Assessing the attitude of surgical trainees towards virtual reality simulation: A national cross-sectional questionnaire study.

BACKGROUND: We performed a cross sectional study to determine the attitudes of surgical trainees and medical students towards virtual reality (VR) simulation in surgical training. A survey was devised through an iterative process before distribution to surgical trainees, foundation year doctors and medical students through online platforms. METHODS: The survey was disseminated within the United Kingdom through social media and email correspondence, in co-operation with national surgical organisations. 91 trainees responded from a variety of clinical specialities. RESULTS: VR technology in surgical training was viewed positively, with 91.3% of trainees agreeing that VR should be both an adjunct in surgical training as well as a competency-based assessment tool. Barriers to access were present, with access notably more challenging for senior surgeons. CONCLUSION: Virtual reality surgical simulation in surgical training is beginning to emerge as a genuine high-fidelity, low-risk solution to the lack of surgical case volume trainees are currently experiencing.

Aberrant right subclavian artery - a rare congenital anatomical variation causing dysphagia lusoria.

An aberrant right subclavian artery (ARSA) is a rare anatomical variation of the aortic arch. Although an incidental finding and asymptomatic in the majority of individuals, an ARSA can cause troubling symptoms during both childhood and in later life. In adulthood, the most common symptom is dysphagia, where the condition is named dysphagia lusoria. In other rare cases it can cause shortness of breath, chronic cough and hoarseness of voice amongst others. We present a case of a 65-year-old female patient who was diagnosed with dysphagia lusoria following a barium swallow examination to investigate a 10-year history of dysphagia. She was further investigated with other imaging modalities to establish her diagnosis. The dysphagia was not progressive, nor did it result in malnutrition, and hence the patient was managed conservatively. There is currently no established guideline to classify the severity of symptoms or radiological findings of this anatomical anomaly. Our case reiterates the importance of such protocols, in order to be able to avoid the risks of an unnecessary surgical procedure, whilst being sure to prevent the undertreatment of affected individuals.

A case of otogenic septic arthritis of the knee.

Septic arthritis is a serious condition resulting in rapid destruction of articular cartilage and potential sepsis. Bacterial invasion of a joint occurs most commonly as a result of haematogenous spread from a distant infection. However, an otogenic source of this transient bacteraemia and resultant septic arthritis has not yet been reported in the literature. We report a case of acute septic arthritis of the knee with Streptococcus pyogenes, secondary to acute otitis media of the ear.

A quality improvement project: Reducing the number of unnecessary plain abdominal radiographs performed in the emergency department of a London district general hospital.

Background: Inappropriate completion of abdominal radiographs results in unnecessary exposure to ionizing radiation. This quality improvement project aimed to reduce the number of inappropriate abdominal radiographs performed in the emergency department. Materials and methods: Abdominal radiograph request forms were analyzed with reference to the Royal College of Radiologists (RCR) iRefer guidance. A teaching session was then delivered to ED clinicians and posters were disseminated within the department. Post-intervention data collection followed. Results: Following the intervention, there was an increase in the proportion of abdominal radiographs meeting iRefer guidance, which was accompanied by an increased diagnostic yield of these investigations. There was a reduction in the number of requests post-intervention. Conclusions: Our interventions helped increase awareness of both the guidelines and radiation dose associated with each study. Routine education of the iRefer guidelines will help reduce inappropriate requests. This in turn will reduce unnecessary radiation exposure, whilst also reducing the financial burden.

Paediatric forearm fractures: assessment and initial management.

The forearm is the most common site of fracture in children. At the time of initial assessment, a thorough examination and neurovascular assessment of the limb is necessary. X-rays allow evaluation of the fracture location and type, in addition to the degree of displacement. With the help of intranasal opiates, manipulation of fracture fragments can be performed in the emergency department. Immobilisation in plaster is the gold standard treatment for paediatric forearm fractures where the degree of displacement is within acceptable parameters. Manipulation and casting should be followed by orthogonal radiographs and a repeated neurovascular assessment of the limb. Oral analgesia and safety netting information should be provided on discharge and the child should be reviewed in fracture clinic within a week of the injury. This article reviews the British Orthopaedic Association Standards for Trauma and Orthopaedics for the early management of paediatric forearm fractures that do not require operative management.

The environmental impact of orthopaedic surgery: assessing strategies for change.

Climate change poses one of the most critical threats to humanity. Surgical care needs to be considered in relation to the impending climate emergency. Little thought appears to have been given to the role of operating departments as a high-yield target for environmental change. This article evaluates the environmental impact of orthopaedic surgery, focusing on anaesthesia, waste management and surgical hardware. Developing 'green' operating protocols should be the minimum expectation of orthopaedic departments. Just as the management of complex surgical pathology requires a multidisciplinary approach, mitigating the environmental impact of surgical endeavour requires collective action and buy-in.

Analysis of an Ambulatory Care Pathway for Patients With COVID-19 Utilising Remote Pulse Oximetry at a London District General Hospital.

The identification of coronavirus disease 2019 (COVID-19) patients with oxygen saturations between 90-94% who can be safely discharged from the emergency department (ED) is challenging due to the difficulty of community monitoring. A pathway consisting of home pulse oximetry with telephone follow-up was devised and implemented at a London District General Hospital to facilitate the safe discharge of these patients from the ED. Twenty patients with confirmed or suspected COVID-19 with oxygen saturations between 90%-94% were discharged on this novel ambulatory care pathway. Eighty-five percent of patients successfully avoided hospitalisation, whilst 15% were re-assessed and subsequently admitted to hospital. Home pulse oximetry monitoring was utilised to aid discharge from the ED and therefore prevent hospital admission. Telephone follow-up identified patients requiring further assessment. This study demonstrates the potential for safe ambulation of a subgroup of patients with COVID-19.

Vomiting-induced pneumomediastinum as a result of recurrent Boerhaave's syndrome.

Vomiting-induced pneumomediastinum can be a result of barotrauma causing alveolar rupture or Boerhaave's syndrome. Although a rare cause of secondary pneumomediastinum, Boerhaave's syndrome allows extravasation of air and fluid due to oesophageal perforation. We report a case of a 20-year-old female who presented with prolonged vomiting during a panic attack. Extensive surgical emphysema and pneumomediastinum were visualised radiologically. A source of oesophageal rupture was not visualised on cross-sectional computed tomography imaging following contrast ingestion. A complication of mediastinitis provided the evidence that this was a case of Boerhaave's syndrome whereby microscopic perforation of the oesophagus led to secondary pneumomediastinum, rather than vomiting-induced spontaneous pneumomediastinum caused by barotrauma. Recurrent Boerhaave's syndrome in this case is owed to the patient having previously experienced identical symptoms which spontaneously resolved.

Rare case of symptomatic empty sella syndrome in a patient treated with intrathecal chemotherapy for acute myeloid leukemia.

The sella turcica is the normal neuroanatomical location of the pituitary gland. Empty sella syndrome (ESS) is a rare condition in which the sella turcica is partially or completely filled with cerebrospinal fluid. It is a radiological diagnosis that is often made incidentally following imaging for another reason (eg, to exclude intracranial hemorrhage following head injury) or as part of the work-up when investigating a patient's neurological symptoms. ESS can be classified as primary or secondary, depending on the identification of underlying etiologies. We report the highly unusual case of a 74-year-old patient who presented with progressive neurological disturbance many years after receiving intrathecal chemotherapy. Clinical assessment (including cross-sectional imaging) led to a diagnosis of secondary ESS.