Navigating the Postgraduate Research Fellowship: A Roadmap for Surgical Residents.

BACKGROUND: To preserve the future of surgical innovation, opportunities for surgical residents to receive structured research training are paramount. The objective of this article is to help surgical residents navigate a research fellowship by overviewing key topics such as choosing an area of focus and supervisor, applying for external funding, transitioning away from clinical duties, managing intellectual property, integrating family planning, and incorporating research experience into independent career development. MATERIALS AND METHODS: Using the framework of the University of Toronto's graduate degree-awarding Surgeon-Scientist Training Program, the authors outline key considerations, decisions, and pearls for surgical residents considering or currently enrolled in a full-time research fellowship training program. RESULTS: Full-time research fellowships offer a unique opportunity for residents interested in an academic career. Such full-time research fellowships away from clinical duties allow surgical trainees to focus on developing key research competencies, including how to generate hypotheses, apply research methodology, gain experience presenting and publishing manuscripts, and ultimately apply these skills as independent investigators to improve patient and population health. Research fellowships may also be an opportunity to develop intellectual property or facilitate family planning. Practical tips are provided for the transition back into clinical training and how to effectively market one's research skills for career advancement. CONCLUSIONS: The authors outline key considerations, decisions, and pearls for surgical residents considering or currently enrolled in a full-time research fellowship training program. By adhering to the principles highlighted in this article, residents will be able to successfully navigate a full-time research fellowship to optimize their intellectual development, maximize their academic productivity, and facilitate their transition into an independent investigator.

Video Technologies for Recording Open Surgery: A Systematic Review.

Video recording of surgical procedures is an important tool for surgical education, performance enhancement, and error analysis. Technology for video recording open surgery, however, is limited. The objective of this article is to provide an overview of the available literature regarding the various technologies used for intraoperative video recording of open surgery. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines using the MEDLINE, Cochrane Central, and EMBASE databases. Two authors independently screened the titles and abstracts of the retrieved articles, and those that satisfied the defined inclusion criteria were selected for a full-text review. A total of 2275 publications were initially identified, and 110 were included in the final review. The included articles were categorized based on type of article, surgical subspecialty, type and positioning of camera, and limitations identified with their use. The most common article type was primary-technical (29%), and the dominant specialties were general surgery (22%) and plastic surgery (18%). The most commonly cited camera used was the GoPro (30%) positioned in a head-mount configuration (60%). Commonly cited limitations included poor video quality, inadequate battery life, light overexposure, obstruction by surgical team members, and excessive motion. Open surgery remains the mainstay of many surgical specialties today, and technological innovation is absolutely critical to fulfill the unmet need for better video capture of open surgery. The findings of this article will be valuable for guiding future development of novel technology for this purpose.

Videos in clinical medicine. Insertion of an intraosseous needle in adults.

Intraosseous needle insertion is used as a temporary measure when intravascular access cannot be achieved through peripheral or central venous routes. The intraosseous needle may remain in situ for 72 to 96 hours, but it is best removed within 6 to 12 hours, as soon as an alternative site of intravascular access has been established. The intraosseous route provides fast and reliable vascular access in emergency medical situations. The use of the appropriate technique will ensure that the procedure is performed as safely and effectively as possible.

"Facekit"-Toward an Automated Facial Analysis App Using a Machine Learning-Derived Facial Recognition Algorithm.

Introduction: Multiple tools have been developed for facial feature measurements and analysis using facial recognition machine learning techniques. However, several challenges remain before these will be useful in the clinical context for reconstructive and aesthetic plastic surgery. Smartphone-based applications utilizing open-access machine learning tools can be rapidly developed, deployed, and tested for use in clinical settings. This research compares a smartphone-based facial recognition algorithm to direct and digital measurement performance for use in facial analysis. Methods: Facekit is a camera application developed for Android that utilizes ML Kit, an open-access computer vision Application Programing Interface developed by Google. Using the facial landmark module, we measured 4 facial proportions in 15 healthy subjects and compared them to direct surface and digital measurements using intraclass correlation (ICC) and Pearson correlation. Results: Measurement of the naso-facial proportion achieved the highest ICC of 0.321, where ICC > 0.75 is considered an excellent agreement between methods. Repeated measures analysis of variance of proportion measurements between ML Kit, direct and digital methods, were significantly different (F[2,14] = 6-26, P<<.05). Facekit measurements of orbital, orbitonasal, naso-oral, and naso-facial ratios had overall low correlation and agreement to both direct and digital measurements (R<<0.5, ICC<<0.75). Conclusion: Facekit is a smartphone camera application for rapid facial feature analysis. Agreement between Facekit's machine learning measurements and direct and digital measurements was low. We conclude that the chosen pretrained facial recognition software is not accurate enough for conducting a clinically useful facial analysis. Custom models trained on accurate and clinically relevant landmarks may provide better performance.

Introduction : Il existe de multiples outils pour procéder aux mesures et à l'analyse des caractéristiques faciales à l'aide des techniques d'apprentissage machine de la reconnaissance faciale. Cependant, il reste plusieurs défis à relever avant qu'ils soient utiles en contexte clinique de chirurgie reconstructive et de chirurgie plastique. Des applications pour téléphone intelligent faisant appel à des outils d'apprentissage machine en libre accès peuvent être rapidement mises au point, déployées et mises à l'essai dans un cadre clinique. Dans la présente étude, les chercheurs comparent un algorithme de reconnaissance faciale sur téléphone intelligent pour effectuer les mesures directes et numériques nécessaires lors de l'analyse faciale. Méthodologie : Facekit est une application pour appareil photo de téléphone Android qui fait appel à ML Kit, une application de vision par ordinateur en libre accès créée par Google. Au moyen du module de repères faciaux, les chercheurs ont mesuré quatre proportions faciales chez 15 sujets en santé et les ont comparées aux mesures de surface directe et aux mesures numériques à l'aide de la corrélation intraclasse et de la corrélation de Pearson. Résultats : La mesure de la proportion nasofaciale a obtenu le coefficient de corrélation intraclasse (CCI) le plus élevé, à 0,321, où un CCI supérieur à 0,75 est considéré comme une excellente corrélation entre les méthodes. Des analyses de variance répétées des mesures de proportion entre le ML Kit, la méthode directe et la méthode numérique différaient considérablement (F[2,14] = 6 à 26, p<<0,05). Les mesures Facekit des ratios entre les mesures orbitale, orbitonasale, naso-orale et naso-faciale avaient une faible corrélation globale et étaient corrélées avec les mesures directes et numériques (R<<0,5, CCI<<0,75). Conclusion : Facekit est une application pour appareil photo de téléphone intelligent visant à analyser rapidement les caractéristiques faciales. La concordance entre les mesures d'apprentissage machine de Facekit et les mesures directes et numériques était faible. Les chercheurs concluent que le logiciel de reconnaissance faciale préentraîné n'est pas assez précis pour procéder à une analyse faciale utile sur le plan clinique. Des modèles personnalisés formés à des repères précis et pertinents sur le plan clinique donneront peut-être un meilleur rendement.

Automated Classification of Radiographic Positioning of Hand X-Rays Using a Deep Neural Network.

BACKGROUND: Hand X-rays are ordered in outpatient, inpatient, and emergency settings, the results of which are often initially interpreted by non-radiology trained health care providers. There may be utility in automating upper extremity X-ray analysis to aid with rapid initial analysis. Deep neural networks have been effective in several medical imaging analysis applications. The purpose of this work was to apply a deep learning framework to automatically classify the radiographic positioning of hand X-rays. METHODS: A 152-layer deep neural network was trained using the musculoskeletal radiographs data set. This data set contains 6003 hand X-rays. The data set was filtered to remove pediatric X-rays and atypical views. The X-rays were all labeled as either posteroanterior (PA), lateral, or oblique views. A subset of images was set aside for model validation and testing. Data set augmentation was performed, including horizontal and vertical flips, rotations, as well as modifications in image brightness and contrast. The model was evaluated, and performance was reported as a confusion matrix from which accuracy, precision, sensitivity, and specificity were calculated. RESULTS: The augmented training data set consisted of 80 672 images. Their distribution was 38% PA, 35% lateral, and 27% oblique projections. When evaluated on the test data set, the model performed with overall 96.0% accuracy, 93.6% precision, 93.6% sensitivity, and 97.1% specificity. CONCLUSIONS: Radiographic positioning of hand X-rays can be effectively classified by a deep neural network. Further work will be performed on localization of abnormalities, automated assessment of standard radiographic measures and eventually on computer-aided diagnosis and management guidance of skeletal pathology.

HISTORIQUE: Les cliniciens demandent des radiographies de la main pour des patients ambulatoires, des patients hospitalisés ou des patients à l'urgence. Souvent, les résultats sont d'abord interprétés par des professionnels de la santé non formés en radio-graphie. Il pourrait être utile d'automatiser l'analyse radiographique des extrémités supérieures pour accélérer l'analyse initiale. Les réseaux neuronaux profonds sont efficaces dans plusieurs applications d'analyse d'imagerie médicale. La présente étude visait à appliquer un cadre d'apprentissage profond pour classer automatiquement le positionnement radiographique de la main. MÉTHODOLOGIE: Un réseau neuronal profond à 152 couches a été formé au moyen de la base de données radiographies musculosquelettiques, qui contient 6 003 radiographies de la main. Les chercheurs l'ont filtrée pour en retirer les radiographies pédiatriques et les vues atypiques. Ils ont classé les radiographies en position postéroantérieure (PA), latérale ou oblique. Ils ont mis de côté un sous-groupe d'images pour valider et vérifier leur modèle. Ils ont optimisé la base de données, y compris des renversements horizontaux et verticaux, des rotations et des modifications à la luminosité et au contraste de l'image. Ils ont ensuite évalué le modèle et rendu compte de son rendement sous forme de matrice de confusion à partir de laquelle ils ont calculé l'exactitude, la précision, la sensibilité et la spécificité. RÉSULTATS: La base de données de formation optimisée contenait 80 672 images. De ce nombre, 38 % étaient des projections PA, 35 %, des projections latérales, et 27 %, des projections obliques. Lors des évaluations de la base de données soumise aux tests, le modèle présentait une exactitude de 96,0 %, une précision de 93,6 %, une sensibilité de 93,6 % et une spécificité de 97,1 %. CONCLUSIONS: Un réseau neuronal profond peut classer avec efficacité les radiographies du positionnement de la main. D'autres travaux seront réalisés sur l'emplacement des anomalies, sur l'évaluation automatisée de mesures radiographiques standards et, un jour, sur les directives diagnostiques et de prise en charge assistées par ordinateur des pathologies squelettiques.

Design and validation of an inertial measurement unit (IMU)-based sensor for capturing camera movement in the operating room.

Intraoperative surgical video enables better surgical training, continued performance enhancement for surgeons and system-level quality improvement initiatives, however the capture of high-quality intraoperative video of open surgical procedures is difficult. Wearable cameras, typically in the form of a head-mounted action camera are frequently used for this purpose, although the video from these devices often contains significant motion artifact due to movement of the surgeon's head. When trying to compare the performance of various wearable cameras in the surgical setting, we could not find a motion sensor appropriate for this purpose. We therefore describe in this article the design, assembly and validation of a small sensor that can be attached to wearable cameras in the operating room to objectively quantify camera motion. The sensor incorporates an inertial measurement unit coupled to a microcontroller. Concurrent validity is established by comparing the positional sensing of the device to a geared tripod head that allows for fine, measured manipulations of the sensor in three orthogonal axes. The methodology of capturing, processing and reporting camera movement for a surgical procedure is also detailed.

Development of the User Experience (UX) and Video Quality Evaluation (VQE) Instruments for Assessment of Intraoperative Video Capture Technology.

OBJECTIVE: There exists a lack of technology to reliably and routinely capture high-quality video of open surgical procedures. To critically evaluate and compare new and existing technology solutions, we must have widely accepted evaluation criteria for intraoperative camera devices. The objective, therefore, was to develop evaluation criteria for intraoperative camera devices, as well as the video product they produce. DESIGN: A modified Delphi process that included 2 iterative surveys was used to build expert consensus and develop 2 evaluation instruments: one to evaluate the user experience (UX) of using an intraoperative camera device, and the second for video quality evaluation (VQE) of the video product. SETTING: Global, through iterative online surveys. PARTICIPANTS: Surgeons who perform open surgery and have experience with intraoperative video capture. RESULTS: Eighty-six experts participated in the first iteration of the survey and 46 in the second. Ten factors met the a priori cutoff for >80% agreement for the UX survey: (1) ease of setup/integration with current practice, (2) comfort, (3) distracting during case, (4) overall satisfaction with wearing the device, (5) would you use this device again, (6) would you recommend this device to colleagues, (7) the weight of wearing the device, (8) sufficient battery life, (9) ability to control device while operating, and (10) degree to which the device interferes or is incompatible with other surgical accessories. Six factors met the cutoff for the VQE survey: (1) camera stability, (2) brightness/exposure, (3) resolution/sharpness, (4) unobstructed view of the surgical field, (5) appropriate field of view, and (6) overall satisfaction with video quality. CONCLUSIONS: These instruments can be used to critically evaluate camera technologies for intraoperative video capture of open surgery.

A novel approach to the proximal interphalangeal joint: The volar oblique incision - a retrospective cohort study.

BACKGROUND: The surgical approach to the volar structures in the digits must be designed to provide adequate exposure of tendons, vessels and nerves but also in a way that prevents flexion contracture of the digit as the scar contracts. This is traditionally done using a zigzag 'Bruner' incision, first described by Dr Julian M Bruner in 1967. In this paper, we describe an alternative approach, the Volar Oblique incision, and present a single institutional cohort of patients who have undergone procedures beginning with this approach. METHODS: A retrospective cohort study was performed on eight cases that involved a Bruner incision and eight similar cases that involved a volar oblique incision. Charts were reviewed for demographic data. Patients were asked to return to clinic postoperatively for scar assessment using the Patient and Observer Scar Assessment Scale (POSAS), where lower scores correspond to more favourable scar characteristics. The average follow-up period was 22 months. While in clinic, standard joint measurements were taken to assess for any proximal interphalangeal joint contracture. Demographics and questionnaire data were analysed using the Mann-Whitney U test for non-parametric data and quantitative joint measurements were analysed using Student's t-test. RESULTS: There was no difference in flexion contracture between the two groups. The POSAS patient score for scar irregularity was lower in the volar oblique group compared to the Bruner group, but there was no difference in any of the other subcategories, the total patient score, nor the overall patient opinion. The total POSAS observer score was lower in the volar oblique group compared to the Bruner group, with lower scores in the scar thickness, observed relief and observed pliability subcategories as well as the overall observer opinion. CONCLUSION: The volar oblique incision appears to be satisfactory alternative to the classic Bruner incision in hand surgery that requires volar exposure of the digits. Future studies are needed to assess the validity of these findings on a larger scale. LAY SUMMARY: There are various types of incisions that surgeons use when they operate on fingers. When choosing an incision, it is important that the incision provides good exposure to the deeper structures but does not form a tight scar that limits movement of the finger (contracture).A commonly used incision for the palmar side of the finger is the zig-zag or 'Bruner' incision. Some people, however, find this zig-zag scar unappealing. We started using a single diagonal incision, which we have called the volar oblique, instead of the zig-zag Bruner for access to the middle joint of the finger. We wanted to describe the volar oblique technique and then compare the quality of these two scars and also assess if one limits movement of the finger more than the other.Our research found no differences in finger contracture between groups. We did, however, find that patients reported scar irregularity more favourably in the volar oblique group and that surgeons rated scar thickness, relief (roughness) and pliability of the volar oblique scar higher than that of the zig-zag Bruner scar.This research presents a novel surgical technique and compares its results with respect to scar quality and finger contracture to the more traditional zig-zag Bruner approach.

Assessment of 3-Dimensional vs 2-Dimensional Imaging and Technical Performance Using a Multiport Intraoperative Data Capture and Analytic System for Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass Surgery.

IMPORTANCE: Errors and adverse events occur frequently in health care. Three-dimensional (3-D) laparoscopic systems claim to provide more realistic depth perception and better spatial orientation compared with their 2-D counterparts. OBJECTIVE: To compare the association of 3-D vs 2-D systems with technical performance during laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures using a multiport intraoperative data capture system. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was performed between May and December 2018, with a total of 50 LRYGB procedures performed in an academic tertiary care center; recordings of the operations were evaluated with a 30-day follow-up. All procedures were performed by the same surgical team. EXPOSURE: Surgical teams used 2-D or 3-D laparoscopic systems. MAIN OUTCOMES AND MEASURES: Technical performance was evaluated using the Objective Structured Assessment of Technical Skill and surgical errors and events using the Generic Error Rating Tool. RESULTS: Of the 50 patients who underwent LRYGB procedures, 42 (86%) were women, with a median (interquartile range) age of 42 (35-47) years and a median (interquartile range) body mass index of 46 (42-48), with no significant demographic differences between the groups whose operations were performed using the 2-D and 3-D systems. The mean (SD) number of errors per case was significantly lower in procedures using the 3-D laparoscopic system than in those using the 2-D system (17 [6] vs 33 [2]; P < .001). The mean (SD) number of error-related events was significantly lower in procedures using the 3-D system than in those using the 2-D system (6 [2] vs 11 [4]; P < .001). Mean (SD) Objective Structured Assessment of Technical Skill scores were significantly higher when the 3-D system was used than when the 2-D system was used (28 [4] vs 22 [3]; P < .001). CONCLUSIONS AND RELEVANCE: In this limited sample of LRYGB procedures, the use of a 3-D laparoscopic system was associated with a statistically significant reduction in errors and events as well as higher Objective Structured Assessment of Technical Skill scores compared with 2-D systems.

Facial Recognition Technology: A Primer for Plastic Surgeons.

The face is arguably the most unique and defining feature of the human body. From birth, humans are conditioned to perceive, interpret, and react to information conveyed by faces both familiar and unfamiliar. Although face recognition is routine for humans, only recently has it become possible for a computer to accurately recognize a human face in an image or video. With advances in artificial intelligence, image capture technology, and Internet connectivity, facial recognition technology has entered the forefront of personal and commercial technology. Plastic surgeons should be prepared to answer questions from patients about the fundamentals of facial recognition technology, and the potential effects of plastic surgery on facial recognition technology performance. This article provides an overview of facial recognition technology, describes its present applications, discusses its relevance within the field of plastic surgery, and provides recommendations for plastic surgeons to consider during preoperative discussions with patients.

The Use of Intravenous and Inhaled Colistin Therapy During a Burn Center Outbreak of Multidrug-Resistant Acinetobacter baumannii.

The authors report on the use of combination intravenous and inhaled colistin therapy in 2 patients with major burns admitted to an American Burn Association-verified burn center during a multidrug-resistant (MDR) Acinetobacter baumannii outbreak. Both patients had documented, culture-proven MDR Acinetobacter ventilator-associated pneumonia and bacteremia leading to sepsis. Both patients were successfully extubated and subsequently discharged from hospital. In this article, the authors provide the timeline of events and treatments that were used in these 2 cases. Combination intravenous and inhaled colistin therapy may be a valuable tool against MDR Acinetobacter infections.

A Peer-Reviewed Instructional Video is as Effective as a Standard Recorded Didactic Lecture in Medical Trainees Performing Chest Tube Insertion: A Randomized Control Trial.

OBJECTIVE: Online medical education resources are becoming an increasingly used modality and many studies have demonstrated their efficacy in procedural instruction. This study sought to determine whether a standardized online procedural video is as effective as a standard recorded didactic teaching session for chest tube insertion. DESIGN: A randomized control trial was conducted. Participants were taught how to insert a chest tube with either a recorded didactic teaching session, or a New England Journal of Medicine (NEJM) video. Participants filled out a questionnaire before and after performing the procedure on a cadaver, which was filmed and assessed by 2 blinded evaluators using a standardized tool. SETTING: Western University, London, Ontario. Level of clinical care: institutional. PARTICIPANTS: A total of 30 fourth-year medical students from 2 graduating classes at the Schulich School of Medicine & Dentistry were screened for eligibility. Two students did not complete the study and were excluded. There were 13 students in the NEJM group, and 15 students in the didactic group. RESULTS: The NEJM group׳s average score was 45.2% (±9.56) on the prequestionnaire, 67.7% (±12.9) for the procedure, and 60.1% (±7.65) on the postquestionnaire. The didactic group׳s average score was 42.8% (±10.9) on the prequestionnaire, 73.7% (±9.90) for the procedure, and 46.5% (±7.46) on the postquestionnaire. There was no difference between the groups on the prequestionnaire (Δ + 2.4%; 95% CI: -5.16 to 9.99), or the procedure (Δ -6.0%; 95% CI: -14.6 to 2.65). The NEJM group had better scores on the postquestionnaire (Δ + 11.15%; 95% CI: 3.74-18.6). CONCLUSIONS: The NEJM video was as effective as video-recorded didactic training for teaching the knowledge and technical skills essential for chest tube insertion. Participants expressed high satisfaction with this modality. It may prove to be a helpful adjunct to standard instruction on the topic.

Developing Cognitive Task Analysis-based Educational Videos for Basic Surgical Skills in Plastic Surgery.

OBJECTIVE: To describe the development of cognitive task analysis (CTA)-based multimedia educational videos for surgical trainees in plastic surgery. DESIGN: A needs assessment survey was used to identify 5 plastic surgery skills on which to focus the educational videos. Three plastic surgeons were video-recorded performing each skill while describing the procedure, and were interviewed with probing questions. Three medical student reviewers coded transcripts and categorized each step into "action," "decision," or "assessment," and created a cognitive demands table (CDT) for each skill. The CDTs were combined into 1 table that was reviewed by the surgeons performing each skill to ensure accuracy. The final CDTs were compared against each surgeon's original transcripts. The total number of steps identified, percentage of steps shared, and the average percentage of steps omitted were calculated. SETTING: Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada, an urban tertiary care teaching center. PARTICIPANTS: Canadian junior plastic surgery residents (n = 78) were sent a needs assessment survey. Four plastic surgeons and 1 orthopedic surgeon performed the skills. RESULTS: Twenty-eight residents responded to the survey (36%). Subcuticular suturing, horizontal and vertical mattress suturing, hand splinting, digital nerve block, and excisional biopsy had the most number of residents (>80%) rank the skills as being skills that students should be able to perform before entering residency. The number of steps identified through CTA ranged from 12 to 29. Percentage of steps shared by all 3 surgeons for each skill ranged from 30% to 48%, while the average percentage of steps that were omitted by each surgeon ranged from 27% to 40%. CONCLUSIONS: Instructional videos for basic surgical skills may be generated using CTA to help experts provide comprehensive descriptions of a procedure. A CTA-based educational tool may give trainees access to a broader, objective body of knowledge, allowing them to learn decision-making processes before entering the operating room.