment these social effects were studied with a different methodological approach, namely, with repeated measurements. One group of 8 animals was tested always alone in an open field over 10 trials on successive days. The second group of 16 animals was also tested alone on Days 1 to 4 and on Day 9, while they were placed in the open field with a conspecific on Days 5 to 8 and again on Day 10. There was markedly reduced defecation and enhanced locomotion with the conspecific present, while with the absence of the conspecific on Day 9 the scores again reached the level of the rats always tested alone. Therefore, the social effects on defecation and locomotion are very robust phenomena which can also be shown with dependent measurements.

Scanning behavior of rats during eating under stressful noise.

Behavioral ecological theories postulate that threatening environments should increase eating speed and vigilance during feeding. In the present experiment, eating speed and scanning behavior during eating were measured in 36 rats in 5 consecutive test sessions under stressful noise (95 dB white noise, n = 18) and control conditions (60 dB, n = 18) after the animals had been habituated to the test environment. Intense noise induced an increase of scanning rate and eating speed. These effects are similar to those reported for novel and light environments.

Effects of stressful noise on eating and non-eating behavior in rats.

Eating and other behaviors were measured in 36 food-deprived rats on 15 consecutive days during 20 min test sessions. During training sessions 1 to 5 all animals were habituated to the test boxes with white noise of 55 dB intensity. For sessions 6 to 10 noise intensity was increased to 95 dB for the experimental rats and to 60 dB for the control rats. The food intake of experimental rats was lower for stress session 1. The duration of eating behavior was lower, and durations of exploring, grooming and resting behaviors were higher for all stress sessions for rats exposed to 95 dB white noise. Speed of eating behavior was higher for all stress sessions in the experimental group. Defecation rate of the experimental rats was higher for all stress sessions. On post-stress sessions 11 to 15 animals were again tested under the stimulus conditions of the training period (55 dB). No significant effects were observed for this period. The results are discussed with respect to models of "stress-induced" eating and behavioral ecology.

Social and non-social open field behaviour of rats under light and noise stimulation.

In two experiments, male rats were observed in pairs under different environmental stimulations in an open field. In Experiment 1, white noise of 85 dB(A) reduced social activities and increased defecation compared to 75 dB(A) and 65 dB(A). In Experiment 2, the illumination of the open field was varied in addition to a variation of the noise intensity. Again, 85 dB(A) as compared to 50 dB(A) reduced social activities and increased defecation, but also led to changes in non-social behaviours such as sniffing, grooming, and rearing. In contrast, 400 lx did not differ substantially in its effects from 40 lx in any of the observed behavioural categories. Altogether, the behaviour pattern under 85 dB(A) white noise cannot satisfactorily be explained only by increased anxiety of fear. Alternative explanations are discussed.

Continuous monitoring of brain ethanol levels by intracerebral microdialysis.

A method is described which allows simultaneous collection of blood and perfusate of discrete brain regions from an individual animal over several hours. This procedure involves catheterization of a peripheral blood vessel (jugular vein) and the insertion of a microdialysis probe into a specified brain area (lateral hypothalamus) for sampling of blood and brain perfusate, respectively. Using this procedure, levels of ethanol in blood and brain perfusates were determined by scintillation counting following administration of [14C]-ethanol (20 mu Ci) to adult male rats at a dose of 0.8 or 2.4 g/kg. Ethanol levels in brain and blood as well as the time-course of disappearance were dependent on the dose administered. Peak blood levels were observed in the first sample taken (i.e., at 10 min), whereas a slight delay was noted in the time to peak level in brain. At subsequent time points, a good correlation was observed between blood and brain perfusate radioactivity levels although perfusate levels were slightly lower. It is concluded that this approach will prove useful for investigating the molecular and cellular mechanisms of action of ethanol by enabling the direct correlation of blood and brain ethanol levels with various behavioral, electrophysiological and/or biochemical measures.

The plasma catecholamine stress response is characteristic for a given animal over a one-year period.

The same male and female rats with indwelling jugular catheters were stressed (immobilization) on two occasions at the ages of 3 to 4 and 15 to 16 months. Plasma levels of the catecholamines (CA) norepinephrine (NE) and epinephrine (E) were determined before and during stress at each session. During stress, plasma NE and E levels increased markedly. At the younger age, female animals showed markedly higher CA levels than male animals. After one year, stress CA levels were higher for both sexes, but had increased markedly in male and little in female animals. A positive correlation was found between the plasma CA stress response of individual animals at both sessions; this correlation was stronger for males and NE. This indicates that "high" responders usually remain high responders, "low" responders remain low and intermediate responders intermediate. In conclusion, the plasma CA stress response increases markedly in male, but little in female rats over the period of 1 year and the relative magnitude of the individual stress response remains a characteristic of each given animal.

Relationships of plasma catecholamines to open-field behavior after inescapable shock.

Male rats with indwelling jugular catheters were exposed to inescapable shock or no shock, and ambulation and defecation were measured 24 h later in an open field. Plasma catecholamine levels were determined from blood samples taken before and during pretreatment as well as before and after testing for aftereffects on open-field behavior. Shocked animals showed higher plasma catecholamine levels during the shock session and lower locomotor activity in the open field. Open-field activity was negatively correlated in shocked animals with both plasma catecholamines before and during shock and also with plasma epinephrine before open-field testing. Defecation was only positively correlated with plasma norepinephrine before open-field testing. Thus, the reduced open-field activity after inescapable shock may indicate heightened fear or anxiety which may also be present when shocked animals are tested for their performance in more complex tasks.