Enhancing Intraoperative Cholangiography Interpretation Skills: A Perceptual Learning Approach for Surgical Residents.

OBJECTIVE: Laparoscopic cholecystectomy is a commonly performed surgery with risk of serious complications. Intraoperative cholangiography (IOC) can mitigate these risks by clarifying the anatomy of the biliary tree and detecting common bile duct injuries. However, mastering IOC interpretation is largely through experience, and studies have shown that even expert surgeons often struggle with this skill. Since no formal curriculum exists for surgical residents to learn IOC interpretation, we developed a perceptual learning (PL)-based training module aimed at improving surgical residents' IOC interpretation skills. DESIGN: Surgical residents were assessed on their ability to identify IOC characteristics and provide clinical recommendations using an online training module based on PL principles. This research had 2 phases. The first phase involved pre/post assessments of residents trained via the online IOC interpretation module, measuring their IOC image recognition and clinical management accuracy (percentage of correct responses), response time and confidence. During the second phase, we explored the impact of combining simulator-based IOC training with the online interpretation module on same measures as used in the first phase (accuracy, response time, and confidence). SETTING: The study was conducted at Rush University Medical College in Chicago. The participants consisted of surgical residents from each postgraduate year (PGY). Residents participated in this study during their scheduled monthly rotation through Rush's surgical simulation center. RESULTS: Total 23 surgical residents participated in the first phase. A majority (95.7%) found the module helpful. Residents significantly increased confidence levels in various aspects of IOC interpretation, such as identifying complete IOCs and detecting abnormal findings. Their accuracy in making clinical management decisions significantly improved from pretraining (mean accuracy 68.1 +/- 17.3%) to post-training (mean accuracy 82.3 +/- 10.4%, p < 0.001). Furthermore, their response time per question decreased significantly from 25 +/- 12 seconds to 17 +/- 12 seconds (p < 0.001). In the second phase, we combined procedural simulator training with the online interpretation module. The 20, first year residents participated and 88% found the training helpful. The training group exhibited significant confidence improvements compared to the control group in various aspects of IOC interpretation with observed nonsignificant accuracy improvements related to clinical management questions. Both groups demonstrated reduced response times, with the training group showing a more substantial, though nonsignificant, reduction. CONCLUSION: This study demonstrated the effectiveness of a PL-based training module for improving aspects of surgical residents' IOC interpretation skills. The module, found helpful by a majority of participants, led to significant enhancements in clinical management accuracy, confidence levels, and decreased response time. Incorporating simulator-based training further reinforced these improvements, highlighting the potential of our approach to address the lack of formal curriculum for IOC interpretation in surgical education.

Meta-analysis and public policy: Reconciling the evidence on deworming.

The WHO recommends mass drug administration (MDA) for intestinal worm infections in areas with over 20% infection prevalence. Recent Cochrane meta-analyses endorse treatment of infected individuals but recommend against MDA. We conducted a theory-agnostic random-effects meta-analysis of the effect of multiple-dose MDA and a cost-effectiveness analysis. We estimate significant effects of MDA on child weight (0.15 kg, 95% CI: 0.07, 0.24; P < 0.001), mid-upper arm circumference (0.20 cm, 95% CI: 0.03, 0.37; P = 0.02), and height (0.09 cm, 95% CI: 0.01, 0.16; P = 0.02) when prevalence is over 20% but not on Hb (0.06 g/dL, 95% CI: -0.01, 0.14; P = 0.1). These results suggest that MDA is a cost-effective intervention, particularly in the settings where it is recommended by the WHO.

Aging Skin and Wound Healing.

Responsible for many essential functions of life, human skin is made up of many components, each of which undergoes significant functional changes with aging and photodamage. Wound healing was previously thought to be defective in the elderly given the higher presence of chronic wounds and the longer time required for re-epithelialization of acute wounds. However, these notions have been challenged in recent research, which has shown that wound healing in the elderly is delayed but not defective. Poor healing of chronic wounds in older populations is more often attributable to comorbid conditions rather than age alone.

Medical education during the COVID-19 pandemic: What students missed and what they did not. A questionnaire-based cross-sectional study.

Background: Medical education was and still is challenged by the COVID-19 pandemic, and several strategies were implemented by the universities worldwide in order to maintain a good level of education. The aim of this work is to point out how strategies adopted in a German university hospital reached students and how comfortable they felt with the proposed solutions in order to define future possibilities in modern teaching. Methods: A questionnaire was answered by medical students at the end of the 8th and 10th semester in a German university hospital asking them about their perception of medical education during the pandemic as well as about strategies adopted by the faculty. Results: A total of 92 out of 117 students answered the questionnaire (78.6% response rate). Students felt disadvantaged in their medical education because of the pandemic on a scale from 0 (not at all) to 10 (completely) (5.34±2.3, range 0-10 points), regardless of semester, gender, and whether they aimed at a surgical career or not. During the pandemic they missed practical exercises most (93.5%), followed by contact with other students (65.2%). Presence lessons were missed (28.3%) the least. Among the strategies offered to maintain education, recorded lessons were appreciated most, followed by skills labs. Live-stream lessons were considered less comfortable. Conclusions: Several aspects of medical education were replaced satisfactorily during the pandemic, others need to be adapted in the future in order to meet the students' needs and expectations. Theoretical online education but not live stream lessons could be an option beyond COVID-19 as they are highly appreciated by students.

Optimal vaccine subsidies for endemic diseases.

In Goodkin-Gold et al. (2021), we analyzed optimal subsidies for a vaccine against an epidemic outbreak like Covid-19. This companion paper alters the underlying epidemiological model to suit endemic diseases requiring continuous vaccination of new cohorts-also suiting an epidemic like Covid-19 if, following Gans (2020), one assumes peaks are leveled by social distancing. We obtain qualitatively similar results: across market structures ranging from perfect competition to monopoly, the subsidy needed to induce first-best vaccination coverage on the private market is highest for moderately infectious diseases, which invite the most free riding; extremely infectious diseases drive more consumers to become vaccinated, attenuating externalities. Stylized calibrations to HIV, among other diseases, suggest that first-best subsidies can be exorbitantly high when suppliers have market power, rationalizing alternative policies observed in practice such as bulk purchases negotiated by the government on behalf of the consumers.

Critically high metal ion levels found in metal-on-metal modular hinged knee arthroplasty : a comparison of two different systems.

AIMS: This study compared the cobalt and chromium serum ion concentration of patients treated with two different metal-on-metal (MoM) hinged total knee arthroplasty (TKA) systems, as well as a titanium nitride (TiN)-coated variant. METHODS: A total of 63 patients (65 implants) were treated using either a MoM-coated (n = 29) or TiN-coated (n = 7) hinged TKA (GenuX mobile bearing, MUTARS; Implantcast, Germany) versus the BPKS (Brehm, Germany) hinged TKA (n = 27), in which the weight placed on the MoM hinge is diffused through a polyethylene (PE) inlay, reducing the direct load on the MoM hinge. Serum cobalt and chromium ion concentrations were assessed after minimum follow-up of 12 months, as well as functional outcome and quality of life. RESULTS: No differences in mean age (69 years, 40 to 86), mean age adapted Charlson Comorbidity Index (3.1 (SD 1.4)), mean BMI (29.2 kg/m2 (SD 5.8)), or number of other implants were observed between groups. Significant improvements in outcome scores and pain levels were achieved for all groups, and there was no difference in quality of life (12-Item Short-Form Health Survey questionnaire (SF-12)). Mean cobalt and chromium ion levels were significantly higher for the GenuX versus the BPKS hinged TKA (GenuX vs BPKS: cobalt: 16.3 vs 9.4 µg/l; chromium: 9.5 vs 5.2 µg/l). The TiN-coated implants did not appear to confer improvement in the metal ion levels. Metal ion concentrations above 7 µg/l were detected in 81%(29/36) of GenuX patients versus 41% (11/27) in the BPKS group. No GenuX patients had normal levels under 2 µg/l, versus 22% of BPKS patients. No significant reduction in outcome scores was observed regardless of the metal ion levels, whereas higher work-related activity was correlated with higher chromium concentrations. CONCLUSION: Hinged TKA, using MoM hinges, resulted in critically high cobalt and chromium ion concentrations. The BPKS hinged TKA showed significantly lower metal ion concentrations compared with the GenuX TKA. No benefits were observed using TiN coating. The different weightbearing mechanics might influence the wear of the component materials. Higher workloads and physical activity could influence chromium levels. Cite this article: Bone Joint J 2022;104-B(3):376-385.

Testing fractional doses of COVID-19 vaccines.

Due to the enormous economic, health, and social costs of the COVID-19 pandemic, there are high expected social returns to investing in parallel in multiple approaches to accelerating vaccination. We argue there are high expected social returns to investigating the scope for lowering the dosage of some COVID-19 vaccines. While existing evidence is not dispositive, available clinical data on the immunogenicity of lower doses combined with evidence of a high correlation between neutralizing antibody response and vaccine efficacy suggests that half or even quarter doses of some vaccines could generate high levels of protection, particularly against severe disease and death, while potentially expanding supply by 450 million to 1.55 billion doses per month, based on supply projections for 2021. An epidemiological model suggests that, even if fractional doses are less effective than standard doses, vaccinating more people faster could substantially reduce total infections and deaths. The costs of further testing alternative doses are much lower than the expected public health and economic benefits. However, commercial incentives to generate evidence on fractional dosing are weak, suggesting that testing may not occur without public investment. Governments could support either experimental or observational evaluations of fractional dosing, for either primary or booster shots. Discussions with researchers and government officials in multiple countries where vaccines are scarce suggests strong interest in these approaches.

Ablation of Tumor Necrosis Factor Alpha Receptor 1 Signaling Blunts Steatohepatitis in Peroxisome Proliferator Activated Receptor α-Deficient Mice.

Tumor necrosis factor -alpha (TNFα) is strongly associated with fatty liver disease (i.e, hepatosteatosis). Cytokine production has been thought of as a consequence of hepatic lipid accumulation which becomes a critical factor in the development of chronic liver pathologies as well as insulin resistance. The purpose of this study was to test the hypothesis that TNFα directly regulates lipid metabolism in liver in the mutant peroxisome-proliferator activated receptor-alpha (PPARα-/-) mouse model with robust hepatic lipid accumulation. At 10 weeks of age, TNFα and TNF receptor 1 expression are increased in livers of PPARα-/- mice compared to wild type. PPARα-/- mice were then crossed with mice lacking the receptor for TNFα receptor 1 (TNFR1-/-). Wild type, PPARα-/-, TNFR1-/-, PPARα-/- x TNFR1-/- mice were housed on ad-libitum standard chow diet for up to 40 weeks. Increases in hepatic lipid and liver injury and metabolic disruption associated with PPARα ablation were largely blunted when PPARα-/- mice were crossed with TNFR1-/- mice. These data support the hypothesis that TNFR1 signaling is critical for accumulation of lipid in liver. Therapies that reduce pro-inflammatory responses, namely TNFα, could have important clinical implications to reduce hepatosteatosis and progression of severe liver disease.

Parental Decision-Making for Surgery and Anesthesia in Young Children.

Millions of young children undergo surgery and anesthesia each year, yet there is a lack of scientific consensus about the safety of anesthesia exposure for the developing brain. Also poorly understood is parental anesthesia-related decision-making and how neurotoxicity information influences their choices. The theoretical model of parental decision-making generated in this research explicates this process. Interviews with 24 mothers yielded a theoretical framework based on their narratives developed using a qualitative grounded theory analysis. Five major themes emerged from these interviews: emotional processing, cognitive processing, relationships as resources, the mother/child dyad, and the health care context. Mothers described a non-linear, iterative process; they moved fluidly through emotional and cognitive processing supported by relationships as resources and influenced by the health care context. A key element was the subtheme of the medical translator, an individual who provided context and information. The mother/child dyad grounded the model in the relationship with the child.

[Current surgical treatment options for liver metastasis]. / Lebermetastasen: aktueller Stand der chirurgischen Behandlungsmöglichkeiten.

Current surgical treatment options for liver metastasis Abstract. Metastasis are the most frequent hepatic tumors. Although current treatment regimens focus highly on interdisciplinarity and are individualized, surgical resection remains the only curative treatment and represents the current gold standard approach. Advances in surgical, systemic and interventional treatment within the last years have resulted in a multidisciplinary therapy, individualized for each patient depending on their disease stage and condition. With these advancements, initially non-resectable liver metastasis can now be candidates for a surgical approach. Neoadjuvant chemotherapy, minimal invasive ablation, two- or multi-staged resections of the liver with or without portal vein embolization have contributed to this development. Advances in surgical and perioperative treatment also account for significantly increased overall survival.

A Commitment to Quality: The History of Nurse Anesthesia Accreditation Part Two: 1983-2019.

In 1934, Gertrude Fife, President of the National Association of Nurse Anesthetists (NANA) sought to elevate the standards of anesthesia practice and standardize the education of nurse anesthetists. NANA members located schools, developed education standards and a school approval process, that eventually led to creation of the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) in 1975. Examination of historical documents demonstrated that COA developed into a well-known accreditation agency recognized by both governmental and non-governmental organizations, enhancing the standards of anesthesia education and promoting high-quality educational programs. Note: See the April 2020 issue of AANA Journal for Part One of this article.

Diagnostic role of the 'white test' with lipidic solution in the early intraoperative identification of open bile ducts for the prevention of bile leakage after liver resection: study protocol for a randomised controlled multicentric superiority trial (BiLe-Trial).

INTRODUCTION: Bile leakage is a frequent complication after liver resection associated with the need of interventional drainage, endoscopic retrograde cholangio pancreatography (ERCP) or reoperation. The intraoperative application of the white test could be a promising strategy to reduce the occurrence of bile leakages. Therefore, we propose to conduct the first multicentric randomised controlled trial with rate of postoperative bile leakage as primary endpoint with and without the white test. METHODS AND ANALYSIS: The Bile-Leakage Trial trial is an investigator-initiated randomised controlled, parallel group, double-blinded, multicentric, superiority trial in four Swiss centres. A total of 210 patients undergoing a resection of at least 2 liver segments will be randomly allocated intraoperatively to either the intervention (identification of open bile ducts with administration of 20-40 mL SMOFlipid5% in the bile tract) or the control group (identification with a white gauze on the liver resection surface).Primary outcome will be the comparison of the postoperative bile leakage rate in both groups within 30 days after liver resection, defined according to the classification of the International Study Group of Liver Surgery. Secondary outcomes will be operative and postoperative complication, including severity grade of the bile leakage, rate of ERCP, interventional drainage, morbidity, intensive care unit stay, and mortality. ETHICS AND DISSEMINATION: The cantonal ethics committees of all participating centres and Swissmedic approved the study. SMOFlipid20% consists of a mixture of oils, no side effects resulting from the intraoperative application of 20-40 mL in the biliary tract with consecutive enteral absorption are expected nor are side effects described in the literature. SMOFlipid20% will be diluted intraoperatively with isotonic saline solution to a concentration of 5%. The results of the BiLe-Trial will be submitted to a peer-reviewed journal regardless of the outcome. As this is an investigator-initiated trial, data are property of the sponsor investigator and can be obtained on request. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov, ID: NCT04523701. Registered on 25 August 2020.Swiss National Clinical Trials Portal (SNCTP), ID: SNCTP000004200. Registered on 20 January 2021. PROTOCOL VERSION: V3.2_14-12-2020_clean.pdf.

Bilateral delayed traumatic diaphragmatic injury.

A 47-year-old patient presented at our emergency department with acute epigastric pain. A thoracic X-ray showed a partially intrathoracic stomach as well as bowel left sided. A following computed tomography scan diagnosed a diaphragmatic hernia. In the patient's history, 20 years ago a serious car accident was reported as the presumable traumatic origin. Intraoperatively, the diaphragmatic hernia was repaired with a direct suture and mesh augmentation. The rest of the abdomen was clear. In a thoracic X-ray following chest tube removal, herniated small bowel appeared intrathoracally on the right. Relaparotomy showed an extensive diaphragmatic hernia with parts of the liver, small bowel and colon in the right thoracic cavity. Only a partial direct repair was possible, an inlay mesh repair was performed. The further recovery was uneventful. Bilateral delayed traumatic diaphragmatic hernias are extremely rare, but with a suggestive trauma history thorough intraoperative exploration of the contralateral side should be evaluated.

Twenty-year economic impacts of deworming.

Estimating the impact of child health investments on adult living standards entails multiple methodological challenges, including the lack of experimental variation in health status, an inability to track individuals over time, and accurately measuring living standards and productivity in low-income settings. This study exploits a randomized school health intervention that provided deworming treatment to Kenyan children, and uses longitudinal data to estimate impacts on economic outcomes up to 20 y later. The effective respondent tracking rate was 84%. Individuals who received two to three additional years of childhood deworming experienced a 14% gain in consumption expenditures and 13% increase in hourly earnings. There are also shifts in sectors of residence and employment: treatment group individuals are 9% more likely to live in urban areas, and experience a 9% increase in nonagricultural work hours. Most effects are concentrated among males and older individuals. The observed consumption and earnings benefits, together with deworming's low cost when distributed at scale, imply that a conservative estimate of its annualized social internal rate of return is 37%, a high return by any standard.

Relationship Between Emotional Intelligence and Clinical Performance in Student Registered Nurse Anesthetists.

ABSTRACT: Emotional intelligence (EI) includes skills such as recognizing, understanding, and managing emotions. This pilot study investigated the utility of the Mayer-Salovey-Caruso Emotional Intelligence Test Version 2.0 as a screening instrument in student registered nurse anesthetists by determining if EI predicted clinical performance. Scores from 11 participants enrolled in a single nurse anesthesia program were correlated with formative clinical evaluations. Relationships between EI and clinical performance were examined. Participants consistently met clinical performance objectives but were unable to use emotion to solve problems or to recognize others' emotions, suggesting that EI abilities could impact future student registered nurse anesthetist clinical performance.

[Revision Total Knee Arthroplasty]. / Revisionsendoprothetik des Kniegelenks.

In addition to periprosthetic infections (PJI), the reconstruction of bony defects is the major challenge of revision total knee arthroplasty (TKA). Infection should be ruled out in all cases prior to operation. Revision TKA requires intensive planning with regard to the needed augmentation possibilities and the stems to be used. The sole biological reconstruction of major defects (AORI II and III) shows high failure rates. Large defects must be augmented by metal (wedges/sleeves/cones). The concept of zonal anchorage (3-zone model) with a stable anchorage in 2 out of 3 zones as close to the joint as possible is currently the standard. According to the model, metaphysis (zone 2) is an increasingly important factor for long-term stable anchoring. The use of cones or sleeves seems to significantly improve the results of revision TKA. The anchorage in zone 3 via stems is still mandatory. Cemented metaphysary anchoring and cement-free diaphysary anchoring stems are available, whereby no clear recommendation for a principle can be given.