Ramin Jamshidi

Surgical training and global health: initial results of a 5-year partnership with a surgical training program in a low-income country.

HYPOTHESIS Surgical trainees in the United States have a growing interest in both clinical experiences and structured training opportunities in global health. Global health training and exposure can be integrated into a surgical residency program. DESIGN The global health activities of surgical residents and faculty in 1 department were evaluated from January 1, 1998, to June 1, 2008, using a survey and personal interviews. RESULTS From January 1, 1998, to December 31, 2002, 4 faculty members made more than 20 overseas volunteer medical expeditions, but only 1 resident participated in global health activities. In 2003, a relationship with a surgical training program in a developing country was established. Ten residents and 12 faculty members have made overseas trips during the last 5 years, and 1 international surgeon has visited the United States. During their research block, 4 residents completed 1- to 3-month clinical rotations and contributed to mentored research projects. Three residents completed a university-based Global Health Clinical Scholars Program, and 3 obtained masters degrees in public health. A joint conference in injury-trauma research was also conducted. A faculty member is based overseas with clinical and research responsibilities, and another is completing a masters degree in public health. CONCLUSIONS Global health training and exposure for residents can be effectively integrated into an academic surgical residency program through relationships with training programs in low-income countries. Legitimate academic experiences improve the success of these programs. Reciprocity with collaborative partners must be ensured, and sustained commitment and funding remain a great challenge to such programs. The long-term effect on the development of global health careers is yet to be determined.

Magnamosis II: Magnetic Compression Anastomosis for Minimally Invasive Gastrojejunostomy and Jejunojejunostomy

BACKGROUND Previously we demonstrated the safety and patency of a magnetic compression anastomosis (magnamosis). We present the further development of this technique, with specific focus on optimizing device design for minimally invasive magnamosis. STUDY DESIGN The magnamosis device was designed to incorporate 3 features: 2 convex-concave radially symmetric halves that magnetically self-align, a central channel for immediate patency, and specially engineered radial topography of the mating surfaces to promote gradual remodeling. Each symmetrical half consists of a ring-shaped neodymium-iron-boron magnet encased in polycarbonate casing. Twenty-one young adult pigs underwent either magnetic gastrojejunostomy (n = 13) or jejunojejunostomy (n = 8). Animals were euthanized at 1, 2, 4, and 6 weeks after operation. Anastomoses were studied with contrast radiography, burst pressure, and histology. RESULTS Gastrojejunostomy: In all animals with successful placement of magnets, anastomoses were patent by contrast fluoroscopy, well healed by histologic examination, and showed excellent burst strength. Jejunojejunostomy: All animals had uneventful clinical courses, indicating that the magnamosis with immediate patency functioned properly without device dislodgement. At sacrifice, all magnamoses were patent, well healed by histology, and had burst strengths that equaled or exceeded that of traditional stapled anastomoses. CONCLUSIONS Minimally invasive placement of a custom magnetic device in the stomach and jejunum allows intraluminal self-alignment and subsequent compression anastomosis over 3 to 10 days. The magnamosis is immediately patent and develops strength equal to or greater than that of hand-sewn or stapled anastomoses. Magnamosis is effective in the pig model, and may be a safe, effective, and minimally invasive alternative to current anastomotic strategies in humans.

Bringing the Skills Laboratory Home: An Affordable Webcam-Based Personal Trainer for Developing Laparoscopic Skills

OBJECTIVE The purpose of this work was to develop a more flexible system of laparoscopic surgery training with demonstrated effectiveness and construct validity. HYPOTHESES A personal, portable, durable laparoscopic trainer can be designed at low cost. The evaluation of expert surgeons on this device will reveal technical superiority over novices. With practice, novice surgeons can improve their performance significantly as measured by scores derived from performing skills with this training device. DESIGN Prospective trial with observation and intervention components. The first aspect was observational comparison of novice and expert performance. The second was a prospective static-group comparison with pretest/posttest single-sample design. SETTING Tertiary-care academic medical center with affiliated general surgery residency. PARTICIPANTS A total of 21 junior surgical residents and 5 experienced operators. MAIN OUTCOME MEASURES Performance was assessed by the 5 tasks in the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS): pegboard transfer, pattern cutting, placement of ligating loop, extracorporeal knotting, and intracorporeal knotting. Each task was assessed for accuracy and speed. RESULTS Expert surgeons scored significantly higher than novices on total score and 4 of the 5 MISTELS tasks (peg transfer, pattern cut, extracorporeal knot, and intracorporeal knot). After 4 months of home-based training, the novices improved in total score and 3 of the 5 tasks (peg transfer, pattern cut, and extracorporeal knot). CONCLUSIONS A low-cost personal laparoscopic training device can be built by individual residents. With their use, residents can significantly improve performance in important surgical skills. Evaluation of the system supports its validity.

Magnetic Mini-Mover Procedure for pectus excavatum: II: initial findings of a Food and Drug Administration–sponsored trial

PURPOSE The Magnetic Mini-Mover Procedure (3MP) uses a magnetic implant coupled with an external magnet to generate force sufficient to gradually remodel pectus excavatum deformities. This is an interim report of the evolution of the 3MP during a Food and Drug Administration-approved clinical trial. METHODS After obtaining Institutional Review Board approval, we performed the 3MP on 10 otherwise healthy patients with moderate to severe pectus excavatum deformities (age, 8-14 years; Haller index >3.5). Operative techniques evolved to improve ease of implantation. Patients were evaluated monthly by a pediatric surgeon and orthotist. Electrocardiograms were performed pre- and postoperatively. Sternal position was documented by pre- and postprocedure computed tomographic scan, interval chest x-ray, depth gauge, and interval photographs. RESULTS There was no detectable effect of the static magnetic field on wound healing or cardiopulmonary function. No detectable injuries and minimal skin changes resulted from brace wear. Operative techniques evolved to include a custom sternal punch and a flexible guide wire to guide the posterior plate into position behind the sternum, reducing outpatient operating time to one-half hour. In 9 patients, the procedure was performed as an outpatient basis; and 1 patient was observed overnight. Three patients required evacuation of retained pleural air postoperatively, and 2 required an outpatient revision. A custom-fitted orthotic brace (Magnatract) was extensively modified to increase user friendliness and functionality while incorporating several novel functions: a screw displacement mechanism so patients can easily self-adjust magnetic force, a miniature data logger to measure force and temperature data every 10 minutes, and an interactive online Web portal for remote patient evaluation. All attempts to quantitate sternal position (radiographic, fluid volume, and depth gauge) were inadequate. Visual assessment remains the best indicator. CONCLUSIONS In this interim report, the 3MP appears to be a safe, minimally invasive, outpatient, cost-effective alternative treatment of pectus excavatum. Outcomes will be reported upon the completion of this phase II clinical trial.

Indication for pediatric muscle biopsy determines usefulness

PURPOSE Diagnostic skeletal muscle biopsy is an invasive procedure used for evaluation of neuromuscular disorders. We hypothesize that the yield of biopsy varies with its indication or suspected diagnosis. METHODS Retrospective review of all muscle biopsies was performed at an academic tertiary care center between January 1, 1996, and August 1, 2006. RESULTS A total of 142 muscle biopsies were performed on 127 children. Mean age at biopsy was 5.3 years (median, 3.3; range, 8 days-21 years) with 48% female. Follow-up was maintained for a mean 3.4 years (median, 2.2; range, 1 month-10.4 years). Specific pathological diagnoses were obtained from 33 (23%) of 142. Changes in therapy resulted from 11 (8%) of 142 biopsies. Treatment changed for all patients with prebiopsy suspicion of inflammatory or neoplastic processes (7/7, 100%); these accounted for 7 (64%) of 11 patients with treatment changes. Thirteen patients underwent multiple biopsies, with 1 (8%) patients treatment adjusted as a result. Fifteen neonates (<100 days) underwent a total of 17 biopsies; none changed treatment plans. CONCLUSIONS Muscle biopsy for neuromuscular disorders is inconsistently useful. Specific diagnoses are occasionally revealed, but treatment changes are infrequent except in those patients with suspected neoplastic or inflammatory disease. Ongoing study is required to determine the most rational indications for this procedure.

In utero repair of gastroschisis in the sheep (Ovis aries) model

OBJECTIVE Gastroschisis is associated with inflammatory changes in the exposed bowel which leads to intestinal dysmotility after postnatal repair. The insult is a combined effect of amniotic fluid exposure and mechanical constriction. We hypothesized that in utero anatomic repair is possible in a sheep model, and that it may halt the inflammatory damage caused by both mechanisms. METHODS Gastroschisis was surgically created in mid-gestation (day 75) in 8 sheep fetuses. On gestational day 100, 2 fetuses underwent open fetal gastroschisis repair, where the eviscerated bowel was returned to the peritoneal cavity, and the abdominal wall was primarily closed. All fetuses were harvested at 135 days of gestation. RESULTS Six fetuses survived the initial operation, and both fetuses that underwent gastroschisis repair survived to term. At 100 and 135 days of gestation, the eviscerated bowel showed progressive signs of inflammation and peel development. The gross and microscopic inflammatory changes in the gastroschisis bowel at 100 days of gestation were completely resolved at term following in utero repair. CONCLUSION In utero anatomic repair of gastroschisis is possible in mid-gestation in the fetal lamb model, and it appears to ameliorate the inflammatory process.

Medical student teaching: a peer-to-peer toolbox for time-constrained resident educators.

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Left Ventricular Aneurysm in a Child With Severe Combined Immunodeficiency Syndrome

We describe the case of a 23-month-old girl with combined immunodeficiency syndrome and a left ventricular aneurysm. Due to the size of the aneurysm and development of an intramural thrombus, repair was performed after confirmation of bone marrow transplant engraftment. Endoventricular circular patch plasty (Dor procedure) was performed, with excellent outcome and normalization of ventricular geometry and function.

Magnet-mediated thoracic remodeling: a new approach to the sunken chest.

Pectus excavatum, or ‘sunken chest’, is the most common congenital chest wall deformity with an incidence of approximately 1 in 1000 births. It is characterized by posterior depression of the sternum and lower anterior costal cartilages. Despite over 60 years of research, opinions vary on whether this anatomic anomaly causes significant cardiopulmonary deficits. A variety of studies have evaluated an array of pulmonary function indices before and after correction of pectus excavatum but the results are inconsistent. Most studies do, however, generally concur that there is some measurable improvement in lung volumes after correction. Cardiac effects have also garnered much attention as compression of the mediastinum between the sternum and vertebral column generally indents the anterior wall of the right ventricle. This is thought to contribute to the development of mitral valve prolapse, which is present in a fifth to two thirds of patients. Approximately half of these cases of prolapse resolve after operation. Again, results have varied when trying to demonstrate improvements in quantities, such as ejection fraction and stroke volume, but exercise tolerance generally appears to improve with operation. While some evidence exists that the altered thoracic geometry can affect cardiopulmonary function, many consider the milder forms of pectus excavatum to simply be a cosmetic issue. This latter view is widely espoused by American insurers, who – swayed by their financial interests – are quick to define this as a cosmetic variant and decline reimbursement for surgical correction. However, discussion with actual patients and their families reveals the significant impact of the condition on patients’ daily lives. Younger children may be undisturbed by their anatomic differences but as they reach adolescence their social development is frequently stunted by the embarrassment of their deformity. Even in those children whose cardiac function or exercise tolerance is not limited, there is a detriment to their development. Parents who themselves have lived with the deformity are crestfallen when they see the same in their children, aware of the social difficulties and self-esteem issues they will face. The bottom line is that pectus excavatum is a genuine and disturbing problem for patients.

Facilitated web‐based case discussions in surgery

Context and setting Although health care professionals frequently struggle with communicating technically challenging information to an increasingly videoand computer-savvy audience, video media remain under-utilised. There may be advantages to using simulation environments for videotaping. Several medical centres have developed programmes and facilities for simulation-based education, which faithfully replicate the dynamic nature of critical care medicine. Why the idea was necessary Health care professionals require on-demand education to learn or review a treatment modality prior to providing patient care. Although written and web-based text plays a central role in education, many people are visual learners and are able to assimilate information better by observing images. The technique of concurrent continuous renal replacement therapy and therapeutic plasma exchange (CCRRT + TPE), which has been described in the treatment of fulminant hepatic failure, is not intuitive to most health care professionals. The technique is difficult to describe using words, but may be demonstrated in a straightforward fashion by video. It was postulated that a medical simulation facility could be of value in creating a CCRRT + TPE video. What was done Prior to filming, a story-board was developed to outline the scenes and filming sequence. Prisma CRRT and Cobe centrifugation plasmapheresis machines (Gambro BCT, Lakewood, CO, USA) were run by dialysis and apheresis nurses familiar with the procedure. Fluids representing blood and 5% albumin were formulated using normal saline and dye powders. An infant manikin (Rescusici-Baby Laerdal NRB 1000; Laerdal Medical, Wappingers Falls, NY, USA) was selected to represent the patient. Numerous pan-tilt, remote-control cameras and highly sensitive microphones located in the ceiling allowed multiple camera angles and clear recording of verbal interactions and machine alarms. All activity was captured on a digital recording deck before it was transferred to a CD-ROM disk in Windows Movie File (WMV) format. A total of 35 minutes of video was needed to demonstrate the storyboard sequences. The final video was created using Microsoft Movie Maker (Microsoft Inc., Redmond, WA, USA). Evaluation of results and impact A 6-minute video was produced for a plenary presentation at a national conference. The video was subsequently placed on an institution intranet website, where it was reviewed by dialysis nurses and doctors. The video was uploaded to YouTube (http://www.youtube.com/watch?v= ARi-61nIcjQ) and has induced several inquiries. Gambro representatives also use the video to teach the technique. This project demonstrates that videotaping a novel, infrequently used technique in a medical simulation facility is possible, given current technologies. The advantages of videotaping in a medical simulation facility include a video-friendly environment, the elimination of competition between filming and patient care goals, the ability to schedule videotaping at a convenient time, and the fact that consent and ethical approval are not necessary. The costs associated with videotaping include costs for the simulation room (typically