Comparing the Quality of Narrative Comments by Rotation Setting.

OBJECTIVE: To investigate the effect of rotation setting on trainee-directed narrative comments within a Canadian General Surgery Residency Program. The primary outcome was to use the McMaster Narrative Comment Rating Scale (MNCRS) to evaluate the quality of narrative comments across five domains: valence of language, degree of correction versus reinforcement, specificity, actionability and overall usefulness. As distributed medical education in the postgraduate training context becomes more prevalent, delineating differences in feedback between various sites will be imperative, as it may affect how narrative comments are interpreted by clinical competency committee (CCC) members. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of 2,469 assessments obtained between July 1, 2014 and May 5, 2019 from the General Surgery Residency Program at the University of British Columbia (UBC) was conducted. Narrative comments were rated using the McMaster Narrative Comment Rating Scale (MNCRS), a validated instrument for evaluating the quality of narrative comments. A repeated measures Analysis of Variance (ANOVA) was conducted to explore the impact of rotation setting, academic, urban tertiary, distributed urban, and distributed rural on the quality of narrative feedback. RESULTS: Overall, the quality of the narrative comments varied substantially between and within rotation settings. Academic sites tended to provide more actionable comments (p = 0.01) and more corrective versus reinforcing comments, compared with other sites (p's < 0.01). Comments produced by the urban tertiary rotation setting were consistently lower in quality across all scale categories compared with other settings (p's < 0.01). CONCLUSION: The type of rotation setting has a significant effect on the quality of faculty feedback for trainees. Faculty development on the provision of feedback is necessary, regardless of rotation setting, and should appropriately combine rotation-specific needs and overarching program goals to ensure trainees and clinical competence committees receive high quality narrative.

'The other right': control strategies and the role of language use in laparoscopic training.

CONTEXT: Laparoscopic techniques present a particular challenge to the academic surgeon in maintaining control and patient safety. The authors explored the use of verbal and physical control strategies including deixis, language used to locate subject in spatio-temporal, social and discoursal contexts, in this setting. METHODS: Forty cases of laparoscopic cholecystectomy at an academic centre were video and audio-recorded. Surgeon and trainee discourses and physical gestures during the crucial anatomical steps of the operation were qualitatively analysed using a hybrid inductive and deductive technique with explicit attention to the use of deixis. RESULTS: Laparoscopic surgeon educators use verbal and physical strategies and engage in bidirectional communication to maintain indirect control of an operation where direct control is not possible. Among verbal strategies, deictic language predominates. DISCUSSION: As in open surgery, laparoscopic surgical educators attempt to exert control over surgical procedures when the instruments are in the hands of a trainee. One dominant strategy is the use of deictic language, which may be ambiguous. In addition to the physical manoeuvres and bidirectional communication used to disambiguate, instructors must attend to potential uncertainties and explicitly clarify frames of reference in order to enhance educational experiences and maximise patient safety.

Systemic Metronidazole May Not Reduce Posthemorrhoidectomy Pain: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Hemorrhoidectomy is associated with significant postoperative pain. Oral metronidazole has been recommended as an adjunct to improve posthemorrhoidectomy analgesia. OBJECTIVE: This study aimed to evaluate the impact of oral metronidazole on patient-reported pain following hemorrhoidectomy. DATA SOURCES: We conducted a systematic search in the MEDLINE, EMBASE, ISI Web of Science, and Cochrane Central Register of Controlled Trials databases. STUDY SELECTION: Randomized controlled trials examining adults who underwent surgical hemorrhoidectomy were included. Participants in an active intervention group received oral metronidazole postoperatively, and those in a control group received placebo or usual care. Postoperative pain was assessed for at least 3 days postoperatively. INTERVENTION: A random-effects model was used. MAIN OUTCOMES MEASURES: The primary outcome was pain during the first 2 postoperative weeks, measured on a visual analogue scale. The secondary outcome was time to return to normal activities. RESULTS: Patients who received oral metronidazole had significantly lower reported pain scores on postoperative day 1 (standardized mean difference, -0.87 ± 0.44; 95% CI, -1.73 to -0.015; p = 0.046; n = 4) and day 4 (standardized mean difference, -1.43 ± 0.71; 95% CI, -2.83 to -0.037; p = 0.044; n = 3). Metronidazole use was associated with a significantly shorter time to return to normal activities (standardized mean difference, -0.76 ± 0.34; 95% CI, -1.43 to -0.088, p = 0.027). The improvements disappeared in a sensitivity analysis excluding the largest trial with a high risk of bias, and no significance was observed during the remaining postoperative days. LIMITATIONS: The meta-analysis was limited by lack of double blinding, absence of a placebo, and unclear or high risk of bias in a proportion of the included trials. CONCLUSIONS: Although a favorable adverse effect profile supports consideration of oral metronidazole to reduce posthemorrhoidectomy pain, pooled analysis reveals inconsistent results with no pain reduction on most postoperative days. The current recommendation for routine prescription of oral metronidazole should be reevaluated in the absence of additional well-designed trials.

Acute gastric volvulus in a six-year-old: a case report and review of the literature.

BACKGROUND: First described in the pediatric population in 1899 by Oltmann, pediatric gastric volvulus is a rare disease, but carries a high mortality rate. Due to vague signs and symptoms it can easily be mistaken for gastroenteritis or appendicitis, but unique radiographic findings can help illuminate the diagnosis. The pathophysiology of gastric volvulus is related to an abnormality in the attachment of at least one of the gastric ligaments, which can occur either primarily or secondarily. The abnormality in these ligaments allows the stomach to freely rotate, eventually causing an obstruction. We describe a unique case occurring in a 6-year-old with no pre-exiting medical conditions as well as the associated radiographic images. OBJECTIVES: Our aim is to discuss the presentation and management of a potentially lethal intra-abdominal process that mimics far more benign disease entities and to highlight the pertinent radiographic findings. CASE REPORT: A previously healthy 6-year-old female presented to the emergency department in the middle of the night after sudden onset of vomiting and abdominal pain. On exam her heart rate was mildly elevated but all other vital signs were within normal limits. She was assessed with an abdominal x-ray and given ondansetron. After settling with her parents and having no further bouts of emesis she was sent home. She returned that afternoon febrile with increasing abdominal pain and emesis. Abdominal x-ray revealed a massively distended stomach and left diaphragmatic eventration. She underwent operative intervention and improved over the course of the following week. CONCLUSION: Acute gastric volvulus presents a diagnostic challenge. In patients with vague abdominal complaints knowledge of the typical x-ray findings is essential in early identification and treatment.

BMP4 and LGL1 are Down Regulated in an Ovine Model of Congenital Diaphragmatic Hernia.

BACKGROUND/PURPOSE: The molecular pathophysiology of lung hypoplasia in congenital diaphragmatic hernia (CDH) remains poorly understood. The Wnt signaling pathway and downstream targets, such as bone morphogenetic proteins (BMP) 4 and other factors such as late gestation lung protein 1 (LGL1), are essential to normal lung development. Nitrofen-induced hypoplastic CDH rodent lungs demonstrate down regulation of the Wnt pathway including BMP4 and reduced LGL1 expression. The aim of the current study was to examine the molecular pathophysiology associated with a surgically induced CDH in an ovine model. METHODS: Left thoracotomy was performed at 80 days in 14 fetal sheep; CDH was created in seven experimental animals. Lungs were harvested at 136 days (term = 145 days). Lung weight (LW) and mean terminal bronchiole density (MTBD) were measured to determine the degree of pulmonary hypoplasia. Quantitative real time PCR was undertaken to analyze Wnt2, Wnt7b, BMP4, and LGL1 mRNA expression. RESULTS: Total LW was decreased while MTBD was increased in the CDH group (p < 0.05), confirming pulmonary hypoplasia. BMP4 and LGL1 mRNA was significantly reduced in CDH lungs (p < 0.05). Wnt2 mRNA was decreased, although not significantly (p < 0.06). CONCLUSION: For the first time, down regulation of BMP4 and LGL1 are reported in an ovine CDH model. In contrast to other animal models, these changes are persistent to near term. These findings suggest that mechanical compression from herniated viscera may play a more important role in causing pulmonary hypoplasia in CDH, rather than a primary defect in lung organogenesis.

Management of chest tubes after pulmonary resection: a systematic review and meta-analysis.

BACKGROUND: We performed a systematic review and meta-analysis to determine the effect of suction with water seal, compared with water seal alone, applied to intra pleural chest tubes on the duration of air leaks in patients undergoing pulmonary surgery. METHODS: We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to find randomized controlled trials (RCTs) comparing the effect of the 2 methods on the duration of air leaks. Trials were systematically assessed for eligibility and validity. Data were extracted in duplicate and pooled across studies using a random-effects model. RESULTS: The search yielded 7 RCTs that met the eligibility criteria. No difference was identified between the 2 methods in duration of air leak (weighted mean difference [WMD] 1.15 days, favours water seal; 95% confidence interval [CI] -0.64 to 2.94), time to discharge (WMD 2.19 d, favours water seal; 95% CI -0.63 to 5.01), duration of chest tubes (WMD 0.96 d, favours water seal; 95% CI -0.12 to 2.05) or incidence of prolonged air leaks (absolute risk reduction [ARR] 0.04, favours water seal; 95% CI -0.01 to 0.09). Water seal was associated with a significantly increased incidence of postoperative pneumothorax (ARR -0.14, 95% CI -0.21 to -0.07). CONCLUSION: No differences were identified in terms of duration of air leak, incidence of prolonged air leak, duration of chest tubes and duration of hospital stay when chest tubes were placed to suction rather than water seal. Chest tube suction appears to be superior to water seal in reducing the incidence of pneumothorax; however, the clinical significance of this finding is unclear.

Better late than never? Impact of local analgesia timing on postoperative pain in laparoscopic surgery: a systematic review and metaanalysis.

BACKGROUND: This study aimed to determine the effect of local anesthesia administered before laparoscopic surgery (preemptive anesthesia) on postoperative pain. METHODS: The authors searched Medline, EMBase, and the Cochrane Central Register of Controlled Trials, as well as reference lists of textbooks and relevant articles. They contacted experts in the field of anesthesia and laparoscopic surgery for randomized controlled trials comparing preemptive administration of local anesthesia at the incision site or intraperitoneally with postoperative anesthesia administration or placebo. Trials were systematically assessed for eligibility and validity, and data were extracted in duplicate. The data were pooled across studies using a random effects model. RESULTS: The 26 studies that met the inclusion criteria were included in the analysis. Preemptive incisional local anesthetic was superior to placebo in terms of visual analog pain scores (VAS) at 4 h (weighted mean difference [WMD], -9.49 mm; 95% confidence interval [CI], -15.50 to -3.48) and 24 h (WMD, -4.75 mm; 95%CI, -8.90 to 0.60). However, no difference was found between these measures and those for postoperative incision-site infiltration. Preemptive intraperitoneal local anesthetic was superior to placebo in terms of VAS at 4 h (WMD, 5.76 mm; 95%CI, -11.27 to -0.25), 8 h (WMD, -9.64 mm; 95%CI, -13.68 to -5.60), 12 h (WMD, -4.68 mm; 95%CI, -5.86 to -3.49), and 24 h (WMD, -5.57 mm; 95%CI, -8.35 to -2.79), and superior to postoperative anesthesia administration at 8 h (WMD, -7.42; 95%CI, -13.40 to -1.45), 12 h (WMD, -7.27 mm; 95%CI, -10.26 to -4.28), and 24 h (WMD, -7.95 mm; 95%CI, -12.33 to -3.56). CONCLUSION: Preemptive administration of local anesthetic at the incision site reduces postoperative pain compared with placebo but achieves an analgesic effect similar to that of postincisional anesthetic infiltration. Preemptive local anesthetic administered intraperitoneally decreases postoperative pain compared with both placebo and postoperative infiltration. Surgeons should use local analgesia in laparoscopic surgery to decrease postoperative pain, but the timing of administration is significant only for intraperitoneal infiltration.