This document provides an update on the Lapco National Training Programme for Laparoscopic Colorectal Surgery in the UK. It discusses the goals and structure of the training programme, including establishing different skill levels from beginner to proficient. It reviews evidence that supervised training leads to better clinical outcomes compared to unsupervised training. It also presents data on the uptake of laparoscopic colorectal surgery in England and learning curves for trainees. The training programme aims to standardize training and assessment to ensure surgeons are competent in laparoscopic colorectal surgery.
On August 24, 2011, United Way South-Southwest Suburban invited me to present information about online social networking.
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My slides from my breakout session at Echo Conference 2011 titled "I Am Not a Trend." I spoke about my journey as an artist/designer and how I've come to find my identity apart from the internet and other people around me.
Fundraising For Youth Radio Groups with Roman Mars and Carol Varneygenerationprx
Slides for a web event with Roman Mars, host and producer of 99% Invisible, and Carol Varney, Director of the Bay Area Video Coalition on helping youth radio groups fundraise with online tools.
Complications in Surgery- Mr G Williamsjimmystrein
Presentation given by Mr Graham Williams, Royal Wolverhampton Hospitals, at the Dukes' Club AGM 2012. Why do complications occur, identification and management of complications, management of the situation.
On August 24, 2011, United Way South-Southwest Suburban invited me to present information about online social networking.
I benefit from www.slideshare.net tremendously and maybe this will help someone also.
My slides from my breakout session at Echo Conference 2011 titled "I Am Not a Trend." I spoke about my journey as an artist/designer and how I've come to find my identity apart from the internet and other people around me.
Fundraising For Youth Radio Groups with Roman Mars and Carol Varneygenerationprx
Slides for a web event with Roman Mars, host and producer of 99% Invisible, and Carol Varney, Director of the Bay Area Video Coalition on helping youth radio groups fundraise with online tools.
Complications in Surgery- Mr G Williamsjimmystrein
Presentation given by Mr Graham Williams, Royal Wolverhampton Hospitals, at the Dukes' Club AGM 2012. Why do complications occur, identification and management of complications, management of the situation.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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1. .
Update on Lapco
Mark G Coleman, Derriford Hospital, Plymouth
Director, Lapco National Training Programme for Laparoscopic Colorectal Surgery
Advisor, LOREC National Training Programme for Low Rectal Cancer
LOREC Low Rectal Cancer National
Development Programme
2.
3.
4.
5.
6. Lapco Training
Centres (11) The National Training Programme (NTP)
Competence – safe performance of an operation to
required standard within a reasonable time
BEGINNER ADVANCED COMPETENT PROFICIENT
APPLICATION COURSE SUPERVISED TRAINING SOLO TRAINING
1-2 YEARS Clinical, CAT
Sign off:
GAS form + clinical CAT, HRA video assessment
GAS form
Selection criteria
60 experts (>100 cases)
Inreach
Outreach
20-25 cases in 6 months
7.
8. Uptake of laparoscopic colorectal surgery in England
30%
25%
20%
15%
10%
5%
0%
2004/2005 2005/2006 2006/2007 2007/2008
Source: Hospital Episode Statistic (HES)
9. Fear of long learning curve is justified
- Big data base: n (patients)=4907, n (surgeons)=27
- Appropriate statistical methods (RA-CUSUM)
CONVERSION COMPLICATION
10
CUSUM (obs-exp)
CUSUM (obs-exp)
5
152 143
0
0 100 200 300 400 500 600 0 100 200 300 400 500 600
CASE NUMBER CASE NUMBER
200
2000
OP TIME LN HARVEST
CUSUM (obs-exp)
CUSUM (obs-exp)
100
1000
139
0
88
0
-100
-500
0 100 200 300 400 500 600 0 100 200 300 400 500 600
CASE NUMBER
CASE NUMBER
Miskovic et al. 2011
10. The impact of the presence of a trainer on clinical
outcomes in laparoscopic colorectal surgery
Meta-analysis of 6’064 patients by surgeons with and without supervised training
Conversion rates
p=0.2835 p=0.0002
p=0.0332
Miskovic and Wyles, Ann Surg 2010 (in press)
11. The impact of the presence of a trainer on clinical outcomes
in laparoscopic colorectal surgery
Meta-analysis of 6’064 patients by surgeons with and without supervised training
Miskovic and Wyles, Ann Surg 2010
12. Rationale for National Training Programme (NTP)
• Evidence of benefits of LCS
• Slow uptake in the UK
• Long learning curve for self-taught surgeons
• Better outcomes for supervised surgeons
• Shortening of proficiency gain curve with active training?
15. Online live learning curve
0
•Online resource for all
CUSUM (obs-exp)
-1
Trainee 1
-2 Trainee 2
•Track trainees -3
-4
Trainee 3
-5
•Task-specific learning curves -6
Trainee 4
1 5 9 13 17 21 25
Procedure number
•Underperformers and “highflyers” can
be identified
•Identification of point when ready for
sign off (flat curve)
16. THE NATIONAL TRAINING PROGRAMME Clinical outcomes of
SIGN OFF PROCEDURE the NTP
Parameter
X2
Experts* NTP Assessor 1
Trainee is invited
Trainer/
trainee agree
to enter sign
Conversionsvideos
to submit 2
of independently 10% 7%
Educational centre
(Imperial College)
performed
off process
procedures Assessor 2
Complications 25% 15%
3%
LCAT x4: If positive result, recommend solo
Anastomotic leak
training, if negative, recommend further 3%
supervised training
Mortality 2% 2%
Aim: safe and solid technique for straight forward case (R/Hemi and L/Hemi)
*Miskovic and Wyles, Ann Surg 2010 (in press)
18. Lapco TT Clinical outcomes of
the NTP
Parameter Experts* NTP
Conversions 10% 7%
•Train theTrainer course
Complications 25% 15%
•2 Day Course
Anastomotic leak
•4 Faculty, 6-8 delegates 3% 3%
Mortality 2% 2%
*Miskovic and Wyles, Ann Surg 2010 (in press)
19. Clinical outcomes of
THE NATIONAL TRAINING PROGRAMME
the NTP
Parameter Experts* NTP
Conversions 10% 7%
25%
Complications 1 - DRY SKILLS
DAY
15%
Lapco TT
Anastomotic leak 3% 3%
Mortality 2% 2%
*Miskovic and Wyles, Ann Surg 2010 (in press)
20. Clinical outcomes of
THE NATIONAL TRAINING PROGRAMME
the NTP
Parameter Experts* NTP
Conversions 10% 7%
DAY 2 – IN THEATRE
Complications
Lapco TT 25% 15%
Anastomotic leak 3% 3%
Mortality 2% 2%
*Miskovic and Wyles, Ann Surg 2010 (in press)
21. Lapco TT Clinical outcomes of
the NTP
Train theTrainer course
•2 Day Course Parameter Experts* NTP
•4 Faculty Conversions 10% 7%
•6 delegates
Complications 25% 15%
•41/60 trainers
participated by
Anastomotic leak 3% 3%
Jan 2012
Mortality 2% 2%
*Miskovic and Wyles, Ann Surg 2010 (in press)
23. Clinical outcomes of
How do I get trained ?
the NTP
1.Plan
Parameter Experts* NTP
2.Talk
Conversions 10% 7%
3.Be there!
Complications 25% 15%
Anastomotic leak 3% 3%
Mortality 2% 2%
*Miskovic and Wyles, Ann Surg 2010 (in press)
24. Clinical outcomes of the NTP
acknowledgments
Training centres :
Basingstoke/Frimley: Mr Tom Cecil, Mr Mark Gudgeon
Parameter Experts*
Bradford: Mr John Griffith, Mr Matt Clarke & Mr Richard Slater NTP
Hull: Mr James Gunn, John Hartley
Conversions 10%
King’s/St Thomas: Mr Savvas Papagrigoriadis, Mr Vivek Datta
Newcastle/Gateshead: Mr Alan Horgan, Mr Hugh Gallagher, Mr Mark Kratory
7%
North West: Mr Selva Sekar, Mr David Watson,
Complications 25%
Nottingham: Mr Charles Maxwell-Armstrong, Mr Austin Acheson, Mr Andy Miller 15%
Oxford: Mr Chris Cunningham, Mr Ian Lindsey, Mr Mike Stellakis
Portsmouth: Mr Amjad Parvaiz, Mr Jim Khan
Anastomotic leak 3% 3%
South West: Mr Nader Francis, Mr Rob Longman, Mr Tony Dixon, Mr Steve Mansfield, Mr Nick Kenefick, Mr
Adam Widdison
St Marks/Colchester/Guildford: Mr Robin Kennedy, Mr Iain Jenkins, Prof Roger Motson, Mr Tan
Mortality 2%
Arulampalam, Prof Tim Rockall, Mr Ralph Austin, Mr Zulfiqar Khan 2%
Programme Manager Laura Langsford Administrator Tania Dorey NCAT Lead Andrew McMeeking
National Director of Cancer Services Professor Sir Michael Richards
*Miskovic and Wyles, Ann Surg 2010 (in press)
Chairmen, Ladies and Gentlemen. Thank you for the opportunity to present our data at this meeting. I am going to talk about educational and clinical outcomes of the National Training programme in Laparoscopic Colorectal Surgery.
This was the rationale for the setup of the an educational programme funded by the Department of health. The Programme has a very pragmatic approach as shown on this diagram. Colorectal consultants who successfully applied for the programme and completed a course in LCS will be allocated to one of the 11 training centres across the country. They will perform laparoscopic colorectal resections under the supervision of an expert laparoscopic surgeon until they reach competence, before they embark on solo training in their own hospitals. >> This should ideally reflect their increasing levels of proficiency and can last up to two years. >> At each step of training a structured assessment and audit process is performed guided by Imperial College. In this presentation I would like to concentrate on the outcomes during this phase of supervised training.
Since the publication of the amended NICE guidelines the benefits of LCS for short term outcomes got official character.
Nevertheless, considering that the introduction of LCS took place in the early nineties it is striking that the uptake of LCS in this country was very poor. For the period of 2007 only 10% of all colorectal procedures have been performed laparoscopically. There are several reasons for this slow uptake.
At the same time a meta-analysis, that will be published in the December issue of the Ann Surg, shows that clinical outcomes are not at risk as long surgeons are adequatly supervised during their training period.
Plotting the overall scores on as CUSUM proficiency gain curves show that on average roughly 25 supervised cases are required before the trainees are recommended for sign off and independent training. It also shows us that different parts of the procedure are learnt at different speeds. >> More importantly, the tool allows us to differentiate between learning curves of different trainees in order to define the time it takes them individually to reach the plateau.