Robert Kleinert

3D Immersive Patient Simulators and Their Impact on Learning Success: A Thematic Review

Background Immersive patient simulators (IPSs) combine the simulation of virtual patients with a three-dimensional (3D) environment and, thus, allow an illusionary immersion into a synthetic world, similar to computer games. Playful learning in a 3D environment is motivating and allows repetitive training and internalization of medical workflows (ie, procedural knowledge) without compromising real patients. The impact of this innovative educational concept on learning success requires review of feasibility and validity. Objective It was the aim of this paper to conduct a survey of all immersive patient simulators currently available. In addition, we address the question of whether the use of these simulators has an impact on knowledge gain by summarizing the existing validation studies. Methods A systematic literature search via PubMed was performed using predefined inclusion criteria (ie, virtual worlds, focus on education of medical students, validation testing) to identify all available simulators. Validation testing was defined as the primary end point. Results There are currently 13 immersive patient simulators available. Of these, 9 are Web-based simulators and represent feasibility studies. None of these simulators are used routinely for student education. The workstation-based simulators are commercially driven and show a higher quality in terms of graphical quality and/or data content. Out of the studies, 1 showed a positive correlation between simulated content and real content (ie, content validity). There was a positive correlation between the outcome of simulator training and alternative training methods (ie, concordance validity), and a positive coherence between measured outcome and future professional attitude and performance (ie, predictive validity). Conclusions IPSs can promote learning and consolidation of procedural knowledge. The use of immersive patient simulators is still marginal, and technical and educational approaches are heterogeneous. Academic-driven IPSs could possibly enhance the content quality, improve the validity level, and make this educational concept accessible to all medical students.

Impact of duct-to-mucosa pancreaticojejunostomy with external drainage of the pancreatic duct after pancreaticoduodenectomy.

BACKGROUND A variety of different techniques are established for the management of the pancreatic remnant after partial pancreaticoduodenectomy. Although pancreaticojejunostomy is one of the most favored methods, technical details are still under discussion. We report about a series of duct-to-mucosa pancreaticojejunostomies with total external drainage of the pancreatic duct. PATIENTS AND METHODS Between 1998 and 2007 257 patients underwent surgical therapy for malignant disease of the pancreas and the periampullary region and for chronic pancreatitis. Of these, 153 partial pancreaticoduodenectomies (85 pylorus preserving resections and 68 Whipples procedures) were performed. In all of these cases, the pancreatic remnant was drained by a duct-to-mucosa pancreaticojejunostomy with external drainage of the pancreatic duct. Presence of postoperative pancreatic fistula (PPF) was defined according to the International Study Group on Pancreatic Fistula (ISGPF). RESULTS Postoperative mortality was 1.9%. The incidence of postoperative pancreatic fistula (PPF) was 19.6% according to the ISGPF criteria. Only one patient required re-laparotomy for complications caused by PPF. Patients with PPF had a significantly longer operation time (7.3 h versus 6.6 h; P=0.041). Incidence of PPF was not influenced by histology. In all cases the fistulas resolved under conservative treatment. CONCLUSION Duct-to-mucosa PJ with external drainage is a safe procedure to enteralize the pancreatic stump after partial pancreaticoduodenectomy.

Laparoscopic deroofing of nonparasitic liver cysts with or without greater omentum flap.

Background Laparoscopic deroofing is the standard therapy for simple nonparasitic liver cysts. The operation is performed with or without a greater omentum flap sutured into the former cyst cavity. The aim of this study was to determine whether a greater omentum flap has influence on the recurrence rate of nonparasitic liver cysts during the long-term follow-up. Methods From September 1999 to November 2009, 23 patients underwent laparoscopic deroofing for single or multiple nonparasitic symptomatic liver cysts. A greater omentum flap to fill the former cyst cavity was used in 8 patients, whereas in 15 patients operation was carried out without such an omentum flap. The patients were identified retrospectively and subject to a follow-up examination. The 2 groups of patients were compared according to the recurrence of the liver cysts. Results The median follow-up time was 59±40 months. There was an overall recurrence rate of 4.3% (1 of 23), with 1 cyst recurrence in the greater omentum flap group (1 of 8). The Fisher exact test showed no difference in the recurrence rate between the 2 groups (P=0.35). Conclusion The overall recurrence rate is low. A greater omentum flap to prevent a local cyst recurrence after laparoscopic deroofing is dispensable and is a potential source of additional complications.

Web-Based Immersive Virtual Patient Simulators: Positive Effect on Clinical Reasoning in Medical Education

Background Clinical reasoning is based on the declarative and procedural knowledge of workflows in clinical medicine. Educational approaches such as problem-based learning or mannequin simulators support learning of procedural knowledge. Immersive patient simulators (IPSs) go one step further as they allow an illusionary immersion into a synthetic world. Students can freely navigate an avatar through a three-dimensional environment, interact with the virtual surroundings, and treat virtual patients. By playful learning with IPS, medical workflows can be repetitively trained and internalized. As there are only a few university-driven IPS with a profound amount of medical knowledge available, we developed a university-based IPS framework. Our simulator is free to use and combines a high degree of immersion with in-depth medical content. By adding disease-specific content modules, the simulator framework can be expanded depending on the curricular demands. However, these new educational tools compete with the traditional teaching Objective It was our aim to develop an educational content module that teaches clinical and therapeutic workflows in surgical oncology. Furthermore, we wanted to examine how the use of this module affects student performance. Methods The new module was based on the declarative and procedural learning targets of the official German medical examination regulations. The module was added to our custom-made IPS named ALICE (Artificial Learning Interface for Clinical Education). ALICE was evaluated on 62 third-year students. Results Students showed a high degree of motivation when using the simulator as most of them had fun using it. ALICE showed positive impact on clinical reasoning as there was a significant improvement in determining the correct therapy after using the simulator. ALICE positively impacted the rise in declarative knowledge as there was improvement in answering multiple-choice questions before and after simulator use. Conclusions ALICE has a positive effect on knowledge gain and raises students’ motivation. It is a suitable tool for supporting clinical education in the blended learning context.

Computed Tomography Volumetry in Preoperative Living Kidney Donor Assessment for Prediction of Split Renal Function.

Background Transplant centers commonly evaluate split renal function (SRF) with Tc-99m-mercapto-acetyltriglycin (MAG3) scintigraphy in living kidney donation. Alternatively, the kidney volume can be measured based on predonation CT scans. The aim of this study was to identify the most accurate CT volumetry technique for SRF and the prediction of postdonation kidney function (PDKF). Methods Three CT volumetry techniques (modified ellipsoid volume [MELV], smart region of interest [ROI] volume, renal cortex volume [RCV]) were performed in 101 living kidney donors. Preoperation CT volumetric SRF was determined and compared with MAG3-SRF, postoperation donor kidney function, and graft function. Results The correlation between donors predonation total kidney volume and predonation kidney function was the highest for RCV (0.58 with creatine clearance, 0.54 with estimated glomerular filtration rate-Cockcroft-Gault). The predonation volume of the preserved kidney was (ROI, MELV, RCV) 148.0 ± 29.1 cm3, 151.2 ± 35.4 and 93.9 ± 25.2 (P < 0.005 MELV vs RCV and ROI vs RCV). Bland-Altman analysis showed agreement between CT volumetry SRF and MAG3-SRF (bias, 95% limits of agreement: ROI vs MAG3 0.4%, −7.7% to 8.6%; MELV vs MAG3 0.4%, −8.9% to 9.7%; RCV vs MAG3 0.8%, −9.1% to 10.7%). The correlation between predonation CT volumetric SRF of the preserved kidney and PDKF at day 3 was r = 0.85 to 0.88, between MAG3-SRF and PDKF (r = 0.84). The difference of predonation SRF between preserved and donated kidney was the lowest for ROI and RCV (median, 3% and 4%; 95th percentile, 9% and 13%). Conclusions Overall renal cortex volumetry seems to be the most accurate technique for the evaluation of predonation SRF and allows a reliable prediction of donors PDKF.

Radiomorphology of the Habib Sealer-Induced Resection Plane during Long-Time Followup: A Longitudinal Single Center Experience after 64 Radiofrequency-Assisted Liver Resections

Background. Radiofrequency (RF-) assisted liver resection devices like the Habib sealer induce a necrotic resection plane from which a small margin of necrotic liver tissue remains in situ. The aim of the present paper was to report our long-time experience with the new resection method and the morphological characteristics of the remaining necrotic resection plane. Methods. 64 RF-assisted liver resections were performed using the Habib sealer. Followup was assessed at defined time points. Results. The postoperative mortality was 3,6% and morbidity was 18%. The followup revealed that the necrotic zone was detectable in all analyzed CT and MRI images as a hypodense structure without any contrast enhancement at all time points, irrespectively of the time interval between resection and examination. Conclusion. Liver resection utilizing radiofrequency-induced resection plane coagulation is a safe alternative to the established resection techniques. The residual zone of coagulation necrosis remains basically unchanged during a followup of three years. This has to be kept in mind when evaluating the follow up imaging of these patients.

Generation Y and surgical residency – Passing the baton or the end of the world as we know it? Results from a survey among medical students in Germany

Introduction The current student generation have their own expectations toward professional life and pay particular attention to their work-life balance. Less interest in work-intensive specialties leads to a shortage of skilled candidates especially in surgery. In order to motivate students into a surgical residency, new priorities become important. A deeper understanding of the underlying arguments and students’ expectations towards a surgical training are necessary to counteract a future shortage of specialized surgeons. Methods We conducted an internet-based survey among medical students at two representative German university hospitals to gain more information about the underlying mechanisms that lead to opting for and against a surgical career. We particularly paid attention to gender differences and differences between students of different academic years. Results A total of 1098 students participated in the survey. Sixty-four percent were female. The majority of the students were of the opinion that surgery is an interesting and meaningful profession. In contrast, when it comes to their own career choice, most students (89% female and 81% male) are not willing to choose a surgical specialty. While students are certainly willing to spend a large amount of time on their professional lives, at the same time they demand planning reliability and a sufficient work-life balance. Flexibility in working hours and an existing childcare program were identified as predominant factors for all students and in particular for female students. The same applies to a respectful conversional tone and appreciation of the individual work. Factors like prestige and salary were less relevant than “self-fulfillment” in terms of respectful interaction and balancing their working and private lives. There was significant difference in female and male students as female students have clearer ideas concerning career planning but at the same time are less self-confident than their male colleagues. Moreover, there was a significant difference between junior and senior students regarding career planning with a shift to less work-intensive specialties and especially away from a surgical residency in older students. Adjustments to working hours models, working environment, clinical curriculum and a respectful interaction are factors that might increase the willingness of young students to choose a surgical career.

Prognosis after "high urgent" kidney transplantation might be determined by control of preexisting septic condition.

INTRODUCTION Dialysis is the standard bridging method for patients with end-stage renal disease. In rare cases, dialysis is impossible and immediate kidney transplantation (KT) is the only option for survival. Most allocation organizations offer an immediate allocation procedure (high urgency [HU]), which focuses on immediate allocation at the cost of immunologic matching. The impossibility of dialysis is mainly caused by multiple systemic thromboses and blood stream infections. This situation creates an ethical dilemma: Accepting the HU-KT allocation potentially saves the patients life albeit with negatively effects on the expected patient and organ survivals. In times of organ shortage, more information is needed regarding this difficult decision; the published literature is limited to 4 papers. METHODS We performed a retrospective analysis of patients who were transplanted by HU allocation in our center between January 1989 and October 2010. RESULTS Of 1040 KT, 10 (0.96%) were performed in HU condition. Mean follow-up time was 37 months. The main reason for HU-KT was exhaustion of vascular access in combination with a bloodstream infection. All recipients showed severe preoperative comorbidities. Patient survival was 90% at 1, 80% at 3, and 60% at 5 years. There was 1 graft loss owing to chronic rejection. CONCLUSION When kidney transplantation is performed as an HU procedure, it is associated with a greater morbidity and mortality compared with elective cases. Bloodstream infections that existed before transplantation contributed considerably to mortality.

Gastric cancer treatment in the world: Germany

Epidemiologically, around 15,500 persons per year contract gastric cancer with continuously decreasing incidence and a 5-year survival rate of only 30% to 35%. Contrary to the Asian countries, there are no prevention programs for gastric cancer in Germany, which leads to the disease frequently being diagnosed in locally advanced stages and predominantly being treated with multimodal therapy concepts. Complete (R0) resection is the therapy of choice for resectable gastric cancer. Special forms of gastric cancer that are limited to the mucosa can be endoscopically resected with a curative intent. Systematic D2 lymphadenectomy (LAD) plays a decisive role in the management of local advanced tumors because it significantly contributes to the reduction of tumor-related death and both local and regional relapse rates. Perioperative chemotherapy improves prognosis in the advanced stages, whereas palliative chemotherapy is normally indicated for metastatic diseases. Standardized resection procedures and the use of individualized multimodal therapy concepts have led to improvement in the 5-year survival rate.

Implantation of venous access devices under local anesthesia: patients’ satisfaction with oral lorazepam

Objective The aim of the study reported here was to evaluate patients’ satisfaction with implantation of venous access devices under local anesthesia (LA) with and without additional oral sedation. Materials and methods A total of 77 patients were enrolled in the prospective descriptive study over a period of 6 months. Subcutaneous implantable venous access devices through the subclavian vein were routinely implanted under LA. Patients were offered an additional oral sedative (lorazepam) before each procedure. The level of anxiety/tension, the intensity of pain, and patients’ satisfaction were evaluated before and immediately after the procedure using a visual analog scale (ranging from 0 to 10) with a standardized questionnaire. Results Patients’ satisfaction with the procedure was high (mean: 1.3±2.0) with no significant difference between the group with premedication and the group with LA alone (P=0.54). However, seven out of 30 patients (23.3%) in the group that received premedication would not undergo the same procedure without general anesthesia. There was no significant influence of lorazepam on the intensity of pain (P=0.88). In 12 out of 30 patients (40%) in the premedication group, the level of tension was higher than 5 on the visual analog scale during the procedure. In 21 out of 77 patients (27.3%), the estimate of the level of tension differed between the interventionist and the patient by 3 or more points in 21 out of 77 patients (27.3%). Conclusion Overall patient satisfaction is high for implantation of venous access devices under LA. A combination of LA with lorazepam administered orally might not be adequate for patients with a high level of anxiety and tension. The level of tension is often underestimated by the interventionist. Pre-procedural standardized questionnaires could be used to identify patients for whom a gradual approach of individualized sedation may be more effective.