"Influential" Intraoperative Educators and Variability of Teaching Styles.

OBJECTIVES: Academic surgeons manage their role as intraoperative educators in a variety of ways. Such variability is neither idiosyncratic nor is there a single best approach. This study sought to explore the practices of surgeons deemed influential by their residents, allowing insight into a variety of potentially effective practices. PARTICIPANTS: Constructivist grounded theory guided data collection and analysis. Data sources included surveys from senior surgical residents (PGY3-6) and recent graduates from an academic hospital in Canada (36% response rate), intraoperative observations of teaching interactions, and semi-structured interviews with observed surgeons. Rigour was supported by data triangulation, constant comparison, and collection to theoretical sufficiency. DESIGN: We developed a framework grouping effective teaching into three overlapping approaches: exacting, empowering, and fostering. The approaches differ based on the level of independence granted and the degree of expectation placed on individual residents. Each demonstrates different strategies for balancing the multiple supervisory roles and patient care obligations faced by academic surgeons. We also identified strategies that could be used across approaches to enhance learning. CONCLUSIONS: For surgical educators seeking to improve upon the quality of the intraoperative supervision they provide, frameworks such as this may serve as models of effective supervision. Enhancing surgeons' knowledge of proven strategies, combined with reflecting on how they teach and how they balance responsibilities to patients and trainees, may allow them to broaden their educational practice.

Utility of a Validated Rating Scale for Self-Assessment in Microsurgical Training.

OBJECTIVE: The purpose of this study is to determine the utility of self-assessment in microsurgical training using a previously validated rating scale. DESIGN: A prospective study of surgical residents taking a hands-on 5-day microsurgical training course. Learners completed multiple self-assessments of their technical skills using the University of Western Ontario Microsurgical Acquisition/Assessment instrument. Simultaneously, preceptors assessed the learners using the same scale. Self-assessment and preceptor scores were compared using the Pearson correlation coefficient (PCC). RESULTS: There was a significant agreement noted between the 32 preceptor assessments and 36 self-assessments that were completed. Correlation between scores for the knot-tying (PCC = 0.62) and anastomosis modules (PCC = 0.77) was good and excellent, respectively. Preceptor scores and self-scores improved over the duration of the course: for preceptors, knot-tying scores increased from 58% on day 1 to 78% on day 5 (p = 0.02) and anastomosis scores improved from 56% to 82% (p = 0.004); for self-scores, knot-tying scores increased from 44% to 81% (p = 0.001) and anastomosis scores from 49% to 84% (p = 0.001). Learners with greater experience (higher postgraduate year level) tended to have higher self as well as preceptor ratings, albeit not statistically significant. CONCLUSION: Self-assessment using the University of Western Ontario Microsurgical Acquisition/Assessment instrument has good to excellent agreement with preceptor-assessment scores suggesting good interrater reliability. Self-assessment using such tools may, therefore, be used along with preceptor supervision and assessment to potentially improve self-directed learning during these courses.

Incidental Internal Mammary Nodes during Recipient Vessel Dissection in Breast Reconstruction: Are They Significant?

SUMMARY: Internal mammary (IM) lymph nodes may be exposed during recipient vessel preparation in free-flap breast reconstruction, and in rare cases, positivity of these nodes may affect treatment in patients with breast cancer. This systematic review examines the incidence and significance of IM nodes identified by plastic surgeons. Eligibility criteria included free-flap breast reconstruction with concurrent IM node biopsy. Data were analyzed for incidence of IM node biopsy and nodal positivity. Ten studies met inclusion criteria, with a total of 2055 patients and 717 nodes submitted to pathology. Incidence of IM positivity ranged approximately from 1% to 11%, for a calculated gross overall incidence of 2.9%. Of 59 patients with a positive IM node, 50 patients received additional adjuvant therapy, with insufficient data to determine the effect of treatment on survival.

Incidence of major and minor brain injuries in facial fractures.

BACKGROUND: Facial fractures can be associated with brain and cervical spine injuries because impact forces are transmitted through the head and neck. Although major brain injury is commonly recognized in these patients, incidence of minor brain injury is not well-known, despite potential morbidity and mortality. OBJECTIVES: This prospective study aimed to determine the incidence of both major and minor brain injuries in 100 patients presenting to a craniofacial surgery service with facial fractures and to identify characteristics associated with brain injury. METHODS: Data were collected for a 9-month period by a craniofacial surgeon at a level I trauma center. A questionnaire and checklist were designed to capture information about major and minor brain injury in patients with facial fractures. Assessments were completed in the outpatient clinic, emergency department, hospital ward, or intensive care unit during the first patient encounters. RESULTS: The average age of patients was 34 years; 79% were male. Time between injury and assessment ranged from less than a few hours to 4 months. Incidence of brain injury was 67% overall: 29% with major brain injury and 38% with minor injury. Major brain injury was commonly diagnosed early in the emergency department or intensive care unit. Conversely, minor brain injury tended to be diagnosed late in the clinic. Patient age, mechanism of injury, and type of facial fracture predicted brain injuries overall, but mechanism of injury was the sole predictor of minor brain injury. CONCLUSIONS: Facial fractures are often associated with brain injury. A high level of suspicion is warranted for minor traumatic brain injuries.

Cloning and characterization of the mouse ortholog of mi-er1.

Mi-er1 is a fibroblast growth factor immediate-early gene whose expression is differentially regulated in breast tumours. MI-ER1 functions as a transcriptional repressor of a number of genes, including Sp1 target genes. The Xenopus and human orthologs have been described and here we report the characterization of the mouse gene and its products. Mouse mi-er1 is a single copy gene located on chromosome 4. It has the same intron-exon structure as the human gene with the exception of exon 3A, in which an upstream 3' splice acceptor is utilized. As described in humans, multiple transcripts are produced in the mouse, and we have isolated the mouse orthologs of the human N1-beta, N2-beta and N3-beta, all of, which differ in their N-terminal sequence. Furthermore, we have isolated a novel isoform, N4-beta, containing sequence from an additional exon located between exon 4 and exon 5 that produces an fourth alternate N-terminus. The human mi-er1 transcripts also include isoforms encoding two alternate C-termini, alpha and beta. Like Xenopus, only isoforms containing the beta C-terminus have been detected in the mouse. Expression analysis, using a panel of mouse tissues and embryos, revealed that the N1-beta and N3-beta are ubiquitously expressed while N4-beta is only expressed in testis. N2-beta is expressed in most tissues but was not detected in heart, brain, eye or skeletal muscle. Sequence comparison revealed 95% identity between mouse and human MI-ER1 isoforms and 72% identity between mouse and Xenopus. The most conserved region in the MI-ER1 protein is the SANT domain, which is identical in all three species. Further analysis of the SANT domain using sequences retrieved from the genome databases for rat, cow, chicken, zebrafish, trout and Xenopustropicalis revealed that this domain is highly conserved, with 88% identity among the 9 species. Moreover, an additional 10 residues C-terminal to the published end of this domain are 100% conserved, suggesting that in MI-ER1, the functional domain includes this extended sequence.