Are There Detrimental Effects From Proficiency-Based Training in Fundamentals of Laparoscopic Surgery Among Novices? An Exploration of Goal Theory.

INTRODUCTION: Goal theory states that novices may experience unintended, detrimental learning effects, with decreased performance, when given performance goals on complex tasks. In these situations, it may be more appropriate to give novices learning goals to help avoid these negative consequences. The purpose of this study was to see whether this tenant of goal theory applied to novices learning 2 tasks of fundamentals of laparoscopic surgery (FLS). MATERIALS AND METHODS: Medical and physician assistant students were randomized to a performance goals group and a learning goals group. The performance goals consisted of the published proficiency standards of FLS. Both groups were pretested on perception of surgery, self-efficacy, and general affect. Each group underwent a practice session for the peg transfer task. They were tested and scored per the published standards of FLS. The participants completed NASA Task Load Index, task complexity, and postaffect questionnaires related to the peg transfer task. This was repeated with the suture with intracorporeal knot task. Posttest perception of surgery and self-efficacy questionnaires were completed. RESULTS: In total, 48 students participated in the study: 23 in the performance goals group and 25 in the learning goals group. Most of the participants (n = 40) were first-year medical and physician assistant students. There were no significant differences between the groups in perception of surgery, affect, goal commitment, subjective task complexity, subjective workload, and self-efficacy. There were no differences between the groups concerning overall FLS score for both the peg transfer and suturing tasks. Both groups exhibited significant increases in self-efficacy and perception of surgery (p < 0.05). CONCLUSION: FLS skills can be given to novice learners without concern for detrimental effects as might be expected by other work on goal theory. Given that performance was the same for both groups, surgical educators may have multiple pathways to educational success when incorporating goals into training programs for basic surgical skills.

Utility of sequencing the erm(41) gene in isolates of Mycobacterium abscessus subsp. abscessus with low and intermediate clarithromycin MICs.

The erm(41) gene confers inducible macrolide resistance in Mycobacterium abscessus subsp. abscessus, calling into question the usefulness of macrolides for treating M. abscessus subsp. abscessus infections. With an extended incubation (14 days), isolates with MICs of ≥8 µg/ml are considered macrolide resistant by current CLSI guidelines. Our goals were to determine the incidence of macrolide susceptibility in U.S. isolates, the validity of currently accepted MIC breakpoints, and the erm(41) sequences associated with susceptibility. Of 349 isolates (excluding those with 23S rRNA gene mutations), 85 (24%) had clarithromycin MICs of ≤8 µg/ml. Sequencing of the erm(41) genes from these isolates, as well as from isolates with MICs of ≥16 µg/ml, including ATCC 19977T, revealed 10 sequevars. The sequence in ATCC 19977T was designated sequevar (type) 1; most macrolide-resistant isolates were of this type. Seven sequevars contained isolates with MICs of >16 µg/ml. The T28C substitution in erm(41), previously associated with macrolide susceptibility, was identified in 62 isolates (18%) comprising three sequevars, with MICs of ≤2 (80%), 4 (10%), and 8 (10%) µg/ml. No other nucleotide substitution was associated with macrolide susceptibility. We recommend that clarithromycin susceptibility breakpoints for M. abscessus subsp. abscessus be changed from ≤2 to ≤4 µg/ml and that isolates with an MIC of 8 µg/ml have repeat MIC testing or erm sequencing performed. Our studies suggest that macrolides are useful for treating approximately 20% of U.S. isolates of M. abscessus subsp. abscessus. Sequencing of the erm gene of M. abscessus subsp. abscessus will predict inducible macrolide susceptibility.

Absence of a functional erm gene in isolates of Mycobacterium immunogenum and the Mycobacterium mucogenicum group, based on in vitro clarithromycin susceptibility.

Macrolide resistance has been linked to the presence of a functional erythromycin ribosomal methylase (erm) gene in most species of pathogenic rapidly growing mycobacteria (RGM). For these Mycobacterium isolates, extended incubation in clarithromycin is necessary to determine macrolide susceptibility. In contrast, the absence of a detectable erm gene in isolates of M. chelonae, M. senegalense, and M. peregrinum and a nonfunctional erm gene in M. abscessus subsp. massiliense and 15% to 20% of M. abscessus subsp. abscessus isolates renders these species intrinsically macrolide susceptible. Not all RGM species have been screened for the presence of an erm gene, including the Mycobacterium mucogenicum group (M. mucogenicum, M. phocaicum, and M. aubagnense) and Mycobacterium immunogenum. A total of 356 isolates of these two pathogenic RGM taxa from two reference laboratories (A.R.U.P. Reference Laboratories and the Mycobacteria/Nocardia Laboratory at the University of Texas Health Science Center at Tyler) underwent clarithromycin susceptibility testing with readings at 3 to 5 days and 14 days. Only 13 of the 356 isolates had resistant clarithromycin MICs at initial extended MIC readings, and repeat values on all available isolates were ≤2 µg/ml. These studies suggest that these two additional RGM groups do not harbor functional erm genes and, like M. chelonae, do not require extended clarithromycin susceptibility testing. We propose to the Clinical Laboratory and Standards Institute that isolates belonging to these above-mentioned six rapidly growing mycobacterial groups based on molecular identification with no known functional erm genes undergo only 3 to 5 days of susceptibility testing (to exclude mutational resistance).