Online case-based educational meetings can increase knowledge, skills, and widen access to surgical training:The nationwideVirtualTrauma & Orthopaedic Meetingseries.

BACKGROUND: Access to surgical training is challenging for undergraduate and early postgraduate trainees due to a greater focus on developing generic knowledge and skills, and a drive to recruit greater numbers into internal medicine and primary care. COVID-19 accelerated the declining access to surgical training environments. Our aims were to: 1) establish the feasibility of an online, specialty-specific, case-based surgical training series, and 2) evaluate its suitability for meeting the needs of trainees. METHODS: A nationwide audience of undergraduate and early postgraduate trainees were invited to a series of bespoke online case-based educational meetings in Trauma & Orthopaedics (T&O) over a six month period. The six sessions, which simulated real-world clinical meetings, were constructed by Consultant sub-specialists and involved the presentation of cases by registrars, followed by structured discussion of basic principles, radiological interpretation, and management strategies. Mixed qualitative and quantitative analyses were conducted. RESULTS: There were 131 participants (59.5% male), consisting mostly of doctors in training (58%) and medical students (37.4%). The mean quality rating was 9.0/10 (SD 1.06), further supported by qualitative analysis. 98% enjoyed the sessions, 97% reported improved knowledge of T&O, and 94% reported a direct benefit to clinical practice. There was a significant improvement in knowledge of T&O conditions, management plans, and radiological interpretation (p = <0.05). CONCLUSION: Structured virtual meetings, underpinned by bespoke clinical cases, may widen access to T&O training, increase flexibility and robustness of learning opportunities, and mitigate the effects of reduced exposure on preparation for surgical careers and recruitment.

Multimodal cue integration in the dung beetle compass.

South African ball-rolling dung beetles exhibit a unique orientation behavior to avoid competition for food: after forming a piece of dung into a ball, they efficiently escape with it from the dung pile along a straight-line path. To keep track of their heading, these animals use celestial cues, such as the sun, as an orientation reference. Here we show that wind can also be used as a guiding cue for the ball-rolling beetles. We demonstrate that this mechanosensory compass cue is only used when skylight cues are difficult to read, i.e., when the sun is close to the zenith. This raises the question of how the beetles combine multimodal orientation input to obtain a robust heading estimate. To study this, we performed behavioral experiments in a tightly controlled indoor arena. This revealed that the beetles register directional information provided by the sun and the wind and can use them in a weighted manner. Moreover, the directional information can be transferred between these 2 sensory modalities, suggesting that they are combined in the spatial memory network in the beetle's brain. This flexible use of compass cue preferences relative to the prevailing visual and mechanosensory scenery provides a simple, yet effective, mechanism for enabling precise compass orientation at any time of the day.

Procedure-based assessments in trauma and orthopaedic training--The trainees' perspective.

INTRODUCTION: The study aimed to gain an understanding of the attitudes of trauma and orthopaedic (T&O) trainees regarding procedure-based assessments (PBAs) and identify factors that influence any perceived educational benefit. METHODS AND MATERIALS: A questionnaire was emailed to all T&O trainees in the UK via an established e-mail communication tool after an initial pilot exercise. The data were analysed using the online survey software. RESULTS: Of the 616 trainees included 53% found PBAs useful as a learning tool for delivery of feedback. Trainees agreed that there were barriers to the successful use of PBAs (61%). Completing the PBA at the time of the procedure (p < 0.001) and the trainer delivering quality feedback with PBAs (p < 0.001) significantly increased the number of trainees perceiving an improvement in their practice. Completing higher numbers of PBAs did not have this effect (p = 0.26). There was wide geographical variation in the use of PBAs by trainees. CONCLUSIONS: This is the first nationwide study offering a deeper insight into factors influencing T&O trainees' perceptions of the educational benefit gained from using PBAs. This study informs the debate on how to improve the effective use of PBAs in T&O training, and generally, of workplace-based assessments in surgical training.

Identification and Management of Obstetric Hemorrhage.

Obstetric hemorrhage remains the leading cause of maternal death and severe morbidity worldwide. Although uterine atony is the most common cause of peripartum bleeding, abnormal placentation, coagulation disorders, and genital tract trauma contribute to adverse maternal outcomes. Given the inability to reliably predict patients at high risk for obstetric hemorrhage, all parturients should be considered susceptible, and extreme vigilance must be exercised in the assessment of blood loss and hemodynamic stability during the peripartum period. Obstetric-specific hemorrhage protocols, facilitating the integration and timely escalation of pharmacologic, radiological, surgical, and transfusion interventions, are critical to the successful management of peripartum bleeding.

Incidence of periprosthetic fractures after hip hemiarthroplasty: Are uncemented prostheses unsafe?

Displaced intracapsular fractures of the neck of femur are routinely treated in the elderly with either cemented or uncemented hemiarthroplasty. Recent evidence suggests a superior outcome with the use of cement, but uncemented prostheses are still employed for those with multiple co-morbidities or particular frailty. In Scotland, the Scottish Intercollegiate Guidelines Network (SIGN) recommendations are used to identify which patients should receive a cemented prosthesis. These are simply based upon the presence of cardiorespiratory disease, particularly in the frail elderly patient. Between January 2007 and June 2010, a total of 1397 patients with neck-of-femur fractures presented to our unit. Retrospective analysis was performed with particular attention given to the rate of postoperative periprosthetic fracture. As many as 546 fractures were treated with hemiarthroplasty, of which 183 were treated with a cemented Exeter Trauma Stem (ETS) and 363 were treated with an uncemented Austin-Moore prosthesis (AMP). At the time of our retrospective analysis, we found that 15 (4%) patients treated with an uncemented prosthesis went on to sustain a periprosthetic fracture. There were no periprosthetic fractures in the cemented group (p=0.004). Data analysis by case-note review of those patients sustaining a periprosthetic fracture was then performed. Seven (50%) suffered from confusion secondary to dementia, six (43%) had a history of significant cardiac disease (recent myocardial infarction (MI) or cardiac failure) and two (14%) had known renal impairment. The mean time to fracture after uncemented hemiarthroplasty was 2 years. The majority (80%) were fractures which required further surgery. Revision surgery in these patients was associated with an overall complication rate of 42% (mainly deep infection and haemorrhage requiring transfusion). Two of the patients had a fracture that could be treated conservatively. It is concluded that, in conjunction with the treating senior anaesthetist, cemented implants should be considered in all patients, especially those who are deemed to be frail and with multiple co-morbidities. A periprosthetic fracture rate of 14% at a mean of 2 years after uncemented hemiarthroplasty represents a potentially unacceptable risk for such a frail population. In particular, we feel that the AMP should not be used for treating displaced intracapsular neck-of-femur fractures.

Highly effective poly(ethylene glycol) architectures for specific inhibition of immune receptor activation.

Architectural features of synthetic ligands were systematically varied to optimize inhibition of mast cell degranulation initiated by multivalent crossing of IgE-receptor complexes. A series of ligands were generated by end-capping poly(ethylene glycol) (PEG) polymers and amine-based dendrimers with the hapten 2,4-dinitrophenyl (DNP). These were used to explore the influence of polymeric backbone length, valency, and hapten presentation on binding to anti-DNP IgE and inhibition of stimulated activation of RBL cells. Monovalent MPEG(5000)-DNP (IC(50) = 50 nM), bivalent DNP-PEG(3350)-DNP (IC(50) = 8 nM), bismonovalent MPEG(5000)-DNP(2) (IC(50) = 20 nM), bisbivalent DNP(2)-PEG(3350)-DNP(2) (IC(50) = 3nM) and DNP(4)-dendrimer ligands (IC(50) = 50 nM) all effectively inhibit cellular activation caused by multivalent antigen, DNP-bovine serum albumin. For different DNP ligands, we provide evidence for more effective inhibition due to (i) preferential formation of intra-IgE cross-links by bivalent ligands of sufficient length, (ii) self-association of monovalent ligands with longer tails, and (iii) higher probability of binding for bisvalent ligands. We also show that larger DNP(16)-dendrimers of higher valency trigger degranulation by cross-linking IgE-receptor complexes, whereas smaller DNP-dendrimers are inhibitory. Thus, features of synthetic ligands can be manipulated to control receptor occupation, aggregation, and inhibition of the cellular response.