Key Topics in Surgical Research and Methodology (eBook)

Key Topics in Surgical Research and Methodology 1
Title Page 2
Copyright Page 3
Foreword 4
Preface 6
Acknowlesgements 8
About the Editors 9
Contents 13
Contributors 19
Chapter 1 30
The Role of Surgical Research 30
1.1 Introduction 30
1.2 The Aims of Surgical Research 31
1.3 Translating Surgical Research into Practice 32
1.4 Challenges Faced by the Twenty-First Century Academic Surgeon 34
1.5 The Role of the Academic Surgeon in Teaching 36
1.6 The Future of Surgical Research 36
References 36
Chapter 2 38
Evidence-Based Surgery 38
2.1 Introduction 38
2.2 What Is Evidence? 39
2.3 Hierarchy of Evidence 39
2.4 Definition and Values 40
2.5 Benefits of Evidence-Based Surgery 40
2.6 History and the So-Called “Discord” Between Surgery and Evidence-Based Practice 41
2.7 Principles of Identifying the Evidence 42
2.8 Sources of Evidence 43
2.9 Managing the Increasing Volume of Evidence 44
2.10 Practising and Delivering the Evidence 44
2.11 Surgical Modelling and Treatment Networks 45
2.11.1 Surgical Thinking and Evidence Synthesis 46
2.11.2 Bayesian Techniques 46
2.11.3 Qualitative Comparative Analysis (QCA) 47
2.12 Surgical Decision-Making and Clinical Judgement Analysis 47
2.13 Cost Effectiveness in Evidence-Based Surgery 49
2.14 Surgical Training in Evidence-Based Techniques 51
2.15 Ethics 51
2.16 Conclusion 52
References 54
Chapter 3 56
The Role of the Academic Surgeon in the Evaluation of Healthcare Assessment 56
3.1 Introduction 56
3.2 Clinical Practice 57
3.3 Training Programme 57
3.4 Advance of Subject and Historical Perspective 57
3.5 Health Technology 59
3.5.1 Clinical Trial Expertise 59
3.5.2 Statistical Knowledge 60
3.5.3 Health Economics 60
3.5.4 Cost Effectiveness Modelling 60
3.5.5 Health-Related Quality of Life and Patient Preference 61
References 61
Chapter 4 62
Study Design, Statistical Inference and Literature Search in Surgical Research 62
4.1 The Basics of Study Design 62
4.1.1 Ecological or Aggregate Studies 62
4.1.2 Cross-Sectional Surveys 63
4.1.3 Case–Control Studies 64
4.1.4 Cohort or Longitudinal Studies 64
4.1.5 Randomised Controlled Trials 65
4.1.6 Systematic Reviews and Meta-Analyses 67
4.2 The Basics of Statistical Analysis 68
4.2.1 The Study Population 68
4.2.2 Hypothesis Testing 68
4.2.3 Type 1 and Type 2 Errors 68
4.2.4 Statistical Power 69
4.2.5 Interpreting “Statistically Signifi cant” Results 69
4.2.6 Confi dence Intervals 69
4.2.7 Interpreting “Negative” Results 69
4.2.8 Correlation and Regression 69
4.3 Causal Inference 70
4.3.1 What Is a Cause? 70
4.3.2 The Multi-Factorial Model of Causation 70
4.3.3 Evaluating Causality in the Multi-Factorial Model 71
4.3.4 Bradford Hill’s Criteria for Causality 72
4.4 Clinical Importance of the Results: Types of Health Outcomes and Measures of the Effect 73
4.4.1 Health Outcomes 73
4.4.2 Clinical Importance 73
4.5 Searching Effi ciently the Biomedical Databases 75
4.5.1 Structure of a Database 75
4.5.2 Structure of PubMed 75
4.5.2.1 Some Important Fields 77
4.5.2.2 Steps for an Effi cient Search 79
4.5.2.3 Some Last Tips 81
References 82
Chapter 5 83
Randomised Controlled Trials: What the Surgeon Needs to Know 83
5.1 Introduction 83
5.2 Current Concepts in Clinical Trials 84
5.3 Basic Concepts of Trial Design 84
5.4 What Do I Need to Know Before Starting a Clinical Trial? 85
5.5 How Do I Evaluate Surgical Procedures? 87
5.6 The Process of Surgical Evaluation 87
5.7 What Do I Do When the Learning Curve Has Been Completed and the New Procedure Appears Feasible and Safe? 88
5.8 Randomised Trials of Surgical Procedures 88
5.9 Selection of Outcomes for Surgical Trials 90
5.10 Practical Issues for Designing Randomised Trials in Surgery 91
5.10.1 Eligibility Criteria 91
5.10.2 Process of Randomisation 91
5.10.3 Blinding of Treatment Allocations 91
5.10.4 Sample Size and Enrolment Issues 91
5.10.5 Costs of Doing Surgical Trials 92
5.10.6 Balance of Benefi ts and Risk 92
5.11 Conclusions 92
References 92
Chapter 6 95
Monitoring Trial Effects 95
6.1 Introduction 95
6.2 Definition and Development of DMCs 96
6.3 Roles of the Committee 96
6.4 DMC Members 97
6.5 Conclusion 98
References 101
Chapter 7 102
How to Recruit Patients in Surgical Studies 102
7.1 Introduction 102
7.2 Planning and Organisation 103
7.3 Timing 103
7.4 Patients’ Point of View 103
7.5 The Recruitment Team 103
7.6 Recruitment Skills 103
7.7 Sources of Recruitment 104
7.8 Balance Between Inclusion/Exclusion Criteria 104
7.9 Prerequisites 105
7.10 Factors to Increase Participation 105
7.11 Factors to Ensure Continued Participation 105
7.12 Patient Subgroups 107
7.13 Practicalities 107
7.14 Conclusion 107
References 107
Chapter 8 109
Diagnostic Tests and Diagnostic Accuracy in Surgery 109
8.1 Introduction 110
8.2 What Is a Diagnostic Test? 110
8.2.1 Criteria for a Useful Diagnostic Test 110
8.2.2 Choosing Diagnostic Endpoints 110
8.2.3 Diagnostic Test Data 111
8.3 Quality Analysis of Diagnostic Studies 111
8.3.1 Reporting in Diagnostic Tests 112
8.3.2 Sources of Bias in Diagnostic Studies 112
8.3.2.1 Reference Standard Bias 112
8.3.2.2 Investigator-Related Factors in Bias 112
8.3.2.3 Population Factors in Bias 114
8.4 Estimates of Diagnostic Accuracy 114
8.4.1 True Disease States 114
8.4.2 Sensitivity, Specificity and Predictive Values 115
8.4.2.1 Sensitivity and Specificity 115
8.4.2.2 Positive and Negative Predictive Values 116
8.4.2.3 Comparison of Terms 116
8.4.3 Likelihood Ratios 116
8.4.4 Diagnostic Odds Ratio 117
8.4.5 Confi dence Intervals and Measures of Variance 117
8.4.6 Concluding Remarks About Estimates of Diagnostic Accuracy 117
8.5 Receiver Operating Characteristic Analysis 117
8.5.1 The ROC Curve 118
8.5.2 Area Under the ROC Curve 118
8.6 Combining Studies: Diagnostic Meta-Analysis 119
8.6.1 Goals and Guidelines 119
8.6.2 Heterogeneity Assessment 119
8.6.2.1 Quality Assessment (Univariate Analysis) 119
8.6.2.2 Random and Fixed Effects 120
8.6.3 Diagnostic Meta-AnalysisTechniques 120
8.6.3.1 Summary Receiver Operating Characteristic (SROC) Analysis 121
8.6.3.2 Bivariate Approach to SROC 122
8.6.3.3 Hierarchical SROC Analysis 122
8.6.3.4 Comparing the Bivariate and HSROC Models 123
8.7 Conclusions 123
References 123
List of Useful Websites 124
Chapter 9 125
Research in Surgical Education: A Primer 125
9.1 Introduction 125
9.2 Qualitative vs. Quantitative Research 126
9.2.1 Generating Questions 126
9.2.2 Qualitative Research 127
9.2.3 Quantitative Research 128
9.3 Research Design 129
9.3.1 Minimizing Threats to Validity 130
9.5.7 Differences Between Independent Groups 138
9.3.2 Design Construction 130
9.3.3 The Nature of Good Design 132
9.4 Measures (Experimental Research) 132
9.4.1 Developing an Instrument 133
9.4.2 Feasibility 133
9.4.3 Validity 134
9.4.4 Reliability 134
9.5 Acquisition and Analysis of Data (Experimental Research) 136
9.5.1 Data Collection 136
9.5.2 Tests of Normality 136
9.5.3 Three Normality Tests 137
9.5.4 Categories of Statistical Techniques 137
9.5.5 Nonparametric Analyses 138
9.5.6 Relationships Between Variables 138
9.5.8 Differences Between Dependent Groups 138
9.6 Funding, Dissemination, and Promotion 139
References 140
Chapter 10 141
Measurement of Surgical Performance for Delivery of a Competency-Based Training Curriculum 141
10.1 Introduction 141
10.2 Surgical Competence, Proficiency and Certification 142
10.3 Five Steps from Novice to Expert 142
10.4 Taxonomy for Surgical Performance 143
10.5 Assessment of Technical Skills in Surgical Disciplines 144
10.6 Dexterity Analysis in Surgery 144
10.7 Video-Based Assessment in Surgery 145
10.8 Virtual Reality Simulators as Assessment Devices 146
10.9 Comparison of Assessment Tools 148
10.10 Beyond Technical Skill 148
10.11 A Systems Approach to Surgical Safety 148
10.12 The Simulated Operating Theatre 148
10.13 Curriculum Development 150
10.14 Innovative Research for Surgical Skills Assessment 151
10.14.1 Eye-Tracking Technologies 151
10.14.2 Functional Neuro-Imaging Technologies 151
10.15 Conclusions 151
References 152
Chapter 11 154
Health-Related Quality of Lifeand its Measurement in Surgery–Concepts and Methods 154
11.1 Introduction 154
11.2 What is Quality of Life? 155
11.3 The Purpose of Measuring HRQL 155
11.4 How to Measure HRQL 156
11.4.1 Types of Instruments 156
11.4.1.1 Generic Instruments 156
11.4.1.2 Disease-Specifi c Instruments 157
11.4.2 Developing and Validating HRQL Instruments 157
11.4.2.1 Literature Search 157
11.4.2.2 Selection of HRQL Domains in Instrument 158
11.4.2.3 Writing Items and Scales 158
11.4.2.4 Pretesting the Provisional HRQL Instrument 158
11.4.2.5 Clinical and Psychometric Validation of HRQL Instruments 158
11.5 Reporting Standards of HRQLin Randomized Controlled Trials and Other Research Settings 159
11.5.1 Choosing a HRQL Instrument for the Research 160
11.5.2 Determining the HRQL Sample Size 161
11.5.3 The Timing of HRQL Assessments 161
11.5.4 Missing Data 162
11.5.5 Dealing with Missing Data 163
11.5.6 Analyses of HRQL Data 163
11.6 The Future Role of HRQL in Evaluating Surgery 164
References 164
Chapter 12 165
Surgical Performance Under Stress: Conceptual and Methodological Issues 165
12.1 Introduction 165
12.2 Part 1: Models and Theories of Stress 166
12.2.1 Systemic Stress: Selye’s Theory 166
12.2.2 Psychological Stress: The Lazarus Theory 166
12.2.3 The Yerkes–Dodson Law 167
12.3 Part 2. Measures of Stress in Surgery 167
12.3.1 Objective Measures of Stress 167
12.3.2 Subjective Measures of Stress 168
12.3.3 Combined Subjective and Objective Measures of Stress 168
12.4 Part 3: Measures of Performance in Surgery 168
12.4.1 Measures of Technical Performance 169
12.4.2 Measures of Non-Technical Performance 169
12.5 Part 4: Impact of Stress on Surgical Performance 170
12.6 Part 5: Discussion 170
12.7 Implications for Surgical Training 171
12.8 Future Research Agenda 172
References 173
Chapter 13 175
How can we Assess Quality of Care in Surgery? 175
13.1 Introduction 175
13.2 Quality of Care 176
13.2.1 Defi ning Quality of Care 176
13.2.2 How Should we Assess Quality of Care? 176
13.3 Measuring Quality of Care 178
13.3.1 Structural Variables 178
13.3.2 Process Measures 179
13.3.3 Outcome Measures 180
13.3.4 Health care Economics 181
13.4 Benchmarking Quality of Care 182
13.4.1 Current Initiatives 182
13.4.2 Pay for Performance Strategies 183
13.4.3 Future Direction 184
13.5 Public Health Implications 184
13.6 How to Design Health Care Quality Reforms 185
13.7 How to Achieve Health Care Quality Improvement 186
13.8 Conclusions 186
References 187
Chapter 14 189
Patient Satisfaction in Surgery 189
14.1 Introduction 189
14.2 The Patient’s Perspective of Health Care 190
14.3 Patient Satisfaction 191
14.3.1 The Meaning of Satisfaction 191
14.3.2 Determinants of Satisfaction: Patient Expectations 191
14.3.3 Determinants of Satisfaction: Patient Characteristics 191
14.3.4 Determinants of Satisfaction: Psychosocial Factors 192
14.3.5 Components of Satisfaction 192
14.3.6 Patient Dissatisfaction 193
14.3.7 The Importance of Measuring Patient Satisfaction 194
14.4 Measurement of Satisfaction 194
14.4.1 How can we Measure Satisfaction? 194
14.4.2 The “Overall Satisfaction” Score 194
14.4.3 Satisfaction Survey Design 195
14.4.4 Guidance for Satisfaction Measurement 196
14.5 Conclusions 196
References 196
Chapter 15 198
How to Measure Inequality in Health Care Delivery 198
15.1 Introduction 198
15.1.1 Access to Health Care 200
15.2 Dimensions of Inequality in Health Care Delivery 203
15.2.1 Patient-Level Characteristics 203
15.2.1.1 Socio-Economic Characteristics 203
15.2.1.2 Socio-Demographic Characteristics 204
Ethnicity 204
Geography 204
15.2.2 Primary (Community) Care Characteristics 205
15.2.3 Secondary (Hospital) Care Characteristics 206
15.2.4 Limitations of Inequality Research 206
15.3 Measuring Inequality in Health Care Delivery 207
15.3.1 What to Measure – Measuring Health Care 207
15.3.2 What to Measure – Measuring Health Inequality and Inequity 208
15.3.3 Data Sources 209
15.3.4 Limitations of Data Sources 211
15.4 Methods for Measuring Health Care Inequality 212
15.4.1 Health Gap Analysis 212
15.4.2 Share-Based Measures 213
15.4.2.1 Lorenz Curve and Gini Coefficient 213
15.4.2.2 Concentration Curve and Concentration Index 213
15.4.2.3 Slope and Relative Index of Inequality (SII and RII) 214
15.4.3 Methodological Limitations 214
15.5 Conclusions 214
References 215
Chapter 16 217
The Role of Volume–Outcome Relationship in Surgery 217
16.1 Introduction 217
16.2 Methodological Framework for Assessing Volume–Outcome Relationship 219
16.2.1 Data Sources and Data Quality 219
16.2.2 Data Presentation 219
16.2.3 Methodological Limitations 221
16.3 Outcome Measures 223
16.3.1 Morbidity/Mortality/Lengthof Stay/Re-Admission Rates 223
16.3.2 Limitations of Case-Mix Adjustment 223
16.3.3 Quality of Life Measures 224
16.4 The Infl uence of the Surgeon and/or Institution 224
16.4.1 The Role of the Surgeon 224
16.4.2 The Role of the Institution 225
16.5 Immeasurable Factors 225
16.6 Public Health Implications 226
16.6.1 Policy Change and Healthcare Restructuring 226
16.6.2 Research and Ethical Implications 227
16.7 Conclusion 227
References 228
Chapter 17 229
An Introduction to Animal Research 229
17.1 Introduction 230
17.2 History of Animal Research 230
17.3 Ethical Considerations 231
17.3.1 The Challenge of Hybrid Embryo Research 232
17.3.2 Animal Rights Extremism 233
17.4 Current Trends in Animal Research 233
17.5 Legal Requirements 234
17.5.1 The United States 234
17.5.2 The European Union 235
17.5.3 The United Kingdom 235
17.6 The Animals (Scientifi c Procedures) Act 1986 236
17.6.1 Definitions 236
17.6.2 Licence to Practice 236
17.6.3 Legal Requirements 236
17.7 Projects to Generate GeneticallyModifi ed Animals 238
17.8 Personal Health Protection and Monitoring 238
17.9 Animal Husbandry 239
17.9.1 Definitions of Lab Animals 239
17.9.2 Disease Recognition 240
17.10 Humane Killing of Animals 241
17.11 Analgesia 242
17.12 Anaesthesia 242
17.12.1 Selection of Methods of Anaesthesia 243
17.12.2 Inhalational Anaesthetics 244
17.12.3 Inhalational Anaesthetic Agents 246
17.12.4 Induction and Maintenance of the Airway 246
17.13 Surgical Technique 247
17.14 Post-Operative Care 247
17.15 Conclusion 248
17.16 Useful Web Sites 248
References 249
Chapter 18 251
The Ethics of Animal Research 251
18.1 Introduction 251
18.2 Development of Ethics in Animal Research 252
18.3 The Benefi ts of Animal Research 253
18.4 The Case Against Animal Experimentation 253
18.5 The Case for Animal Experimentation 254
18.6 Conclusions (The Middle Ground) 255
References 256
Chapter 19 258
Ethical Issues in Surgical Research 258
19.1 Introduction 258
19.2 Randomized Controlled Trials in Surgery 259
19.3 Innovation in Surgery 261
19.3.1 What Is a “Last Resort” Innovation? 261
19.3.2 What Is Institutionally Regulated Innovation? 262
19.3.3 What Is Peer Regulated Innovation? 262
19.4 Conclusion 263
References 263
Chapter 20 264
Principles and Methodsin Qualitative Research 264
20.1 Introduction 264
20.1.1 What Is Qualitative Research? 264
20.2 Why Should Surgeons Know AboutQualitative Research? 265
20.2.1 Engaging with Key Literature 265
20.2.2 Conducting Qualitative Studies 266
20.3 Common Misconceptions 266
20.4 When Should Qualitative ResearchNot Be Used? 267
20.5 Characteristics of the QualitativeResearch Process 267
20.6 Qualitative Methods 268
20.6.1 Additional Types of Study 268
20.7 Issues in Conducting Qualitative Research 270
20.7.1 Objectivity, Subjectivity and Bias 270
20.7.2 Achieving Rigour 271
20.7.3 Ethical Permission, Risk and Ownership of Data 271
20.7.4 Presentation and Writing Up 271
20.8 Conclusion 272
References 272
Further Reading 272
Appendix 272
Common Terms in Qualitative Research 272
Chapter 21 275
Safety in Surgery 275
21.1 Introduction 275
21.2 Methods of Studying Errorsand Adverse Outcomes 276
21.3 Safety in Health Care: The Scale of the Problem 276
21.4 Understanding Errors and Adverse Outcomes 278
21.5 The Person and the System 279
21.6 Systems Factors and Patient Safety 280
21.7 Understanding How Things Go Wrong 280
21.7.1 Incident Analysis 280
21.7.2 Human Reliability Analysis Techniques 281
21.8 Understanding Surgical Error and Surgical Outcomes 282
21.8.1 Studies of Closed Claims in Surgery 282
21.8.2 Observational Studies of Success and Failure and Studies of Communication 283
21.9 The Next Steps: Improving Surgical Safety 284
21.9.1 Reporting and Analysis of Incidents 284
21.9.2 Standardization of Clinical Processes: Guidelines and Protocols 284
21.9.3 Information Technology 285
21.9.4 Improving Communication: Checklists and Briefing 285
21.9.5 Individual Attitudes and Behaviors 286
21.9.6 Simulation-Based Training 286
21.9.7 Improving the Safety Culture 287
21.9.8 The Patient’s Role in Patient Safety 287
References 288
Chapter 22 290
Safety and Hazards in Surgical Research 290
22.1 Introduction 290
22.2 Health and Safety Law 291
22.3 Common Hazards in the ResearchLaboratory 292
22.3.1 Biological Hazards 292
22.3.2 Animal Material 293
22.3.3 Human Material 293
22.4 Theatre Safety and Surgical Smoke 294
22.5 Transport of Material 294
22.6 Genetic Modifi cation. 294
22.7 Chemicals 294
22.8 Radiation 297
22.9 Other Hazards 297
22.10 Routes of Transmission for Chemicals, Biologicals and Radiation 298
22.11 Risk Assessment and Control Mechanisms 298
22.11.1 Five Steps to Risk Assessment 298
22.11.2 Principles for Control Measures 299
22.12 Waste Disposal 300
22.13 Health Surveillance 300
22.14 Reporting of Injuries, Diseases and DangerousOccurrences Regulations 1995 300
References 301
Chapter 23 302
Fraud in Surgical Research – A Framework of Action Is Required 302
23.1 Introduction 303
23.2 History of Fraud 303
23.3 Prevalence of Fraud 303
23.4 Reasons for Fraud 303
23.5 Types of Fraud 304
23.5.1 Fabrication 304
23.5.2 Duplication 304
23.5.3 Plagiarism 305
23.5.4 Authorship 305
23.5.5 Impact Factors and Misconduct 306
23.5.6 Conflicts of Interest 307
23.6 Managing Research Misconduct 307
23.7 A Framework of Action 308
23.8 Conclusion 309
References 311
Chapter 24 312
A Framework Is Required to Reduce Publication Bias The Academic Surgeon’s View 312
24.1 Introduction 312
24.2 Evidence of Publication Bias 313
24.3 Sources of Publication Bias 313
24.4 Implications of Publication Bias 315
24.5 A Framework to Reduce PublicationBias and its Impact 316
24.5.1 Reducing Submission Bias of the Investigators 316
24.5.1.1 Education of Individual Investigator 317
24.5.1.2 Institutional Monitoring 317
24.5.2 Reducing Reviewer and Editorial Selection Bias 319
24.5.2.1 Standards of Publication 319
24.5.2.2 Clinical Trial Registry 320
25.5.2.3 Open Access Online Journals 320
25.5.3 Detecting Publication Bias in Metaanalysis 321
25.6 Conclusions 321
References 322
Chapter 25 324
Data Collection, Database Development and Quality Control: Guidance for Clinical Research Studies 324
25.1 Introduction 324
25.2 Data Collection 325
25.2.1 Documentation 325
25.2.1.1 Protocol Design 325
25.2.1.2 Manual of Operations and Procedures 327
25.2.1.3 Document Revisions 327
25.2.2 Training and Certifi cation 327
25.2.3 Procedures 328
25.2.3.1 Preparation for Data Acquisition 328
25.2.3.2 Randomisation 328
25.2.3.3 Blinding 329
25.3 Clinical Research Audit 329
25.4 Database systems 329
25.4.1 Database Software 329
25.4.2 Database Design 330
25.4.3 Database Models 330
25.4.3.1 Flat File 330
25.4.3.2 Hierarchical 331
25.4.3.3 Network 331
25.4.3.4 Relational 331
25.4.4 Good Database Design 333
25.4.4.1 Data Considerations 333
25.4.4.2 Primary Keys 334
25.4.4.3 Indices 334
25.4.4.4 Foreign Keys 334
25.4.4.5 Relationships 334
25.4.4.6 Referential Integrity 335
25.4.4.7 Look-Up Tables 335
25.4.5 Graphical User Interface (GUI) 336
25.4.6 Exporting Data for Analysis 337
25.4.7 Quality Control and Data Integrity 337
25.4.8 Data Security 338
25.5 Conclusions 338
References 338
Further Reading 339
Chapter 26 340
The Role of Computers and the Type of Computing Skills Required in Surgery 340
26.1 Introduction 340
26.2 Hardware 341
26.2.1 Desktop Computer 341
26.2.1.1 Microsoft-Based 341
26.2.1.2 Macintosh-Based 341
26.2.1.3 UNIX®-Like Operating Systems 342
26.2.2 Laptop Computers 342
26.2.3 Moore’s Law 342
26.2.4 Smart Phones and Personal Digital Assistants 342
26.3 Software 342
26.4 Computing Skills 343
26.4.1 Basic Computing Skills 343
26.4.1.1 Word Processing 343
26.4.1.2 Spreadsheet 344
26.4.1.3 Presentation 344
26.4.1.4 Mind Map 344
26.4.1.5 Email 344
POP3 345
IMAP4 345
SMTP 345
MAPI 345
26.4.1.6 Internet Browsing 345
26.4.1.7 Backup 346
Local Copy 346
Network Drive 346
Internet Backup Solutions 346
26.4.1.8 Communications 346
Voice over Internet Protocol (VOIP) 346
Virtual Worlds 346
26.4.1.9 File Management 347
26.4.2 Needs-Based Computing Skills 347
26.4.2.1 Manuscript Preparation and Reference Management 347
26.4.2.2 Databases 347
26.4.2.3 Programming 347
26.4.3 The Internet Resources 348
26.4.3.1 Google™ 348
26.4.3.2 Google™ Image 348
26.4.3.3 Doctors.net.uk 348
26.4.3.4 Medscape® 348
26.4.3.5 Sermo™ 348
26.4.3.6 Wikisurgery 348
26.4.4 Role of Computers in Specifi c Environment 349
26.4.4.1 Education Environment 349
26.4.4.2 Bedside Teaching 349
26.4.4.3 Creating Lecture Presentations 349
Pictures 349
Movies 349
Codec 349
Capture and Editing 350
Inserting Movies and Package for CD 350
Converting Whole Presentations into Flash 351
26.5 Clinical Environment 351
26.5.1 Picture Archiving and CommunicationsSystem (PACS) 351
26.5.2 Logbook 352
26.5.3 Web-Based Clinical Resources 352
26.5.4 Hospital Information System 352
26.5.5 Medical Software for Hand-Held Devices 352
26.6 Research Environment 353
26.6.1 Electronic Journals 353
26.6.2 Bibliographic Database 353
26.6.3 Citation Report 353
26.6.4 Publish or Perish 354
26.6.5 Statistical Packages 354
26.6.6 Ethical Approval 354
26.7 The Future 354
26.7.1 Web 2.0 354
26.7.2 Virtual Reality 354
26.7.3 Robotics 355
26.8 Conclusions 355
Chapter 27 356
Computational and Statistical Methodologies for Data Mining in Bioinformatics 356
27.1 Introduction 357
27.1.1 Advents and Early Approaches in Development of Medical Diagnostics 357
27.2 Experimental Methods 357
27.2.1 Mass Spectrometry 357
27.2.2 Microarrays 357
27.3 Challenges in Biomarker Discovery 358
27.3.1 Quality Control 358
27.3.2 Dimensionality and Complexity of the Data 358
27.3.3 Reproducibility 359
27.3.4 Multiple Testing and Control of Error Rates 359
27.4 Computational Methods for Data Analysis 359
27.4.1 Conventional Parametric Statistics 359
27.4.2 Pattern Classification and Modelling Using Unsupervised Methods 360
27.4.2.1 Principal Components Analysis 360
27.4.2.2 Clustering 360
27.4.2.3 Self-Organising Maps 361
27.4.2.4 Decision Trees, Classification and Regression Trees (Cart), Boosted Decision Trees and Random Forest Methods 361
27.4.3 Pattern Classification Using Predictive Supervised Methods 362
27.4.3.1 Logistic Regression 362
27.4.3.2 K-Nearest Neighbours 362
27.4.3.3 Linear Discriminant Analysis 363
27.4.3.4 Artificial Neural Networks 363
27.4.3.5 Genetic Algorithms 364
27.4.3.6 Support Vector Machines 364
27.4.3.7 Bayesian Approaches 364
27.5 Model Evaluation Using Cross-Validation 365
27.5.1 Measuring Performance with ROC Curves 366
27.6 Summary and Conclusions 366
References 367
Chapter 28 370
The Use of Bayesian Networks in Decision-Making 370
28.1 Introduction 370
28.2 Bayes’ Theorem 371
28.3 Bayesian Networks 372
28.4 How to Use Belief Networks 373
28.4.1 Making Predictions 373
28.4.2 Exposing the Underlying Logic and Assumptions 373
28.4.3 Handling Evidences 375
28.4.4 Incorporating Expert Judgments 375
28.5 Measuring Model Performance 376
28.6 Dynamic Bayesian networks 377
28.7 Inference Diagrams 377
28.8 Conclusions 377
References 378
Further Reading 378
Chapter 29 379
A Bayesian Framework for Assessing New Surgical Health Technologies 379
29.1 Introduction 379
29.2 A Bayesian Framework for Health Technology Assessment 380
29.3 Applying the Framework: Pre-Operative Optimisation 382
29.4 Background to the Clinical Example 382
29.5 Trial Analysis 383
29.6 Pre-Trial Analysis: Modelling the Available Information Set 384
29.6.1 Probabilities 384
29.6.2 Survival 386
29.6.3 Costs 386
29.6.4 Results 386
29.7 Post-Trial Analysis: Combining Information Sets 387
29.7.1 Priors 387
29.7.1.1 Survival 387
29.7.1.2 Costs 387
29.7.1.3 Results 388
29.8 Discussion on the Framework 389
29.8.1 Impact of the Iterative Framework 389
29.8.2 Implications of the Framework for Health Technology Assessment 389
29.8.3 Employing Bayesian Methods 390
29.9 Conclusions 390
References 391
Chapter 30 392
Systematic Reviews and Meta-Analyses in Surgery 392
30.1 Introduction to Systematic Reviews 393
30.1.1 The Rationale for the Systematic Review 393
30.1.1.1 The Problem of Information Overload 393
30.1.1.2 The Presence of Confl icting Results 393
30.1.1.3 The Narrative Review and its Shortcomings 393
30.1.1.4 The Limitations in Randomised Controlled Trials 393
30.1.1.5 The Problem of Insuffi cient High-Quality Trial Data in Surgical Research 394
30.1.1.6 The Solution 394
30.1.2 So What Is a Systematic Review? 394
30.1.3 The Meta-Analysis 395
30.1.4 Advantages over Narrative Reviews 395
30.1.5 Advantages over Randomised Controlled Trials 396
30.2 The Science of a Meta-Analysis 396
30.2.1 Careful Planning is Important 396
30.2.2 Defi ning the Objectives of the Study 396
30.2.3 Defi ning the Population of Studies to be Included 396
30.2.4 Defi ning the Outcome Measures 398
30.2.5 Locating all Relevant Studies 398
30.2.6 Screening, Evaluation and Data Abstraction 398
30.2.7 Choose and Standardise the Outcome of Measure 399
30.2.8 Statistical Methods for Calculating Overall Effect 400
30.2.9 Fixed and Random Effects Models 400
30.2.9.1 Fixed Effects Meta-Analysis 400
30.2.9.2 Random Effects Meta-Analysis 402
30.2.10 Heterogeneity Between Study Results 403
30.2.10.1 Assessing for the Presence of Heterogeneity 403
30.2.10.2 Graphical Display – Forest Plot 403
30.2.10.3 Sensitivity Analysis 404
30.2.10.4 Sub-Group Analysis 404
30.2.11 Meta-Regression 404
30.2.12 Conducting a Meta-Analysis in the Surgical Context 404
30.2.13 The Learning Curve 405
30.3 Assessing the Quality of a Meta-Analysis 405
30.4 Pitfalls in Conducting a Meta-Analysis 406
30.4.1 Confl icting Results Between Meta-Analyses Compared with Large-scale RCTs 406
30.4.1.1 Why Is There Bias in Meta-Analysis Then? 406
30.5 Pitfalls in the Variable Quality of Included Trials 406
30.5.1 The Importance of Quality 406
30.5.1.1 So what is Quality in an RCT? 406
30.5.2.2 Internal Validity 407
30.5.2 Quality of Reporting 407
30.5.2.1 Assessing the Quality of Reporting in RCTs 407
30.5.2.2 Dealing with Small Studies Effects 407
30.5.2.3 External Validity 407
30.5.2.4 Why Is Study Quality Important? 408
30.6 Pitfalls in Biased Inclusion Criteria 408
30.6.1 Dealing with Personal Bias and Inclusion Bias 408
30.7 Which Meta-Analyses Should be Published? 408
30.8 Systematic Review of Observational Studies 408
30.8.1 Use Cases for Observational Studies 409
30.8.2 Problems in Systematic Review of Observational Studies 409
30.8.2.1 Confounding Bias 409
30.8.2.2 Selection Bias and Other Forms of Bias 409
30.8.2.3 Heterogeneity in Study Methodology and Populations 410
30.8.3 Solutions to Problems in Observational Studies 410
30.9 Other Types of Meta-Analyses 410
30.9.1 Data: Meta-Analysis of Individual Patient Data 410
30.9.1.1 Advantages 411
30.9.1.2 Disadvantages 411
30.9.2 Study Type: Meta-Analysis of Observational and Epidemiological Studies 411
30.9.3 Study Type: Meta-Analysis of Survival Data 411
30.9.4 Method: Cumulative Meta-Analysis 411
30.9.5 Method: Mixed-Treatment Comparison (MTC) Meta-Analysis 412
30.10 What Is the Use of Meta-Analyses? 412
30.11 Meta-Analysis Software 412
30.12 Conclusion 413
References 413
Further Reading 414
Chapter 31 415
Decision Analysis 415
31.1 Introduction 415
31.2 The Role of Decision Analysisin Healthcare Evaluation 416
31.3 The Principles of Decision Analysis 416
31.3.1 Identifying and Bounding the Problem 416
31.3.2 Structuring the Problem 416
31.3.3 Acquiring the Model Parameters 417
31.3.4 Determine the Value of eachAlternative Strategy 417
31.3.5 Investigating Uncertainty 418
31.3.5.1 Univariate Sensitivity Analysis 419
31.3.5.2 Multivariate Sensitivity Analysis 419
31.3.5.3 Probabilistic Sensitivity Analysis 420
31.3.5.4 Alternative Analysis 421
31.4 Introducing Time Dependence 421
31.4.1 Constructing a Markov Model 422
31.4.2 Analyzing a Markov Model 423
31.5 Critical Appraisal 423
31.6 Limitations of Decision Analysis 423
31.7 Conclusions 424
References 424
Chapter 32 426
Cost-Effectiveness Analysis 426
32.1 Introduction 426
32.2 What is Cost-Effectiveness Analysis? 427
32.3 Perspective 427
32.4 Measures of Effect 427
32.4.1 Cost-Minimisation Analysis 428
32.4.2 Cost-Effectiveness Analysis 428
32.4.3 Cost-Benefi t Analysis 428
32.4.4 Cost-Utility Analysis 428
32.5 The Quality-Adjusted Life Year 428
32.6 Discounting 429
32.7 Interpreting the Results of Economic Analysis 429
32.7.1 The Incremental Cost-Effectiveness Ratio 429
32.7.2 Ranking Cost-Effectiveness Ratios 430
32.7.3 The Cost-Effectiveness Threshold 430
32.7.4 The Willingness-to-Pay Threshold 431
32.8 Handling Uncertainty 431
32.8.1 Sensitivity Analysis 431
32.8.2 Interpreting the Results of Probabilistic Sensitivity Analysis 432
32.9 Accessing the Quality and Relevance of Cost-Effectiveness Analysis 432
32.10 Limitations of Cost-Effectiveness Analysis 434
32.11 Conclusions 434
References 435
Chapter 33 436
Value of Information Analysis 436
33.1 Introduction 436
33.2 Calculating the Expected Value of Perfect Information 437
33.3 Population Expected Value of Perfect Information 438
33.4 Expected Value of Partial Perfect Information 440
33.5 Expected Value of Sample Information 441
33.6 Challenges and Limitations of EVPI Analysis 441
33.7 Conclusions 442
References 442
Chapter 34 444
Methodological Frameworkfor Evaluation and Prevention of Publication Bias in Surgical Studies 444
34.1 Introduction on Publication Bias in Surgical Studies 444
34.2 Importance of Identifi cation of Publication Bias in Meta-Analyses and Evidence-Based Medicine 445
34.3 Types of Publication Bias 446
34.3.1 Subject Selection Bias 446
34.3.2 Performance Bias 447
34.3.3 Attrition Bias 447
34.3.4 Detection Bias 447
34.3.5 Time Lead Bias 447
34.4 Methods to Detect Publication Bias 448
34.4.1 Graphical Methods 448
34.4.1.1 Funnel Plot 448
34.4.1.2 Galbraith Plot 448
34.4.1.3 Ordered Forest Plot 449
34.4.1.4 Normal Quantile Plot 449
34.4.2 Numerical Methods 449
34.4.2.1 Effect Assessment Methods 449
34.4.2.2 Sensitivity Analysis Methods 450
34.5 Prevention of Publication Bias 453
34.5.1 Trial Registries 453
34.5.2 Prospective Meta-Analyses 453
34.5.3 Searching the Grey Literature 454
34.6 Conclusions 454
References 454
Chapter 35 456
Graphs in Statistical Analysis 456
35.1 Introduction 457
35.1.1 Commonly Used Statistical Terms 457
35.2 Categorising Data and Data Handling 457
35.2.1 Types of Data 457
35.2.2 Data-Handling Techniques 458
35.2.2.1 Statistical and Data-Handling Software Packages 458
35.2.2.2 Data Coding 459
35.2.3 Checking for Errors 459
35.3 Describing and Summarising the Data 459
35.3.1 Types of Average 460
35.3.1.1 The Arithmetic Mean 460
35.3.1.2 The Geometric Mean 460
35.3.1.3 The Harmonic Mean 460
35.3.1.4 The Weighted Mean 460
35.3.1.5 The Median 461
35.3.1.6 The Mode 461
35.3.2 Measures of Spread 461
35.3.2.1 The Range 461
35.3.2.2 The Variance 461
35.3.2.3 The Standard Deviation 463
35.3.2.4 The Standard Error 463
35.3.3 The “Shape” of the Data 463
35.3.3.1 The Skew of the Data 464
35.3.3.2 The Kurtosis of the Data 464
35.4 Displaying Data Graphically 464
35.4.1 Categorical Data 465
35.4.2 Continuous Data 465
35.4.3 Multiple Variables 465
35.5 Probability Distributions 466
35.5.1 An Introduction to Probability 466
35.5.2 Probability Distributions 468
35.5.3 Discrete Probability Distributions 469
35.5.3.1 The Binomial Distribution 469
35.5.3.2 The Poisson Distribution 469
35.5.4 Continuous Distributions 469
35.5.4.1 The Normal Distribution 471
35.5.4.2 Student’s t-Distribution 473
35.5.4.3 The Chi-Squared Distribution 473
35.5.4.4 The F-Distribution 473
35.5.4.5 The Lognormal Distribution 473
35.6 Transformations 473
35.7 Confi dence Intervals 475
35.7.1 Confi dence Intervals for the Mean Using the Normal Distribution 475
35.7.2 Confi dence Intervals for the Mean Using Student’s t-Distribution 476
35.7.3 Confi dence Interval for the Proportion 476
35.7.4 Bootstrapping 476
35.8 Hypothesis Testing 477
35.8.1 Step 1: Defi ning the Null and Alternative Hypotheses 477
35.8.2 Step 2: Sampling the Data 477
35.8.3 Step 3 & 4: Data Analysis
35.8.4 Step 5: Interpreting the Results 478
35.8.4.1 p-Values 478
35.8.4.2 Relationship Between Hypothesis Tests and Confi dence Intervals 479
35.8.5 Types of Statistical Tests 479
35.8.5.1 Numerical Data, One Group 479
35.8.5.2 Numerical data, Two Related Groups 480
35.8.5.3 Numerical data, Two Unrelated Groups 480
35.8.5.4 Numerical data, More Than Two Groups 481
35.8.5.5 Categorical Data: One Group 481
35.8.5.6 Categorical Data: Two Independent Groups 482
35.8.5.7 Categorical Data: Two Related Groups 482
35.8.5.8 Categorical Data: More Than Two Categories 483
35.9 Investigating the Relationship Between Two Variables 483
35.9.1 Correlation 483
35.9.2 Spearman’s Rank Correlation Coeffi cient 485
35.9.3 Univariate or Simple Linear Regression 485
35.9.3.1 Performing Simple Linear Regression Analysis 485
35.9.3.2 Multiple Linear Regression 487
35.9.3.3 Nonlinear Regression 488
35.9.4 Generalised Linear Models 489
35.9.5 Miscellaneous Problems in Regression Modelling 489
35.10 Summary 490
References 490
Chapter 36 491
Questionnaires, Surveys, Scales in Surgical Research: Concepts and Methodology 491
36.1 Introduction 491
36.2 Surveys 492
36.2.1 Stages of Building a Survey 492
36.2.1.1 Design Work 492
36.2.1.2 Construction of Data Collection Tools 493
36.2.1.3 Determining the Population and the Sample to be Selected 493
36.2.1.4 Sampling 493
36.2.1.5 Sample Size and Statistical Power 494
36.2.1.6 Selecting the Population Sample 495
36.2.1.7 Sampling Error 495
36.3 Types of Surveys 495
36.4 Data Collection Methods in Surveys 497
36.5 Survey Advantages and Disadvantages 497
36.6 Error in Survey Research 497
36.7 Questionnaires 498
36.7.1 Questionnaire Design 498
36.7.2 Distribution 501
36.7.3 Response and Non-Response 501
36.7.4 Advantages and Disadvantages of Questionnaires 501
36.8 Scales 502
36.8.1 Attitude Measurement Scales 503
36.8.2 Semantic Differential Scales 504
36.8.3 Other Scaling Techniques 504
36.9 Validation 504
36.10 Factor Analysis 505
36.11 Structural Equation Modelling 506
36.12 Research Approval 507
36.13 Future Research 507
References 507
Further Reading 508
Chapter 37 509
How to Perform Analysis of Survival Data in Surgery 509
37.1 Introduction 509
37.2 Features of Survival Data 510
37.2.1 Timescale 510
37.2.2 Types of Censoring 510
37.3 Standard Survival Analysis 512
37.3.1 Basic Quantities 512
37.4 Methods for Analysing Survival Data 512
37.4.1 Non-Parametric 512
37.4.2 Semi-Parametric 514
37.4.3 Parametric 515
37.5 Further Issues in Survival Analysis 516
37.5.1 Competing Risks 516
37.5.2 Time-Dependent Covariates 517
37.5.3 Missing Data 518
37.5.4 Long-Term Survivor Models 519
37.5.5 Meta-Analysis 519
References 520
Further Reading 520
Chapter 38 521
Risk Stratifi cation and Prediction Modelling in Surgery 521
38.1 Introduction 522
38.2 Historical Perspective 523
38.3 Overview of Examples of Risk Stratification Models 523
38.3.1 American Society of Anaesthesiology (ASA) Grade 524
38.3.2 Acute Physiology and Chronic Health Evaluation (APACHE) Methodology 524
38.3.3 The Simplifi ed Acute Physiology Score (SAPS) Methodology 526
38.3.4 The Mortality Prediction Model (MPM) Methodology 526
38.3.5 The Surgical Mortality Score (SMS): A Model Based on Administrative Data 526
38.3.6 The Physiology and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) Methodology 526
38.3.7 Other Risk Stratifi cation Models 529
38.4 Logistic Regression in Risk Stratification Modelling 530
38.4.1 Multiple Logistic Regression Analysis 530
38.4.2 Hierarchical (Multilevel) Logistic Regression Analysis Models 531
38.4.3 The Need for Progress in Statistical Methodology of Non-Randomised Designs 532
38.4.3.1 Matching 533
38.4.3.2 Multivariable Logistic Regression Analysis and Adjustment 534
38.4.3.3 Use of Multilevel and Hierarchical Modelling 534
38.4.3.4 Use of Bayesian Methods and Statistical Simulation Techniques 534
38.4.3.5 Use of Balancing Scores 534
38.5 Artificial Neural Networks 535
38.5.1 Clinical Applications of ANN 537
38.6 Development and Validation of Risk Stratifi cation Models 537
38.6.1 Discrimination 538
38.6.2 Calibration 538
38.6.3 Sub-group Analysis 538
38.6.4 Recalibration 538
References 539
Chapter 39 543
The Principles and Role of Medical Imaging in Surgery 543
39.1 Introduction 544
39.1.1 Imaging for Pre-Operative Planning 544
39.1.2 Intra-Operative Imaging 546
39.1.2.1 Real-Time Adaptive Imaging 548
39.1.2.2 Co-Registration with Pre-Operative Data 550
39.1.2.3 Visualisation, Modelling and Augmented Reality 551
39.1.3 Post-Operative Imaging 552
39.2 The Future of Surgical Imaging 554
39.3 Summary 556
References 556
Chapter 40 558
How to Read a Paper 558
40.1 Introduction 558
40.2 The Conceptual Basis of A Scientifi c Paper 559
40.3 Reasons to Read a Research Journal 559
40.4 The Psychology of Reading a Paper 559
40.5 Originality 560
40.6 Types of Paper and Quality of Evidence 561
40.7 Core Components 562
40.8 Title 563
40.9 Authorship and Ancillary Information 563
40.10 Abstract/Summary 564
40.11 Introduction/Backround 564
40.12 Materials and Methods 564
40.13 Results, Tables, Figures 565
40.14 Discussion 565
40.15 Acknowledgements and Declarations 566
40.16 References and Bibliography 566
40.17 Supplementary fi les 566
40.18 Conference Discussion 566
40.19 Editorial 566
40.20 The importance of assessing a paper 566
40.21 Conclusions 567
References 567
Chapter 41 569
How to Evaluate the Quality of the Published Literature 569
41.1 Introduction 569
41.2 The Meaning of Quality 570
41.3 The Traditional Hierarchy of Evidence 570
41.4 Measuring Quality 571
41.5 Systematic Review and Meta-analysis 571
41.6 Randomised Controlled Trials 572
41.7 Non-Randomised Trials 572
41.8 Studies of Diagnostic Accuracy 572
41.9 The Problems with Quality Assessment Tools 576
41.10 Summary and Conclusions 577
References 578
Chapter 42 580
How to Write a Surgical Paper 580
42.1 Introduction 580
42.2 How to Find a Successful Title? 581
42.3 Getting the Salient Point of the Publication Across 582
42.4 Writing for a Particular Journal 582
42.5 Following a Recognised Structure for Surgical Journals 582
42.6 Being Prepared to Write, Rewrite and Rewrite Again and Again and Again 583
42.7 An Effi cient Utilisation of Tables, Diagrams, Images and Flowcharts 584
42.8 Careful Formatting and Referencing as Appropriate 584
42.9 A Clear Understanding of How to Submit the Manuscript Appropriately 586
42.10 Being Open Minded to Review Criticism and Answering Reviewer Comments Well 586
42.11 Working as a Team – The Best Papers are Never Written by Individuals 587
42.12 Case Reports, Letters, Techniques and Images in Surgery 587
42.13 Summary 587
Further reading 588
Chapter 43 589
A Primer for Grant Applications 589
43.1 Introduction 589
43.2 Reasons for Application 590
43.3 Sources of Funding 590
43.4 Who Should Apply to which Grant? 592
43.5 Practicalities of Applying 592
43.6 Costing 594
43.7 An insight into Application Processing 594
43.8 Common Reasons for Failure 595
43.9 After Success or Failure 595
43.10 Conclusion 595
References 596
Chapter 44 597
Key Aspects of Grant Applications: The Surgical Viewpoint 597
44.1 Introduction 597
44.2 The Importance and Contribution of Surgical Research 598
44.3 Unique Aspects of Surgical Grant Application 599
44.4 Funding Availability and Bodies for Surgical Research 600
44.5 Funding for Surgical Residents and Fellows 600
44.6 The Grant Review Process 602
44.7 Writing 602
44.8 Outline of Grant Structure and Format 603
44.8.1 The Investigator, Research Environment and Budget 603
44.9 The Plan of Investigation 604
44.10 Further Points for Basic Science Proposals 604
44.11 Further Points for Clinical Proposals 604
44.12 Programme Grants 605
44.13 Conclusions 605
References 605
Web Links 606
Chapetr 45 607
How to Organise an Educational Research Programme Within an Academic Surgical Unit 607
45.1 Introduction 607
45.2 Fundamentals of Educational Research Methodologies 608
45.3 Key Points to Design a Surgical Educational Research Programme 609
45.3.1 Pre-Requisites for Planning Educational Research 610
45.3.2 Sequence of Steps in an Educational Research Project 610
45.3.2.1 Defi ning the Need for Research: Literature Reviews, Surveys and Audits of Practice 610
45.3.2.2 Designing the Research and Methods of Data Collection 610
45.3.2.3 Data Analysis 611
45.3.3 Writing a Project Proposal 611
45.4 Factors Infl uencing Surgical Educational Research 612
45.4.1 Academic Support 612
45.4.2 Credibility 613
45.4.3 Collaboration 613
45.4.4 Time 613
45.5 Conclusions 613
References 613
Chapter 46 615
How to Structure an Academic Lecture 615
46.1 Definition of an Academic Lecture 615
46.2 Types of Academic Lecture 616
46.3 Principles of Lecture Format and Structure 616
46.4 Lecture Planning and Delivery 616
46.5 Practical Aspects of Lecture Delivery 618
46.6 Newer Aspects of Academic Lecturing 619
46.7 Conclusions 619
References 620
Web Links 620
Chapter 47 621
How to Write a Book Proposal 621
47.1 Introduction 621
47.2 The Book Proposal 621
47.2.1 The Synopsis or Overview 622
47.2.2 The Author(s) 622
47.2.3 Market Analysis 622
47.2.4 Competitors 623
47.2.5 Annotated Table of Contents 623
47.2.6 Sample Material 623
47.3 The Cover Letter 623
47.4 Finding a Publisher 623
47.5 After the Proposal Is Accepted 624
47.6 Sources of Additional Information 624
References 624
Chapter 48 625
How to Organise a Surgical Meeting: National and International 625
48.1 Purpose 625
48.2 Principles of Congress Organisation 626
48.3 When and Where 627
48.4 Constructing the Budget 628
48.5 The Meeting Programme 629
48.6 Planning the Meeting Sessions 630
48.7 The Panel Discussion 630
48.8 Seminars and Workshops 630
48.9 The Business Meeting 631
48.10 The Conference Secretariat 631
48.11 Trade and Exhibition 631
48.12 Computing, I-T and A-V 632
48.13 Telecast Meetings 632
48.14 Evaluation and CME 633
48.15 Conclusions 633
References 633
Chapter 49 635
Presentation Skills in Surgery 635
49.1 Introduction 635
49.2 Content of Presentation 636
49.3 Verbal Presentation and Poise 636
49.4 Slides 636
49.5 Audio–Visual Tools for Presentations 637
49.6 Other Materials That May Be Used as Adjuncts for Presentations 638
49.7 Feedback and Learning New Techniques 638
49.8 Summary 638
Further Reading 638
Useful Web Sites 638
Chapter 50 639
Internet Research Resources for Surgeons 639
50.1 Introduction 639
50.2 Bibliographic Databases 639
50.3 Journal Collections 640
50.4 Web Search Engines 641
50.5 Medical Statistics 641
50.6 Images and Audio-visual Resources 641
50.7 Online Anatomy Resources 641
50.8 Training 643
50.9 Interview and Exam Preparation 643
50.10 Administration in Surgery 643
50.11 Social Networks 644
50.12 Summary 644
Further Reading 645
Chapter 51 646
Clinical Practice Guidelines in Surgery 646
51.1 Introduction 646
51.2 What Are Guidelines? 647
51.3 Developing Guidelines 648
51.3.1 Defining the Scope of a Clinical Practice Guideline 648
51.3.2 Reviewing the Literature 649
51.3.3 Assessing Study Quality and Level of Evidence in Surgery 649
51.3.4 Formulating Recommendations 650
51.4 External Review of a New Guideline 650
51.5 Updating Guidelines 650
51.6 Implementation of Guidelines 651
51.7 User Issues 651
51.7.1 Rating Guidelines 651
51.7.2 Practice Guidelines-Can They Effect Change? The Cancer Care Ontario Experience 651
51.8 Conclusion 653
References 653
Chapter 52 655
From Idea to Bedside: The Process of Surgical Invention and Innovation 655
52.1 Introduction 655
52.2 Determining the Value of an Innovation 656
Suggested Resources 658
52.3 Intellectual Property 658
Suggested Resources 659
52.4 Prototyping 659
Suggested Resources 660
52.5 Institutional Technology Transfer 660
52.5.1 FDA Regulation of Medical Devices 660
Suggested Resources 662
52.6 Cost Effectiveness 662
Suggested Resources 662
52.7 Teaching and Mentoring Surgical Innovation 662
52.8 Confl ict of Interest 663
Suggested Resources 663
References 663
Chapter 53 665
Research Governance and Research Funding in the USA: What the Academic Surgeon Needs to Know 665
53.1 Research as a Core Mission 665
53.2 A Culture of Investigation 666
53.3 Creating Investigative Diversity 666
53.3.1 Investigators 666
53.3.2 Investigative Topics 669
53.3.3 Investigative Facilities 670
53.4 Applying for a Grant 671
53.5 Administrative Research Infrastructure 673
53.6 Running an Academic Department as a Business Activity 673
53.7 Research Bridging Funds Policy 675
References 675
Chapter 54 676
Research Governance in the UK: What the Academic Surgeon Needs to Know 676
54.1 Introduction 676
54.2 Regulation 677
54.2.1 The Medicines for Human Use (Clinical Trials) Regulations 677
54.2.2 Medical Device Regulations 678
54.2.3 The Human Tissue Act 678
54.2.4 The Data Protection Act 679
54.2.5 The Mental Capacity Act 680
54.3 Approvals 680
54.3.1 Ethics Approval 680
54.3.2 Amendments 681
54.3.2.1 Substantial Amendment 681
54.3.2.2 Minor (“Non-Substantial”) Amendments 681
54.3.3 Sponsor Approval 682
54.3.4 NHS Trust Approval 682
References 683
Chapter 55 684
Research Funding, Applying for Grants and Research Budgeting in the UK: What the Academic Surgeon Needs to Know 684
55.1 Introduction 684
55.2 Applying for Research Project/Programme Funding: Funding Sources 685
55.2.1 Research Councils 685
55.2.2 Other Government Departments 686
55.2.3 Charities 686
55.2.4 Industry/Private Companies (National and Multinational) 687
55.2.5 International Organisations (e.g. Commission of the European Communities, National Institutes of Health) 687
55.3 Applying for Research Project/Programme Funding: Administrative Considerations 688
55.4 Applying for Research Project/Programme Funding: Financing 688
55.5 Principles of Full Economic Costing 688
55.5.1 Directly Incurred Costs 690
55.5.1.1 Directly Incurred Staff Costs 690
55.5.1.2 Directly Incurred Non-Staff Costs 691
55.5.2 Directly Allocated Costs 691
55.5.2.1 Directly Allocated Investigator Costs 691
55.5.2.2 Directly Allocated Estates Costs 694
55.5.2.3 Directly Allocated FEC Research Facility Charge-Out Rates 695
55.5.2.4 Directly Allocated Shared Laboratory Technicians 695
55.5.3 Indirect Costs 695
55.6 Principles of Pricing 696
Appendix Key terms 697
References 699
Chapter 56 701
How to Enhance Development and Collaboration in Surgical Research 701
56.1 Background and Introduction 702
56.1.1 Situation 702
56.2 Complications 703
56.3 Opportunity 703
56.3.1 Academic Institutions 703
56.4 Public Benefi ts of Research 704
56.4.1 Research into the Determinants of Health 705
56.4.2 Medical Research 705
56.4.3 Health Care Delivery Research 705
56.4.4 Translational Research 706
56.5 Collaboration and Its Benefi ts 706
56.6 Evidence of Value/Demonstrated Benefit 707
56.7 Implications of Collaboration 710
56.7.1 Virtual Organisation 710
56.7.2 Co-Location 710
56.7.3 Joint Ventures 710
56.7.4 Merger 710
56.8 Benefi ts of Collaboration to Research 711
56.8.1 Discovery Research 711
56.8.2 Clinical Research 711
56.8.3 Health Services Research 712
56.8.4 Clinical and Population Epidemiology 712
56.8.5 Technology Convergence 712
56.9 Additional Benefits of Collaboration 712
56.9.1 Advantages to Education 712
56.9.2 Impact on Allied Professions 712
56.9.3 Advantages to Health Service Delivery (NHS) 712
56.9.3.1 Proximity 713
56.9.3.2 Recruitment and Retention 713
56.9.3.3 IP Exploitation 713
56.9.3.4 Improved Resource Utilisation 713
56.9.4 Aligned Capital and Funding Opportunities 713
56.9.5 Commercial Opportunities and Economic Spin-Off Benefits 714
56.10 Contract and Industry Research 714
56.11 Biosciences Cluster 714
56.12 Advantages to Biotech Sector Development 715
56.13 Biosciences Business Park and Incubators 715
56.14 Alternative Models 715
56.14.1 Successful Models from Other Jurisdictions (Academic Health Science Centres) 715
56.14.1.1 University owned Health Science Centres 716
56.14.1.2 Hospital Owned Academic Institutions 716
56.14.1.3 Joint Governance Alliances 716
56.14.1.4 Coalition 716
56.14.1.5 Community Networks 717
56.15 Aligned Vision, Structure, Process and Resources 717
56.16 Conclusion and Summary 719
56.17 Search Strategy and Interviews 719
References 720
Chapter 57 721
Mentoring in Academic Surgery 721
57.1 The Mentoring Construct: Background 721
57.2 Current Challenges 722
57.3 Mentoring: An Important Developmental Tool 722
57.3.1 What Is Mentoring? 722
57.3.2 Potential Benefi ts of Mentoring 723
57.3.3 How Should Mentoring Be Delivered, and by Whom? 724
57.3.3.1 Formal vs. Informal Mentoring 724
57.3.3.2 Who Should Mentor? 724
57.3.3.3 Peer Mentoring 725
57.3.3.4 Senior Mentors: “Internal” 725
57.3.3.5 External or “Distance” Mentors 725
57.4 Creating a Formal Mentoring Scheme and Establishing a Clear Purpose for the Mentoring Relationship or Scheme 726
57.4.1 Gaining Visible, Senior Support 726
57.4.2 Defi ning the Mentoring Process to All Involved 726
57.4.3 Understanding the Possible Costsof Implementing a Mentoring Scheme 726
57.4.4 Identifying Suitable Participants as Mentees and Clearly Defining Their Responsibilities 727
57.4.5 Identifying Suitable Participants as Mentors and Clearly Defining Their Responsibilities 728
57.4.6 Creating “The Contract”: Clarifying the Ground Rules and Commitments 729
57.4.7 Matching Mentors and Mentees 729
57.4.8 Training 729
57.4.9 Administering, Quality Assuring and Evaluating the Scheme 729
57.5 Conclusion 730
References 730
Chapter 58 732
Leadership in Academic Surgery 732
Introduction 732
58.1 What is Leadership? 733
58.1.1 Early Work on Leadership 733
58.1.2 Transactional and Transformational Leadership 734
58.1.3 Management and Leadership 735
58.1.4 More Recent Work 736
58.2 A Selection of Leadership and Managerial Models 738
58.2.1 Lewin’s Leadership Styles 738
58.2.2 Situational Leadership Model 738
58.2.3 The Managerial Grid 739
58.2.4 Four Framework Approach 739
58.2.4.1 The Structural Framework 739
58.2.4.2 The Human Resource Framework 740
58.2.4.3 The Political Framework 740
58.2.4.4 The Symbolic Framework 740
58.3 Leading in Teams 740
58.4 Leadership in Academic Surgery 741
58.4.1 The Challenge 741
58.4.2 Why Is Clinical Leadership Important? 741
58.4.3 What Aspects of Care Should We Be Improving? 741
58.4.4 What Are the Differing Leadership Roles in Delivering These Clinical Aims? 742
58.4.5 What Are the Common Attributes of Academic Surgical Leaders and Their Requirements? 742
58.5 How Best to Develop Leadership Skills in Surgeons? 742
58.5.1 What Methods Are Available to Develop Leadership? 743
58.5.2 Who Should Be Responsible for Leadership Development in Academic Surgeons and How Should It Be Delivered? 744
References 745
Chapter 59 746
Using Skills from Art in Surgical Practice and Research-Surgery and Art 746
59.1 Introduction 746
59.2 Historical Perspectives 747
59.2.1 Anatomical Art 747
59.2.2 Leonardo Da Vinci 747
59.2.3 Recording Surgical History 748
59.2.4 Recording Surgical Technique 748
59.2.5 Methods of Illustration 749
59.3 Similarities Between Art and Surgery 749
59.3.1 Fine Motor Control 749
59.3.2 Spatial Awareness 749
59.3.3 Form and Shape 750
59.3.4 Observational Skills 750
59.4 Interpreting Visual Information 750
59.4.1 Depth Perception 751
59.4.2 Interpretation of Laparoscopic Images 751
59.5 Practical Uses of Art in Surgery 751
59.5.1 Memory and Revision 751
59.5.2 Art in Clinical Practice 751
59.5.3 Art and Teaching 751
59.5.4 Digital Images and Manipulation 752
59.5.5 Art and Aesthetic Surgery 753
59.6 Art Therapy 754
59.7 Art in Hospitals 754
59.8 Sources of Art Information and Useful Resources 754
59.9 Inter-Relationships Between Professional Artists and Surgeons 755
59.9.1 Illustration and Research 755
59.9.2 Surgical Simulation 755
59.9.3 Innovation 755
59.10 Advantages of Artistic Training for Surgeons 755
59.11 Summary 755
References 756
Chapter 60 757
Administration of the Academic Department of Surgery 757
60.1 Introduction 757
60.2 Challenges Faced by Modern Academic Departments of Surgery 758
60.2.1 Rapid Pace of Scientific and Technological Change 758
60.2.2 Increasing Tensions in the Allocation of Time 758
60.2.3 Financial Pressures 759
60.2.3.1 Market-Based Healthcare 759
60.2.3.2 Increased Reliance on Hospital Funding 759
60.2.3.3 Increased Competition for Research Awards 759
60.2.4 Workforce Challenges 759
60.2.4.1 Generational Issues 759
60.2.4.2 Gender, Ethnicity, and Other Social Factors 760
60.2.4.3 Control and Regulation of Resident Work Hours 760
60.3 Addressing the Challenge: Strategic Themes for Seizing and Opportunities in the Twenty-First Century 761
60.3.1 Organizing the Department for the Twenty-First Century 761
60.3.2 Leadership Excellence: Qualities and Skills 762
60.3.3 Surgical Divisions 762
60.3.4 The Interdisciplinary Model 763
60.3.4.1 Interdisciplinary Research in Basic Sciences 764
Active Role in NIH in Interdisciplinary Collaborations: Clinical Translational Research Institutes 765
Interdisciplinary Model in Health Services Research 765
Interdisciplinary Model in Clinical Delivery and Training Programs 765
60.3.4.2 Interdisciplinary Model in Surgical Education 766
60.4 Surgical Innovation and Partnership with Industry 767
60.5 Philanthropy and Fundraising, an Essential Function of a Modern Department 767
60.6 Ethics, Professionalism, Quality 767
60.7 Focus on the Future Generations: Training, Development, Evaluation 768
60.7.1 Medical Students: Attracting the Best and the Brightest 768
60.7.2 Residency Training 768
60.7.3 Fellowship Training 769
60.8 Faculty 769
60.8.1 Recruitment and Retention 769
60.8.2 Development of Faculty 769
60.8.3 Balancing Faculty Efforts 770
60.8.4 Faculty Compensation 770
60.8.5 Role of Promotion in IncentiveSystem 772
60.8.6 Metrics of Academic Productivity 772
60.9 Conclusions 772
References 773
Chapter 61 774
Information Transfer and Communication in Surgery: A Need for Improvement 774
61.1 Communication as a Pivotal Factor for Surgical Safety 774
61.2 Models of Communication 775
61.3 Communication Errors: Culprit of Major Disasters in High-Risk Industries 777
61.4 Strategies to Improve Communication in High Risk-Industries: Can It Be Adapted in Surgical Care? 777
61.5 Communication Failures & Medical Errors
61.6 Assessing Communication & Identifying Communication Failures in Surgical Care
61.6.1 Operating Theatre Communication 779
61.6.2 Postoperative Handover Communication 779
61.6.3 Shift Handover Communication 779
61.6.4 Clinical Units Communication 780
61.7 Impact of Information Transfer and Communication on Outcomes 780
61.8 Interventions Used to Improve Communication 780
61.8.1 Standardizing the ITC Process 780
61.8.2 Changing Teams 781
61.8.3 Technology Innovations 781
61.9 Conclusion 782
References 782
Chapter 62 784
General Surgery: Current Trends and Recent Innovations 784
62.1 Introduction 784
62.2 Trends in General Surgery Research 785
62.2.1 The Call for Patient Safety and Medical Information Technology 785
62.2.2 Requirements for Reporting 786
62.2.3 Trends Across Institutional Review Boards 787
62.2.4 Privacy Legislation 787
62.2.5 Trends in Funding for Surgical Research 787
62.2.6 Partnerships for Clinical Trials 788
62.3 Recent Innovations 788
62.3.1 Surgical Robotics 788
62.3.2 Natural Orifice Translumenal Endoscopic Surgery (NOTES) 790
62.3.3 Artificial Organs and Device Engineering 791
62.3.4 Training the Surgeon of the Future 792
References 793
Chapter 63 795
Upper Gastrointestinal Surgery: Current Trends and Recent Innovations 795
63.1 Introduction 796
63.2 Innovation Within the Specialty 796
63.2.1 Robotics in Upper Gastro-Intestinal Surgery 796
63.2.1.1 Telerobotically Assisted Laparoscopic Cholecystectomy (TALC) 796
63.2.1.2 Robot-Assisted Laparoscopic Fundoplication (RALF) 797
63.2.1.3 Robotic Esophagectomy 797
63.2.2 Natural Orifice Transluminal Endoscopic Surgery (NOTES) 797
63.2.3 Endoluminal Therapy 798
63.2.4 Endoscopic Mucosal Resection (EMR) 799
63.2.5 Photodynamic Therapy 799
63.3 Techniques Within Specialty 799
63.3.1 Obesity Surgery Techniques 799
63.3.1.1 Obesity and All-Cause Mortality 799
63.3.1.2 Surgical Treatment of Obesity 799
Restrictive Procedures 800
Vertical Banded Gastroplasty 800
Laparoscopic Adjustable Gastric Banding 800
Sleeve Gastrectomy 800
Endoluminal Procedures 801
Malabsorptive Operations 801
Biliopancreatic Bypass with or Without Duodenal Switch Procedure 801
Roux-en-y Gastric Bypass 802
63.3.2 Debates 803
63.3.2.1 Extent of Lymphadenectomy Needed for Cancer Clearance 803
63.3.2.2 Minimal Access Esophagectomy 804
63.4 Recent Advances in Choice of Management Within Specialty 804
63.4.1 Gastro-Esophageal Reflux Disease (GERD) and Achalasia 804
63.4.1.1 GERD 804
Medication vs. Operation 804
Total vs. Partial Fundoplication 804
63.4.1.2 Achalasia 805
Pharmacotherapy 805
Botulinum Toxin 805
Pneumatic Dilation 805
Surgical Therapy 805
63.4.2 Barrett’s Esophagus and Esophageal Cancer 806
63.4.2.1 Combined Modality Adjuvant Treatment 806
63.4.2.2 Palliative Management of Esophageal Cancer 807
63.4.2.3 Targeted Therapy 807
63.4.2.4 Gene Therapy 807
63.5 Molecular and Biological Developments Within Specialty 807
63.5.1 Progression of Barrett’s Disease and Adenocarcinoma of the Esophagus 807
63.5.1.1 Invasion 808
E-cadherin 808
COX-2 808
63.5.1.2 Dysplasia 808
63.5.2 ASPECT Study 808
63.5.3 Tumor Markers in Esophageal Cancer Staging 809
63.5.4 Diagnostic Laparoscopy/Thoracoscopy 809
63.5.5 Detection of Micrometastases in Bone Marrow 809
63.6 Imaging and Diagnostics 809
63.6.1 Upper Gastrointestinal Barium Examination (UGI) 809
63.6.2 Staging Modalities and Prognostic Indicators 810
63.6.2.1 Endoscopic Ultrasound 810
63.6.2.2 Computed Tomography 810
63.6.2.3 Magnetic Resonance (MR) 810
63.6.2.4 Positron Emission Tomography (PET) 810
63.6.2.5 Prognostic Factors in Gastroesophageal Cancer 811
63.7 Training Within Specialty 811
63.7.1 Surgical Skills Training 811
63.7.2 Hospital Volume/Outcome Relationship 811
63.8 Future Directions in Research and Management Within Specialty 811
63.8.1 Future Directions in Drug Therapy 811
63.8.2 Staging of Gastric and Esophageal Cancer 812
63.8.3 Prediction of Survival and Guidance of Treatment 812
63.8.4 Global molecular profiling 812
References 812
Chapter 64 817
Colorectal Cancer Surgery: Current Trends and Recent Innovations 817
64.1 Introduction 817
64.2 Colorectal Imaging Techniques for Diagnosis and Staging 818
64.2.1 Colon Cancer Diagnosis 818
64.2.2 Colon Cancer Staging 819
64.2.3 Rectal Cancer Staging 819
64.2.4 Endorectal Ultrasound Staging in Rectal Cancer 820
64.2.5 ERUS Restaging of Rectal Cancer After Chemoradiation 820
64.2.6 EUS for Detection of Recurrent Rectal Cancer 821
64.2.7 MR Imaging in Rectal Cancer 821
64.2.8 Determining Tumour Characteristics and Outcomes from Imaging 821
64.2.9 Sentinel Lymph Node Mapping in Colorectal Cancer 822
64.2.10 The Role of Chemotherapy in Colorectal Cancer 822
64.3 Rectal Cancer Surgery 823
64.3.1 Total Mesorectal Excision 823
64.3.2 The Role of Neoadjuvant Therapy in Rectal Cancer Surgery 824
64.3.3 Management of Early Rectal Cancer 824
64.3.3.1 Local Transanal Excision of Rectal Cancer 824
64.3.3.2 Transanal Endoscopic Microsurgery 824
64.3.4 Surgeon as a Source of Variability in Outcomes 825
64.3.5 Hospital and Variability in Outcome 826
64.4 Laparoscopic Surgery 826
64.5 Enhanced Recovery 827
64.6 Robotic Colorectal Surgery 828
64.7 Future Perspectives 828
64.7.1 Telementoring and Remote Telepresence Surgery 828
64.7.2 New Devices for Robotic Surgery 830
64.7.3 Real-Time Intra-Operative Anatomy and Histology 830
64.7.4 Natural Orifi ce Transluminal Endoscopic Surgery 830
64.7.5 Individualisation of Treatment 831
References 831
Chapter 65 834
Urology: Current Trends and Recent Innovations 834
65.1 Innovation in Urology 834
65.2 New Surgical Techniques 835
65.2.1 Renal Surgery 835
65.2.1.1 Local Disease 835
65.2.1.2 Advanced Renal Cancer 836
65.3 Prostate Cancer Surgery 836
65.3.1 Radical Prostatectomy 836
65.4 Bladder Cancer Surgery 838
65.4.1 Novel Endoscopic Diagnostic Techniques 838
65.4.2 Surgical Approaches 838
65.5 Penile Cancer Surgery 839
65.6 Molecular and Biological Developments 839
65.6.1 Biomarkers 839
65.6.1.1 Prostate Cancer 839
65.6.1.2 Bladder Cancer 840
65.6.2 Metabonomics 841
65.6.3 Tissue Engineering 841
65.7 Diagnostic Imaging 842
65.7.1 PET & PET-CT
65.7.2 Magnetic Resonance Spectroscopic Imaging 843
65.7.3 USPIO 844
65.7.4 Ultrasound 844
65.8 Screening and Chemoprevention in Prostate Cancer 845
References 846
Chapter 66 849
Cardiothoracic Surgery: Current Trends and Recent Innovations 849
66.1 Innovation in Cardiac Surgery 849
66.2 New Surgical Techniques 851
66.2.1 Surgical Treatment of Atrial Fibrillation 851
66.2.1.1 Incidence 851
66.2.1.2 Pathophysiology 851
66.2.1.3 Clinical Sequelae 852
66.2.1.4 Medical Treatment 852
66.2.1.5 Catheter Ablation 852
66.2.1.6 Surgical Ablation 853
66.2.1.7 Cox-Maze III 853
66.2.1.8 Pulmonary Vein Isolation 853
66.2.1.9 Mini-Maze Type Procedures 854
66.2.1.10 Energy Sources 854
66.2.1.11 Radiofrequency Ablation 854
66.2.1.12 Cryoablation 855
66.2.1.13 Microwave 855
66.2.1.14 Ultrasound 855
66.2.1.15 Future Directions 855
66.2.2 Off-Pump and Minimally Invasive Cardiac Surgery 855
66.2.2.1 Rationale for Off-Pump Surgery 856
66.2.2.2 Evidence for Off-Pump vs. On-Pump Surgery 857
66.2.2.3 Minimally Invasive On-Pump Surgery 858
66.2.2.4 Minimally Invasive Alternatives to Aortocaval Cardiopulmonary Bypass 858
66.2.2.5 Minimally Invasive Coronary Artery Bypass Grafting 858
66.2.2.6 Minimally Invasive Conduit Harvest 859
66.2.2.7 Minimally Invasive Valve Surgery 859
66.2.2.8 Thoraco-Abdominal Aortic Aneurysm Repair 860
66.2.3 Ventricular Assist Devices 860
66.2.3.1 Recent Developments in Assist Device Technology 861
66.2.3.2 Bridge to Transplantation 861
66.2.3.3 Destinational Therapy 863
66.2.3.4 Bridge to Recovery 863
66.3 Molecular and Biological Developments Within the Speciality 864
66.3.1 Cellular and Tissue Engineering 864
66.3.2 Donor Cells 864
66.3.3 Methods of Cell Delivery 865
66.3.4 Acute Myocardial Infarction 865
66.3.5 Ischemic Cardiomyopathy 865
66.3.6 Heart Failure 866
66.3.7 Tissue Engineering 866
66.4 Diagnostics and Imaging in Cardiac Surgery 867
66.4.1 Three-Dimensional Echocardiography 867
66.4.2 Cardiac Magnetic Resonance Imaging 867
66.4.3 Multi-Slice Computerized Tomography 868
66.4.4 Single Positron Emission Computed Tomography 868
66.5 Future Developments 868
66.5.1 Percutaneous Valve Technology 868
66.5.2 Mitral Valve Repair 869
66.5.3 Aortic Valve Replacement 869
66.5.4 Pulmonary Valve Replacement 870
66.5.5 Robotic Cardiac Surgery 870
66.6 Cardiovascular Surgery Clinical Research Network 871
References 871
Chapter 67 875
Vascular Surgery: Current Trends and Recent Innovations 875
67.1 Innovation Within the Specialty 875
67.2 New Surgical Techniques Within Specialty 876
67.2.1 Clinical Applications 877
67.2.1.1 Aneurysmal Disease 877
67.2.1.2 Aortic Debranching 877
67.2.1.3 Great Vessel Reconstruction 879
67.2.1.4 Ruptured AAA (rAAA) 882
67.2.1.5 Carotid Stenting 885
67.2.1.6 Venous Disease 885
67.3 Molecular and Biological Developments 886
67.3.1 Emerging Therapies, Tissue Repair 886
67.3.2 Growth Factor Therapies 886
67.3.3 Living Human Dermal Substitutes 886
67.3.4 Stem Cell Therapies 888
67.4 Imaging and Diagnostics 888
67.5 Training 888
67.6 Future Developments and Research Focus 889
67.6.1 Aneurysmal Disease 889
67.6.1.1 Abdominal Aortic Aneurysms 889
67.6.1.2 Current Limitations 889
67.6.1.3 Specific Treatment Concerns 890
Neck Quality 890
Neck Angle 890
Neck Length 890
67.6.1.4 Branched Concepts 890
67.6.1.5 Migration/Fixation 891
67.6.1.6 Metal/Fabric Fatigue 891
67.6.2 Thoracic Disease 891
67.6.3 Carotid Disease/Peripheral Arterial Disease 892
67.6.4 Venous Disease/Wound Care/Prevention 892
References 892
Chapter 68 895
Breast Surgery: Current Trends and Recent Innovations 895
68.1 Breast Cancer 895
68.2 Diagnosis 896
68.3 Rationale for Loco-Regional Resectional Surgery in Breast Cancer Patients 897
68.4 Factors Determining Local Recurrence 898
68.4.1 Importance of Margins 898
68.4.2 The Importance of Post-Operative Radiotherapy 898
68.4.3 Other Pathological Parameters and the Age-Factor 899
68.5 Ductal Carcinoma in Situ (DCIS) 899
68.6 Surgery for Breast Cancer 900
68.6.1 Oncoplastic Resections 900
68.6.2 Reconstruction after Total Mastectomy 900
68.6.3 The Management of the Axilla 900
68.7 Systemic Therapies in Breast Cancer 901
68.7.1 Hormonal Manipulation 901
68.7.2 Neo-Adjuvant Chemotherapy 902
References 903
Chapter 69 905
Thyroid Surgery: Current Trends and Recent Innovations 905
69.1 Introduction 905
69.2 Innovation 906
69.2.1 Surgical Robotics 906
69.3 New Surgical Techniques 907
69.3.1 Minimally-Invasive Video-Assisted Thyroidectomy (MIVAT) 907
69.3.2 Instrumentation: The Harmonic Scalpel 907
69.4 Molecular and Biological Developments 908
69.4.1 RET PROTO-Oncogene 908
69.4.2 RAF Proteins 908
69.4.3 Multiple Endocrine Neoplasia 909
69.5 Imaging and Diagnostics 909
69.5.1 Ultrasound and the Thyroid 909
69.5.2 PET CT Scanning 910
69.6 Training 910
69.7 Future Development and Research Focus 911
References 911
Chapter 70 913
Orthopaedic Surgery: Current Trends and Recent Innovations 913
70.1 Introduction 913
70.2 Innovation Within Specialty 914
70.2.1 Pre-Disease: Genetic Markers 914
70.2.2 Epidemiology 914
70.2.2.1 The Epidemiology of Osteoarthritis 914
70.2.3 Late Disease 915
70.2.3.1 Hip Resurfacing 915
70.2.3.2 The Unicompartmental Knee 915
70.2.3.3 Tendon Repair 915
70.2.4 Delivery of Treatment 916
70.3 New Surgical Techniques Within Specialty 916
70.4 Molecular and Biological Developments Within Specialty 916
70.5 Imaging and Diagnostics Within Specialty 918
70.6 Imaging Modalities Utilised in Early Disease Monitoring 918
70.7 Biochemical Imaging 919
70.8 Biomarkers in Early Osteoarthritis 919
70.9 Utilising Imaging Technologies to Understanding the Link Between Pathology and Pain 919
70.10 Training Within Specialty 920
70.10.1 OCAP and the Improved Objective Assessment of Surgical Skills 920
70.11 Future Developments and Research Focus 921
References 922
Chapter 71 923
Plastic, Reconstructive and Aesthetic Surgery: Current Trends and Recent Innovations 923
71.1 Innovations in Plastic and Reconstructive Surgery 923
71.2 New Surgical Techniques Within the Specialty 924
71.2.1 Reconstructive Techniques 924
71.2.1.1 Microvascular Surgery 924
71.2.1.2 Tissue Expansion 925
71.2.1.3 Tissue Distraction 925
71.2.2 Wound Management 926
71.2.2.1 Wound Debridement 926
71.2.2.2 Negative Pressure Therapy 927
71.2.3 Composite Tissue Allotransplantation 927
71.2.3.1 Hand Allotransplantation 927
71.2.3.2 Facial Allotransplantation 927
71.2.4 Minimally Invasive Surgery 928
71.2.5 Aesthetic Surgery 928
71.2.5.1 Face and Scalp 928
71.2.5.2 Breast 929
71.2.6 Obesity Surgery 929
71.2.7 The Multidisciplinary Team 930
71.2.8 Cleft Lip and Palate Service 930
71.3 Molecular and Biological Developments Within the Specialty 930
71.3.1 Wound Repair and Scar-Free Healing 930
71.3.1.1 Normal Tissue Repair and Scarring 930
71.3.1.2 Modulation of Wound Repair and Scar-Free Wound Healing 931
71.3.2 Tissue Engineering and Regenerative Medicine 932
71.3.2.1 Introduction 932
71.3.2.2 Skin 932
71.3.2.3 Musculoskeletal and Soft Tissue 933
71.3.2.4 Nerve 934
71.3.2.5 Vascularisation 935
71.3.3 Gene Therapy 935
71.3.3.1 Introduction 935
71.3.3.2 Tissue Healing and Flap Survival 936
71.3.3.3 Skin Cancer 936
71.4 Imaging and Diagnostics Within the Specialty 936
71.4.1 Imaging 936
71.4.2 Free Flap Monitoring 937
71.4.3 Sentinel Node Biopsy for Malignant Melanoma 937
71.5 Future Developments and Research Focus 938
References 939
Chapter 72 941
Neurosurgery: Current Trends and Recent Innovations 941
72.1 Introduction 941
72.2 Neurotrauma 942
72.3 Brain and Spinal Tumours 943
72.4 Neurovascular 946
72.5 Functional Neurosurgery 946
72.6 Spine 947
72.7 The Future 948
References 949
Chapter 73 950
Molecular Techniques in Surgical Research 950
73.1 General Introduction 950
73.2 Single Molecule Analysis 951
73.2.1 Introduction 951
73.2.2 In Situ Techniques 951
73.2.2.1 Brief Description 951
73.2.2.2 In Situ Detection of Nucleic Acids 952
Fluorescent In Situ Hybridization (FISH) 952
Chromogenic In Situ Hybridization (CISH) 952
In Situ Detection of Apoptotic Cells or TUNEL Assay 953
73.2.2.3 In Situ Detection of Protein Expression 953
Immunohistochemistry 953
Immunofluorescence (IF) 955
73.2.2.4 Tissue Microarrays (TMAs) 955
73.2.3 Techniques for Molecular Analysis in Solution 955
73.2.3.1 Introduction 955
73.2.3.2 Southern Blot 956
Brief Description 956
Experimental Procedure of Southern Blot 956
Applications of Southern Blot 957
73.2.3.3 Northern Blot 958
Brief Description 958
Experimental Procedure of Northern Blot 958
Applications of Northern Blot 958
73.2.3.4 Western Blot 958
Brief Description 958
Experimental Procedure of Western Blot 959
Applications of Western Blot 960
73.2.3.5 Polymerase Chain Reaction Analysis 960
Brief Description 960
Experimental Procedure of PCR 960
Applications of PCR 962
73.2.3.6 Nucleic Acid Sequence Analysis (Sequencing) 963
Brief Description 963
Experimental Procedure of Sequencing 963
Experimental Procedure of Automated Sequencing 963
Applications of DNA Sequencing 965
73.3 Whole Genome Analysis Techniques 965
73.3.1 Introduction 965
73.3.2 DNA-Arrays 965
73.3.2.1 Brief Description 965
73.3.2.2 Experimental Procedure of DNA-Arrays 965
73.3.2.3 Variations of DNA-Arrays 966
73.3.2.4 Applications of DNA-Arrays 967
73.3.3 Comparative Genomic Hybridization Analysis 967
73.3.3.1 Brief Description 967
73.3.3.2 Experimental Procedure of CGH Analysis 967
73.3.3.3 Applications of CGH Analysis 968
73.4 Cell Cultures and Functional Assays 968
73.4.1 Introduction 968
73.4.2 Isolation of Cells and Establishment of Cell Lines 968
73.4.3 Plasmid Transfections and Viral Infections 969
73.4.4 RNA Interference 970
73.4.5 Drug Treatments 970
73.4.5.1 MTT Assay 970
73.4.5.2 Clonogenic Assay 971
73.4.5.3 Annexin V 971
73.5 Animal Models 971
73.5.1 Introduction 971
73.5.2 Brief Description 971
73.5.3 Methods of Gene Delivery 971
73.5.3.1 Microinjection 971
73.5.3.2 Embryonic Stem Cell Gene Delivery 971
73.5.3.3 Retrovirus-Mediated Gene Transfer 972
References 972
Chapter 74 974
Molecular Carcinogenesis 974
74.1 Introduction 974
74.2 Molecular Basis of Cancer 975
74.2.1 Cellular Independence of External Growth Signals: Role of Oncogenes 975
74.2.1.1 Growth Factors 976
74.2.1.2 Growth Factor Receptors 976
74.2.1.3 Signal Transducers 978
74.2.1.4 Nuclear Transcription Factors 981
74.2.1.5 Cell Cycle Regulators 982
74.2.2 Insensitivity to Growth-Inhibitory Signals: Role of Tumor Suppressor Genes 984
74.2.3 Evasion of the Anti-tumor Barriers (Apoptosis and Senescence) 986
74.2.4 Umlimited Replicative Potential 989
74.2.5 DNA Damage Response, Repair and Mitotic Surveillance in Cancer 990
74.2.6 Sustained Angiogenesis 992
74.2.7 Invasion and Metastasis 993
74.3 Multistep Carcinogenesis 994
74.4 Carcinogens 994
74.4.1 Chemicals 994
74.4.2 Radiation 995
74.4.3 Viral Agents 996
74.4.3.1 DNA Viruses 996
74.4.3.2 RNA Viruses 997
74.4.4 Genetic Predisposition 998
References 999
Index 1003