Jennie Mickelson

Transverse abdominis plane block: a new approach to the management of secondary hyperalgesia following major abdominal surgery

SIR—I was interested in the paper by Ngwenyama et al. (1) which demonstrated and discussed a 30–40% propofolsparing effect of a concurrent dexmedetomidine infusion in children undergoing spinal surgery. The paper also discussed the problems of propofol infusion syndrome and it is extremely important that users of total intravenous anesthesia techniques are aware of this syndrome and take measures to limit the dose of propofol emulsion infused in pediatric patients undergoing anesthesia. I think, however, it is useful to think of this in terms of lipid load and this did not really come across in this paper. The authors do not tell us which formulation of propofol they used and whether this was a 1% (10 mgÆml propofol) solution or a 2% (20 mgÆml propofol) solution. A simple method of reducing the lipid load is to use 2% propofol emulsion formulations in pediatric patients. This immediately results in a halving of the lipid load. The main disadvantage of this formulation is more frequent and severe injection pain. In the UK and parts of Europe we now have available open targetcontrolled infusion devices which contain validated pediatric pharmacokinetic models for 2% propofol solutions which can be used in children from age 1 year. Injection pain can be ameliorated by use of a larger vein, preinjection of lignocaine and preinjection of a short or ultrashort-acting opioid.

L Stent for Stomal Stenosis in Catheterizable Channels

PURPOSE Stomal stenosis in patients with catheterizable channels can be a difficult problem that is managed by surgical revision or dilation. The L stent is a short, knotted catheter that lies flush with skin. The stent is used for any stomal narrowing, typically overnight for several days. The stent bridges the area of stenosis without passing into bowel or bladder lumen. We assessed whether the L stent is effective for preventing and managing stomal stenosis. MATERIALS AND METHODS We retrospectively reviewed the records of patients with catheterizable channels. A telephone survey and chart review were done to identify patients who required an L stent and those with stomal stenosis. Patient satisfaction was evaluated with Likert scale questions. RESULTS We identified 50 patients with a total of 66 catheterizable urinary and enteric channels. Eight patients with a total of 11 (17%) affected stomas had stomal stenosis. Seven of 8 patients used the L stent for management and 100% reported improvement in stenosis. Six of 7 patients used the stent or catheterization with topical betamethasone cream. Four of 7 patients used the L stent greater than 6 months postoperatively and 3 reported that stenosis occurred immediately postoperatively. All patients who used the L stent reported intermittent self-directed stent use as a prophylactic measure to prevent recurrence. CONCLUSIONS Conservative management for stomal stenosis with an L stent is a simple, effective and well tolerated technique. This patient centered management significantly decreases the risk of surgical revision.

Computer Enhanced Visual Learning Method to Train Urology Residents in Pediatric Orchiopexy Provided a Consistent Learning Experience in a Multi-Institutional Trial

PURPOSE Computer enhanced visual learning is a new method to train residents to perform surgery using components and provide them with access to a personalized surgical feedback archive using the Internet. At the parent institution in Chicago we have already noted that this method is effective to train residents to perform orchiopexy. To assess whether this new methodology to enhance resident surgical instruction is generalizable we performed a prospective, multi-institutional clinical trial. MATERIALS AND METHODS We prospectively compared ratings of resident skills in performing pediatric orchiopexy at 4 institutions as novices to computer enhanced visual learning curriculum (study group) vs those at the single institution accustomed to that curriculum (control group). All urology residents and attending physicians accessed the computer enhanced visual learning curriculum. After each case was completed the attending urologist rated resident performance of each step and provided feedback on weaknesses for the resident to remediate at the next case. The learning score was calculated for each case as the sum of the ratings × case difficulty. Scores on the first case and the best case were compared between the study and control groups by resident and institution. RESULTS The study group included 6 attending physicians and 36 residents (99 orchiopexies). The control group included 8 attending physicians and 21 residents (108 orchiopexies). Between the study and control groups we noted no significant differences in average resident postgraduate year (2.9 vs 2.7), number of procedures per resident (3.9 vs 4.9), frequency with which residents viewed computer enhanced visual learning preoperatively (63% vs 74%) or attending physician provision of feedback (63% vs 88%) (each p not significant). Similarly of residents who completed more than 1 surgery there was no significant difference in the percent who showed an improved learning score in the study vs the control group (86% vs 79%) or in the magnitude of average improvement (10.5 vs 13.4) (each p not significant). CONCLUSIONS The institutional groups did not differ in training resident skills using computer enhanced visual learning for pediatric orchiopexy. Thus, the program provides a consistent learning experience and is generalizable across institutions. We believe that this tool will change the practice of how training programs educate residents by enhancing learning by a checklist approach and a computer platform to archive feedback and remediation.

Computer-enhanced visual learning method: a paradigm to teach and document surgical skills.

INNOVATION Changes in health care are stimulating residency training programs to develop new methods for teaching surgical skills. We developed Computer-Enhanced Visual Learning (CEVL) as an innovative Internet-based learning and assessment tool. The CEVL method uses the educational procedures of deliberate practice and performance to teach and learn surgery in a stylized manner. AIM OF INNOVATION CEVL is a learning and assessment tool that can provide students and educators with quantitative feedback on learning a specific surgical procedure. Methods involved examine quantitative data of improvement in surgical skills. Herein, we qualitatively describe the method and show how program directors (PDs) may implement this technique in their residencies. RESULTS CEVL allows an operation to be broken down into teachable components. The process relies on feedback and remediation to improve performance, with a focus on learning that is applicable to the next case being performed. CEVL has been shown to be effective for teaching pediatric orchiopexy and is being adapted to additional adult and pediatric procedures and to office examination skills. The CEVL method is available to other residency training programs.

Fetal Pyelectasis as Predictor of Decreased Differential Renal Function

PURPOSE A decreased percent of differential function is a common indication for infant pyeloplasty but there is no recognized fetal ultrasound parameter to predict this deficit. We determined whether there is a correlation between fetal pyelectasis and the newborn percent differential function that may enhance prenatal counseling and guide postnatal evaluation. MATERIALS AND METHODS Our database was queried for fetal and newborn measures with fetal pyelectasis on ultrasound and the percent of differential function on renal scintigraphy. Fetal pyelectasis data were stratified by estimated gestational age and the percent of differential function. The affected cohort was defined as having 35% or less differential function and the unaffected cohort was defined as having greater than 35%. The Wilcoxon 2-sample test was used for statistical analysis with logistic regression to generate estimated probability models of a decreased percent of differential function vs mm fetal pyelectasis. RESULTS A total of 831 cases had fetal and newborn ultrasound data available with a total of 229 renal scans identified. Of the 229 cases 36 (16%) had 35% or less differential function on scintigraphy. At estimated gestational age 33 weeks or less the affected cohort had 8 mm greater pyelectasis than the unaffected cohort (OR 1.2, p <0.0001). At estimated gestational age greater than 33 weeks the affected cohort had 4 mm greater pyelectasis than the unaffected cohort (OR 1.07, p <0.07). Subgroup analysis before 33 weeks of estimated gestational age showed similar significance (OR >1, p <or=0.001). CONCLUSIONS Approximately 16% of all fetuses with pyelectasis have 35% or less differential function as newborns, including 36% identified by pyelectasis greater than 10 mm at estimated gestational age 20 to 24 weeks. Fetal pyelectasis greater than 10 mm at estimated gestational age 20 to 24 weeks and greater than 16 mm at greater than 33 weeks is associated with 35% or less differential function in the newborn.

Residency Training in Neonatal Circumcision: A Pilot Study and Needs Assessment

PURPOSE Routine neonatal circumcision is one of the most commonly performed procedures in a neonate. Residents are expected to acquire the skills to properly evaluate the neonate and gain proficiency in performing circumcision despite significant variability in training. We performed a needs assessment to evaluate obstetric-gynecology residency training in neonatal circumcision. MATERIALS AND METHODS We performed an online self-assessment survey of obstetric-gynecology residents at Prentice Hospital, Chicago, from November 2008 to February 2009. Using images of uncircumcised penises residents were asked to identify which patients were candidates for routine neonatal circumcision. RESULTS Of 36 obstetric-gynecology residents 27 responded to the survey. Most respondents planned to perform neonatal circumcision when in practice, 44% had no formal training in circumcision and most were comfortable performing routine neonatal circumcision. Overall respondents were less comfortable evaluating whether the a newborn penis could undergo circumcision safely. When presented with 10 pictures of penises and asked to determine whether the neonate should undergo circumcision, 0% of respondents correctly identified all contraindications to neonatal circumcision with an average of 42% of contraindications identified correctly. Of the respondents 77% listed practical experience as the first choice to learn a procedure with an online module preferred by 55% as the second choice. CONCLUSIONS Although most residents feel competent to technically perform the procedure, they are not confident in their ability to judge the appropriate contraindications to neonatal circumcision. This needs assessment highlights the necessity for further curriculum development and formalized training in this domain.

Urologic issues of the pediatric spina bifida patient: A review of the genitourinary concerns and urologic care during childhood and adolescence

Myelodysplasia is a complex patient problem that continues to present challenges for multidisciplinary care teams. The spectrum of bladder and bowel dysfunction created by this neurologic lesion is broad and requires long-term surveillance of these organ systems. This review outlines the diagnosis and management of urologic issues of the spina bifida patient throughout infancy, childhood and adolescence. Specifically, examining different approaches to care of these patients (proactive vs reactive), quality of life issues and medical and surgical management options and decision-making at each phase of life.