Explore the vast range of titles available.

Background Increased uptake of robotic surgery has led to interest in learning curves for robot‐assisted procedures. Learning curves, however, are often poorly defined. This systematic review was conducted to identify the available evidence investigating surgeon learning curves in robot‐assisted surgery. Methods MEDLINE, Embase and the Cochrane Library were searched in February 2018, in accordance with PRISMA guidelines, alongside hand searches of key congresses and existing reviews. Eligible articles were those assessing learning curves associated with robot‐assisted surgery in patients. Results Searches identified 2316 records, of which 68 met the eligibility criteria, reporting on 68 unique studies. Of these, 49 assessed learning curves based on patient data across ten surgical specialties. All 49 were observational, largely single‐arm (35 of 49, 71 per cent) and included few surgeons. Learning curves exhibited substantial heterogeneity, varying between procedures, studies and metrics. Standards of reporting were generally poor, with only 17 of 49 (35 per cent) quantifying previous experience. Methods used to assess the learning curve were heterogeneous, often lacking statistical validation and using ambiguous terminology. Conclusion Learning curve estimates were subject to considerable uncertainty. Robust evidence was lacking, owing to limitations in study design, frequent reporting gaps and substantial heterogeneity in the methods used to assess learning curves. The opportunity remains for the establishment of optimal quantitative methods for the assessment of learning curves, to inform surgical training programmes and improve patient outcomes. Antecedentes La aceptación creciente de la cirugía robótica ha generado interés en las curvas de aprendizaje para los procedimientos asistidos por robot. Sin embargo, las curvas de aprendizaje a menudo están mal definidas. Esta revisión sistemática se realizó para identificar la evidencia disponible en relación a las curvas de aprendizaje del cirujano en la cirugía asistida por robot. Métodos En Febrero de 2018, se realizaron búsquedas en MEDLINE, Embase y Cochrane Library, de acuerdo con las recomendaciones PRISMA, junto con búsquedas manuales de congresos clave y de revisiones ya existentes. Los artículos elegibles fueron aquellos que evaluaron las curvas de aprendizaje asociadas con la cirugía asistida por robot efectuada en pacientes. Resultados Las búsquedas bibliográficas identificaron 2.316 registros de los cuales 68 cumplían los criterios de elegibilidad y correspondían a 68 estudios primarios. De estos 68 estudios, 49 evaluaron las curvas de aprendizaje basadas en datos de pacientes de 10 especialidades quirúrgicas. Los 49 estudios eran todos estudios observacionales, en su mayoría de un solo brazo (35/49 (71%)) e incluían pocos cirujanos. Las curvas de aprendizaje mostraban una notable heterogeneidad, variando entre procedimientos, estudios y parámetros analizados. Los estándares de presentación de informes fueron generalmente deficientes, con solo 17/49 (35%) cuantificando la experiencia previa. Los métodos utilizados para evaluar la curva de aprendizaje fueron heterogéneos, a menudo carecían de validación estadística y usaban terminología ambigua. Conclusión Las estimaciones de la curva de aprendizaje estaban sujetas a una considerable incertidumbre, careciendo de evidencia robusta por las limitaciones en el diseño del estudio, lagunas de información en los artículos y heterogeneidad sustancial en los métodos utilizados para evaluar las curvas de aprendizaje. Queda pendiente establecer métodos cuantitativos óptimos para evaluar las curvas de aprendizaje, informar de los programas de formación quirúrgica y mejorar los resultados del paciente. A broad systematic literature review was performed to characterize the current evidence base and appraise the methods used to measure and define learning curves for surgeons performing robot‐assisted surgery, taking a holistic, panspecialty view. The learning curve estimates identified are subject to considerable uncertainty, and robust evidence was often lacking due to limitations in study design and frequent reporting gaps. Thus, the opportunity remains for the establishment of optimal quantitative methods for the assessment of learning curves, which may inform surgical training programmes and improve patient outcomes. Little consistency between studies

IntroductionGlobally, burns are responsible for around 11 million injuries and 180 000 burn-related deaths yearly. Unfortunately, 9 of 10 burn injuries and deaths happen in low-and-middle-income countries (LMICs) such as Pakistan. One in three people admitted to hospitals with burn injuries die within three weeks, and survivors face serious lifelong physical, emotional and psychosocial problems. This may result in anxiety, depression, post-traumatic stress disorder, increased mortality and social disintegration. This study aims to evaluate if implementation of a culturally adapted multidisciplinary rehabilitation programme for burn survivors is clinically and cost-effective, sustainable and scalable across Pakistan.Objectives- To understand lived experiences of burn survivors, families, and other stakeholders including the experience of care and impact of burns To work together with key stakeholders (such as burn survivors, family members) to adapt a culturally appropriate affordable burn rehabilitation programme- To undertake social media campaigns to promote burn prevention and risk assessment at communities, workplaces/industries/households; improve first aid; and address burn related stigma- To work with policy makers/parliamentarians to develop national guidelines for burns care and prevention in PakistanMethodsThere are 6 work-packages (WPs). WP1 is to co-adapt a culturally appropriate burn care and rehabilitation programme. WP2 will develop and implement national burn registry on WHO’s initiative. WP3 is a cluster randomised controlled trial to determine clinical and cost-effectiveness in Pakistan. WP4 will evaluate social media campaigns for burn prevention and reduce stigma. WP5 involves working with key-stakeholders for burns-related care and policy and WP6 offers sustainable capacity and capability for burns treatment and rehabilitation.ResultsA clinical and cost-effective burn care quality and rehabilitation programme may have a huge potential to save lives and contribute health and socio-economic benefits for patients, families, and the healthcare system in Pakistan. The nation-wide implementation and involvement of burn centres across all provinces offer an excellent opportunity to overcome the problem of burn care access experienced in LMICs.ConclusionsTo date, burns prevention, care and rehabilitation have not received sufficient attention in policy initiatives in Pakistan and other LMICs. This study is an excellent opportunity to evaluate culturally adapted burn care and rehabilitation programmes that can be implemented across LMICs. We will disseminate our findings widely, using a variety of approaches, supported by our stakeholder and patient advisory groups.Disclosure of InterestNone Declared

Cancer of the oesophagus, gastro-oesophageal junction (GOJ) and stomach remains a major health problem worldwide. The evidence base for the optimal management of patients with operable oesophago-gastric cancer is evolving. Accepted approaches include preoperative chemotherapy followed by surgery (oesophageal cancer), chemo-radiotherapy alone (oesophageal cancer) and perioperative chemotherapy (gastric and gastro-oesophageal adenocarcinomas). The underlying principles behind neoadjuvant therapy are to improve resectability of the tumour by tumour shrinkage/downstaging and to treat occult metastatic disease as early as possible. The response rate to cytotoxic therapy is about 40% in oesophago-gastric cancer. Available evidence suggests that a favourable histopathological response to cytotoxic therapy may be a useful positive predictive marker in oesophago-gastric cancer. However, the ability to predict tumour response in routine clinical practice is difficult and is an area of intense investigation. There is evolving evidence for the role of predictive biomarkers in cancer in general and oesophago-gastric cancer in particular. We provide an overview on the current status of radiological and biological predictive biomarkers. We have focussed on clinical translational investigations and, where appropriate, provided pre-clinical insights. Whether predictive markers will be routinely incorporated in clinical practice remains to be seen as biomarker research is expensive and the data generated from these investigations are complex. It is clear that a concerted international effort between academia and industry is critical if personalised medicine as a practical reality for our cancer patients is to be realised.

Background Minimally invasive surgery is the standard technique for many operations. Laparoscopic training has a long learning curve. Robotic solutions may shorten the training pathway. The aim of this study was to compare laparoscopic with robotic training in surgical trainees and medical students. Methods Surgical trainees (ST group) were randomized to receive 6 h of robotic or laparoscopic simulation training. They then performed three surgical tasks in cadaveric specimens. Medical students (MS group) had 2 h of robotic or laparoscopic simulation training followed by one surgical task. The Global Rating Scale (GRS) score (maximum 30), number of suture errors, and time to complete each procedure were recorded. Results The median GRS score for the ST group was better for each procedure after robotic training compared with laparoscopic training (total GRS score: 27·00 (i.q.r. 22·25–28·33) versus 18·00 (16·50–19·04) respectively, P < 0·001; 10 participants in each arm). The ST group made fewer errors in robotic than in laparoscopic tasks, for both continuous (7·00 (4·75–9·63) versus 22·25 (20·75–25·25); P < 0·001) and interrupted (8·25 (6·38–10·13) versus 29·50 (23·75–31·50); P < 0·001) sutures. For the MS group, the robotic group completed 8·67 interrupted sutures with 15·50 errors in 40 min, compared with only 3·50 sutures with 40·00 errors in the laparoscopic group (P < 0·001) (10 participants in each arm). Fatigue and physical comfort levels were better after robotic compared with laparoscopic operating for both groups (P < 0·001). Conclusion The acquisition of surgical skills in surgical trainees and the surgically naive takes less time with a robotic compared with a laparoscopic platform. Antecedentes La cirugía mínimamente invasiva (minimally invasive surgery, MIS) es la técnica considerada como el patrón oro para muchas intervenciones quirúrgicas. La formación en laparoscopia tiene una curva de aprendizaje larga. El empleo de la robótica puede acortar dicho periodo de entrenamiento. El objetivo de este estudio fue comparar el entrenamiento laparoscópico con el robótico en residentes de cirugía y estudiantes de medicina. Métodos Los integrantes del grupo de residentes de cirugía (surgical trainees, ST) fueron aleatorizados a recibir 6 horas de entrenamiento con simulación laparoscópica o robótica. Seguidamente, efectuaron tres procedimientos quirúrgicos en especímenes de cadáver. El grupo de estudiantes de medicina (medical students, MS) recibió 2 horas de entrenamiento de simulación laparoscópica o robótica, seguidas de un procedimiento quirúrgico. Se registró el resultado de la escala global de puntuación (global rating scale score, GRS, máxima puntuación = 30), el número de errores cometidos en las suturas y el tiempo para completar cada procedimiento. Resultados La mediana de GRS para el grupo ST fue mejor para cada procedimiento tras el entrenamiento robótico (GRS puntuación total 27,00 ± 6, n = 10) en comparación con el entrenamiento laparoscópico (18,00 ± 5, n = 10, P < 0,001). Se cometieron menos errores en las tareas robóticas en comparación con las laparoscópicas, tanto para las suturas continuas (7,00 ± 5 y 22,25 ± 5; P < 0,001) como discontinuas (8,25 ± 4 y 29,50 ± 8; P < 0,001). En el grupo de MS, el grupo de robótica completó 8,67 suturas discontinuas con 15,50 errores en 40 minutos, en comparación con solo 3,50 suturas con 40,00 errores en el grupo laparoscópico (P < 0,001). Los niveles de fatiga y de confort físico fueron mejores tras la cirugía robótica en comparación con la laparoscópica (P < 0,001) para ambos grupos. Conclusión En los residentes de cirugía y en personas sin contacto previo con la cirugía, las habilidades quirúrgicas se adquirieron en menos tiempo con una plataforma robótica que laparoscópica. Medical students and surgical trainees were randomized to robotic or laparoscopic simulator training followed by cadaveric surgical tasks. The robotic groups had a shorter learning curve with better task performance. Another advantage for robotic surgery

During the transition period, fatty liver syndrome may be caused in cows undergo negative energy balance, ketosis or hypocalcemia, retained placenta or mastitis problems. During the transition stage, movement of non-esterified fatty acids (NEFA) increases into blood which declines the hepatic metabolism or reproduction and consequently, lactation performance of dairy cows deteriorates. Most of studies documented that, choline is an essential nutrient which plays a key role to decrease fatty liver, NEFA proportion, improve synthesis of phosphatidylcholine, maintain lactation or physiological function and work as anti-oxidant in the transition period of dairy cows. Also, it has a role in the regulation of homocysteine absorption through betaine metabolite which significantly improves plasma α-tocopherol and interaction among choline, methionine and vitamin E. Many studies reported that, supplementation of rumen protected form of choline during transition time is a sustainable method as rumen protected choline (RPC) perform diverse functions like, increase glucose level or energy balance, fertility or milk production, methyl group metabolism, or signaling of cell methionine expansion or methylation reactions, neurotransmitter synthesis or betaine methylation, increase transport of lipids or lipoproteins efficiency and reduce NEFA or triacylglycerol, clinical or sub clinical mastitis and general morbidity in the transition dairy cows. The purpose of this review is that to elucidate the choline importance and functions in the transition period of dairy cows and deal all morbidity during transition or lactation period. Furthermore, further work is needed to conduct more studies on RPC requirements in dairy cows ration under different feeding conditions and also to elucidate the genetic and molecular mechanisms of choline in ruminants industry.

BackgroundThe TNM classification for renal cell cancer (RCC) should accurately predict and assign prognostic information for patients. In this study the recent 2010 revision to the TNM classification was compared with the previous 2002 classification with regard to survival outcomes.MethodsAll patients having radical nephrectomy for RCC in the 5-year period 2004–8 at a tertiary referral centre were included. Pathological and radiological records were reviewed to identify TNM stage (2002 and 2010 classification) and survival data were captured.Results345 patients with RCC were identified. Based on the 2002 TNM staging system and using outcomes in T1 staged tumours as a baseline, statistically significant differences in disease-specific survival were noted between patients with T1 and T3b tumours (log rank p<0.001) but not between those with T1 and T3a tumours (p=0.33). However, when tumour stage was reassigned according to the 2010 classification, patients with T3a tumours were also found to do statistically worse than T1 staged disease (p<0.001).ConclusionIn our cohort, the new 2010 TNM reclassification of T3 tumours showed better correlation with predicting worsening outcomes compared with localised disease.

The optimal management of resectable oesophageal adenocarcinoma is controversial, with many centres using neoadjuvant chemotherapy following the Medical Research Council (MRC) oesophageal working group (OE02) trial and the MRC Adjuvant Gastric Infusional Chemotherapy (MAGIC) trial. The more intensive MAGIC regimen is used primarily in gastric cancer but some also use it for oesophageal cancer. A database of cancer resections (2001–2013) provided information on survival of patients following either OE02 or MAGIC-type treatment. The data were compared using Kaplan–Meier analysis. Straight-to-surgery patients were also reviewed and divided into an ‘early’ cohort (2001–2006, OE02 era) and a ‘late’ cohort (2006–2013, MAGIC era) to estimate changes in survival over time. Subgroup analysis was performed for responders (tumour regression grade [TRG] 1–3) versus non-responders (TRG 4 and 5) and for anatomical site (gastro-oesophageal junction [GOJ] vs oesophagus). An OE02 regimen was used for 97 patients and 275 received a MAGIC regimen. Those in the MAGIC group were of a similar age to those undergoing OE02 chemotherapy but the proportion of oesophageal cancers was higher among MAGIC patients than among those receiving OE02 treatment. MAGIC patients had a significantly lower stage following chemotherapy than OE02 patients and a higher median overall survival although TRG was similar. On subgroup analysis, this survival benefit was maintained for GOJ and oesophageal cancer patients as well as non-responders. Analysis of responders showed no difference between regimens. ‘Late’ group straight-to-surgery patients were significantly older than those in the ‘early’ group. Survival, however, was not significantly different for these two cohorts. Although the original MAGIC trial comprised few oesophageal cancer cases, our patients had better survival with MAGIC than with OE02 chemotherapy in all anatomical subgroups, even though there was no significant change in operative survival over the time period in which these patients were treated. The use of the MAGIC regimen should therefore be encouraged in cases of operable oesophagogastric adenocarcinoma.

Enterococcus mundtii QAUEM2808 has been isolated from dahi, an indigenous fermented milk product of Pakistan. Here, we report the draft genome sequence for this strain, which consists of 160 contigs corresponding to 2,957,514 bp and a G+C content of 38.5%.