Clinical validity of consultant technical skills assessment in the English National Training Programme for Laparoscopic Colorectal Surgery.

BACKGROUND: The English National Training Programme for Laparoscopic Colorectal Surgery introduced a validated objective competency assessment tool to accredit surgeons before independent practice. The aim of this study was to determine whether this technical skills assessment predicted clinical outcomes. METHODS: Established consultants, training in laparoscopic colorectal surgery, were asked to submit two operative videos for evaluation by two blinded assessors using the competency assessment tool. A mark of 2·7 or above was considered a pass. Clinical and oncological outcomes were compared above and below this mark, including regression analysis. RESULTS: Eighty-five consultant surgeons submitted 171 videos. Of these, 44 (25·7 per cent) were in the fail group (score less than 2·7). This low scoring group had more postoperative morbidity (25 versus 8·7 per cent; P = 0·005), including surgical complications (18 versus 6·3 per cent; P = 0·020) and fewer lymph nodes harvested (median 13 versus 18; P = 0·004). A score of less than 2·7 was an independent predictor of surgical complication, lymph node yield and distal resection margin clearance. Consultants with higher scores had performed similar numbers of laparoscopic colorectal operations (median 37 versus 40; P = 0·373) but more structured training operations (18 versus 9; P < 0·001). CONCLUSION: An objective technical skills assessment provided a discriminatory tool with which to accredit laparoscopic colorectal surgeons.

Type 1-prophospholipase A2 propeptide immunoreactivity is released from activated granulocytes.

OBJECTIVE: To establish a ELISA assay to measure release of type 1-phospholipase A2 propeptide from activated granulocytes. Human type 1-prophospholipase A2 (1-proPLA2) is biosynthesized and stored as inactive zymogen. Activation involves tryptic-like cleavage at the N-terminus, with equimolar release of the heptapeptide DSGISPR. METHODS: Using antibodies directed to the carboxyterminus of synthetic DSGISPR we developed a sensitive solid-phase ELISA specific for the released propeptide that accurately reports the activation of 1-proPLA2. The presence of the 1-proPLA2 precursor itself can be determined by trypsinization of the sample and subsequent assay for free DSGISPR. RESULTS: Using this ELISA, we demonstrated the presence of immunoreactive DSGISPR and its 14 kDa 1-proPLA2-like precursor in human granulocytes, but their absence in human macrophages and lymphocytes. Stimulation of cultured granulocytes with 1 pM of TNF alpha or GM-CSF caused rapid release of DSGISPR and precursor into the surrounding medium. The immunoreactive signal coeluted with standard synthetic DSGISPR on G50 Sephadex chromatography. CONCLUSION: Release of DSGISPR immunoreactivity appears to be a specific consequence of granulocyte activation of potential relevance to the clinical pathophysiology of conditions like acute lung injury.

Role of interleukin-6 in mediating the acute phase protein response and potential as an early means of severity assessment in acute pancreatitis.

A number of laboratory and clinical studies have shown that interleukin-6 is the principal mediator of the acute phase protein response. In this study the relationship between serum concentrations of interleukin-6 and C-reactive protein in acute pancreatitis are examined and the ability of interleukin-6 to discriminate between severe and mild attacks is assessed. We have studied 24 patients (10 severe and 14 mild). Serum samples were collected on admission, six hourly for 48 hours and then 12 hourly for a further three days. When the areas under the curves of individual patients were compared there was a strong correlation between the total production of interleukin-6 and C-reactive protein (r = 0.73) (Spearman rank correlation) and peak interleukin-6 and C-reactive protein concentrations (r = 0.75), suggesting a close relationship between interleukin-6 and C-reactive protein production. Both on admission and peak interleukin-6 concentrations were significantly higher in patients with severe than mild disease. There was no significant difference in on admission C-reactive protein concentrations, although significant differences were seen when peak concentrations were considered. Utilising a peak interleukin-6 concentration of > 130 u/ml, we were able to distinguish between severe and mild attacks of acute pancreatitis with a sensitivity of 100% and specificity of 71%. These figures were comparable with those for peak C-reactive protein, a C-reactive protein of > 150 mg/l detecting severe attacks of acute pancreatitis with a sensitivity of 90% and specificity of 79%. In view of the fact that interleukin-6 concentrations peaked earlier than those of C-reactive protein, interleukin-6 is capable of providing comparable, but earlier severity prediction than C-reactive protein.