Remote Instruction in Focused Assessment With Sonography in Trauma (FAST) Exams for Surgery Residents: A Pilot Study.

BACKGROUND: The Focused Assessment with Sonography in Trauma (FAST) exam is an important component to the evaluation of trauma patients. With advances in technology and meeting limitations due to COVID-19, remote instruction and learning have gained popularity. We sought to determine whether remote instruction of FAST exams was feasible as sustainable surgical education and a possible alternative to traditional in-person teaching. METHODS: General surgery residents completed a baseline survey and skills assessment on FAST exams and were then randomized to remote or in-person instruction. The remote group participated in an instructional session with a content expert through video conference and then practiced on a simulated mannequin while the expert remotely provided feedback. The in-person group received the experience with the content expert in the room. Both groups completed a post-course survey immediately after the session and a follow-up survey and objective assessment at six-months. Results were compared with two-way analysis of variance (ANOVA). RESULTS: 14 residents underwent the curriculum, seven in each group. There was a significant increase in self-reported confidence when comparing pre- and immediate post-course results for both the remote and in-person groups. At six months, confidence scores remained elevated and skill assessment scores improved, although the latter did not reach significance. There was no significant difference in post-course results between the groups. CONCLUSIONS: Remote instruction of FAST exams was feasible. Pilot data demonstrated an increase in confidence and suggest outcomes that are similar to in-person instruction, which has positive implications for future remote educational and potentially clinical initiatives.

Shifting the narrative: equity, evidence, effectiveness, and innovation in the era of Ending the HIV Epidemic.

BACKGROUND: The use of evidence-based (EB) and evidence-informed (EI) criteria in determining the effectiveness of health interventions has been widely adopted by national and international agencies in their attempt to address health gaps, particularly around Ending the HIV Epidemic (EHE) initiatives. Utilization of these rigorous standards has proven critical in making progress towards achieving EHE goals, yet many communities remain unreached and underserved despite widespread adoption of EB/EI standards in public health research and practice. Although a crucial tool for innovative healthcare delivery, emphasis on the use of EB/EI parameters has created bias within the cycle of knowledge creation that favors well-resourced institutions given their capacity to meet the rigorous evaluation standards required of EB/EI science. This bias can systematically exclude institutions more aligned with community needs, such as community-based organizations and other grass-roots initiatives, which may have long-standing interventions that more effectively engage marginalized groups but do not have the capacity to meet EB/EI standards. MAIN BODY: This paper will explore the manifestation of systematic bias and research inequity in the process of identifying and assessing EB/EI HIV care interventions through the lens of a Health Resources and Services Administration funded initiative, coined the Center for Innovation and Engagement, which supports people living with HIV in the United States. An overview of the initiative is provided along with examples of how promising interventions with positive outcomes for members of marginalized communities are excluded in place of interventions that meet traditional standards of scientific rigor but are not novel or particularly innovative. Themes around academic imperialism and power hierarchies will be considered along with key barriers, lessons learned, and recommendations for promoting more equitable EB/EI research practice. CONCLUSIONS: It is crucial for entities supporting public health interventions to prioritize equity and inclusion in all stages of funding, design, and implementation. This is particularly true for conditions, such as HIV, that disproportionally impact the most marginalized. This will require approaching EB/EI research with a critical lens towards power and a willingness to dismantle historical dynamics that perpetuate inequities as a way of encouraging truly innovative solutions to support those who need it most.

Reviewing ACGME Plastic Surgery Fellowship Case Logs: Is Surgical Experience Increasing?

INTRODUCTION: Over the last decade, there has been a 32% decrease in independent plastic surgery fellowships. The growing prevalence of 6-year integrated plastic surgery residencies, duty hour restrictions, and new subspecialty training fellowships for general surgeons have changed the training experience of plastic surgery fellows. METHODS: A retrospective review of the Accreditation Council for Graduate Medical Education (ACGME) case logs for graduating fellows of independent plastic surgery fellowships in the United States was conducted from 2011 to 2019. A linear regression analysis was conducted for each case log code and category, and a 95% level of confidence was assumed (α = 0.05). RESULTS: In 2011, 141 residents from 69 programs graduated with an average of 1469.7 cases. In 2019, 84 residents from 47 programs graduated with an average of 1952 cases. Index procedures significantly increased overall during the 9 y (P < 0.001). Categorical cases increased in esthetics (P < 0.001), including facelift, browlift, blepharoplasty, and more. Categorical cases increased in reconstructive surgery (P < 0.001), including treatment of deformities of the skin, lower extremities, and trunk, nerve decompression, and hand reconstruction. In breast procedures, an increase was seen in the reduction of mammoplasty, reconstruction, and treatment of other breast deformities. In head and neck procedures, an increase was seen in resection of head and neck neoplasms and secondary cleft lip repair. Decreases in procedural numbers were seen in primary cleft lip repair and hand reconstruction by primary closure. CONCLUSIONS: Despite a 32% decline in the number of independent plastic surgery fellowships over the last 9 y, plastic surgery fellows are obtaining significantly more surgical experience, both in esthetic and reconstructive surgery.

Utilizing In-Hospital Fabrication to Decrease Simulation Costs.

BACKGROUND: Two restrictive factors for surgical training through simulation, are the cost of and accessibility to materials and consoles for simulation models. Commercial surgical simulation models continue to maintain high prices with a wide range of fidelity levels. We believe that by utilizing in-house fabrication, these barriers can be decreased while maintaining and even improving the functionality of surgical simulation models as well as increase their individualization and customization. METHODS: By using a combination of digital and manual fabrication techniques such as 3D printing and basic mold making methods, we were able to create models equivalent to current commercial products by utilizing the first of its kind MakerHEALTH space and collaborating with our surgical simulation staff. We then compared our research and development, start-up, materials, operational, and labor costs to buying comparable commercial models with the simulation usage rates of our institution. RESULTS: We were able to decrease the costs of a 6 model simulation sample set (appendectomy, cholecystectomy, common bile duct exploration, ventral hernia, chest tube insertion, and suture pads) at our institution from $99,646.60 to $13,817.21 for a medical student laborer, $14,500.56 for a surgical resident laborer, $15,321.08 for a simulation staff laborer, and $18,984.48 for an attending physician laborer. CONCLUSION: We describe successful approaches for the creation of cost-effective and modular simulation models with the aim of decreasing the barriers to entry and improving surgical training and skills. These techniques make it financially feasible for learners to train during larger faculty-led workshops and on an individual basis, allowing for access to simulation at any time or place.

Development of a Low-cost, High-fidelity Skin Model for Suturing.

BACKGROUND: In a survey of students at our institution, suturing was the most desired workshop for simulation; however, cost, quality, and availability of skin pads is often prohibitive for suturing workshops. In-hospital fabrication may be utilized to manufacture noncommercial, high-fidelity, and low-cost simulation models. We describe the production, value, and face validation of our simulated skin model. MATERIALS AND METHODS: Using an in-hospital fabrication laboratory, we have developed a model for skin and subcutaneous tissue. Our model uses a variety of commercially available materials to simulate the epidermis, dermis, subcutaneous fat, fascia, and muscle. A cost analysis was performed by comparing it with other commonly used commercial skin models. Expert surgeons assessed the material characteristics, durability, and overall quality of our model in comparison with other commercial models. RESULTS: The materials cost of our novel skin pad model was 30.9% of the mean cost of five different commonly used foam and silicone-based commercial skin models. This low-cost model is more durable than the commercial models, does not require skin pad holders, and is of higher fidelity than the commercial products. In addition to skin closure, our model may be used to simulate fascial closure or fasciotomy. CONCLUSIONS: Model creation using in-hospital workspaces is an effective strategy to decrease cost while improving quality of surgical simulation. Our methods for creation of an inexpensive and high-fidelity skin pad may be purposed for several soft tissue models.

Methods of gestational age assessment influence the observed association between antiretroviral therapy exposure, preterm delivery, and small-for-gestational age infants: a prospective study in Cape Town, South Africa.

PURPOSE: Heterogeneous findings exist on antiretroviral therapy (ART) use in pregnancy and preterm delivery (PTD) or infants born small-for-gestational age (SGA). Whether reported differences may be explained by methods used to ascertain gestational age (GA) has not been explored. METHODS: We enrolled consecutive pregnant women attending a large primary care antenatal clinic in South Africa. Public-sector midwives assessed GA by last menstrual period (LMP) and symphysis-fundal height (SFH). Separately, if clinical GA was less than 24 weeks, ultrasound (US) was performed by a research sonographer blinded to midwife assessments. In analysis, the impact of measurement error on the association between HIV/ART status and birth outcome by GA method was assessed, and factors associated with clinical GA underestimation or overestimation identified. RESULTS: In 1787 women included overall, estimated PTD incidence was 36% by LMP, 17% by SFH, and 11% by US. PTD risk was higher for HIV-infected than HIV-uninfected women using US-GA (adjusted odds ratio [aOR] 1.95; 95% CI 1.10-3.46); for LMP/SFH-GA, the associations were smaller and not significant. These findings persisted after adjustment for age, parity, height, and previous PTD. PTD risk did not vary by timing of ART initiation (before or during pregnancy) for any method. Elevated BMI and older age were associated with decreased risk of underestimation by both LMP and SFH; HIV status and obesity were associated with increased risk of overestimation by SFH. There were no differences in SGA incidence across GA methods. CONCLUSIONS: Findings for an association between HIV/ART and birth outcomes are substantially influenced by GA assessment method. With growing public health interest in this association, future research efforts should seek to standardize optimal measures of gestation.