Microsurgery in the clinic and laboratory

Laboratory animals have been crucial to the development of modern microsurgical techniques which are now routinely used in many clinical departments worldwide. In return, microsurgical techniques are important in biomedical research as they allow many surgical procedures to be performed on rodents instead of dogs, pigs or primates. This has obvious advantages in terms of low cost, the use statistically valid numbers for comparison and the availability of genetically defined animals which are more likely to give valid answers to immunological questions. Microsurgical reconstruction is important in plastic, orthopaedic, urogenital, vascular and peripheral nerve surgery in man and it is likely that it will become part of every surgeon's training in the near future. In this review, the instrumentation essential to any microsurgical enterprise and the sutures available are described. Basic microsurgical techniques for end-to-end and end-to-side anastomosis of small vessels and for joining peripheral nerves, oviducts and other tubular structures are given in outline. Techniques for transplanting kidney, heart, heart and lung, liver, spleen, pancreas, small bowel, stomach, testicle, ovary and whole joint are only outlined but key references are given. Finally, some of the clinical indications for microsurgical reconstruction are reviewed.     

A program for simulated rodent surgical training

For the inexperienced individual, learning surgical techniques can be taxing. The authors developed a rodent surgery dry lab training program to assist educational and research institutions in providing low-stress training for basic surgical techniques using handmade, cost-effective simulation models. The program not only helps students develop essential skills in basic surgery, but also fulfills the mandate of the 3Rs by allowing students to repeatedly practice and refine their skills on models rather than live animals. This type of training is a valuable tool in bridging the gap between computer training and training with live animals.     

Rat uterus anastomoses in a single and a double layer

The Authors display their results on microsurgical operations in rat's uteri. After having described the instruments and methods used, the surgical techniques and the differences between a single and a double layer suture are discussed. However the formation of intraoperative adherences, which can damage the functional results of the intervention, is studied. And what's more the mean number of live born foetuses is seen as an attainable parameter for future validations.     

Rat ear reattachment as an animal model

The external ear of the rat is an excellent model for practicing microsurgical dissection and for the refinement of microvascular anastomoses, techniques that are crucial for microvascular en bloc tissue transfer and replantation. Preparation of the rat ear for replantation requires familiarity with the vascular anatomy and gentle tissue handling with atraumatic dissection of arterial and venous pedicles, steps similarly crucial in raising free flaps for microvascular transfer. The strategy of performing accurate reduction and stabilization of the tubal cartilage prior to vessel repairs, anastomosing the more deeply seated external carotid artery prior to the more superficial posterior facial vein, is as critical to rat ear replantation as for digital reattachment. In addition, the rat ear as compared to other animal models such as the rabbit ear or canine hindlimbs is much less expensive. Compared to the rat hindlimb model, rat ears are much easier to observe, which is a distinct advantage when used as a model for long-term study of replantation, revascularization, or transplantation.     

Control of adenovirus acute respiratory disease in U.S. Army trainees.

Although limited almost exclusively to military trainees, acute respiratory disease (ARD) caused by adenovirus types 4 and 7 had been the leading cause of hospitalization in U.S. Army personnel. This decrease which resembles influenza in clinical manifestations led to hospitalization of as many as 50% of military trainees in midwinter and imposed a heavy burden on military hospitals and training programs. In studies undertaken from 1965 to 1970, live adenovirus type 4 and subsequently type 7 vaccines were found to be safe and immunogenic and to confer protection against type specific adenovirus ARD. For the past 5 yr. military trainees have been immunized with both adenovirus vaccines during periods of expected adenovirus disease. Since 1966, use of adenovirus vaccines has been monitored through the adenovirus surveillance program which yields weekly data on incidence and etiology of ARD in basic combat trainees. Since 1973, stable adenovirus vaccines have resulted in excellent control of adenovirus ARD. Potential problems with this immunization program are discussed.     

Use of biophotonic imaging as a training aid for administration of substances in laboratory rodents

Dosing of experimental animals and the removal of blood are two of the most frequent procedures performed in biomedical research using live animals. Despite the apparently simple nature of these procedures, they can, if not correctly carried out, have significant effects on the welfare of the animals and the scientific value of the results. There are several methods by which research staff may obtain training in the administration of substances. These include practical demonstrations during teaching courses; observation of techniques; videos and educational computer programs and practising on recently killed animal cadavers or plastic animal models. Each method has its own advantages and disadvantages. A common factor encountered during training is the difficulty in assessing competency. This paper reports a pilot study on the use of bioluminescent imaging technology to assess competency in the administration of substances to rodents. Bioluminescence was rapidly detected after dosing of animals with a bioluminescent substance. However, living animals were required for a signal to be generated. The data presented suggest that this technology is ideal for use as a teaching aid and may also prove valuable in assessing the effectiveness of 'complex' and novel administration routes in 'realtime'.     

Training strategies for research investigators and technicians

Training programs for research personnel are discussed as a key resource that must be part of an effective animal care and use program. Because of the legal responsibility to ensure that research staff are qualified to use animals, many institutions have justified the necessity for a training coordinator and/or trainers for their animal care and use programs. Effective training programs for research personnel must meet the needs of the client base (research scientists and staff) so that they are relevant, practical, and timely. To meet these objectives, it is useful to involve the scientific staff in the analysis of their learning needs. To meet a performance standard necessary for quality research, a large percentage of the institutional staff must participate in the training program. Often it is the principal investigators who set the tone for their staff members regarding the importance of receiving training. Garnering support from this client base will create a culture that encourages training and engenders a positive attitude about humane animal care and use. One effective approach is to incorporate nonanimal models as alternatives to live animals to teach humane handling techniques and methods, thereby contributing to refinement, reduction, and replacement (the 3Rs). Also discussed are the necessity of timely feedback from clients, documentation of personnel training for regulatory purposes, and the collection of training metrics, which assists in providing justification for the granting of additional fiscal support for the program. Finally, the compliance procedures and opportunities for essential refresher training are discussed and related to high performance standards, humane animal use, and quality research, all of which contribute to the 3Rs.     

Surgical training: an objective assessment of recent changes for a single health board.

The reduction in doctors'' hours and the introduction of specialist training have reduced general surgical training by 60%. This study assessed the implications for a single health board. A questionnaire listing 13 representative operations was sent to 44 trainees and 52 trainers to determine the number of operations a trainee should perform. The total number of operations required for training was compared against the total actually performed across the health board. Operating times for five representative operations were audited prospectively. Trainers and trainees recommended a similar and conservative number of operations. The total number of operations available for training (4913) was 38% less than the number recommended (7946). Trainees required 50-75% more operating time than consultants. To increase the proportion of operations undertaken by trainees from the current 30% to 70% would require an extra 270 theatre days (of pounds 1.3m) yearly. The minimum number of operations required for training must be defined and the proportion of supervised operations undertaken by trainees substantially increased. Service and financial implications will have to be addressed. Action is needed urgently, as the first trainees will become consultants in less than five years.     

Do trainees see patients with chronic illness?

From 1976 to 1979 trainees in the Oxford region had their clinical work monitored while in their training practices in relation to 16 conditions requiring long term supervision. Although the mean numbers of patients seen were not greatly different from national figures, the range identified some trainees whose number of patients was very low. Consultation rates and follow up figures indicated that many patients did not return to the trainees again.     

Outcomes of a pilot fish telemetry workshop for developing countries

Fisheries management is a crucial issue worldwide, but it is proportionally more crucial in developing countries that rely heavily on inland fisheries. Management requires proper knowledge of fish behaviour and habitat use, as can be achieved through telemetry techniques, although these are most rarely used in tropical regions. Here we report briefly on the outcomes of a pilot workshop and training course aiming at improving technology transfer and capacity building, laying the stress on strengths and weaknesses of this approach, as evaluated by trainees.     

GP trainees' views on hospital obstetric vocational training.

OBJECTIVES--To examine the content of hospital obstetric vocational training for general practice, the beliefs of general practitioner trainees about this training, and their perceived competence at practical obstetric procedures and the effect of training. DESIGN--Confidential postal questionnaire. SUBJECTS--A random one in four sample of all general practitioner trainees in the United Kingdom on vocational training schemes or in training practices in Autumn 1990. MAIN OUTCOME MEASURES--Trainees'' competence and beliefs on Likert scale, numbers of procedures witnessed and performed, type of maternity care trainees intended to provide. RESULTS--Of 1019 trainees sent questionnaires, 765 (75.1%) replied; 517 had done some hospital obstetric training. After six months as a senior house officer 232/367 (63%) believed they were competent to perform a normal delivery unaided, 228 (62%) to manage a severe postpartum haemorrhage, and 227 (62%) to resuscitate a newborn infant. 272 (35.6%) trainees intended to provide intrapartum care and 56 (7.5%) to book home deliveries in the future. Hospital training increased confidence in performing most obstetric procedures in all trainees. However, a greater proportion of trainees who intended to provide full care than shared care felt competent at performing a normal vaginal delivery (63% (170/272) full v 45% (215/473) shared), low forceps delivery (38% (103) v 17% (79)), manual removal of placenta (24% (65) v 17% (82)), and intubating a neonate (42% (114) v 34% (161)). Trainees who had done any obstetric training were less likely to think that training encouraged future provision of intrapartum care (113/509 (22%) training v 65/213 (31%) no training). CONCLUSION--Hospital vocational obstetric training increases the perceived competence of trainees but fails to encourage them to use obstetric skills.     

Training the trainee: the institution's responsibility to the often forgotten

Because some trainees are not university employees, regulatory agencies, oversight committees, and investigators may overlook those who work with animals when it comes to training related to animal care and use. The authors draw attention to a common problem facing universities and suggest ways to close the gap in training.     

Resuscitation teaching room in a district general hospital: concept and practice.

Practical training in cardiopulmonary resuscitation presents a problem because of the shortage of teacher time and the many potential trainees. A resuscitation teaching room in district general hospital has been established, equipped with training mannikins and models, together with wall diagrams and cassette recordings. The arrangement enables many trainees to gain training in small groups with minimal demand on teachers. Experience with the room in use has suggested that the concept may have an application in many district general hospitals and possibly also in large industrial concerns.     

Role of adipose-derived stromal cells in pedicle skin flap survival in experimental animal models

The use of skin flaps in reconstructive surgery is the first-line surgical treatment for the reconstruction of skin defects and is essentially considered the starting point of plastic surgery. Despite their excellent usability, their application includes general surgical risks or possible complications, the primary and most common is necrosis of the flap. To improve flap survival, researchers have used different methods, including the use of adiposederived stem cells, with significant positive results. In our research we will report the use of adipose-derived stem cells in pedicle skin flap survival based on current literature on various experimental models in animals.     

Tubo-ovarian transplantation in the treatment of sterility. Experimental research]

Microsurgical transposition of fallopian tube and ovary has the potential of being an efficient therapeutic treatment in patients with tubal sterility. The Authors present their experience of microsurgical adnexal transplantation in rabbit by two different techniques: the first procedure by microvascular anastomosis of the ovarian vessels, the second one without vascular pedicle. Function is evaluated at various time after grafting by: exploratory laparotomy on day 30 to establish whether circulation to the grafts was still maintained; macroscopic and microscopic examination of ovaries and fallopian tubes. The microvascular techniques prove highly reliable in terms of immediate vascular patency rate but it is disappointing that 50% of the autografts has failed with blocked vessels by day 30. Perhaps this is due to the difficult techniques in anastomosing the ovarian vessels of small caliber. In spite of these outcomes the vascularized autografts were viable and functional after transplantation in contrast with the non-vascularized tubo-ovarian grafts which all failed. This experience encourages to believe that the microsurgical technique could be employed for homograft transplantation in woman with extensive ovarian and tubal damages.     

Reduction of numbers of animals used in the quality control of biologicals

Laboratory animals are used for the quality control of vaccines. In particular, the potency testing of batches of inactivated vaccine requires large numbers of animals. The possibilities for reduction have been evaluated, and the results are summarised in this paper. Several approaches were studied, including the retrospective analysis of test data, with the objectives of determining the minimum number of animals required per vaccine dilution group, and evaluating the feasibility of a single-dose potency test. Other studies focused on the development of serology-based models and the use of genetically uniform animals. Based on the outcome of these studies, a substantial reduction in the number of animals used for the potency testing of toxoid vaccines has been achieved or will be achieved in the near future. As reduction alternatives can generally be explored in a relatively simpler and less time-consuming way than replacement alternatives, more emphasis should be placed on reduction strategies than at present.     

Reduction strategies in animal research: a review of scientific approaches at the intra-experimental, supra-experimental and extra-experimental levels

When discussing animal use and considering alternatives to animals in biomedical research and testing, the number of animals required gets to the root of the matter on ethics and justification. In this paper, some reduction strategies are reviewed. Many articles and reports on reduction of animal use focus mostly on the experimental level, but other approaches are also possible. Reduction at the intraexperimental level probably offers the greatest scope for reduction, as the design and statistical analysis of individual experiments can often be improved. Supra-experimental reduction aims to reduce the number of animals by a change in the setting in which a series of experiments take place--for example, by improved education and training, reduction of breeding surpluses, critical analysis of test specifications, and re-use of animals. At the extra-experimental level, reduction is a spin-off of other developments, rather than the direct goal. Through improved research or production strategies, aimed at better quality, consistency and safety, reduction in the number of animals used can be substantial. A revised definition of reduction is proposed, which does not include the level of information needed, as in some cases reduction in the number of animals resulting in less information or data, is still acceptable.     

The Helsinki Rat Microsurgical Sidewall Aneurysm Model

Experimental saccular aneurysm models are necessary for testing novel surgical and endovascular treatment options and devices before they are introduced into clinical practice. Furthermore, experimental models are needed to elucidate the complex aneurysm biology leading to rupture of saccular aneurysms.Several different kinds of experimental models for saccular aneurysms have been established in different species. Many of them, however, require special skills, expensive equipment, or special environments, which limits their widespread use. A simple, robust, and inexpensive experimental model is needed as a standardized tool that can be used in a standardized manner in various institutions.The microsurgical rat abdominal aortic sidewall aneurysm model combines the possibility to study both novel endovascular treatment strategies and the molecular basis of aneurysm biology in a standardized and inexpensive manner. Standardized grafts by means of shape, size, and geometry are harvested from a donor rat''s descending thoracic aorta and then transplanted to a syngenic recipient rat. The aneurysms are sutured end-to-side with continuous or interrupted 9-0 nylon sutures to the infrarenal abdominal aorta.We present step-by-step procedural instructions, information on necessary equipment, and discuss important anatomical and surgical details for successful microsurgical creation of an abdominal aortic sidewall aneurysm in the rat.     

Psychiatric training in the UK: the next steps

Postgraduate education and training in the UK is undergoing tremendous change. In this paper the changes affecting psychiatry are described, with an account of the drivers. Patients, their carers and politicians all expect psychiatric service providers to have certain characteristics. Psychiatric training is becoming more competency focused and it is right that assessments of competencies also occur at the place that trainees work. There are key competencies that trainees need to take into account while learning and working. These are described along with the way forward