Wound drainage following groin dissection for malignant disease in adults.

BACKGROUND: Groin dissection is commonly performed for the treatment of a variety of cancers, including melanoma, and squamous cell carcinoma of the skin, penis or vulva. It is uncertain whether insertion of a drain reduces complication rates, and, if used, the optimum time for drain removal after surgery is also unknown. OBJECTIVES: To assess the current level of evidence to determine whether placement of a drain is beneficial after groin dissection in terms of reducing seroma, haematoma, wound dehiscence and wound infection rates, and to determine the optimal type and duration of drainage following groin dissection if it is shown to be beneficial. SEARCH METHODS: In September 2014 we searched the following electronic databases using a pre-designed search strategy: the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library). In November 2013 we searched Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We did not restrict the search and study selection with respect to language, date of publication or study setting. SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) comparing wound drainage with no wound drainage in individuals undergoing groin dissection, where the most superior node excised was Cloquet's node (the most superior inguinal lymph node). No limits were applied to language of publication or trial location. Two review authors independently determined the eligibility of each trial. DATA COLLECTION AND ANALYSIS: Two review authors, working independently, screened studies identified from the search; there were no disagreements. MAIN RESULTS: We did not identify any RCTs that met the inclusion criteria for the review. AUTHORS' CONCLUSIONS: There is a need for high quality RCTs to guide clinical practice in this under-researched area.

Unveiling the language of scars: A patient-centric themed framework for comprehensive scar morphology.

BACKGROUND: Scarring, a pervasive issue spanning across medical disciplines, lacks a comprehensive terminology for effective communication, patient engagement, and outcome assessment. Existing scar classification systems are constrained by specific pathologies, physician-centric features, and inadequately account for emerging technologies. This study refrains from proposing yet another classification system and instead revisits the foundational language of scar morphology through a theme analysis of primary patient complaints. METHOD: Data encompassing five years of a high-volume scar practice was analysed. Primary complaints were aggregated into collective descriptors and further organized into theme domains. The resulting hierarchical map of presenting complaints revealed five key domains: Loss of Function, Contour, Texture, Vector, and Colour Presenting complaints were codified into 42 items, which were then categorised into 14 collective descriptor terms. The latter were in turn organised into five overarching themes. RESULT: Loss of Function, accounting for 10% of primary concerns, signifies reduced function attributed solely to the scar. Contour, encompassing 41% of concerns, pertains to scar height, shape, and depth. Texture, representing 12% of concerns, denotes tactile variations such as hardness, roughness, and moisture. Vector, comprising 13% of concerns, refers to scar tissue tension and associated distortions. Colour, the concern in 24% of cases, encompasses variations in pigmentation, vascularity, and exogenous pigments. DISCUSSION: Standardized terminology enhances patient care, communication, and research. This study underscores the fundamental question of "what bothers the patient," reviving a patient-centred approach to scar management. By prioritizing themes based on patient complaints, this study innovatively integrates function, aesthetics, and patient experience. In conclusion, this study pioneers a paradigm shift in scar management by presenting a patient-driven theme framework that offers a common language for healthcare professionals and patients. Embracing this language harmonizes scar treatment, fosters innovation, and transforms scars from silent reminders into stories of resilience and healing.

Wound drainage after axillary dissection for carcinoma of the breast.

BACKGROUND: Axillary dissection is commonly performed for breast carcinoma. It is uncertain whether insertion of a drain reduces complication rates. OBJECTIVES: To assess the effects of wound drainage after axillary dissection for breast carcinoma on the incidence of postoperative seroma formation. Secondary outcome measures include the incidence of infection and length of hospital stay. SEARCH METHODS: We searched the Cochrane Wound and Breast Cancer Group's Specialised Registers (22 February 2013), MEDLINE (1950 to 22 February 2013), EMBASE (1966 to 22 February 2013), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (22 February 2013) for all prospectively registered and ongoing trials (22 February 2013). Reference lists of included studies were handsearched by two independent review authors to look for additional eligible trials. SELECTION CRITERIA: All randomised controlled trials (RCTs) comparing wound drainage versus no wound drainage in individuals after axillary dissection for the treatment of breast carcinoma were included. All disease stages were considered. Breast-conserving surgery and mastectomy were considered. Patients undergoing sentinel node biopsy without axillary dissection were not included. No limits were applied to language or study location. Two review authors independently determined the eligibility of each study. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data for each included study using a predesigned data extraction proforma and assessed risk of bias using The Cochrane Collaboration's 'Risk of bias' tool. Discrepancies were resolved by consensus discussion with a third review author. Dichotomous variables were analysed using a Mantel-Haenszel model to produce odds ratios (ORs). Continuous variables were analysed using an inverse variance model to produce a mean difference (MD). MAIN RESULTS: Seven RCTs including 960 participants were identified. The quality of trials was generally low, with several studies at risk of selection bias, and no studies used blinding during treatment or outcome assessment. There was a high level of statistical variation between the studies, which therefore reduces the reliability of the evidence. The OR for seroma formation was 0.46 (95% confidence interval (CI) 0.23 to 0.91, P = 0.03) in favour of a reduced incidence of seroma in participants with drains inserted. There was no significant difference in infection rates between drainage and no drainage groups (OR = 0.70; 95% CI 0.44 to 1.12, P = 0.14). The mean difference in length of hospital stay, reported in four trials consisting of 600 participants, was 1.47 days greater in the drained population (95% CI 0.67 to 2.28, P = 0.0003). A mean difference of 0.79 fewer postoperative seroma aspirations was found in the drained population (95% CI 1.23 to 0.35 fewer, P = 0.0004) in two trials including 212 participants. No significant difference in volume of seroma aspirations was reported (MD -19.44, 95% CI -59.45 to 20.57, P = 0.34) in three trials including 519 participants. No significant difference in the incidence of lymphoedema was noted (OR 2.31 favouring no drainage, 95% CI 0.47 to 11.37, P = 0.30), with only six instances reported in three trials of 360 participants, nor was any significant difference in the incidence of haematoma observed (OR 1.68, 95% CI 0.33 to 8.51, P = 0.53), with only five instances reported in two trials of 314 participants. AUTHORS' CONCLUSIONS: There is limited quality evidence that insertion of a drain following axillary lymphadenectomy reduced the odds of developing a seroma and reduced the number of post-operative seroma aspirations. These benefits should be balanced against an increased length of hospital stay in the drained population.

Extrapolating novel techniques utilised in solid organ transplantation to the microsurgical and vascularised composite allograft arena.

Ischemia reperfusion injury (IRI) is characterised initially by restriction of oxygenated blood flow to an organ bed, resulting in tissue hypoxia and ischaemic injury, followed by further 'reperfusion' injury upon restoration of perfusion, with an influx of oxygen, inflammatory cells and generation of free radicals. The culmination is a complex interplay between cellular and biochemical processes involved in inflammation and coagulation, exhibited as the 'no re-flow' phenomenon. Under ideal circumstances, autologous free tissue transfer is performed with short ischemic times. However, there are certain clinical scenarios where the ischaemic period can be prolonged due to technical and non-technical factors. IRI is inevitable and can be possibly more pronounced in such cases. In these cases, there may be a role for plastic surgeons to adopt some of the anti-ischaemia reperfusion injury (IRI) practices used in solid organ transplantation (SOT). Knowledge of the current trends in SOT IRI reduction should be discussed by plastic surgeons to assess whether certain facets can be extrapolated into the plastic and reconstructive armamentarium. These can be applicable to more challenging microsurgical cases, including composite free tissue transfer. Three important aspects are discussed further in this editorial: (1) cold flushing, (2) machine perfusion and pharmacological manipulation. Ongoing research will need to study the impact these potential interventions will have on the acute complications but also in which subset of patients they would be most beneficial. This area is novel and exciting but cautious implementation is advised with careful scrutiny of future data.

Tuberculosis complicating tertiary hyperparathyroidism in a patient with end-stage renal disease: a case report.

A 36-year-old Nigerian woman on thrice-weekly dialysis presented with symptoms and signs of hypercalcaemia. Laboratory findings were consistent with tertiary hyperparathyroidism. Parathyroid hormone levels remained elevated and she underwent elective parathyroidectomy. Intra-operatively all 4 parathyroid glands and local lymph nodes showed necrotising granulomas with occasional acid-fast bacilli, pathognomonic of tuberculosis (TB). Post-operatively she completed a full course of anti-TB therapy and at 9 months she experienced complete resolution in her plasma biochemistry and was essentially symptom-free. This is a rare yet fascinating cause of hypercalcaemia in a dialysis patient and is the first recorded case of tubercular involvement of parathyroid tissue in a case of tertiary hyperparathyroidism. This report demonstrates the coexistence of 2 diseases that simultaneously worsened hypercalcaemia and thus emphasises the importance of the differential diagnosis and of careful histological examination post-operation.

Mineral and bone disorder after renal transplantation: a review.

Chronic kidney disease-mineral bone disorder is a common clinical picture encountered in patients with end-stage renal disease and is the result of additive pathophysiological processes. Renal transplantation remains the treatment of choice for these patients, especially as advances in this field have allowed for enhanced allograft survival. However, with increasing success of renal transplantation has come a greater appreciation of some of its subsequent complications, such as posttransplantation bone disease. Recently, persistent hyperparathyroidism and osteopenia-osteoporosis have been given specific attention. Traditionally, persistent hyperparathyroidism has been treated with parathyroidectomy, although the role that calcimimetics may play in the future is promising. Newer aspects to medical management of osteopenia-osteoporosis, such as the efficacy of bisphosphonate therapy and early steroid withdrawal, are becoming apparent and some of the newer drugs for the treatment of osteoporosis are yet to be investigated in this subgroup of patients.

How Educational Theory Can Inform the Training and Practice of Plastic Surgeons.

It is important to optimize our current learning and teaching models, particularly in a climate of decreased clinical exposure. With technical advancements and clinical care now more accountable, traditional methods of skill acquisition need to be revisited. The past decade has seen changes in plastic surgery curricula. There has also been a shift toward competency-based training programs reflecting the growing emphasis on outcomes-based surgical education. This review explores the role of educational theory in promoting effective learning in practical skills teaching. Key models of educational theory are presented and their application to plastic surgery training to an expert level are highlighted. These models include (1) learning within communities of practice (Lave and Wenger's theory); (2) the role of the zone of proximal development and importance of the availability of expert assistance (Vygotsky's theory); (3) skill acquisition and retention (Dreyfus' and Dreyfus', and Fitts' and Posner's theories); (4) development of expertise after repeated practice and regular reinforcement (Ericsson's theory); and (5) the assessment of competence (Miller's triangle). Future plastic surgeons need to possess a thorough understanding of the technical and nontechnical skills required to manage patients effectively. Surgical educators are therefore compelled to develop practical training programs that can teach each of these skills in a safe, learner-centric manner. It is hoped that new approaches to surgical skills training are designed in light of our understanding of educational theory to optimize the training of the next generation of plastic surgeons.

Burns education: The emerging role of simulation for training healthcare professionals.

Burns education appears to be under-represented in UK undergraduate curricula. However current postgraduate courses in burns education provide formal training in resuscitation and management. Simulation has proven to be a powerful modality to advance surgical training in both technical and non-technical skills. We present a literature review that summarises the format of current burns education, and provides detailed insight into historic, current and novel advances in burns simulation for both technical and non-technical skills, that can be used to augment surgical training. Addressing the economic and practical limitations of current immersive surgical simulation is important, and this review proposes future directions for integration of innovative simulation strategies into training curricula.

Does Overestimation of Burn Size in Children Requiring Fluid Resuscitation Cause Any Harm?

Overestimation of burn size especially in children is common. It is unclear if this may cause harm. This study was designed to assess the accuracy of burn size estimation by referring non-burn clinicians and investigate whether inaccurate estimates caused any harm. Three and a half years retrospective review of pediatric resuscitation burns (ie, ≥10% TBSA) referred to a tertiary burns center from other hospitals was performed. This included basic demographics, data from referring emergency departments (initial TBSA estimations and fluid volumes prescribed), and data on arrival to the burn center (actual burn TBSA sustained, fluid volumes given prior to arrival, and actual fluid volumes required). Clinical parameters at 8 and 24 hr after injury were also examined. Forty-six patients were identified. Mean age was 3.9 years and weight 18 kg. Mean time to arrival from initial burn injury to our tertiary center was 5 hr. Thirty-two children (70%) had their burns overestimated, seven (15%) underestimated, and another seven (15%) were correctly estimated. After accurate calculations of the burn size and the required resuscitation fluids on arrival to the burns center, only five children of the entire cohort of 46 patients (11%) had received more fluids than required. These five children were in the overestimated burn size group. Only three children received the appropriate amount of fluid prior to arrival to the burns center. There were no mortalities or significant clinical adverse events in any of the children. Overestimation led to overprescription of fluid volumes, but this did not translate into over-resuscitation, and in most cases was in fact associated with inadequate fluid administration. Although 70% of the children in our cohort had the burn size overestimated, only 11% had actually received more fluids than required before arrival. None of these children went on to have any significant complications as a result of overestimation. Training and education is essential for clinicians in emergency departments. However, estimation of size in pediatric burns, in particular scalds, is challenging and the importance of early transfer to a specialist service cannot be overemphasized.

Using "The Burns Suite" as a Novel High Fidelity Simulation Tool for Interprofessional and Teamwork Training.

Educational theory highlights the importance of contextualized simulation for effective learning. The authors recently published the concept of "The Burns Suite" (TBS) as a novel tool to advance the delivery of burns education for residents/clinicians. Effectively, TBS represents a low-cost, high-fidelity, portable, immersive simulation environment. Recently, simulation-based team training (SBTT) has been advocated as a means to improve interprofessional practice. The authors aimed to explore the role of TBS in SBTT. A realistic pediatric burn resuscitation scenario was designed based on "advanced trauma and life support" and "emergency management of severe burns" principles, refined utilizing expert opinion through cognitive task analysis. The focus of this analysis was on nontechnical and interpersonal skills of clinicians and nurses within the scenario, mirroring what happens in real life. Five-point Likert-type questionnaires were developed for face and content validity. Cronbach's alpha was calculated for scale reliability. Semistructured interviews captured responses for qualitative thematic analysis allowing for data triangulation. Twenty-two participants completed TBS resuscitation scenario. Mean face and content validity ratings were high (4.4 and 4.7 respectively; range 4-5). The internal consistency of questions was high. Qualitative data analysis revealed two new themes. Participants reported that the experience felt particularly authentic because the simulation had high psychological and social fidelity, and there was a demand for such a facility to be made available to improve nontechnical skills and interprofessional relations. TBS provides a realistic, novel tool for SBTT, addressing both nontechnical and interprofessional team skills. Recreating clinical challenge is crucial to optimize SBTT. With a better understanding of the theories underpinning simulation and interprofessional education, future simulation scenarios can be designed to provide unique educational experiences whereby team members will learn with and from other specialties and professions in a safe, controlled environment.

A Video Analysis of Intra- and Interprofessional Leadership Behaviors Within "The Burns Suite": Identifying Key Leadership Models.

OBJECTIVE: Leadership is particularly important in complex highly interprofessional health care contexts involving a number of staff, some from the same specialty (intraprofessional), and others from different specialties (interprofessional). The authors recently published the concept of "The Burns Suite" (TBS) as a novel simulation tool to deliver interprofessional and teamwork training. It is unclear which leadership behaviors are the most important in an interprofessional burns resuscitation scenario, and whether they can be modeled on to current leadership theory. The purpose of this study was to perform a comprehensive video analysis of leadership behaviors within TBS. METHODS: A total of 3 burns resuscitation simulations within TBS were recorded. The video analysis was grounded-theory inspired. Using predefined criteria, actions/interactions deemed as leadership behaviors were identified. Using an inductive iterative process, 8 main leadership behaviors were identified. Cohen's κ coefficient was used to measure inter-rater agreement and calculated as κ = 0.7 (substantial agreement). Each video was watched 4 times, focusing on 1 of the 4 team members per viewing (senior surgeon, senior nurse, trainee surgeon, and trainee nurse). The frequency and types of leadership behavior of each of the 4 team members were recorded. Statistical significance to assess any differences was assessed using analysis of variance, whereby a p < 0.05 was taken to be significant. Leadership behaviors were triangulated with verbal cues and actions from the videos. RESULTS: All 3 scenarios were successfully completed. The mean scenario length was 22 minutes. A total of 362 leadership behaviors were recorded from the 12 participants. The most evident leadership behaviors of all team members were adhering to guidelines (which effectively equates to following Advanced Trauma and Life Support/Emergency Management of Severe Burns resuscitation guidelines and hence "maintaining standards"), followed by making decisions. Although in terms of total frequency the senior surgeon engaged in more leadership behaviors compared with the entire team, statistically there was no significant difference between all 4 members within the 8 leadership categories. This analysis highlights that "distributed leadership" was predominant, whereby leadership was "distributed" or "shared" among team members. The leadership behaviors within TBS also seemed to fall in line with the "direction, alignment, and commitment" ontology. CONCLUSIONS: Effective leadership is essential for successful functioning of work teams and accomplishment of task goals. As the resuscitation of a patient with major burns is a dynamic event, team leaders require flexibility in their leadership behaviors to effectively adapt to changing situations. Understanding leadership behaviors of different team members within an authentic simulation can identify important behaviors required to optimize nontechnical skills in a major resuscitation. Furthermore, attempting to map these behaviors on to leadership models can help further our understanding of leadership theory. Collectively this can aid the development of refined simulation scenarios for team members, and can be extrapolated into other areas of simulation-based team training and interprofessional education.

Surgical skills training: time to start early.

BACKGROUND: Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there are limited formal basic surgical skills programmes integrated into UK undergraduate curricula. CONTEXT: Early skills targeting is valuable for students entering surgical, related allied specialties and even traditionally non-surgical specialties, such as General Practice. Such experience can make students more confident and subsequently competent future junior doctors and trainees. INNOVATION: The integration of skills training through the use of simple low-fidelity training models can bridge the gap between undergraduate skills education and postgraduate training, whereas approaches involving more recent advances in simulation may prepare students further by making available more contextualised and scenario-based learning environments. IMPLICATIONS: We suggest that it is an ideal time for the introduction of dedicated basic surgical skills programmes into UK undergraduate medical curricula. Training will benefit all students. Importantly, training can inspire confidence, clinical interest, and can also provide a solid foundation of skills that can support and enable junior doctors' further postgraduate training.

Proposing "the burns suite" as a novel simulation tool for advancing the delivery of burns education.

Educational theory highlights the importance of contextualized simulation for effective learning. We explored this concept in a burns scenario in a novel, low-cost, high-fidelity, portable, immersive simulation environment (referred to as distributed simulation). This contextualized simulation/distributed simulation combination was named "The Burns Suite" (TBS). A pediatric burn resuscitation scenario was selected after high trainee demand. It was designed on Advanced Trauma and Life Support and Emergency Management of Severe Burns principles and refined using expert opinion through cognitive task analysis. TBS contained "realism" props, briefed nurses, and a simulated patient. Novices and experts were recruited. Five-point Likert-type questionnaires were developed for face and content validity. Cronbach's α was calculated for scale reliability. Semistructured interviews captured responses for qualitative thematic analysis allowing for data triangulation. Twelve participants completed TBS scenario. Mean face and content validity ratings were high (4.6 and 4.5, respectively; range, 4-5). The internal consistency of questions was high. Qualitative data analysis revealed that participants felt 1) the experience was "real" and they were "able to behave as if in a real resuscitation environment," and 2) TBS "addressed what Advanced Trauma and Life Support and Emergency Management of Severe Burns didn't" (including the efficacy of incorporating nontechnical skills). TBS provides a novel, effective simulation tool to significantly advance the delivery of burns education. Recreating clinical challenge is crucial to optimize simulation training. This low-cost approach also has major implications for surgical education, particularly during increasing financial austerity. Alternative scenarios and/or procedures can be recreated within TBS, providing a diverse educational immersive simulation experience.

Handover practice amongst core surgical trainees at the Oxford School of Surgery.

PURPOSE: To date no studies have specifically evaluated the use of handovers amongst core surgical trainees (CSTs) in the United Kingdom. We examined handover practice at the Oxford School of Surgery to assess and improve CSTs'perception of handover use as well as its quality, and ultimately patient care. METHODS: Based on guidelines published by the British Medical Association and Royal College of Surgeons, a 5-point Likert style questionnaire that collected data on handover practice, its educational value, and the CSTs'satisfaction with handover was given to 50 CSTs in 2010. RESULTS: Forty CSTs (80.0%) responded to the questionnaire. The most striking findings revolved around the perceived educational value, formal training, and auditing practice of handovers throughout various units, which were all remarkably lower than expected. As a result, handover practice amongst CSTs was targeted and revised at the University Hospital's Department of Plastic Surgery, with the implementation of targeted changes to improve handover practice. CONCLUSION: The execution of daily handovers was an underused educational tool amongst surveyed CSTs and may be an important modality to target, particularly in the competency-based, time-limited training CSTs receive. We recommend modifications to current practice based on our results and the literature and encourage the assessment of handover practice at other institutions.

Surgical experts: born or made?

The concept of surgical expertise and the processes involved in its development are topical, and there is a constant drive to identify reliable measures of expert performance in surgery. This review explores the notion of whether surgical experts are "born" or "made", with reference to educational theory and pertinent literature. Peer-reviewed publications, books, and online resources on surgical education, expertise and training were reviewed. Important themes and aspects of expertise acquisition were identified in order to better understand the concept of a surgical expert. The definition of surgical expertise and several important aspects of its development are highlighted. Innate talent plays an important role, but is insufficient on its own to produce a surgical expert. Multiple theories that explore motor skill acquisition and memory are relevant, and Ericsson's theory of the development of competence followed by deliberate self-practice has been especially influential. Psychomotor and non-technical skills are necessary for progression in the current climate in light of our training curricula; surgical experts are adaptive experts who excel in these. The literature suggests that surgical expertise is reached through practice; surgical experts are made, not born. A deeper understanding of the nature of expert performance and its development will ensure that surgical education training programmes are of the highest possible quality. Surgical educators should aim to develop an expertise-based approach, with expert performance as the benchmark.

Is it time for integration of surgical skills simulation into the United Kingdom undergraduate medical curriculum? A perspective from King's College London School of Medicine.

PURPOSE: Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there is no basic surgical skills (BSS) programme integrated into undergraduate curricula in the United Kingdom. We explored the role of a dedicated BSS programme for undergraduates in improving confidence and influencing careers in King's College London School of Medicine, and the programme was evaluated. METHODS: A programme was designed in-line with the established Royal College of Surgeons course. Undergraduates were taught four key skills over four weeks: knot-tying, basic-suturing, tying-at-depth and chest-drain insertion, using low-fidelity bench-top models. A Likert-style questionnaire was designed to determine educational value and influence on career choice. Qualitative data was collected. RESULTS: Only 29% and 42% of students had undertaken previous practice in knot-tying and basic suturing, respectively. 96% agreed that skills exposure prior to starting surgical rotations was essential and felt a dedicated course would augment undergraduate training. There was a significant increase in confidence in the practice and knowledge of all skills taught (p<0.01), with a greater motivation to be actively involved in the surgical firm and theatres. CONCLUSION: A simple, structured BSS programme can increase the confidence and motivation of students. Early surgical skills targeting is valuable for students entering surgical, related allied, and even traditionally non-surgical specialties such as general practice. Such experience can increase the confidence of future junior doctors and trainees. We advocate the introduction of a BSS programme into United Kingdom undergraduate curricula.