Lymphocytes of BRCA1 and BRCA2 germ-line mutation carriers, with or without breast cancer, are not abnormally sensitive to the chromosome damaging effect of moderate folate deficiency

Mutations in BRCA1 and BRCA2 genes may cause defective DNA repair and increase risk for breast cancer. Folate deficiency is associated with increased breast cancer risk and induces chromosome abnormalities. We hypothesised that BRCA1 and BRCA2 germ-line mutation carriers are more sensitive to the genome damaging effect of folate deficiency compared to healthy non-carrier controls and that this sensitivity is further increased in those carriers who develop breast cancer. We tested these hypotheses in lymphocytes cultured in medium containing 12 nM or 120 nM folic acid (FA) for 9 days and measured proliferative capacity and chromosomal instability using the cytokinesis-block micronucleus (CBMN) assay. BRCA1 and BRCA2 mutation carriers with or without breast cancer were not abnormally sensitive to FA deficiency-induced chromosome instability however BRCA2 mutation carriers had significantly reduced cell proliferation. FA deficiency reduced cell proliferation and increased micronucleus formation significantly accounting for 45-59% and 70-75% of the variance in these parameters compared to 0.3-8.5% and 0.2-0.3% contributed by BRCA1 or BRCA2 mutation carrier status respectively. The results of this study suggest that moderate folate deficiency has a stronger effect on chromosomal instability than BRCA1 or BRCA2 mutations found in breast cancer families.Sasja Beetstra, Carolyn Salisbury, Julie Turner, Meryl Altree, Ross McKinnon, Graeme Suthers and Michael Fenec

Surgical simulation training: mobile and anywhere

Guilherme N Pena, Meryl Altree, Wendy Babidge and Guy J Madder

Demand for surgical simulated learning. Supervisors and trainees views: do they align?

Guilherme N. Pena, Meryl J. Altree, John B. F. Field, Wendy Babidge, Guy J. Madder

The efficacy of laparoscopic skills training in a Mobile Simulation Unit compared with a fixed site: a comparative study

BACKGROUND Laparoscopic skills development via simulation-based medical education programs has gained support in recent years. However, the impact of training site type on skills acquisition has not been examined. The objective of this research was to determine whether laparoscopic skills training outcomes differ as a result of training in a Mobile Simulation Unit (MSU) compared with fixed simulation laboratories. METHODS An MSU was developed to provide delivery of training. Fixed-site and MSU laparoscopic skills training outcomes data were compared. Fixed-site participants from three Australian states were pooled to create a cohort of 144 participants, which was compared with a cohort derived from pooled MSU participants in one Australian state. Data were sourced from training periods held from October 2009 to December 2010. LapSim and Fundamentals of laparoscopic surgery (FLS) simulators were used at the MSU and fixed sites. Participants self-reported on demographic and experience variables. They trained to a level of competence on one simulator and were assessed on the other simulator, thus producing crossover scores. No participants trained at both site types. RESULTS When FLS-trained participants were assessed on LapSim, those who received MSU training achieved a significantly higher crossover score than their fixed-site counterparts (p < 0.001). Compared with baseline data, MSU LapSim-trained participants assessed on FLS displayed a performance increase of 23.1 %, whereas MSU FLS-trained participants assessed on LapSim demonstrated a 12.4 % increase in performance skills. Participants at fixed sites displayed performance increases of 5.2 and 10.9 %, respectively. CONCLUSIONS Mobile Simulation Unit-delivered laparoscopic simulation training is not inferior to fixed-site training.Vicki Xafis, Wendy Babidge, John Field, Meryl Altree, Nicholas Marlow, Guy Madder

Low-Dose Morphine Does Not Cause Sleepiness in COPD: A Secondary Analysis of a Randomized Trial

RATIONALE: Regular, low-dose, sustained-release morphine is frequently prescribed for persistent breathlessness in chronic obstructive pulmonary disease (COPD). However, effects on daytime sleepiness, perceived sleep quality and daytime function have not been rigorously investigated. OBJECTIVES: Determine the effects of regular, low-dose, sustained-release morphine on sleep parameters in COPD. METHODS: Pre-specified secondary analyses of validated sleep questionnaire data from a randomized trial of daily, low-dose, sustained -release morphine versus placebo over four weeks commencing at 8mg or 16mg/day with blinded up-titration over two weeks to a maximum of 32mg/day. Primary outcomes for these analyses were week-1 Epworth Sleepiness Scale (ESS) and Karolinska Sleepiness Scale (KSS) responses on morphine versus placebo. Secondary outcomes included Leeds Sleep Evaluation Questionnaire (LSEQ) scores (end of weeks 1 and 4), KSS and ESS beyond week-1 and associations between breathlessness, morphine, and questionnaire scores. MEASUREMENTS AND MAIN RESULTS: 156 people were randomized. Week-1 sleepiness scores were not different on morphine versus placebo (∆ESS [95%CI] versus placebo: 8mg group: -0.59 [-1.99, 0.81], p=0.41; 16mg group: -0.72 [-2.33, 0.9], p=0.38; ∆KSS versus placebo: 8mg group: 0.11 [-0.7, 0.9], p=0.78; 16mg group: -0.41 [-1.31, 0.49], p=0.37). This neutral effect persisted at later timepoints. In addition, participants who reported reduced breathlessness with morphine at 4 weeks also had improvement in LSEQ domain scores including perceived sleep quality and daytime function. CONCLUSIONS: Regular, low-dose morphine does not worsen sleepiness when used for breathlessness in COPD. Individual improvements in breathlessness with morphine may be related to improvements in sleep.Thomas J. Altree, Barbara Toson, Kelly A. Loffler, Magnus Ekström, David C. Currow, and Danny J. Ecker

Mobile simulation unit: taking simulation to the surgical trainee

Background: Simulation-based training has become an increasingly accepted part of surgical training. However, simulators are still not widely available to surgical trainees. Some factors that hinder the widespread implementation of simulation-based training are the lack of standardized methods and equipment, costs and time constraints. We have developed a Mobile Simulation Unit (MSU) that enables trainees to access modern simulation equipment tailored to the needs of the learner at the trainee’s workplace. Methods: From July 2012 to December 2012, the MSU visited six hospitals in South Australia, four in metropolitan and two in rural areas. Resident Medical Officers, surgical trainees, Fellows and International Medical Graduates were invited to voluntarily utilize a variety of surgical simulators on offer. Participants were asked to complete a survey about the accessibility of simulation equipment at their workplace, environment of the MSU, equipment available and instruction received. Utilization data were collected. Results: The MSU was available for a total of 303 h over 52 days. Fifty-five participants were enrolled in the project and each spent on average 118 min utilizing the simulators. The utilization of the total available time was 36%. Participants reported having a poor access to simulation at their workplace and overwhelmingly gave positive feedback regarding their experience in the MSU. Conclusion: The use of the MSU to provide simulation-based education in surgery is feasible and practical. The MSU provides consistent simulation training at the surgical trainee’s workplace, regardless of geographic location, and it has the potential to increase participation in simulation programmes.Guilherme Pena, Meryl Altree, Wendy Babidge, John Field, Peter Hewett, and Guy Madder

Laparoscopic skills acquisition: a study of simulation and traditional training

Background: Training in basic laparoscopic skills can be undertaken using traditional methods, where trainees are educated by experienced surgeons through a process of graduated responsibility or by simulation-based training. This study aimed to assess whether simulation trained individuals reach the same level of proficiency in basic laparoscopic skills as traditional trained participants when assessed in a simulated environment. Methods: A prospective study was undertaken. Participants were allocated to one of two cohorts according to surgical experience. Participants from the inexperienced cohort were randomized to receive training in basic laparoscopic skills on either a box trainer or a virtual reality simulator. They were then assessed on the simulator on which they did not receive training. Participants from the experienced cohort, considered to have received traditional training in basic laparoscopic skills, did not receive simulation training and were randomized to either the box trainer or virtual reality simulator for skills assessment. The assessment scores from different cohorts on either simulator were then compared. Results: A total of 138 participants completed the assessment session, 101 in the inexperienced simulation-trained cohort and 37 on the experienced traditionally trained cohort. There was no statistically significant difference between the training outcomes of simulation and traditionally trained participants, irrespective of the simulator type used. Conclusions: The results demonstrated that participants trained on either a box trainer or virtual reality simulator achieved a level of basic laparoscopic skills assessed in a simulated environment that was not significantly different from participants who had been traditionally trained in basic laparoscopic skills.N. Marlow, M. Altree, W. Babidge, J. Field, P. Hewett and G.J. Madder

Surgeons' and trainees' perceived self-efficacy in operating theatre non-technical skills

Background: An important factor that may influence an individual’s performance is self-efficacy, a personal judgement of capability to perform a particular task successfully. This prospective study explored newly qualified surgeons’ and surgical trainees’ self-efficacy in non-technical skills compared with their non-technical skills performance in simulated scenarios. Methods: Participants undertook surgical scenarios challenging non-technical skills in two simulation sessions 6 weeks apart. Some participants attended a non-technical skills workshop between sessions. Participants completed pretraining and post-training surveys about their perceived self-efficacy in non-technical skills, which were analysed and compared with their performance in surgical scenarios in two simulation sessions. Change in performance between sessions was compared with any change in participants’ perceived self-efficacy. Results: There were 40 participants in all, 17 of whom attended the non-technical skills workshop. There was no significant difference in participants’ self-efficacy regarding non-technical skills from the pretraining to the post-training survey. However, there was a tendency for participants with the highest reported self-efficacy to adjust their score downwards after training and for participants with the lowest self-efficacy to adjust their score upwards. Although there was significant improvement in non-technical skills performance from the first to second simulation sessions, a correlation between participants’ self-efficacy and performance in scenarios in any of the comparisons was not found. Conclusion: The results suggest that new surgeons and surgical trainees have poor insight into their non-technical skills. Although it was not possible to correlate participants’ self-belief in their abilities directly with their performance in a simulation, in general they became more critical in appraisal of their abilities as a result of the intervention.G. Pena, M. Altree, J.Field, M.J.W.Thomas, P.Hewett, W. Babidge, and G. J. Madder

Effect of fatigue on laparoscopic skills: a comparative historical cohort study

Background: Fatigue has been shown to have a negative impact on surgical performance. However, there is a lack of research investigating its effect on laparoscopy, particularly in Australia. This study investigated whether fatigue associated with a surgeon’s usual workday led to a measurable drop off in laparoscopic surgical skills as assessed on a laparoscopic simulator. Methods: A comparative study involving two cohorts was undertaken: a study group whose data were collected prospectively was compared to a historical control group. Participants were required to reach a predetermined level of proficiency in each laparoscopic task on either a FLS or LapSim simulator. The participants in the study cohort were re-tested approximately 1 month after completing 10 h of work. The participants in the historical non-fatigued group were re-tested approximately 1 month after reaching proficiency. Comparisons between cohorts were made using a ‘decrease in score per day elapsed’ value to account for the natural attrition in skills over time and the variability in testing times within and between the two cohorts. Results: The decrease in overall score per day elapsed for fatigued participants was significantly greater than for historical non-fatigued participants, irrespective of the simulator type. Fatigue had a greater impact on certain laparoscopic skills, including peg transfer and knot tying. Participants who self-reported higher level of fatigue demonstrated significantly better skills than those who self-reported lower levels. Conclusion: Overall laparoscopic skill proficiency was reduced in the fatigued participants compared to the historical non-fatigued participants, with certain laparoscopic skills more affected than others.J. Daruwalla, N. Marlow, J. Field, M. Altree, W. Babidge, P. Hewett and G.J. Madder