Development and validation of a virtual teaching method for minimally invasive surgery skills: a prospective cohort study.

INTRODUCTION: The COVID-19 pandemic led to a significant reduction in operative exposure for surgical trainees, necessitating alternative training methods to mitigate the impact on surgical education. This study sought to evaluate whether minimally invasive surgery (MIS) skills could be taught remotely using widely available technology with objective assessments of proficiency. METHODS: This was a pilot observational study with comparative assessment of face-to-face (F2F) and virtual training of novice learners in MIS skills. Performance and objective cognitive workload parameters (Surgical Task Load Index (SURG-TLX) score, heart rate and pupil metrics) were evaluated. The assessments were peg transfer (McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS)) and suturing (Suturing Training and Testing (SUTT)) tasks performed using box trainers. Virtual teaching was conducted by expert trainers using a web-based streaming platform. RESULTS: Technical challenges of delivering a virtual MIS skills course were addressed after a pilot course. Participants (n = 20) in the final course had similar baseline characteristics and were randomly allocated to F2F (n = 8) and virtual (n = 12) teaching groups. Participants in the online group completed the peg transfer task faster than the F2F group (11.25 minutes vs. 16.88 minutes; P = 0.015). There were no significant differences in all other MISTELS and SUTT performance measures between groups. Cognitive workload parameters (SURG-TLX score, heart rate and pupil metrics) were also similar between groups. CONCLUSION: This study has demonstrated that virtual teaching of MIS skills using a web-based streaming platform is feasible and effective, providing the foundation for low-cost, effective, and scalable MIS skills programs in the future.

Deep neck space infection extending to the mediastinum that was treated conservatively.

Deep neck space infections (DNSIs) are challenging to diagnose and manage. A female ex-smoker presented with difficulty breathing and chest pain. She was initially treated for exacerbation of emphysema with intravenous antibiotics. The ear, nose and throat team were later asked to review the patient for left submandibular swelling and odynophagia. CT of the neck was performed 10 days later, due to limited availability during COVID-19. It showed an extensive retropharyngeal collection from the level of the vallecula to just above the carina. Normally, a DNSI extending to the mediastinum would require prompt surgical management. However, the patient was clinically well once imaged, so the abscess was managed conservatively with intravenous antibiotics.

Persistent sore throat: a case of laryngeal mucous membrane pemphigoid.

We present a case of a 72-year-old women who presented with a persistent sore throat and productive cough. On flexible nasendoscopy examination, she was found to have a fairly superficial ulcer affecting the laryngeal surface and tip of her epiglottis. On her second microlaryngoscopy and biopsy, direct immunofluorescent staining of the biopsy was analysed and the histological findings were in keeping with a diagnosis of mucous membrane pemphigoid (MMP). MMP is a rare chronic autoimmune condition characterised by the presence of blistering subepithelial lesions that can cause scarring. Laryngeal MMP affects only 1 in 10 million people and can lead to life-threatening airway compromise arising from scarring and stenosis. As there is a large spectrum of disease, it is important to adopt a multidisciplinary approach including dermatologists, otolaryngologists and ophthalmologists for prompt diagnosis and early recognition of potential complications, maximising functional outcomes for patients.

Lipoedematous scalp: is there an association with fatty infiltration of the parotid?

Lipoedematous scalp (LS) is an extremely rare condition characterised by a soft and boggy consistency in the scalp due to an increased layer of subcutaneous tissue.In this report, we present a case of LS in a 64-year-old Indian woman. Clinical examination revealed only vague boggy lumpiness involving the whole of occipital scalp extending to parietal scalp. MRI scalp showed diffuse fatty infiltration of the scalp, particularly at the posterior parietal and occipital convexity extending to both lateral aspects of the cranium, with homogeneous signal in keeping with fat. Incidentally MRI also found diffuse fatty infiltration of the parotids.The aethiopathogenesis of LS is still unknown, however it is believed that the hormone leptin could be the key hormone in the dysregulation of fat deposition and distribution. This case report highlights the subtle features with which these cases can present and explores the literature on reported cases of LS.

Endothelial disruptive proinflammatory effects of nicotine and e-cigarette vapor exposures.

The increased use of inhaled nicotine via e-cigarettes has unknown risks to lung health. Having previously shown that cigarette smoke (CS) extract disrupts the lung microvasculature barrier function by endothelial cell activation and cytoskeletal rearrangement, we investigated the contribution of nicotine in CS or e-cigarettes (e-Cig) to lung endothelial injury. Primary lung microvascular endothelial cells were exposed to nicotine, e-Cig solution, or condensed e-Cig vapor (1-20 mM nicotine) or to nicotine-free CS extract or e-Cig solutions. Compared with nicotine-containing extract, nicotine free-CS extract (10-20%) caused significantly less endothelial permeability as measured with electric cell-substrate impedance sensing. Nicotine exposures triggered dose-dependent loss of endothelial barrier in cultured cell monolayers and rapidly increased lung inflammation and oxidative stress in mice. The endothelial barrier disruptive effects were associated with increased intracellular ceramides, p38 MAPK activation, and myosin light chain (MLC) phosphorylation, and was critically mediated by Rho-activated kinase via inhibition of MLC-phosphatase unit MYPT1. Although nicotine at sufficient concentrations to cause endothelial barrier loss did not trigger cell necrosis, it markedly inhibited cell proliferation. Augmentation of sphingosine-1-phosphate (S1P) signaling via S1P1 improved both endothelial cell proliferation and barrier function during nicotine exposures. Nicotine-independent effects of e-Cig solutions were noted, which may be attributable to acrolein, detected along with propylene glycol, glycerol, and nicotine by NMR, mass spectrometry, and gas chromatography, in both e-Cig solutions and vapor. These results suggest that soluble components of e-Cig, including nicotine, cause dose-dependent loss of lung endothelial barrier function, which is associated with oxidative stress and brisk inflammation.