Sleep deprivation among surgical residents: Does it affect performance while practising a laparoscopic intestinal anastomosis?

INTRODUCTION: To assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis. METHODS: A prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the FATIGUE group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the REST group(R), being those who slept at home for more than 7 h. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches. RESULTS: 402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33.5% anastomoses, as opposed to 19.4% in the rest group (P < .01). El rest group performed the anastomosis in 56.75 min and the fatigue group in 61,49 min (P = .006). There were no significant differences in the others parameters. CONCLUSIONS: Fatigue increases the risk of leakage and the time to do the exercise.

Fatiga por deprivación de sueño en residentes de cirugía: ¿Afecta a los resultados al realizar una anastomosis laparoscópica intestinal? / Sleep deprivation among surgical residents: does it affect performance while practising a laparoscopic intestinal anastomosis?

IntroducciónEvaluar el impacto de la fatiga por incorrecto descanso nocturno en la realización de una anastomosis manual laparoscópica.MétodosSe lleva a cabo un estudio prospectivo observacional evaluando la realización de una anastomosis manual enteroenteral en endotrainer por residentes. Se dividen en dos grupos; el grupo descanso incluye a residentes que han dormido en casa siete o más horas vs. al grupo fatiga formado por residentes de guardia o que han dormido menos de siete horas. Se evalúa el tiempo empleado, la longitud de la anastomosis, la correcta tensión de la línea de sutura, la correcta aposición de los bordes, la distancia entre puntos y la fuga de aire, en prueba neumática de estanqueidad.ResultadosSe evalúan 402 anastomosis, siendo 211 pertenecientes al grupo descanso y 191 al grupo fatiga. Se detecta fuga en el 33,5% de las anastomosis del grupo fatiga frente al 19,4% en el grupo descanso (p < 0,01). El tiempo empleado en el grupo descanso es de 56,75 vs. 61,49 min en el grupo fatiga (p = 0,006). No hay diferencias en el resto de los parámetros.DiscusiónLa fatiga aumenta el riesgo de fuga y el tiempo que se tarda en completar el ejercicio (AU)

IntroductionTo assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis.MethodsA prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the fatigue group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the rest group (R), being those who slept at home for more than 7 hours. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches.Results402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33,5% anastomoses, as opposed to 19,4% in the rest group (p < 0.01). El rest group performed the anastomosis in 56,75 min and the fatigue group in 61,49 min (p = 0.006). There were no significant differences in the others parameters (AU)

Análisis de los estilos de aprendizaje en un curso de habilidades técnicas laparoscópicas. Implicaciones para el entrenamiento quirúrgico / Analysis of learning styles in a laparoscopic technical skills course. Implications for surgical training

Introducción: El aprendizaje de las técnicas quirúrgicas es un proceso dinámico. David Kolb describió en los años ochenta un modelo de aprendizaje que permite adaptar el tipo de enseñanza y mejorar los resultados de esta. El objetivo del estudio es identificar los estilos de aprendizaje según Kolb de los participantes en un curso de habilidades técnicas laparoscópicas y comprobar si existe relación con el rendimiento final de la tarea realizada. Métodos: Estudio observacional descriptivo que incluye 64 participantes que completaron un curso intensivo donde realizaron anastomosis intestinales manuales laparoscópicas. Todos ellos completaron el inventario de estilos de aprendizaje de Kolb. En cada anastomosis se recogió el tiempo de ejecución y se valoró su calidad. Posteriormente, los datos fueron analizados estadísticamente. Resultados: El estilo de aprendizaje más frecuente fue el asimilador (39,1%). No se observan diferencias significativas entre los estilos y el sexo de los participantes, su categoría profesional, el tiempo en realizar la anastomosis o su calidad. Conclusiones: El estilo de aprendizaje predominante es el asimilador, sin diferencias entre categorías, edad o sexo. No existe relación entre el estilo de aprendizaje de los participantes y los resultados obtenidos en el curso. (AU)

Introduction: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. Methods: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. Results: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. Conclusions: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course. (AU)

Analysis of learning styles in a laparoscopic technical skills course. Implications for surgical training.

INTRODUCTION: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. METHODS: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. RESULTS: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. CONCLUSIONS: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course.

Corneal endothelial cell loss after trabeculectomy and phacoemulsification in one or two steps: a prospective study.

OBJECTIVE: The objective of this study was to analyse the results of the surgical treatment of coexisting cataract and glaucoma and its effects on corneal endothelial cell density (CECD). METHODS: We include two longitudinal prospective studies: one randomised that included 40 eyes with open angle glaucoma that received one- (n = 20) or two-step (n = 20) phacotrabeculectomy and another that included 20 eyes that received phacoemulsification. We assess the impact of surgery on different clinical variables and in particular in CECD using Confoscan 4™ confocal microscopy and semiautomatic counting methods. RESULTS: Phacoemulsification and phacotrabeculectomy, but not trabeculectomy, increase significantly best-corrected visual acuity and anterior chamber depth and trabeculectomy and one- or two-step phacotrabeculectomy decreased similarly the intraocular pressure. We document percentages of endothelial cell loss of 3.1%, 17.9%, 31.6% and 42.6% after trabeculectomy, phacoemulsification and one- or two-step phacotrabeculectomy, respectively. The coefficient of variation did not increase significantly after surgery but the percentage of hexagonality decreased significantly after phacoemulsification and after two-step phacotrabeculectomy. CONCLUSIONS: Trabeculectomy, phacoemulsification and phacotrabeculectomy are surgical techniques that cause morphological changes and decrease the densities of the corneal endothelial cells. Trabeculectomy produces lesser endothelial cell loss than phacoemulsification, and phacoemulsification lesser cell loss than phacotrabeculectomy. Two-step phacotrabeculectomy (trabeculectomy followed 3 months later by phacoemulsification) causes more cell loss than one-step phacotrabeculectomy, and this could be due to the cumulative effects of two separate surgical traumas or to a negative conditioning lesion effect of the first surgery. For the treatment of coexisting glaucoma and cataract, one-step phacotrabeculectomy is the treatment of choice.

Sleep deprivation among surgical residents: does it affect performance while practising a laparoscopic intestinal anastomosis? / Fatiga por deprivación de sueño en residentes de cirugía: ¿Afecta a los resultados al realizar una anastomosis laparoscópica intestinal?

INTRODUCTION: To assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis. METHODS: A prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the fatigue group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the rest group (R), being those who slept at home for more than 7 hours. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches. RESULTS: 402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33,5% anastomoses, as opposed to 19,4% in the rest group (p < 0.01). El rest group performed the anastomosis in 56,75 min and the fatigue group in 61,49 min (p = 0.006). There were no significant differences in the others parameters. CONCLUSIONS: Fatigue increases the risk of leakage and the time to do the exercise.

Analysis of learning styles in a laparoscopic technical skills course. Implications for surgical training. / Análisis de los estilos de aprendizaje en un curso de habilidades técnicas laparoscópicas. Implicaciones para el entrenamiento quirúrgico.

INTRODUCTION: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. METHODS: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. RESULTS: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. CONCLUSIONS: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course.

Influencia de la experiencia previa en los beneficios del entrenamiento quirúrgico laparoscópico basado en la simulación / Influence of previous experience on the benefits of laparoscopic surgical training based on simulation

Introducción: El entrenamiento quirúrgico basado en simulación busca la adquisición de habilidades en los participantes noveles y la capacitación en los expertos. El objetivo de este estudio es valorar la evolución de los alumnos en un curso intensivo de anastomosis laparoscópica y el análisis de sus resultados dependiendo de su nivel y experiencia previa. Métodos: Se analizaron los alumnos de todos los cursos de anastomosis realizados durante 30 meses en el Hospital virtual Valdecilla (Santander). Se realizaron anastomosis intestinales latero-laterales manuales con vísceras «ex vivo» porcinas en un endotrainer laparoscópico. Se analizaron las diferencias técnicas y de calidad entre la primera y la última anastomosis y se comparó la progresión entre residentes y los facultativos especialistas. Resultados: Se analizaron 45 participantes, 22 de ellos residentes y 23 especialistas. Se observó una mejoría estadísticamente significativa del 80,5% en todos los parámetros procedimentales (94,8% residentes vs. 67,3% especialistas). El tiempo se redujo un 48,1% en los residentes y un 43,2% en los especialistas (p < 0,001). En cuanto a calidad, se obtuvieron mejorías significativas en el grupo de residentes: incremento del 90% de tensión adecuada, reducción del 75% de bordes evertidos y 60% de las fugas. Además, obtuvieron resultados comparables a los especialistas (27,3% fuga en última anastomosis vs. 34,8% especialistas, p = 0,59), los cuales presentaron mejoría sin significación estadística. Conclusiones: El grupo de residentes presenta una mejora mayor y significativa en habilidades procedimentales y en calidad de la técnica, alcanzando el nivel de los especialistas tras completar el curso

Introduction: Surgical training based on simulation seeks the acquisition of skills in novice participants and ongoing sill development in experts. The aim of this study is to assess the evolution of students in an intensive laparoscopic anastomosis course and to analyse their results depending on their level and previous experience. Methods: The students of all the anastomosis courses conducted during 30 months in the Valdecilla virtual hospital (Santander) were analysed. Manual side-to-side intestinal anastomoses with porcine ‘ex vivo’ viscera were performed in a laparoscopic endotrainer. The technical and quality differences between the first and the last anastomoses were analyzed and the progression between residents and specialists was compared. Results: We analyzed 45 participants, 22 of them residents and 23 specialists. A statistically significant improvement of 80.5% was observed in all procedural parameters (94.8% residents vs. 67.3% specialists). The time was reduced by 48.1% in the residents and 43.2% in the specialists (p < .001). In terms of quality, significant improvements were obtained in the group of residents: an increase of 90% in adequate tension, and a reduction of 75% of everted edges and 60% of leaks. In addition, they obtained results comparable to the specialists (27.3% leak in the last anastomosis vs. 34.8% by the specialists, p = .59), which presented improvement without statistical significance. Conclusions: The group of residents presented a major and significant improvement in procedural skills and in the quality of the technique, reaching the level of the specialists after completion of the course

Optimisation of a key cross-coupling reaction towards the synthesis of a promising antileishmanial compound.

During the course of a research program aimed at identifying novel antileishmanial compounds, a multi-gram synthesis of N-(trans-4-((4-methoxy-3-((R)-3-methylmorpholino)-1H-pyrazolo[3,4-d]pyrimidin-6-yl)amino)cyclohexyl)-2-methylpropane-1-sulfonamide (( R )-1) was required. This letter describes optimisation of the reaction conditions and protecting group strategy for a key Buchwald-Hartwig coupling, delivering the required quantities of ( R )-1, as well as further compounds in the series.

Influence of previous experience on the benefits of laparoscopic surgical training based on simulation. / Influencia de la experiencia previa en los beneficios del entrenamiento quirúrgico laparoscópico basado en la simulación.

INTRODUCTION: Surgical training based on simulation seeks the acquisition of skills in novice participants and ongoing sill development in experts. The aim of this study is to assess the evolution of students in an intensive laparoscopic anastomosis course and to analyse their results depending on their level and previous experience. METHODS: The students of all the anastomosis courses conducted during 30 months in the Valdecilla virtual hospital (Santander) were analysed. Manual side-to-side intestinal anastomoses with porcine 'ex vivo' viscera were performed in a laparoscopic endotrainer. The technical and quality differences between the first and the last anastomoses were analyzed and the progression between residents and specialists was compared. RESULTS: We analyzed 45 participants, 22 of them residents and 23 specialists. A statistically significant improvement of 80.5% was observed in all procedural parameters (94.8% residents vs. 67.3% specialists). The time was reduced by 48.1% in the residents and 43.2% in the specialists (p<.001). In terms of quality, significant improvements were obtained in the group of residents: an increase of 90% in adequate tension, and a reduction of 75% of everted edges and 60% of leaks. In addition, they obtained results comparable to the specialists (27.3% leak in the last anastomosis vs. 34.8% by the specialists, p=.59), which presented improvement without statistical significance. CONCLUSIONS: The group of residents presented a major and significant improvement in procedural skills and in the quality of the technique, reaching the level of the specialists after completion of the course.

Assessment of genetically modified soybean MON 87708 × MON 89788 × A5547-127, for food and feed uses, under Regulation (EC) No 1829/2003 (application EFSA-GMO-NL-2016-135).

Soybean MON 87708 × MON 89788 × A5547-127 (three-event stack soybean) was produced by conventional crossing to combine three single events: MON 87708, MON 89788 and A5547-127. The GMO Panel previously assessed the three single events and did not identify safety concerns. No new data on the single events, leading to modification of the original conclusions on their safety have been identified. The molecular characterisation, comparative analysis (agronomic, phenotypic and compositional characteristics) and the outcome of the toxicological, allergenicity and nutritional assessment indicate that the combination of the single soybean events and of the newly expressed proteins in the three-event stack soybean does not give rise to food and feed safety and nutritional concerns. The GMO Panel concludes that the three-event stack soybean, as described in this application, is as safe as and nutritionally equivalent to its conventional counterpart and the non-GM reference varieties tested. The nutritional impact of food/feed derived from the three-event stack soybean is expected to be the same as that of food/feed derived from the conventional counterpart and non-GM reference varieties. In the case of accidental release of viable seeds of the three-event stack soybean into the environment, this would not raise environmental safety concerns. The post-market environmental monitoring plan and reporting intervals are in line with the intended uses of the three-event stack soybean. Post-market monitoring of food/feed is not considered necessary. The GMO Panel concludes that the three-event stack soybean is as safe as its conventional counterpart and the tested non-GM reference varieties with respect to potential effects on human and animal health and the environment.

Identification of GSK3186899/DDD853651 as a Preclinical Development Candidate for the Treatment of Visceral Leishmaniasis.

The leishmaniases are diseases that affect millions of people across the world, in particular visceral leishmaniasis (VL) which is fatal unless treated. Current standard of care for VL suffers from multiple issues and there is a limited pipeline of new candidate drugs. As such, there is a clear unmet medical need to identify new treatments. This paper describes the optimization of a phenotypic hit against Leishmania donovani, the major causative organism of VL. The key challenges were to balance solubility and metabolic stability while maintaining potency. Herein, strategies to address these shortcomings and enhance efficacy are discussed, culminating in the discovery of preclinical development candidate GSK3186899/DDD853651 (1) for VL.

La simulación como modelo de enseñanza en cirugía / Simulation as a surgical teaching model

La enseñanza de la cirugía se ha visto afectada por múltiples factores a lo largo de estos últimos años, como son la reducción de la jornada laboral, la optimización del uso del quirófano o la seguridad del paciente. La metodología de enseñanza tradicional no logra minimizar el impacto de estos factores en la formación de los cirujanos. La simulación como modelo de enseñanza minimiza dicho impacto y es más eficaz que los métodos docentes tradicionales para integrar los conocimientos y las habilidades clínico-quirúrgicas complejas. La simulación complementa la asistencia clínica al paciente con la formación, creando un entorno de aprendizaje seguro en el que no se ve afectada la seguridad del paciente ni se generan conflictos éticos ni legales. Las metodologías de aprendizaje que utilizan la simulación permiten individualizar la enseñanza adaptándola a las necesidades de aprendizaje de cada alumno. Además, permiten entrenar todo tipo de habilidades técnicas, cognitivas o de comportamiento (AU)

Teaching of surgery has been affected by many factors over the last years, such as the reduction of working hours, the optimization of the use of the operating room or patient safety. Traditional teaching methodology fails to reduce the impact of these factors on surgeons training. Simulation as a teaching model minimizes such impact, and is more effective than traditional teaching methods for integrating knowledge and clinical-surgical skills. Simulation complements clinical assistance with training, creating a safe learning environment where patient safety is not affected, and ethical or legal conflicts are avoided. Simulation uses learning methodologies that allow teaching individualization, adapting it to the learning needs of each student. It also allows training of all kinds of technical, cognitive or behavioural skills (AU)

Assessment of genetically modified maize 1507 × NK603 for renewal of authorisation under Regulation (EC) No 1829/2003 (application EFSA-GMO-RX-008).

Following the submission of application EFSA-GMO-RX-008 under Regulation (EC) No 1829/2003 from Pioneer Hi-Bred International, Inc. and Dow AgroSciences LLC, the Panel on Genetically Modified Organisms of the European Food Safety Authority was asked to deliver a scientific risk assessment on the data submitted in the context of the renewal of authorisation application for the insect-resistant, herbicide-tolerant genetically modified maize 1507 × NK603, for food and feed uses, import and processing, excluding cultivation within the EU. The data received in the context of this renewal application contained a systematic search and evaluation of literature, updated bioinformatic analyses and additional documents or studies performed by or on behalf of the applicant. The GMO Panel assessed these data for possible new hazards, modified exposure or new scientific uncertainties identified during the authorisation period and not previously assessed in the context of the original application. In conclusion, under the assumption that the DNA sequence of the events in maize 1507 × NK603 considered for renewal are identical to the newly reported 1507 sequence and the NK603 sequence of the originally assessed two-event stack maize, the GMO Panel concludes that there is no evidence in the renewal application EFSA-GMO-RX-008 for new hazards, modified exposure or scientific uncertainties that would change the conclusions of the original risk assessment on maize 1507 × NK603 (EFSA, 2006).

Simulation as a surgical teaching model. / La simulación como modelo de enseñanza en cirugía.

Teaching of surgery has been affected by many factors over the last years, such as the reduction of working hours, the optimization of the use of the operating room or patient safety. Traditional teaching methodology fails to reduce the impact of these factors on surgeons training. Simulation as a teaching model minimizes such impact, and is more effective than traditional teaching methods for integrating knowledge and clinical-surgical skills. Simulation complements clinical assistance with training, creating a safe learning environment where patient safety is not affected, and ethical or legal conflicts are avoided. Simulation uses learning methodologies that allow teaching individualization, adapting it to the learning needs of each student. It also allows training of all kinds of technical, cognitive or behavioural skills.

Hipertensión intracraneal idiopática y fístula espontánea de líquido cefalorraquídeo. Utilidad de la monitorización de la presión intracraneal / Idiopathic intracranial hypertension and spontaneous cerebrospinal fluid fistula. Usefulness of intracranial pressure monitoring

Las fístulas espontáneas de líquido cefalorraquídeo (LCR) constituyen una entidad clínica relativamente frecuente en la práctica neuroquirúrgica. El tratamiento quirúrgico va encaminado al cierre del defecto y el porcentaje de recurrencias no es bajo. La asociación de fístula espontánea de LCR e hipertensión intracraneal idiopática (HII) es frecuente y posiblemente sea la causa de esta baja tasa de éxito. La semiología clínica de la HII asociada a la fístula espontánea de LCR no es típica, lo que hace que su diagnóstico pase a menudo desapercibido. La monitorización continua de la presión intracraneal permite diagnosticar situaciones de hipertensión intracraneal crónica en estos pacientes, por lo que su utilización es de extraordinaria utilidad a la hora de plantear alternativas terapéuticas

Spontaneous cerebrospinal fluid (CSF) fistulas are rather common in daily practice. The aim of the surgical treatment is closure of the leak, but recurrences are quite frequent. The association between spontaneous CSF fistulas and idiopathic intracranial hypertension (IIH) is not uncommon, and this is probably the cause of the low rate of success of the surgical treatment. Symptoms of IIH associated with spontaneous CSF fistula are atypical, and diagnosis is often missed. Continuous intracranial pressure monitoring is very useful in the diagnosis of chronic IIH and in patients with spontaneous CSF fistula, as it helps in making decisions on the treatment of these patients

[Idiopathic intracranial hypertension and spontaneous cerebrospinal fluid fistula. Usefulness of intracranial pressure monitoring]. / Hipertensión intracraneal idiopática y fístula espontánea de líquido cefalorraquídeo. Utilidad de la monitorización de la presión intracraneal.

Spontaneous cerebrospinal fluid (CSF) fistulas are rather common in daily practice. The aim of the surgical treatment is closure of the leak, but recurrences are quite frequent. The association between spontaneous CSF fistulas and idiopathic intracranial hypertension (IIH) is not uncommon, and this is probably the cause of the low rate of success of the surgical treatment. Symptoms of IIH associated with spontaneous CSF fistula are atypical, and diagnosis is often missed. Continuous intracranial pressure monitoring is very useful in the diagnosis of chronic IIH and in patients with spontaneous CSF fistula, as it helps in making decisions on the treatment of these patients.

Learning curve patterns generated by a training method for laparoscopic small bowel anastomosis.

BACKGROUND: The identification of developmental curve patterns generated by a simulation-based educational method and the variables that can accelerate the learning process will result in cost-effective training. This study describes the learning curves of a simulation-based instructional design (ID) that uses ex vivo animal models to teach laparoscopic latero-lateral small bowel anastomosis. METHODS: Twenty general surgery residents were evaluated on their performance of laparoscopic latero-lateral jejuno-jejunal anastomoses (JJA) and gastro-jejunal anastomoses (GJA), using swine small bowel and stomach on an endotrainer. The ID included the following steps: (1) provision of references and videos demonstrating the surgical technique, (2) creation of an engaging context for learning, (3) critical review of the literature and video on the procedures, (4) demonstration of the critical steps, (5) hands-on practice, (6) in-action instructor's feedback, (7) quality assessment, (8) debriefing at the end of the session, and (9) deliberate and repetitive practice. Time was recorded from the beginning to the completion of the procedure, along with the presence or absence of anastomotic leaks. RESULTS: The participants needed to perform 23.8 ± 6.96 GJA (12-35) and 24.2 ± 6.96 JJA (9-43) to attain proficiency. The starting point of the learning curve was higher for the GJA than for the JJA, although the slope and plateau were parallel. Further, four types of learning curves were identified: (1) exponential, (2) rapid, (3) slow, and (4) no tendency. The type of pattern could be predicted after procedure number 8. CONCLUSIONS: These findings may help to identify the learning curve of a trainee early in the developmental process, estimate the number of sessions required to reach a performance goal, determine a trainee's readiness to practice the procedure on patients, and identify the subjects who lack the innate technical abilities. It may help motivated individuals to become reflective and self-regulated learners. Moreover, the standardization of the ID may help to measure the effectiveness of learning strategies and make comparisons with other educational strategies.

Corneal endothelial cell loss after trabeculectomy or after phacoemulsification, IOL implantation and trabeculectomy in 1 or 2 steps.

BACKGROUND: To assess endothelial cell damage after glaucoma surgery and combined glaucoma and cataract surgery in one or two steps using confocal biomicroscopy. METHODS: This is an observational retrospective study. Eighty eyes from 62 patients between 60 and 83 years of age were studied. Eyes fell into a control group (n = 21) and three experimental groups, in which trabeculectomy (group 1; n = 21) or trabeculectomy and phacoemulsification and intraocular lens implantation had been performed, in one (group 2; n = 21) or two (group 3; n = 17) steps between 6 months and 5 years before. RESULTS: In the control group, mean corneal endothelial cell density (+/-SD) was 2,619 +/- 319 cells/mm(2), whereas in the experimental groups 1, 2 and 3 it was 2,447 +/- 425, 1,968 +/- 342 and 1,551 +/- 323 cells/mm(2) respectively. Cell densities found in the combined surgery groups were significantly smaller than the densities of the control or trabeculectomy groups. The variation coefficient of the endothelial cell area (+/-SD) was 41.19 +/- 7.46% in the control group and 38.9 +/- 6.02, 42.37 +/- 9.53 and 45.71 +/- 11.96% in groups 1, 2 and 3 respectively, differences that were not statistically significant. The percentage of hexagonality (+/-SD) was 51.10 +/- 8.41% in the control group and 51.4 +/- 6.88, 45.13 +/- 8.40 and 42.37 +/- 9.53% in the experimental groups 1, 2 and 3 respectively, but again there were no significant differences between them. CONCLUSIONS: Combined trabeculectomy, phacoemulsification and intraocular lens implantation causes more endothelial cell damage than trabeculectomy alone, and the two-step combined procedure causes more damage to the endothelium than the one-step combined procedure.