A Hollow Tridimensional Silicone Template for Microtia Reconstruction and Postoperative Scar Compression.

Microtia poses a great challenge in auricular reconstruction, due to a great number of anatomical details on the anterior aspect, and its tridimensional shape. Numerous techniques have been described in an attempt to optimize results. We have designed a hollow tridimensional silicon template to serve as an intrasurgical guide for ear's anatomy, size and projection, according to the normal side, which allows better results of auricular reconstruction. It also can be used as a customized post-operative compression method. We believe it could be a valuable tool for microtia reconstruction surgery. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Standardising the management of open extremity fractures: a scoping review of national guidelines.

INTRODUCTION: Open extremity fractures can be life-changing events. Clinical guidelines on the management of these injuries aim to standardise the care of patients by presenting evidence-based recommendations. We performed a scoping systematic review to identify all national clinical practice guidelines published to date. MATERIALS AND METHODS: A PRISMA-compliant scoping systematic review was designed to identify all national or federal guidelines for the management of open fractures, with no limitations for language or publication date. EMBASE and MEDLINE database were searched. Article screening and full-text review was performed in a blinded fashion in parallel by two authors. RESULTS: Following elimination of duplicates, 376 individual publications were identified and reviewed. In total, 12 clinical guidelines were identified, authored by groups in the UK, USA, the Netherlands, Finland, and Malawi. Two of these focused exclusively on antibiotic prophylaxis and one on combat-related injuries, with the remaining nine presented wide-scope recommendations with significant content overlap. DISCUSSION: Clinical practice guidelines serve clinicians in providing evidence-based and cost-effective care. We only identified one open fractures guideline developed in a low- or middle-income country, from Malawi. Even though the development of these guidelines can be time and resource intensive, the benefits may outweigh the costs by standardising the care offered to patients in different healthcare settings. International collaboration may be an alternative for adapting guidelines to match local resources and healthcare systems for use across national borders.

MicrosimUC: Validation of a Low-Cost, Portable, Do-It-Yourself Microsurgery Training Kit.

BACKGROUND: Microsurgery depends largely on simulated training to acquire skills. Courses offered worldwide are usually short and intensive and depend on a physical laboratory. Our objective was to develop and validate a portable, low-cost microsurgery training kit. METHODS: We modified a miniature microscope. Twenty general surgery residents were selected and divided into two groups: (1) home-based training with the portable microscope (MicrosimUC, n = 10) and (2) the traditional validated microsurgery course at our laboratory (MicroLab, n = 10). Before the intervention, they were assessed making an end-to-end anastomosis in a chicken wing artery. Then, each member of the MicrosimUC group took a portable kit for remote skill training and completed an eight-session curriculum. The laboratory group was trained at the laboratory. After completion of training, they were all reassessed. Pre- and posttraining procedures were recorded and rated by two blind experts using time, basic, and specific scales. Wilcoxon's and Mann-Whitney tests were used to compare scores. The model was tested by experts (n = 10) and a survey was applied to evaluate face and content validity. RESULTS: MicrosimUC residents significantly improved their median performance scores after completion of training (p < 0.05), with no significant differences compared with the MicroLab group. The model was rated very useful for acquiring skills with 100% of experts considering it for training. Each kit had a cost of U.S. $92, excluding shipping expenses. CONCLUSION: We developed a low-cost, portable microsurgical training kit and curriculum with significant acquisition of skills in a group of residents, comparable to a formal microsurgery course.

[Proposal of an informed consent form to obtain audiovisual material from patients]. / Panel de expertos para la elaboración de un modelo de consentimiento informado de obtención y uso de material audiovisual clínico.

BACKGROUND: An informed consent is mandatory to obtain any clinical audiovisual material from patients. Although there are some documents created for this purpose, there are some barriers for their application, such as the context in which they were created, the language and download availability. AIM: To create a proposal for an informed consent form (ICF) for the capture and different uses for audiovisual material from patients. MATERIAL AND METHODS: A bibliographic search was carried out to obtain different ICFs in Spanish and English, which were subjected to a process of translation, counter-translation and fragmentation. Subsequently, a panel of experts was formed by members of the Chilean Society of Plastic Surgery with extensive experience in social networks. Delphi methodology was applied to reach a consensus about the definitive content of the ICF based on the previously selected fragments. RESULTS: ICFs available for download were identified. The panel was made up of seven Plastic Surgeons and two Delphi rounds were carried out through electronic surveys. At the end of the process, an ICF proposal was obtained for therapeutic, academic or scientific purposes and another for dissemination or education in the mass media. CONCLUSIONS: The proposed ICFs were liberated for their use among health care professionals in Chile, who could use them, provided that they are approved by the local healthcare ethics committees.

Video-Based Guided Simulation without Peer or Expert Feedback is Not Enough: A Randomized Controlled Trial of Simulation-Based Training for Medical Students.

BACKGROUND: Feedback is a pivotal cornerstone and a challenge in psychomotor training. There are different teaching methodologies; however, some may be less effective. METHODS: A prospective randomized controlled trial was conducted in 130 medical students to compare the effectiveness of the video-guided learning (VLG), peer-feedback (PFG) and the expert feedback (EFG) for teaching suturing skills. The program lasted 4 weeks. Students were recorded making 3-simple stitches (pre-assessment and post-assessment). The primary outcome was a global scale (OSATS). The secondary outcomes were performance time, specific rating scale (SRS) and the impact of the intervention (IOI), defined as the variation between the final and initial OSATS and SRS scores. RESULTS: No significant differences were found between PFG and EFG in post-assessment results of OSATS, SRS scores or in the IOI for OSATS and SRS scores. Post-assessment results of PFG and EFG were significantly superior to VLG in OSATS and SRS scores [(19.8 (18.5-21); 16.6 (15.5-17.5)) and (20.3 (19.88-21); 16.8 (16-17.5)) vs (15.7 (15-16); 13.3 (12.5-14)) (p < 0.05)], respectively. The results of PFG and EFG were significantly superior to VLG in the IOI for OSATS [7 (4.5-9) and 7.4 (4.88-10) vs 3.5 (1.5-6) (p < 0.05)] and SRS scores [5.4 (3.5-7) and 6.3 (4-8.5) vs 3.1 (1.13-4.88) (p < 0.05)], respectively. CONCLUSION: The video-guided learning methodology without any kind of feedback is not enough for teaching suturing skills compared to expert or peer feedback. The peer feedback methodology appears to be a viable alternative to handling the emerging demands in medical education.

Evaluation of Research Opportunities and Limitations for Plastic Surgery Residents: An International Survey.

BACKGROUND: Conducting research during specialty training provides an opportunity to develop critical thinking and leadership skills along with a better understanding of the scientific literature. However, trainees often find it difficult to undertake research, in the context of labor-intensive surgical training. The aim of this study is to evaluate the research output and limitations of plastic surgery residents in different countries. METHODS: An international cross-sectional study involving plastic surgery trainees and recent postgraduates from Brazil, Chile, Germany, and the United Kingdom was conducted. A survey inquiring into academic productivity, limitations to conducting research, and working-hours patterns was distributed among eligible participants. RESULTS: From September to December 2019, 106 surveys were retrieved. Most respondents declared having participated in at least 1 project that resulted in a presentation or publication during their training (90.6% in national presentations, 68% international presentations, 67% in national publications, and 66% international publications). Having completed a previous research fellowship was associated with a statistically higher academic output (P < 0.05). Seventy-nine percent of respondents felt that their participation in research activities would have been greater if limiting factors had been addressed, including lack of time (72.5%) and insufficient supervision and mentoring (55%). CONCLUSIONS: Optimizing plastic surgery trainees' participation in scientific research is beneficial both for residents and their mentors. Research fellowships can provide an opportunity for academically oriented trainees to further develop their research skills. Protected time and adequate mentoring can help not only to increase residents' research output, but also to recruit the next generation of academic plastic surgeons.

Mind the Gap: a Competency-Based Scoping Review of Aesthetic and Reconstructive Reported Simulation Training Models.

BACKGROUND: Simulation training has become an integral part of plastic surgery postgraduate curricula. It facilitates the acquisition of skills in a safe environment that can be later transferred to real-life settings. A variety of models have been described covering some aspects of the specialty better than others. The aim of this study was to identify and classify all the previously reported plastic surgery simulation models and the possible gaps having the Accreditation Council for Graduate Medical Education (ACGME) list of competencies as a guide. METHODS: Through a Delphi process, the complete list of ACGME minimum requirements for certification was analyzed to identify domains amenable for simulation training. A systematic search was conducted in Pubmed looking for all previously reported simulation models in plastic surgery. Predefined inclusion and exclusion criteria and parallel blind review were used to identify eligible models. RESULTS: A total of 81 ACGME competencies were identified. Following a 3-round Delphi process, consensus was reached on 19 reconstructive and 15 aesthetic surgery domains suitable for simulation training. 1667 articles were initially retrieved from Pubmed, of which 66 articles were eligible for inclusion. Descriptive (65%), quasi-experimental (24%) and experimental studies (11%) were found. For the 34 identified ACGME competencies, there were simulation models described for 58.8% of these, mostly covering reconstructive surgery (84.2%) while for aesthetic surgery it was 13.3%. CONCLUSIONS: This scoping review has identified that there are still gaps in ACGME competencies that could benefit from new simulation training models, especially in those related to aesthetic surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Minimally invasive tele-mentoring opportunity-the mito project.

BACKGROUND: Simulation training is a validated method for acquiring laparoscopic skills. Training sessions may be sporadic or lack continuity in oversight by instructors since traditional programs mandate in-person teaching and evaluation. This study presents the development, implementation, and results of a novel smartphone application that enables remote teacher-student interaction. This interface is used to complete a validated program that provides learner-specific feedback. Outcomes of training via Lapp were compared to outcomes of traditional in-person training. METHODS: A web-based and mobile iOS and Android application (Lapp) was developed to enable a remote student-teacher interaction. Instructors use Lapp to assess video recorded training sessions of students at distant locations and guide them through the laparoscopic skill course with specific and personalized feedback. Surgical trainees at two remote training centers were taught using Lapp. A control group was assessed during traditional simulation training at the training facility, with in-person feedback. Pre- and post-training performances were video recorded for each trainee and blindly evaluated by two experts using a global rating scale (GRS) and a specific rating scale (SRS). RESULTS: A total of 30 trainees were trained via Lapp and compared with 25 locally taught. Performance in the Lapp group improved significantly after the course in both GRS and SRS scores, from 15 [6-17] to 23 [20-25], and from 12 [11-15] to 18 [15-20], respectively. The results between both groups were comparable. CONCLUSION: Laparoscopic simulation training using a mobile app is as effective as in-person instruction in teaching advanced laparoscopic surgical skills. Lapp provides an effective method of teaching through simulation remotely and may allow expansion of robust simulation training curriculums.

Avoiding a Second Wave of Medical Errors: The Importance of Human Factors in the Context of a Pandemic.

The COVID-19 pandemic has had an unprecedented impact on the delivery of healthcare services around the globe. This has resulted in important loss of life for our communities, including health professionals that have been exposed to the disease in their workplace. A human factors approach to the recent changes introduced due to the pandemic can help identify how we can minimize the impact of human error in these circumstances. We hereby present a case study illustrating the application of human factors in the difficult times we are going through at present.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Adherence to COVID-19 trasmission prevention measures among health care workers]. / Prevención en la transmisión de Coronavirus-19: ¿qué tan preparado está el personal de salud en Chile?

BACKGROUND: COVID-19 is highly transmissible, thus requiring strict measures to prevent its propagation. AIM: To report a survey about self-reported adherence to recommendations aimed to reduce the transmission of COVID-19, among health care personnel. MATERIAL AND METHODS: A cross-sectional survey among health professionals about adherence to recommendations to prevent COVID-19 transmission was carried out in a public hospital in Chile. The survey had 11 questions and was developed using Delphi methodology, according to the recommendations of the World Health Organization and the Centers for Disease Control. RESULTS: The survey was answered by 137 of 155 invited workers. Hand washing, use of personal protection equipment, use of the elbow or tissue to sneeze, out-of-hospital hand washing and exclusive use of the uniform in the hospital, had an adherence of over 90%. The adherence to face touching avoidance during working hours, and face mask use in the public areas, was over 50%. No statistical differences were observed between gender or professionals. CONCLUSIONS: The adherence reported by health care workers was adequate in most of the evaluated recommendations.

Simulated training program in abdominal paracentesis for undergraduate medical students.

BACKGROUND AND AIMS: Abdominal paracentesis is an area that every general physician should know about, and the current learning model is unsafe for patients. Simulation allows students to develop their skills prior to clinical confrontation with minimal risks. The aims of this study were to design and evaluate a paracentesis simulation workshop for undergraduate students. METHODS: A workshop was implemented using a specially designed and validated simulation model for abdominal paracentesis. The simulated technique considered the recognition of materials, operator equipment, asepsis, anesthesia, puncture and obtaining liquid, collecting samples for analysis, withdrawal of the material and occlusion. A 24-point direct observation checklist was administered to assess the student. We assessed two students at the beginning of the workshop and all the students at the end. A perception survey was applied to attendees at the end of the workshop. RESULTS: 247 students were included and a workshop that involved 8 students per session was held. Students significantly improved their skills comparing pre- and post-evaluation results [13.36±4.46 (55.7%) vs. 22.3±1.83 (92.9%) respectively (n=69) p<0.001]. The students' perception questionnaire (n=38) showed that the training sessions were highly valued, averaging 4.8±0.38 on a Likert scale of 1-5. CONCLUSIONS: Simulated training in abdominal paracentesis is a very good teaching method. This teaching methodology should be highly recommended as an educational strategy in medicine because it could accelerate the acquisition of clinical skills in a safe learning environment.

[Undergraduate student's perception of clinical simulation workshops: assessment of an instrument]. / Percepción de estudiantes de pregrado de Medicina de talleres de simulación de procedimientos médico-quirúrgicos.

BACKGROUND: Simulation is a useful training tool for undergraduate medical students. A valid instrument is needed to assess students' perception of simulation workshops. AIM: To adapt and validate an instrument to assess the undergraduate medical student's perception of simulation workshops of clinical procedures. MATERIAL AND METHODS: Delphi Methodology was used to adapt the instrument. Exploratory and confirmatory analyses were performed to determine the construct validity and Cronbach's Alpha (0 to 1) for internal consistency of the instrument. RESULTS: A Delphi panel of 10 experts adapted a seven-item questionnaire (Likert scale 1-5; ranging from 7 to 35) and four open-questions. After 3-delphi-rounds, the instrument was administered to 210 students in six simulation training programs (Paracentesis, Cardiopulmonary Resuscitation, Airway management, Sutures, Thoracentesis and Nursing Procedures). The instrument was considered unidimensional in the factorial analysis. The overall median (Q1-Q3) score was 34 ranging from 32 to 35 and the Cronbach Alpha coefficient was 0.72, indicating a good reliability. CONCLUSIONS: The perception questionnaire is a useful and reliable instrument to assess students' perceptions of clinical simulations.

Allowing New Opportunities in Advanced Laparoscopy Training Using a Full High-Definition Training Box.

INTRODUCTION: Simulated laparoscopy training is limited by its low-quality image. A high-definition (HD) laparoscopic training box was developed under the present necessity of simulating advanced surgery. OBJECTIVE: To describe and test a new HD laparoscopic training box for advanced simulation training. METHODS: We describe the features and image quality of the new training box. The simulator was tested and then evaluated by a group of 76 expert surgeons using a 4-item questionnaire. To assess the effectiveness of training using this simulation box, 15 general surgery residents were trained to perform a laparoscopic jejuno-jejunostomy in a validated simulation program. They were assessed with objective rating scales before and after the training program, and their results were compared with that of experts. RESULTS: The training box was assembled using high-density fiberglass shaped as an insufflated abdomen. It has an adapted full-HD camera with a LED-based illumination system. A manually self-regulated monopod attached to the camera enables training without assistance. Of the expert surgeons who answered the questionnaire, 91% said that the simulation box had a high-quality image and that it was very similar to real laparoscopy. All residents trained improved their rating scores significantly when comparing their initial versus final assessment ( P < .001). Their performance after completing the training in the box was similar to that of experts ( P > .2). CONCLUSIONS: This novel laparoscopic training box presents a high-resolution image and allows training different types of advanced laparoscopic procedures. The simulator box was positively assessed by experts and demonstrated to be effective for laparoscopy training in resident surgeons.

[Serum levels of alanine aminotransferase in Chilean population: analysis of results of the national health survey 2009-2010]. / Niveles séricos de alanino-aminotransferasa en población Chilena: análisis de los resultados de la encuesta nacional de salud 2009-2010.

BACKGROUND: Determination of Alanine aminotransferase serum levels ([ALT]s) is a sensitive ana reliable test for liver diseases. AIM: To report the prevalence of abnormal [ALT]s in Chilean population and to identify associated variables. METHODS: We analyzed data from a random sub-sample of 2,794 adults surveyed during the second Chilean National Health Survey. Abnormal [ALT]s were defined by using three different cut-off values (COV), two fixed COV (COV1: > 30 IU/L in men and > 19 IU/L in women and COV2 pre-defined by the performing laboratory) and a COV adjusted by age, weight and sex (COV3 > 31 IU/L for women and > 44 IU/L and men > 42 IU/L and > 66 IU/L with a BMI > 23). Logistic regression analysis was performed to determine risk factors for elevated [ALT]s. RESULTS: Mean [ALT]s values were 30.14 I U/L in men and 22.03 IU/L in women. The observed prevalence of abnormal [ALT]s defined by different COV were 38%, 11.5%, and 8.1% for COV1, COV2 and COV3 respectively. Variables independently associated to abnormal [ALT]s in a multivariate analysis were the following: serum gamma-glutamyl-transpeptidase (OR: 1.055 [95% CI 1.033-1.078]) and body mass index (OR:1.13 [95% CI 1.09-1.17]). Variables inversely associated with abnormal [ALT]s (COV1) were mole gender (OR-.0.976 [95% CI 0.96-0.99) and HDL-cholesterol (OR:0979 [95% CI 0.96-0.99]). CONCLUSIONS: Independently of the COV used, Chilean population exhibits a high prevalence of abnormal [ALT]s which may reflect a significant burden of liver disease. Non-alcoholic fatty liver disease could be a major contributor to elevated [ALT]s considering the association of abnormal [ALT]s and metabolic variables.

IMPACT OF A SIMULATED LAPAROSCOPIC TRAINING PROGRAM IN A THREE-YEAR GENERAL SURGERY RESIDENCY.

BACKGROUND: A General Surgery Residency may last between 2-6 years, depending on the country. A shorter General Surgery Residency must optimize residents' surgical exposure. Simulated surgical training is known to shorten the learning curves, but information related to how it affects a General Surgery Residency regarding clinical exposure is scarce. AIM: To analyze the effect of introducing a validated laparoscopic simulated training program in abdominal procedures performed by residents in a three-year General Surgery Residency program. METHODS: A non-concurrent cohort study was designed. Four-generations (2012-2015) of graduated surgeons were included. Only abdominal procedures in which the graduated surgeons were the primary surgeon were described and analyzed. The control group was of graduated surgeons from 2012 without the laparoscopic simulated training program. Surgical procedures per program year, surgical technique, emergency/elective intervention and hospital-site (main/community hospitals) were described. RESULTS: Interventions of 28 graduated surgeons were analyzed (control group=5; laparoscopic simulated training program=23). Graduated surgeons performed a mean of 372 abdominal procedures, with a higher mean number of medium-to-complex procedures in laparoscopic simulated training program group (48 vs. 30, p=0.02). Graduated surgeons trained with laparoscopic simulated training program performed a higher number of total abdominal procedures (384 vs. 319, p=0.04) and laparoscopic procedures (183 vs. 148, p<0.05). CONCLUSIONS: The introduction of laparoscopic simulated training program may increase the number and complexity of total and laparoscopic procedures in a three-year General Surgery Residency.