A best evidence topic was written according to a structured protocol. The question addressed is the learning curve for video-assisted thoracoscopic (VATS) lobectomy affected by prior experience in open lobectomy? Two hundred and two studies were identified of which seven presented the best evidence on the topic. The authors, date, journal, country of publication, study type, participating surgeon and relevant outcomes are tabulated. The studies presented discuss the learning experiences of surgeons with a range of proficiency in open lobectomy in performing VATS lobectomy. Four of the studies made direct comparisons between the outcomes achieved by trainees and fully qualified surgeons. Trainees performed a total of 154 VATS lobectomies and the consultants performed 714. The reported number of open lobectomies performed by trainees ranged 14-50. In one study, a qualified surgeon who had performed 100 open lobectomies achieved a statistically significant progression in his learning curve and was able to safely perform VATS lobectomies after 6 months. A trainee who had performed only 14 open lobectomies achieved a similar blood loss to his experienced supervisors (P = 0.79). Two trainee surgeons who had each performed at least 20 open lobectomies achieved similar mean intraoperative blood loss (P = 0.2) and complication rate (P = 0.4) to their experienced consultant when performing VATS lobectomy. Average duration of chest drainage was similar between consultant and trainee groups (P = 0.34) and was improved in favour of trainees in one group (P < 0.001); this might be due to the fact that they operated on more technically straightforward cases. Four trainee surgeons who had performed at least 50 open pulmonary resections each managed to achieve a similar mean operative time to their consultant in their first 46 cases, and a lower morbidity (26 vs 34.7%). There was no increase in mortality in the trainee groups. Surgeons with limited experience in open lobectomy can achieve good outcomes in VATS lobectomy comparable with their more experienced seniors.
BackgroundLyme disease is endemic in the UK with a high incidence in southwest England. Neurological involvement occurs in approximately 5% of infected individuals. Previous reviews in southwest England have shown a consistent phenotype in most cases, however anecdotal review suggests a small number of atypical cases, with diverse presentations, which provide a diagnostic challenge, even to experienced neurologists.MethodsWe performed a retrospective, observational study of all identified cases (positive screening ELISA confirmed by immunoblot and neurological symptoms) of neuroborreliosis from six hospitals between January 2015 and December 2017. In addition, we reviewed atypical cases seen over the last decade in the regional neurosciences centre in depth.Results72 patients were included in the observational study. 83% had characteristics of Bannwarth’s syndrome (cranial neuropathy, radiculopathy and CSF pleocytosis). Unusual cases included mononeu- ritis multiplex.Central nervous system involvement was rare. We saw cases presenting with cerebrovascular events, meningitis and encephalitis. Complete resolution of symptoms was reported in 72% of patients. 28% of patients reported residual symptoms, most commonly fatigue and memory problems.ConclusionsThis is the largest UK review of neuroborreliosis. The presentation is usually typical, but atypical presentations vary and can be challenging. The majority of patients recover fully.amyrossrussell@gmail.com
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