The Learning Curve of the Deliberate Practice of Phacoemulsification in the Ophthalmic Training System

Objective: To determine the number of surgeries needed for trainees to achieve competence in performing phacoemulsification with deliberate practice (DP). Materials and Methods: The present study was a prospective observational study, the residents were observed as they progressed through their third year of residency. Resident and patient demographic data were recorded. Complexities of the cases and surgical steps and rate of surgical complications were recorded. Self and staff assessments as to the DP learning zone attained by the trainees were collected. Risk adjusted-cumulative summation (RA-CUSUM) was used to evaluate the competency of the trainees to achieve the acceptable posterior capsule rupture (PCR) rate of 5%. Kaplan-Meier analysis was used to determine the median number of surgeries required to attain competency. Results: Eight of the 10 trainees achieved competence in performing phacoemulsification. A median of 28 cases and 278 days was required before competence was attained. There were no statistically significant associations between the achievement of competence and the gender of the trainees, perceived complexity of the cases, or the grade-point average of the residents during their tenure in medical school. A median of four cases were required for a shift in the trainees’ DP confidence levels from “panic” to “learning” from self-assessment, while the median of ten case were required from staff assessment. The PCR was 8.53% and dropped to 6% at two years after the trainees finished residency training. Conclusion: Trainees require at least 28 cases of non-complicated phacoemulsification surgery to achieve a minimum level of competency. The perceived skill in performing phacoemulsification differs between novice and experienced surgeons. Phacoemulsification skills can be further developed after graduating from the training program. Assisting staff should be attentive when trainees perform lens nucleus division and lens nucleus removal to avoid complications. Keywords: Residency training; Phacoemulsification; CUSUM; Deliberate practice; Cataract

The Learning Curve in Vaginal Pelvic Reconstruction Surgery for Severe Pelvic Organ Prolapse: Analysis of the Cumulative Summation Test (CUSUM)

Women who underwent vaginal pelvic reconstructive surgery with or without mesh consecutively between 2004 and 2018 were retrospectively analyzed to determine the learning curve in vaginal pelvic reconstructive surgery. With cumulative summation (CUSUM) analysis of surgical failure and operation time, we assessed the learning curve of vaginal pelvic reconstructive surgery, including sacrospinous ligament fixation, anterior colporrhaphy, posterior colporrhaphy, and optional vaginal hysterectomy with or without mesh placement. Two hundred and sixty-four women with stage III or IV pelvic organ prolapse underwent vaginal pelvic reconstructive surgery by surgeon A or B. The median follow-up time of 44 months ranged from 24 to 120 months. Surgical proficiency was achieved in 32-54 vaginal pelvic reconstructive surgery procedures without mesh and 37-61 procedures in the same surgery with mesh. The surgical success rates for surgeons A and B were 82.2% and 94.1%, with median follow-up times of 60 and 33 months, respectively. The learning phase of vaginal pelvic reconstructive surgery in advanced pelvic organ prolapse in this institutional cohort required 54 and 61 procedures, respectively. A higher number of procedures were required for the learning curve of vaginal pelvic reconstructive surgery with mesh. Having crossed the boundary of proficiency, the surgical success rate and operation time were improved.

Proctored Step by Step Training Program for GreenLight Laser Anatomic Photovaporization of the Prostate: A Single Surgeon's Experience

Objectives: To evaluate the feasibility and safety of a proctored step-by-step training program for GreenLight laser anatomic photovaporization (aPVP) of the prostate.Methods: Data from patients undergoing aPVP between January 2019 and December 2020 operated by a single surgeon following a dedicated step-by-step proctored program were prospectively collected. The procedure was divided into five modular steps of increasing complexity. Preoperative patients' data as well as total operative time, energy delivered on the prostate and postoperative data, were recorded. Then, we assessed how the overall amount of energy delivered and the operative times varied during the training program. Surgical steps were analyzed by cumulative summation. Univariable and multivariable regression models were built to assess the predictors of the amount of energy delivered on the prostate.Results: Sixty consecutive patients were included in the analysis. Median prostate volume was 56.5 mL. The training program was succesfully completed with no intraoperative or meaningful post-operative complications. The energy delivered reached the plateau after the 40th case. At multivariable analysis, increasing surgeon experience was associated with lower amounts of energy delivered as well as lower operative times.Conclusions: A step-by-step aPVP training program can be safely performed by surgeons with prior endoscopic experience if mentored by a skilled proctor. Considering the energy delivered as an efficacy surrogate metrics (given its potential impact on persistent postoperative LUTS), 40 cases are needed to reach a plateau for aPVP proficiency. Further studies are needed to assess the safety of our step-by-step training modular program in other clinical contexts.

Accuracy of soft tissue balancing in total knee arthroplasty using surgeon-defined assessment versus a gap-balancer or electronic sensor

Background Soft tissue balancing is essential for the success of total knee arthroplasty (TKA) and is mainly dependent on surgeon-defined assessment (SDA) or a gap-balancer (GB). However, an electronic sensor has been developed to objectively measure the gap pressure. This study aimed to evaluate the accuracy of soft tissue balancing using SDA and GB compared with a sensor. Methods Forty-eight patients undergoing TKA (60 knees) were prospectively enrolled. Soft tissue balancing was sequentially performed using SDA, a GB, and an electronic sensor. We compared the SDA, GB, and sensor data to calculate the sensitivity, specificity, and accuracy at 0°, 45°, 90°, and 120° flexion. Cumulative summation (CUSUM) analysis was performed to assess the surgeon’s performance during the sensor introductory phase. Results The sensitivity of SDA was 63.3%, 68.3%, 80.0%, and 80.0% at 0°, 45°, 90°, and 120°, respectively. The accuracy of the GB compared with sensor data was 76.7% and 71.7% at 0° and 90°, respectively. Cohen’s kappa coefficient for the accuracy of the GB was 0.406 at 0° (moderate agreement) and 0.227 at 90° (fair agreement). The CUSUM 0° line achieved good prior performance at case 45, CUSUM 90° and 120° showed a trend toward good prior performance, while CUSUM 45° reached poor prior performance at case 8. Conclusion SDA was a poor predictor of knee balance. GB improved the accuracy of soft tissue balancing, but was still less accurate than the sensor, particularly for unbalanced knees. SDA improved with ongoing use of the sensor, except at 45° flexion.

FRACTAL ANALYSIS OF MODELS OF TEXTS OF DIFFERENT STYLES SUBMITTED INTEGER EQUIDISTANT SEQUENCES NUMBER OF LETTERS IN WORDS

This paper presents the results of fractal analysis of models of texts of different styles. Integer numerical sequences, the elements of which are the number of letters in the words of the text, are used as models. An algorithm for calculating the exact value of the fractal dimension is presented, which provided the determination of the exact value of the Hirst index. In addition, the value of the power dependence constant R / S is calculated. The obtained indicators in the aspect of fractality fully describe the objects of research. This method is in fact a logical implementation of the known procedures of fractal analysis and its advantage is that it provides a rigorous mathematical representation of the values of the fractal dimension, the Hirst index and the constant in relation to the indicators of variation. The essence of his presentation is, first of all, as a warning to researchers against misinterpretation of the relationship R / S, because many researchers ignore the existence of a constant for this relationship. Indeed, this relation is a function with two unknown parameters and cannot be directly determined. With regard to the fractal dimension, we can point out that the least important is the conversational style, and the most – poetic. In other words, the model of colloquial text is the smallest part of its environment, poetic – the largest. From the point of view of Hirst’s index, the model of the spoken text contains a trend, while the model of the poem has a character closer to the random one. The largest scope of the cumulative series has a model of spoken text, and the smallest – a model of artistic style of the text. Since the cumulative series is a sequential (cumulative) summation of the sequence of deviations of elements from its arithmetic mean, its scope will depend on the presence of groups of elements of the sequence with very large deviations. Artistic style has the least significance of scope.

Assessment of operator performance during oocyte retrievals: residents’ learning curve and continuous monitoring of senior physicians

Background The learning curve cumulative summation test (LC CUSUM test) allows to define an individualized learning curve and determine the moment when clinical proficiency is attained. After acquisition of the skills, the cumulative summation test (CUSUM test) allows to monitor the maintenance of the required level over time. The LC CUSUM test has been frequently used in the field of Obstetrics and Gynecology (Ob/Gyn) for several procedures, but only once for OR. Methods We performed a retrospective study at Angers university hospital between May 2017 and September 2018. Seven Ob/Gyn residents and 5 senior physicians were included, and all OR performed during that time (n = 690) were analyzed. The performance index assessed was the oocyte retrieval rate (ORR), defined as the ratio of oocytes retrieved to follicles aspirated. We used the LC CUSUM test to analyze the learning curves of residents, and the CUSUM test to monitor the performance of senior physicians. An ORR ≥50% in 60% of retrievals was defined as the threshold for clinical proficiency. Results Six hundred seventy-four oocyte retrieval (OR) were included: 315 were performed by residents, 220 by senior physicians, and 139 by both residents and physicians (mixed retrievals). Four residents (57%) reached the threshold after aspirating 82, 67, 53 and 46 ovaries, respectively. The mean number of ovaries aspirated in order to reach clinical proficiency was 62, and the mean number of weeks needed was 21. The duration of the learning period varied between 26 and 80 days. Two senior physicians (40%) remained proficient across the duration of the study, while two physicians (40%) had one statistically “suboptimal” OR, and one physician (20%) had two suboptimal retrievals. Conclusion There is a large variability in the duration of the learning period and the number of procedures needed for a resident to master OR. Senior physicians maintain an adequate performance.