Initial Learning Period Research Articles

Clinical outcomes of bioresorbable vascular scaffolds implanted with routine versus selective optical coherence tomography guidance: results from a single-centre experience.

We aimed to investigate the effects of an initial learning period with mandatory optical coherence tomography (OCT) guidance for the implantation of everolimus-eluting bioresorbable vascular scaffolds (BVS). We analysed procedural and clinical outcomes of all BVS implantations at a single centre where OCT guidance was mandatory in the initial rollout (OCT-mandatory) phase. We compared these data with the later phase where use of OCT was at operator discretion (OCT-selective or angiography). We implanted 406 BVS in 306 vessels (201 OCT, 105 angiography) in 272 patients. Follow-up duration was 38±10 months. Annualised rates of device-oriented cardiac events (DOCE) and scaffold thrombosis (ScT) were 1.4% and 0.4%, respectively. The risks of DOCE (HR 1.06, 95% CI: 0.33-3.34; p=0.71) and ScT (HR 0.48, 95% CI: 0.07-3.85; p=0.49) were not significantly different when comparing the OCT and angiography groups. Routine use of OCT to guide and optimise BVS implants results in very acceptable outcomes. Further, the benefits of such an early OCT-mandatory "learning" period persist after cessation of routine OCT usage when imaging is not routinely used. A period of mandatory OCT usage for BVS implants may therefore be beneficial in improving patient outcomes with these devices.

The use of apps to promote energy saving: a study of smart meter\u2013related feedback in the Netherlands

Feedback systems with direct feedback have shown to be effective in stimulating households to change their energy consumption levels. This research is one of the first to explore the use of apps to influence household energy use. Compared to dedicated in-home displays, smartphone/tablet apps provide a low-cost and simple design solution for making energy feedback available. This research consisted of three studies conducted with different samples within a selection of households where a smart meter was installed as part of the smart meter implementation program in the Netherlands. First, for a period of 16 months, electricity and gas consumption levels were measured for a large sample of households (n = 519) divided into an application user group and a reference group. Second, questionnaires (n = 270) provided insight in how people used the applications and to what extent the applications increased households’ insight in their energy consumption and stimulated behavior changes. Third, interviews (n = 12) were held to obtain more in-depth insight. In the sample with measured energy consumption, we did not find a significant reduction in electricity and gas consumption during this research. Yet in the questionnaires, the application users reported more energy awareness and indicated to have made more investments and changes in their behavior than the reference group. Most app users started using the first app they found and did not explore the other options. The interview results indicate that, after an initial learning period, the app was used to monitor the electricity and gas consumption levels, rather than to lower them. In line with other research into feedback, the interview results suggest that the apps could be more effective with information that is more actionable and meaningful with respect to one’s own specific situation and goals for the household. Further exploration is recommended with respect to how the design of such apps can encourage a wide audience not only to monitor their consumption, but also guide them in taking action to change their consumption levels.

Robotic Anatomical Segmentectomy: An Analysis of the Learning Curve

Robotic segmentectomy has been suggested as a safe and effective management for early lung cancer and benign lung diseases. However, no large case series have documented the learning curve for this technically demanding procedure. We conducted a retrospective study for robotic segmentectomy performed by the same surgeon between June 2015 and November 2017. The learning curve was initially analyzed using the cumulative sum (CUSUM) method to assess changes in the total operative times across the case sequence. Subsequently, an in-depth learning curve was generated using the risk-adjusted CUMSUM method, which considered perioperative risk factors and surgical failure. This study included 104 cases, and 87 were malignant. The median operative time was 145 minutes (interquartile range [IQR], 120 to 180) and the median blood loss was 100 mL (IQR, 50 to 100). The median length of stay was 4 days (IQR, 3 to 5). Based on the CUSUM and risk-adjusted CUSUM analyses, the learning curve could be divided into 3 different phases: phase I, the initial learning period (first to 21st operation); phase II, the consolidation period (22nd to 46th operation); and phase III, the experienced period (47th to 104th operation). The operative time and intraoperative blood loss tended to decrease after the initial learning phase. Other perioperative outcomes were not significantly different among the 3 phases. The learning curve of robotic segmentectomy consisted of 3 phases. The technical competency for assuring feasible perioperative outcomes was achieved in phase II at the 40th operation.

Field test of neural-network based automatic bucket-filling algorithm for wheel-loaders

Abstract Automation of earth-moving industries (construction, mining and quarry) require automatic bucket-filling algorithms for efficient operation of front-end loaders. Autonomous bucket-filling is an open problem since three decades due to difficulties in developing useful earth models (soil, gravel and rock) for automatic control. Operators make use of vision, sound and vestibular feedback to perform the bucket-filling operation with high productivity and fuel efficiency. In this paper, field experiments with a small time-delayed neural network (TDNN) implemented in the bucket control-loop of a Volvo L180H front-end loader filling medium coarse gravel are presented. The total delay time parameter of the TDNN is found to be an important hyperparameter due to the variable delay present in the hydraulics of the wheel-loader. The TDNN network successfully performs the bucket-filling operation after an initial period (100 examples) of imitation learning from an expert operator. The demonstrated solution show only 26% longer bucket-filling time, an improvement over manual tele-operation performance.

The Impact of Electronic Medical Record Implementation on Labor Cost and Productivity at an Outpatient Orthopaedic Clinic.

Widespread adoption of electronic medical record (EMR) systems is increasing. EMR implementation can be costly and typically requires workflow redesign. To our knowledge, no studies to date have examined the impact of EMR implementation using advanced cost accounting methods or the impact of its implementation on orthopaedic surgeons in an outpatient setting. Time-driven activity-based costing (TD-ABC) was used to evaluate the effect of EMR implementation in an outpatient adult reconstruction clinic. One hundred and forty-three patients were prospectively timed throughout their visit to clinics, before implementation of a hospital system-wide EMR system and then again 2 months, 6 months, and 2 years after implementation. Data were analyzed to investigate the effects of EMR implementation on labor cost and provider time. Total labor costs per patient visit significantly increased at 2 months after EMR implementation (from $36.88 to $46.04; p = 0.05). Drivers of this change included increases in the amount of time that attending surgeons spent per patient (from 9.38 to 10.97 minutes, with the cost increasing from $21.10 to $27.01), as well as increased time that certified medical assistants spent assessing patients (from 3.4 to 9.1 minutes; p < 0.001). Two months after EMR implementation, providers were spending more than twice as long documenting patient encounters (7.6 compared with 3.3 minutes; p < 0.001). However, by 6 months after implementation, total labor costs were similar to those before implementation ($38.75 compared with $36.88; p = 0.689) and they remained similar at 2 years after implementation ($36.88 compared with $37.73; p = 0.84). After the initial learning period following EMR implementation, providers spent more time documenting encounters (8.43 compared with 3.28 minutes; p < 0.001) but less time interacting with patients (10.03 compared with 14.65 minutes; p = 0.013). Using TD-ABC, we observed the EMR implementation learning period, returning to pre-introduction efficiency at 6 months. Cost increases because of increased certified medical assistant time spent with patients and physician time on documentation were offset by less patient-physician interaction. Health-care systems and policymakers should be aware that the length of the implementation period is approximately 6 months and that implementation may alter the time that providers spend with patients. This article offers insight into the impact of EMR implementation on the orthopaedic surgeon's clinic efficiency and workflows.

Multidimensional analyses of the learning curve for single‐incision plus one port laparoscopic surgery for sigmoid colon and upper rectal cancer

Single-incision plus one port surgery (SILS + 1) provides the advantages of being minimally invasive and easier to perform than pure single-incision laparoscopic surgery. The aim of this study was to investigate the learning curve (LC) for SILS + 1 for sigmoid colon and upper rectal cancer. From November 2012 to May 2014, a series of 85 consecutive patients underwent selective SLIS + 1 for sigmoid colon and upper rectal cancer performed by a single surgeon at Nanfang Hospital. The LC for SILS + 1 was evaluated using cumulative sum control chart (CUSUM) and risk-adjusted CUSUM methods. Data for all the perioperative variables and pathologic results among the phases were compared. The LC had three phases: phase 1 (cases 1-13) was the initial learning period; phase 2 (cases 14-44) was the learning plateau period; and phase 3 (cases 45-85) was the competent period. The differences in total operating time among the three phases were significant. The number of harvested lymph nodes increased along with increases in the surgeon's experience. For experienced CLS surgeons, the learning process reached the plateau period after the 13th case, and technical competence was achieved after the 44th case.

Feasibility of predicting tumor motion using online data acquired during treatment and a generalized neural network optimized with offline patient tumor trajectories.

The accurate prediction of intrafraction lung tumor motion is required to compensate for system latency in image-guided adaptive radiotherapy systems. The goal of this study was to identify an optimal prediction model that has a short learning period so that prediction and adaptation can commence soon after treatment begins, and requires minimal reoptimization for individual patients. Specifically, the feasibility of predicting tumor position using a combination of a generalized (i.e., averaged) neural network, optimized using historical patient data (i.e., tumor trajectories) obtained offline, coupled with the use of real-time online tumor positions (obtained during treatment delivery)was examined. A 3-layer perceptron neural network was implemented to predict tumor motion for a prediction horizon of 650ms. A backpropagation algorithm and batch gradient descent approach were used to train the model. Twenty-seven 1-min lung tumor motion samples (selected from a CyberKnife patient dataset) were sampled at a rate of 7.5Hz (0.133s) to emulate the frame rate of an electronic portal imaging device (EPID). A sliding temporal window was used to sample the data for learning. The sliding window length was set to be equivalent to the first breathing cycle detected from each trajectory. Performing a parametric sweep, an averaged error surface of mean square errors (MSE) was obtained from the prediction responses of seven trajectories used for the training of the model (Group 1). An optimal input data size and number of hidden neurons were selected to represent the generalized model. To evaluate the prediction performance of the generalized model on unseen data, twenty tumor traces (Group 2) that were not involved in the training of the model were used for the leave-one-out cross-validation purposes. An input data size of 35 samples (4.6s) and 20 hidden neurons were selected for the generalized neural network. An average sliding window length of 28 data samples was used. The average initial learning period prior to the availability of the first predicted tumor position was 8.53±1.03s. Average mean absolute error (MAE) of 0.59±0.13mm and 0.56±0.18mm were obtained from Groups 1 and 2, respectively, giving an overall MAE of 0.57±0.17mm. Average root-mean-square-error (RMSE) of 0.67±0.36 for all the traces (0.76±0.34mm, Group 1 and 0.63±0.36mm, Group 2), is comparable to previously published results. Prediction errors are mainly due to the irregular periodicities between cycles. Since the errors from Groups 1 and 2 are within the same range, it demonstrates that this model can generalize and predict on unseen data. This is a first attempt to use an averaged MSE error surface (obtained from the prediction of different patients' tumor trajectories) to determine the parameters of a generalized neural network. This network could be deployed as a plug-and-play predictor for tumor trajectory during treatment delivery, eliminating the need for optimizing individual networks with pretreatment patient data.

Single-center implementation of endoscopic submucosal dissection (ESD) in the colorectum: Low recurrence rate after intention-to-treat ESD.

Colorectal endoscopic submucosal dissection (ESD) shows higher R0 resection and lower local recurrence rates than endoscopic mucosal resection (EMR) in Japan. In Europe, independent learning of ESD in the colorectum is feasible, but yet to be analyzed for curative resection and recurrence rates. After experimental training under supervision by Japanese experts (T.O., N.Y.), three endoscopists independently carried out 83 ESD procedures intention-to-treat for lesions in the entire colorectum of 67 patients in a prospective registry (November 2009 to June 2016). ESD was feasible in 80 (96%) colorectal neoplasias (mean diameter 33.6[±1.8]mm), and three more required conversion to piecemeal EMR. The lesions were adenomas in 66% with low-grade intraepithelial neoplasia (LGIN), 29% with high-grade intraepithelial neoplasia, and 5% with carcinomas (G2, pT1). ESD had to be facilitated by the final use of snaring (hybrid-ESD, n=45), especially in the initial learning period. En-bloc resection rate was 85%. Complications were microperforations (7%, conducive to one hemicolectomy), and delayed bleeding (1%) without mortality or long-term morbidity. Residual adenomas with LGIN (5%) after hybrid-ESD did not recur after endoscopic ablation. All malignant neoplasias (34%) were curatively resected without recurrence after a mean follow up of 19.5(±3.2) months. During independent ESD learning in the colorectum, ESD intention-to-treat showed a low recurrence rate after appropriate training, and hybrid-ESD showed acceptable complication and recurrence rates, justifying hybrid-ESD as a strategy for self-completion and rescue.

Learning curve in concurrent application of laparoscopic and robotic-assisted hysterectomy with lymphadenectomy in endometrial cancer

ObjectiveTo evaluate the concurrent interaction of laparoscopic and robotic-assisted surgery in the initial learning period of endometrial cancer staging. Materials and methodsA retrospective cohort study was performed for the first 44 consecutive patients with endometrial cancer underwent laparoscopic (LSS) or robotic-assisted staging surgery (RSS) from February 2012 to October 2015 by a single surgeon in a tertiary care referral hospital. Demographics, diagnosis, perioperative variables, and complications were recorded. Quality of surgery was determined by the number of lymph nodes dissected and learning curve was estimated by operative time with respect to chronologic order of operation. ResultsTwenty-four patients received LSS and 20 patients received RSS. RSS required longer operative time, but obtained more total number of lymph nodes compared with LSS (286.9 vs. 201.9 min (p < 0.001); 26.2 vs. 20.7 (p < 0.05), respectively. There were no difference in blood loss, number of para-aortic nodes removed, complications and hospital stay between the two types of surgery. An additive model based on tumor grade, body mass index, estimated blood loss and chronological order of operation was constructed to fit operative time of these two types of surgery. Proficiency of achievement was not observed for LSS and was 6 for RSS. ConclusionsOperative time was longer but Lymph node dissection was easier in RSS. Learning curve for LSS to maintain similar surgical quality as RSS was not observed. The concurrent use of robotic platform in the initial practice of minimally invasive staging surgery could optimize surgical technique for LSS.

With the Advent of Tomosynthesis in the Workup of Mammographic Abnormality, is Spot Compression Mammography Now Obsolete? An Initial Clinical Experience.

To determine if the routine use of spot compression mammography is now obsolete in the assessment of screen detected masses, asymmetries and architectural distortion since the availability of digital breast tomosynthesis. We introduced breast tomosynthesis in the workup of screen detected abnormalities in our screening center in January 2015. During an initial learning period with tomosynthesis standard spot compression views were also performed. Three consultant breast radiologists retrospectively reviewed all screening mammograms recalled for assessment over the first 6-month period. We assessed retrospectively whether there was any additional diagnostic information obtained from spot compression views not already apparent on tomography. All cases were also reviewed for any additional lesions detected by tomosynthesis, not detected on routine 2-view screening mammography. 548 women screened with standard 2-view digital screening mammography were recalled for assessment in the selected period and a total of 565 lesions were assessed. 341 lesions were assessed by both tomosynthesis and routine spot compression mammography. The spot compression view was considered more helpful than tomosynthesis in only one patient. This was because the breast was inadequately positioned for tomosynthesis and the area in question was not adequately imaged. Apart from this technical error there was no asymmetry, distortion or mass where spot compression provided more diagnostic information than tomosynthesis alone. We detected three additional cancers on tomosynthesis, not detected by routine screening mammography. From our initial experience with tomosynthesis we conclude that spot compression mammography is now obsolete in the assessment of screen detected masses, asymmetries and distortions where tomosynthesis is available.

The effect of inhibitory control and its training on L1 and a new learned language switching

Aims: This study aimed to investigate how individuals’ inhibitory control (IC) ability affects language switching in the initial period of language learning. Design: Using a pretest/posttest design and event-related potential (ERP) methodology, we investigated the effect of IC on Chinese–English bilinguals during their language switching between Chinese (L1) and Korean (a language new to the participants, Lnew). All participants were required to name pictures (picture-naming task) in their L1 and Lnew in the pretest and posttest. Low-IC participants received an IC task training between the pretest and the posttest, while the high-IC group did not. Data and analysis: Analyses of both response latencies and ERP data were conducted by repeated-measures ANOVA. Findings: Results showed that the high-IC group exhibited symmetrical switch costs in both the pretest and the posttest. Besides, a more obvious late positive component (LPC) was observed when the high-IC participants switched from L1 to Lnew than the other way around, indicating their ability to inhibit cross-language interference. In contrast, the low-IC group exhibited asymmetrical switch costs, and no amplitude difference when switching between Lnew and L1 in the pretest. However, in the posttest, the switch costs pattern and the LPC results of the low-IC group became similar to those of the high-IC group. Innovation: The present study was a first attempt to provide electrophysiological evidence that IC ability plays an important role during L1–Lnew switching. Significance: These findings support the hypothesis that individuals’ IC ability plays a role of suppressing the non-target lexical access during language switching in the initial period of second language learning. The results also indicate that the relevant training in IC ability could contribute to the improvement of the language-switching efficiency in the initial period of language learning.

Analysis of the learning curve for peroral endoscopic myotomy for esophageal achalasia: Single-center, two-operator experience.

Peroral endoscopic myotomy (POEM) has emerged as an advanced technique for the treatment of achalasia, and defining the learning curve is mandatory. From August 2011 to June 2014, two operators in our institution (A&B) carried out POEM on 35 and 33 consecutive patients, respectively. Moving average and cumulative sum (CUSUM) methods were used to analyze the POEM learning curve for corrected operative time (cOT), referring to duration of per centimeter myotomy. Additionally, perioperative outcomes were compared among distinct learning curve phases. Using the moving average method, cOT reached a plateau at the 29th case and at the 24th case for operators A and B, respectively. CUSUM analysis identified three phases: initial learning period (Phase 1), efficiency period (Phase 2) and mastery period (Phase 3). The relatively smooth state in the CUSUM graph occurred at the 26th case and at the 24th case for operators A and B, respectively. Mean cOT of distinct phases for operator A were 8.32, 5.20 and 3.97 min, whereas they were 5.99, 3.06 and 3.75 min for operator B, respectively. Eckardt score and lower esophageal sphincter pressure significantly decreased during the 1-year follow-up period. Data were comparable regarding patient characteristics and perioperative outcomes. This single-center study demonstrated that expert endoscopists with experience in esophageal endoscopic submucosal dissection reached a plateau in learning of POEM after approximately 25 cases.

Robotic right hemicolectomy: Analysis of 108 consecutive procedures and multidimensional assessment of the learning curve

PurposeSurgeons tend to view the robotic right colectomy (RRC) as an ideal beginning procedure to gain proficiency in robotic general and colorectal surgery. Nevertheless, oncological RRC, especially if performed with intracorporeal ileocolic anastomosis confectioning, cannot be considered a technically easier procedure. The aim of this study was to assess the learning curve of the RRC performed for oncological purposes and to evaluate its safety and efficacy investigating the perioperative and pathology outcomes in the different learning phases. MethodsData on a consecutive series of 108 patients undergoing RRC with intracorporeal anastomosis between June 2011 and September 2015 at our institution were prospectively collected to evaluate surgical and short-term oncological outcomes. CUSUM (Cumulative Sum) and Risk-Adjusted (RA) CUSUM analysis were performed in order to perform a multidimensional assessment of the learning curve for the RRC surgical procedure. Intraoperative, postoperative and pathological outcomes were compared among the learning curve phases. ResultsBased on the CUSUM and RA-CUSUM analyses, the learning curve for RRC could be divided into 3 different phases: phase 1, the initial learning period (1st–44th case); phase 2, the consolidation period (45th–90th case); and phase 3, the mastery period (91th–108th case). Operation time, conversion to open surgery rate and the number of harvested lymph nodes significantly improve through the three learning phases. ConclusionsThe learning curve for oncological RRC with intracorporeal anastomosis is composed of 3 phases. Our data indicate that the performance of RRC is safe from an oncological point of view in all of the three phases of the learning curve. However, the technical skills necessary to significantly reduce operative time, conversion to open surgery rate and to significantly improve the number of harvested lymph nodes were achieved after 44 procedures. These data suggest that it might be prudent to start the RRC learning curve by treating only benign diseases and to reserve the performance of oncological resection to when at least the initial learning phase has been completed.

Predictive risk factors of postoperative urinary incontinence following holmium laser enucleation of the prostate during the initial learning period.

ABSTRACTPurpose:To determine the predictive factors for postoperative urinary incontinence (UI) following holmium laser enucleation of the prostate (HoLEP) during the initial learning period.Patients and Methods:We evaluated 127 patients with benign prostatic hyperplasia who underwent HoLEP between January 2011 and December 2013. We recorded clinical variables, including blood loss, serum prostate-specific antigen levels, and the presence or absence of UI. Blood loss was estimated as a decline in postoperative hemoglobin levels. The predictive factors for postoperative UI were determined using a multivariable logistic regression analysis.Results:Postoperative UI occurred in 31 patients (24.4%), but it cured in 29 patients (93.5%) after a mean duration of 12 weeks. Enucleation time >100 min (p=0.043) and blood loss >2.5g/dL (p=0.032) were identified as significant and independent risk factors for postoperative UI.Conclusions:Longer enucleation time and increased blood loss were independent predictors of postoperative UI in patients who underwent HoLEP during the initial learning period. Surgeons in training should take care to perform speedy enucleation maneuver with hemostasis.

Sci‐Thur AM: YIS – 05: Prediction of lung tumor motion using a generalized neural network optimized from the average prediction outcome of a group of patients

Purpose:In image‐guided adaptive radiotherapy systems, prediction of tumor motion is required to compensate for system latencies. However, due to the non‐stationary nature of respiration, it is a challenge to predict the associated tumor motions. In this work, a systematic design of the neural network (NN) using a mixture of online data acquired during the initial period of the tumor trajectory, coupled with a generalized model optimized using a group of patient data (obtained offline) is presented.Methods:The average error surface obtained from seven patients was used to determine the input data size and number of hidden neurons for the generalized NN. To reduce training time, instead of using random weights to initialize learning (method 1), weights inherited from previous training batches (method 2) were used to predict tumor position for each sliding window.Results:The generalized network was established with 35 input data (∼4.66s) and 20 hidden nodes. For a prediction horizon of 650 ms, mean absolute errors of 0.73 mm and 0.59 mm were obtained for method 1 and 2 respectively. An average initial learning period of 8.82 s is obtained.Conclusions:A network with a relatively short initial learning time was achieved. Its accuracy is comparable to previous studies. This network could be used as a plug‐and play predictor in which (a) tumor positions can be predicted as soon as treatment begins and (b) the need for pretreatment data and optimization for individual patients can be avoided.

The Learning Curve for Transcatheter Mitral Valve Repair With MitraClip

This study sought to assess the learning curve for TMVR for treatment of primary mitral regurgitation (MR). Data are lacking regarding the technical experience required to achieve optimal clinical outcomes with transcatheter mitral valve repair (TMVR) using the edge-to-edge MitraClip technique. We examined the sequential experience of the first 75 patients (age 80 ± 9 years; 77% male) who underwent TMVR at our institution. A sequence number of each patient was assigned as a continuous variable and in tertiles for analysis. TMVR with MitraClip was successful in 97% with an average procedural time of 106 ± 39 minutes. The 30-day rate of major adverse cardiovascular events was 7%. With increased case experience, there were decreases in procedural time, fluoroscopy time, length of hospital stay, and major adverse cardiovascular events. Procedural success, residual mitral regurgitation and NYHA functional classification at 30-day follow-up remained unchanged throughout the experience. The learning curve for TMVR with MitraClip for treatment of primary MR is characterized by a sequential reduction in procedure time, fluoroscopy time, procedural complications, and hospital length of stay at a tertiary academic medical center. Thirty-day procedural results are favorable and similar during the initial learning period.

Learning Curve for Laparoscopic Pancreaticoduodenectomy: a CUSUM Analysis

BackgroundLaparoscopic pancreaticoduodenectomy (LPD), an advanced minimally invasive technique, has demonstrated advantages to open pancreaticoduodenectomy (OPD). However, this complex procedure requires a relatively long training period to ensure technical proficiency. This study was therefore designed to analyze the learning curve for LPD. MethodsFrom October 2010 to September 2015, 63 standard pancreaticoduodenectomy procedures were to be performed laparoscopically by a single surgeon at the Department of Pancreatic Surgery, West China Hospital, Sichuan University, China. After applying the inclusion and exclusion criteria, a total of 57 patients were included in the study. Data for all the patients, including preoperative, intraoperative, and postoperative variables, were prospectively collected and analyzed. The learning curve for LPD was evaluated using both cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. All of the variables among the learning curve phases were compared. ResultsBased on the CUSUM and the RA-CUSUM analyses, the learning curve for LPD was grouped into three phases: phase I was the initial learning period (cases 1–11), phase II represented the technical competence period (cases 12–38), and phase III was regarded as the challenging period (cases 39–57). The operative time, intraoperative blood loss, and postoperative ICU demand significantly decreased with the learning curve. More lymph nodes were collected after the initial learning period. There were no significant differences in terms of postoperative complications or the 30-day mortality among the three phases. More challenging cases were encountered in phase III. ConclusionsAccording to this study, the learning curve for LPD consisted of three phases. Conservatively, to attain technical competence for performing LPD, a minimum of 40 cases are required for laparoscopic surgeons with a degree of laparoscopic experience.

Early Outcomes of Endoscopic Vein Harvesting during the Initial Learning Period.

BackgroundThe endoscopic vein harvesting (EVH) method has been used in coronary artery bypass surgery in many countries. We started using the EVH method recently, and investigated the results during the early learning period.MethodsBetween March 2012 and June 2014, 75 patients (31 patients in the EVH method group, and 44 patients in the open method group) who underwent isolated first-time coronary artery bypass grafting using vein grafts were retrospectively analyzed with respect to the early outcomes including graft patency and risk factors for leg wound complications. For assessing the patency of vein graft, we performed coronary computed tomography angiography during the immediate postoperative period and 6 months later.ResultsMean harvesting time of endoscopic method was about 15 minutes. Patency rate during the immediate operative period and the 6-month patency rate were similar between the two groups (postoperative period: EVH 100% vs. open method 94.4%, p=0.493; at 6 months: EVH 93.3% vs. open method 90.9%, p=0.791). Leg wound complications occurred more frequently in the open method group (EVH 3.2% vs. open method 13.6%, p=0.127). According to the analysis, age was an independent risk factor for leg wound complications.ConclusionEVH is a feasible method even for beginners and can be performed satisfactorily during their learning period.

Femtosecond laser will not be a standard method for cataract extraction ten years from now

The femtosecond laser was recently introduced to cataract surgery in order to replace several highly successful and low risk manual surgical techniques with automated laser techniques. Despite the hope that femtosecond laser-assisted cataract surgery (FLACS) would lead to safer and more predictable surgical outcomes, the literature consistently demonstrates that FLACS has provided no advantage over standard phacoemulsification cataract surgery (SP). Yet, the disadvantages of FLACS as compared to SP are clear. FLACS is more expensive and time-consuming, may increase surgical complications during the surgeon's initial learning period, introduces unique risks due to the additional steps of laser docking and treatment, and is limited in its scope of use as compared to SP due to factors including small pupils and orbital anatomy. While FLACS may one day prove to be advantageous for a small subset of patients, such as those with corneal endothelial cell dysfunction or zonular instability, these patients have not been the targets of this technology, and FLACS will not become the standard technique for cataract extraction in the coming decade.

ANALYZING COMPLAINTS BY INDONESIAN EFL SPEAKERS

The English language competence of an EFL learner can be reflectedin his pragmatic competence. Yet, for language learners and teachers a mastery of the pragmatic competence may unconsciously be neglected. In other words, it may not be taught in line with the grammatical competence since the initial period of learning. The article centers on two problems: (1) the similarities and differences of speech act of complaints among Indonesian EFL learners, Indonesian EFL teachers and American native speakers, and (2) the evidence of any pragmatic transfer in the complaint performance. DCT was used to gather the data, which was then analyzed using Rinnert, Nogami and Iwai?s aspects of complaining (2006). It was found that there were both differences and similarities of complaints performed by both the native and non-native speakers of English when power and social status were involved. Some evidence on pragmatic transfer was also tangible; mainly it was due to cultural differences