The Preservation of Cued Recall in the Acute Mentally Fatigued State: A Randomised Crossover Study.

PURPOSE: The objective of this study is to investigate the impact of acute mental fatigue on the recall of clinical information in the non-sleep-deprived state. Acute mental fatigue in the non-sleep-deprived subject is rarely studied in the medical workforce. Patient handover has been highlighted as an area of high risk especially in fatigued subjects. This study evaluates the deterioration in recall of clinical information over 2 h with cognitively demanding work in non-sleep-deprived subjects. METHOD: A randomised crossover study involving twenty medical students assessed free (presentation) and cued (MCQ) recall of clinical case histories at 0 and 2 h under low and high cognitive load using the N-Back task. Acute mental fatigue was assessed through the Visual Analogue Scale, Stanford Scale and NASA-TLX Mental Workload Rating Scale. RESULTS: Free recall is significantly impaired by increased cognitive load (p < 0.05) with subjects demonstrating perceived mental fatigue during the high cognitive load assessment. There was no significant difference in the amount of information retrieved by cued recall under high and low cognitive load conditions (p = 1). DISCUSSION: This study demonstrates the loss of clinical information over a short time period involving a mentally fatiguing, high cognitive load task. Free recall for the handover of clinical information is unreliable. Memory cues maintain recall of clinical information. This study provides evidence towards the requirement for standardisation of a structured patient handover. The use of memory cues (involving recognition memory and cued recall methodology) would be beneficial in a handover checklist to aid recall of clinical information and supports evidence for their adoption into clinical practice.

Structured cues or modafinil for fatigue amelioration in clinicians? A double-blind, randomized controlled trial of critical clinical information recall in fatigued clinicians.

OBJECTIVES: To evaluate the impact of modafinil on "free" and "cued" recall of clinical information in fatigued but nonsleep-deprived clinicians. SUMMARY BACKGROUND DATA: Despite attempts to minimize sleep deprivation through redesign of the roster of residents and staff surgeons, evidence suggests that fatigue remains prevalent. The wake-promoting agent modafinil improves cognition in the sleep-deprived fatigued state and may improve information recall in fatigued nonsleep-deprived clinicians. METHODS: Twenty-four medical undergraduates participated in a double-blind, parallel, randomized controlled trial (modafinil-200 mg:placebo). Medication was allocated 2 hours before a 90-minute fatigue-inducing, continuous performance task (dual 2-back task). A case history memorization task was then performed. Clinical information recall was assessed as "free"(no cognitive aids) and "cued"(using aid memoirs). Open and closed cues represent information of increasing specificity to aid the recall of clinical information. Fatigue was measured objectively using the psychomotor vigilance task at induction, before and after the dual 2-back task. RESULTS: Modafinil decreased false starts and lapses (modafinil = 0.50, placebo = 9.83, P < .05) and improved psychomotor vigilance task performance (Decreased Performance, modafinil = 0.006, placebo = 0.098, P < .05). Modafinil improved free information recall (modafinil = 137.8, placebo = 106.0, P < .01). There was no significant difference between groups in the amount of information recalled with open (modafinil = 62.3, placebo = 52.8, P = .1) and closed cues (modafinil = 80.1, placebo = 75.9, P = .3). CONCLUSION: Modafinil attenuated fatigue and improved free recall of clinical information without improving cue-based recall under the design of our experimental conditions. Memory cues to aid retrieval of clinical information are convenient interventions that could decrease fatigue-related error without adverse effects of the neuropharmacology.

Aortic stiffness is an indicator of cognitive dysfunction before and after aortic valve replacement for aortic stenosis.

OBJECTIVES: Post-cardiac surgical cognitive dysfunction occurs more commonly following valvular procedures. Cognitive function has been related to vascular health status; however, the relation between pre-existent arterial stiffness and perioperative cognitive dysfunction is yet to be defined. The objective of this study was to assess whether aortic stiffness is related to cognitive dysfunction in surgical aortic stenosis (AS) pre- and postoperatively. METHODS: Between June 2010 and August 2012, patients undergoing aortic valve replacement (AVR) for AS were recruited for inclusion in this prospective observational study. Aortic pulse wave velocity (PWV) was used as a measure of aortic stiffness and cognitive function was assessed using the computerized Cambridge Neuropsychological Test Automated Battery (CANTAB) preoperatively and (409 ± 159 days) post-AVR. RESULTS: Fifty-six patients (age 71 ± 8.4 years) were recruited. Of the total, 50 (89%) completed postoperative follow-up. Pre- and postoperatively, patients with normal PWV (PWV-norm) had significantly superior delayed memory, sustained visual attention and executive function compared with those with high PWV (PWV-high). Immediate memory and decision-making were similar between groups. Postoperatively, improvement in cognitive function was more marked in PWV-high compared with PWV-norm patients. In two models of multiple regression analysis, PWV as a continuous variable was independently related to all preoperative main cognitive components as well as postoperative executive function. PWV as a dichotomous variable was independently related to all pre- and postoperative main cognitive function components. CONCLUSIONS: AVR may not be associated with an independent or homogeneous effect on cognitive decline. Aortic PWV might be useful as an additional indicator for cognitive dysfunction before and after surgical intervention for AS.

A randomized controlled trial evaluating endoscopic and laparoscopic training in skills transfer for novices performing a simulated NOTES task.

BACKGROUND: The NOSCAR white paper lists training as an important step to the safe clinical application of natural orifice translumenal endoscopic surgery (NOTES). The aim of this randomized controlled trial was to evaluate whether training novices in either a laparoscopic or endoscopic simulator curriculum would affect performance in a NOTES simulator task. METHODS: A total of 30 third-year medical undergraduates were recruited. They were randomized to 3 groups: no training (control; n = 10), endoscopy training on a validated colonoscopy simulator protocol (n = 10), and training on a validated laparoscopy simulator curriculum (n = 10). All participants subsequently completed a simulated NOTES task, consisting of 7 steps, on the ELITE (endoscopic-laparoscopic interdisciplinary training entity) model. Performance was assessed as time taken to complete individual steps, overall task time, and number of errors. RESULTS: The endoscopy group was significantly faster than the control group at accessing the peritoneal cavity through the gastric incision (median 27 vs 78 s; P = .015), applying diathermy to the base of the appendix (median 103.5 vs 173 s; P = .014), and navigating to the gallbladder (median 76 vs 169.5 s; P = .049). Endoscopy participants completed the full NOTES procedure in a shorter time than the laparoscopy group (median 863 vs 2074 s; P < .001). CONCLUSION: This study highlights the importance of endoscopic training for a simulated NOTES task that involves both navigation and resection with operative maneuvers. Although laparoscopic training confers some benefit for operative steps such as applying diathermy to the gallbladder fossa, this was not as beneficial as training in endoscopy.

What are the effects of sleep deprivation and fatigue in surgical practice?

Sleep deprivation and fatigue have long been linked with accidents in high-risk industries and serious errors in the medical profession, but their effects on surgical performance are less well understood. This article outlines the important functions that human sleep serves and describes the neurobehavioral effects of wakefulness extension and mental fatigue that are relevant to surgical performance, including attentional failure, risk taking, and decision-making bias. Methods used to explore the effects of sleep deprivation and fatigue on surgical performance, from laboratory studies to outcomes data, are discussed; the findings are summarized; and important deficiencies in the literature are highlighted. Future strategies to mitigate performance decline, such as novel assessment tools and countermeasures with proven efficacy, are presented, and their deployment is discussed in the context of key ethical principles.

The development of a virtual reality training curriculum for colonoscopy.

OBJECTIVES: The development of a structured virtual reality (VR) training curriculum for colonoscopy using high-fidelity simulation. BACKGROUND: Colonoscopy requires detailed knowledge and technical skill. Changes to working practices in recent times have reduced the availability of traditional training opportunities. Much might, therefore, be achieved by applying novel technologies such as VR simulation to colonoscopy. Scientifically developed device-specific curricula aim to maximize the yield of laboratory-based training by focusing on validated modules and linking progression to the attainment of benchmarked proficiency criteria. METHODS: Fifty participants comprised of 30 novices (<10 colonoscopies), 10 intermediates (100 to 500 colonoscopies), and 10 experienced (>500 colonoscopies) colonoscopists were recruited to participate. Surrogates of proficiency, such as number of procedures undertaken, determined prospective allocation to 1 of 3 groups (novice, intermediate, and experienced). Construct validity and learning value (comparison between groups and within groups respectively) for each task and metric on the chosen simulator model determined suitability for inclusion in the curriculum. RESULTS: Eight tasks in possession of construct validity and significant learning curves were included in the curriculum: 3 abstract tasks, 4 part-procedural tasks, and 1 procedural task. The whole-procedure task was valid for 11 metrics including the following: "time taken to complete the task" (1238, 343, and 293 s; P < 0.001) and "insertion length with embedded tip" (23.8, 3.6, and 4.9 cm; P = 0.005). Learning curves consistently plateaued at or beyond the ninth attempt. Valid metrics were used to define benchmarks, derived from the performance of the experienced cohort, for each included task. CONCLUSIONS: A comprehensive, stratified, benchmarked, whole-procedure curriculum has been developed for a modern high-fidelity VR colonoscopy simulator.

The adoption of advanced surgical techniques: are surgical masterclasses enough?

BACKGROUND: The surgical master class is a traditional method for a surgeon to learn new operations. However, there is limited evidence to support that it can help a surgeon adopt a new technique. The aim of this study was to investigate the adoption of surgical techniques after attendance at a surgical master class. METHODS: A questionnaire was sent to surgeons attending surgical master classes in laparoscopic bariatric and colorectal surgery. The questionnaire examined operative experience before attending the master class and the consequent adoption of techniques. RESULTS: There was a significant adoption of colorectal procedures, from 33% to 79% (P = .00011), and bariatric procedures, from 27% to 66% (P = .014), after attendance at the surgical master classes. CONCLUSIONS: This study shows a significant increase in surgeons' performing advanced surgical procedures after attendance at a surgical master class. This is the first study to demonstrate the effectiveness of the master class in terms of surgeons' adopting new techniques.

Effect of pharmacological enhancement on the cognitive and clinical psychomotor performance of sleep-deprived doctors: a randomized controlled trial.

OBJECTIVES: To investigate the effect of modafinil 200 mg on the performance of a cohort of healthy male doctors after 1 night of supervised sleep deprivation. SUMMARY BACKGROUND DATA: Sleep-deprived and fatigued doctors pose a safety risk to themselves and their patients. Yet, because of the around-the-clock nature of medical practice, doctors frequently care for patients after periods of extended wakefulness or during circadian troughs. Studies suggest that a group of substances may be capable of safely and effectively reversing the effects of fatigue. However, little work has been done to investigate their role within our profession. METHODS: We conducted a parallel, double-blind, randomized, and placebo-controlled study to investigate the effect of pharmacological enhancement on performance doctors. Thirty-nine healthy male resident doctors received either lactose placebo (n = 19) or modafinil 200 mg (n = 20) after 1 night of sleep deprivation. A selection of CANTAB neuropsychological tests was used to assess higher cognitive function. Clinical psychomotor performance was assessed using the Minimally Invasive Surgical Trainer Virtual Reality. Assessments were carried out between 6.00 AM and approximately 8.00 AM. RESULTS: Modafinil improved performance on tests of higher cognitive function; participants in the modafinil group worked more efficiently when solving working memory (F1,38 = 5.24, P = 0.028) and planning (F1,38 = 4.34, P = 0.04) problems, were less-impulsive decision makers (F1,37 = 6.76, P = 0.01), and were more able to flexibly redirect their attention (F1,38 = 4.64, P = 0.038). In contrast, no improvement was seen in tests of clinical psychomotor performance. CONCLUSIONS: Our results suggest that fatigued doctors might benefit from pharmacological enhancement in situations that require efficient information processing, flexible thinking, and decision making under time pressure. However, no improvement is likely to be seen in the performance of basic procedural tasks.

Assessment and feedback in the skills laboratory and operating room.

Significant advances have been made in recent years in the accurate and reliable assessment of surgical skill. The many applications for such a facility range from selection and training to certification, revalidation, and the implementation of new technologies. In the process of developing an assessment procedure it is necessary to select elements that safely, feasibly, and reliably capture variations in technical and nontechnical performance. The laboratory lends itself well to the assessment of deconstructed skills in a safe environment, whereas the operating room demands integration of technical and nontechnical skill in a high-risk setting. Therefore, both have an important role to play and should coexist within a continuous assessment pathway.