Development of a proficiency-based virtual reality simulation training curriculum for laparoscopic appendicectomy

This paper was presented at the 10th Annual Academic Surgical Congress (ASC), 3–5 February 2015 in Las Vegas, NV, USA.Background: Proficiency-based virtual reality (VR) training curricula improve intraoperative performance, but have not been developed for laparoscopic appendicectomy (LA). This study aimed to develop an evidence-based training curriculum for LA. Methods: A total of 10 experienced (>50 LAs), eight intermediate (10–30 LAs) and 20 inexperienced (<10 LAs) operators performed guided and unguided LA tasks on a high-fidelity VR simulator using internationally relevant techniques. The ability to differentiate levels of experience (construct validity) was measured using simulator-derived metrics. Learning curves were analysed. Proficiency benchmarks were defined by the performance of the experienced group. Intermediate and experienced participants completed a questionnaire to evaluate the realism (face validity) and relevance (content validity). Results: Of 18 surgeons, 16 (89%) considered the VR model to be visually realistic and 17 (95%) believed that it was representative of actual practice. All ‘guided’ modules demonstrated construct validity (P < 0.05), with learning curves that plateaued between sessions 6 and 9 (P < 0.01). When comparing inexperienced to intermediates to experienced, the ‘unguided’ LA module demonstrated construct validity for economy of motion (5.00 versus 7.17 versus 7.84, respectively; P < 0.01) and task time (864.5 s versus 477.2 s versus 352.1 s, respectively, P < 0.01). Construct validity was also confirmed for number of movements, path length and idle time. Validated modules were used for curriculum construction, with proficiency benchmarks used as performance goals. Conclusion: A VR LA model was realistic and representative of actual practice and was validated as a training and assessment tool. Consequently, the first evidence-based internationally applicable training curriculum for LA was constructed, which facilitates skill acquisition to proficiency.Pramudith Sirimanna and Marc A. Gladma

Rapid coastal deoxygenation due to ocean circulation shift in the NW Atlantic.

Global observations show that the ocean lost approximately 2% of its oxygen inventory over the last five decades 1-3, with important implications for marine ecosystems 4, 5. The rate of change varies with northwest Atlantic coastal waters showing a long-term drop 6, 7 that vastly outpaces the global and North Atlantic basin mean deoxygenation rates 5, 8. However, past work has been unable to resolve mechanisms of large-scale climate forcing from local processes. Here, we use hydrographic evidence to show a Labrador Current retreat is playing a key role in the deoxygenation on the northwest Atlantic shelf. A high-resolution global coupled climate-biogeochemistry model 9 reproduces the observed decline of saturation oxygen concentrations in the region, driven by a retreat of the equatorward-flowing Labrador Current and an associated shift toward more oxygen-poor subtropical waters on the shelf. The dynamical changes underlying the shift in shelf water properties are correlated with a slowdown in the simulated Atlantic Meridional Overturning Circulation 10. Our results provide strong evidence that a major, centennial-scale change of the Labrador Current is underway, and highlight the potential for ocean dynamics to impact coastal deoxygenation over the coming century

A note on Joseph Black and the smell of "fixed air"

A brief biog. of Joseph Black and his early work on carbon dioxide

Integrative Treatment for Children with Cerebral Palsy

Cerebral palsy is a highly prevent motor disorder that is well studied but not necessarily well understood. Caused through various damaged neural mechanisms, cerebral palsy has wide spread implications on both physiological and psychological health. Through use of both occupational and constraint-induced therapy, improvements in motor movements can be seen but the issue of psychology well being is not addressed. The author argues for the use of longitudinal studies in order to better understand the impact of various therapeutic methods

Prevalence of methicillin-resistant Staphylococcus aureus colonization in HIV-infected patients in Barcelona, Spain: a cross-sectional study

Background: Colonization by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has been found to be markedly more common in HIV-infected individuals in the USA. Studies evaluating the prevalence MRSA colonization in HIV-infected populations in Europe are scarce. The aim of this study was to investigate the prevalence of MRSA colonization in a cohort of HIV-infected patients in Barcelona, Spain. Methods: Nasal and pharyngeal S. aureus carriage was assessed in a random sample of 190 patients from an outpatient HIV clinic. Nasal and pharyngeal swab specimens were obtained for staphylococcal culture from 190 and 110 patients respectively. All MRSA isolates were screened for Panton-Valentine leukocidin (PVL) genes by PCR. Molecular characterization of MRSA isolates was performed by multilocus sequence typing. Data related to HIV infection, healthcare exposure, and previously described risk factors for MRSA were collected from medical records and a questionnaire administered to each patient. Results: The patients' characteristics were as follows: male, 83 %; median (IQR) age, 45 (39-49) years; intravenous drug users, 39 %; men who have sex with men, 32 %; heterosexual, 26 %; CD4 count, 528/μL (IQR 351-740); on antiretroviral therapy, 96 %; and undetectable plasma viral load, 80 %. Sixty-five patients (34 %) were colonized by S. aureus. MRSA colonization was found in 1 % and 2 % of nasal and pharyngeal samples respectively. No PVL positive MRSA strains were detected and all the MRSA isolates belonged to typical hospital-acquired clones. Conclusions: Our data suggest that CA-MRSA colonization is not currently a problem in HIV-infected individuals in our area

The concept of participation in contemporary political interpretations : a critical analysis.

Political ScienceDoctor of Philosophy (PhD

Eddy diffusivities estimated from observations in the Labrador Sea

Eddy diffusivities in the Labrador Sea (LS) are estimated from deep eddy resolving float trajectories, moored current meter records, and satellite altimetry. A mean residence time of 248 days in the central LS is observed with several floats staying for more than 2 years. By applying a simple random walk diffusion model, the observed distribution of float residence times in the central LS could be explained by a mean eddy diffusivity of about 300 m2 s−1. Estimates from float trajectories themselves and from moored current meter records yield significantly higher eddy diffusivities in the central LS of 950–1100 m2 s−1. This discrepancy can be explained by an inhomogeneity of the eddy diffusivity at middepth with high/low values in the central LS/region between central LS and deep Labrador Current, which could be conjectured from the mean altimetric eddy kinetic energy (EKE) distribution. The different diffusivities explain both (1) a fast lateral homogenization of water masses in the central LS and (2) a weak exchange between central LS and boundary current. The mean Lagrangian length scale of 11.5 ± 0.7 km as estimated from deep float trajectories is only slightly larger than the mean Rossby radius of deformation (8.8 km). Largest eddy diffusivities within the central LS are associated with strong eddy drifts, rather than with large swirl velocities and associated large EKE. between central LS and deep Labrador Current, which could be conjectured from the mean altimetric eddy kinetic energy (EKE) distribution. The different diffusivities explain both (1) a fast lateral homogenization of water masses in the central LS and (2) a weak exchange between central LS and boundary current. The mean Lagrangian length scale of 11.5 ± 0.7 km as estimated from deep float trajectories is only slightly larger than the mean Rossby radius of deformation (8.8 km). Largest eddy diffusivities within the central LS are associated with strong eddy drifts, rather than with large swirl velocities and associated large EKE

Week 96 efficacy and safety results of the phase 3, randomized EMERALD trial to evaluate switching from boosted-protease inhibitors plus emtricitabine/tenofovir disoproxil fumarate regimens to the once daily, single-tablet regimen of darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) in treatment-experienced, virologically-suppressed adults living with HIV-1

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg was investigated through 96 weeks in EMERALD (NCT02269917). Virologically-suppressed, HIV-1-positive treatment-experienced adults (previous non-darunavir virologic failure [VF] allowed) were randomized (2:1) to D/C/F/TAF or boosted protease inhibitor (PI) plus emtricitabine/tenofovir-disoproxil-fumarate (F/TDF) over 48 weeks. At week 52 participants in the boosted PI arm were offered switch to D/C/F/TAF (late-switch, 44 weeks D/C/F/TAF exposure). All participants were followed on D/C/F/TAF until week 96. Efficacy endpoints were percentage cumulative protocol-defined virologic rebound (PDVR; confirmed viral load [VL] >= 50 copies/mL) and VL = 50 copies/mL (VF) (FDA-snapshot analysis). Of 1141 randomized patients, 1080 continued in the extension phase. Few patients had PDVR (D/C/F/TAF: 3.1%, 24/763 cumulative through week 96; late-switch: 2.3%, 8/352 week 52-96). Week 96 virologic suppression was 90.7% (692/763) (D/C/F/TAF) and 93.8% (330/352) (late-switch). VF was 1.2% and 1.7%, respectively. No darunavir, primary PI, tenofovir or emtricitabine resistance-associated mutations were observed post-baseline. No patients discontinued for efficacy-related reasons. Few discontinued due to adverse events (2% D/C/F/TAF arm). Improved renal and bone parameters were maintained in the D/C/F/TAF arm and observed in the late-switch arm, with small increases in total cholesterol/high-density-lipoprotein-cholesterol ratio. A study limitation was the lack of a control arm in the week 96 analysis. Through 96 weeks, D/C/F/TAF resulted in low PDVR rates, high virologic suppression rates, very few VFs, and no resistance development. Late-switch results were consistent with D/C/F/TAF week 48 results. EMERALD week 96 results confirm the efficacy, high genetic barrier to resistance and safety benefits of D/C/F/TAF