Chronic Pulmonary Aspergillosis after Surgical Treatment for Non-Small Cell Lung Cancer-An Analysis of Risk Factors and Clinical Outcomes.

Chronic pulmonary aspergillosis (CPA) is a rare but significant complication of lung cancer surgery. Its effect on survival remains unclear. Our aim was to describe the outcomes of the patients who developed CPA following the surgery for non-small cell lung cancer (NSCLC), identify the risk factors associated with its development following lung resection, and evaluate its impact on survival. All the patients with a diagnosis of CPA and operated NSCLC were identified in the National Aspergillosis Centre (NAC) database (2009-2020). Additional patients were identified in the Northwest Clinical Outcomes Research Registry (2012-2019) database. A regression analysis was performed to examine potential links between CPA and long-term outcomes and also to identify the factors associated with the development of CPA. The primary outcomes were the development of CPA, 1-year and 5-year mortality, and overall survival. Thirty-two patients diagnosed with CPA after lung resection were identified in the NAC database, of which 11 were also contained within the NCORR database, with a prevalence of 0.2% (n = 11/4425). Post-operative CPA was associated with significantly lower survival on log-rank analysis (p = 0.020). Mortality at one year was 25.0% (n = 8) and 59.4% (n = 19) at five years after the CPA diagnosis. On univariable analysis, a lower mean percentage-predicted forced expiratory volume in 1 s, ischaemic heart disease, and chronic obstructive pulmonary disease were all significantly associated with CPA development. CPA is a rare complication following lung cancer surgery which has a significant impact on long-term survival. Its development may be associated with pre-existing cardiopulmonary comorbidities. Further research in larger cohorts is required to substantiate these findings.

Current Status of Simulation in Thoracic Surgical Training.

BACKGROUND: Simulation is playing an increasingly important role in surgical training but is not yet a mandatory part of most surgical curricula. A simulator must undergo rigorous validation to verify it as a reliable tool. The aim of this study was to review the literature to identify simulators that are currently available to augment thoracic surgical training and to analyze any evidence supporting or validating them. METHODS: A literature search of the MEDLINE (1946 to November 2022) and Embase (1947 to November 2022) databases was performed to identify simulators for basic skills and procedures in thoracic surgery. A selection of keywords were used to perform the literature search. After identification of appropriate articles, data were extracted and analyzed. RESULTS: Thirty-three simulators were found in 31 articles. Simulators for basic skills (n = 13) and thoracic lobectomy (n = 13) were most commonly described, followed by miscellaneous (n = 7). Most models were of a hybrid modality (n = 18). Evidence of validity was established in 48.5% (n = 16) of simulators. In total, 15.2% (n = 5) of simulators had 3 or more elements of validity demonstrated, and only 3.0% (n = 1) accomplished full validation. CONCLUSIONS: Numerous simulators of varying modality and fidelity exist for a variety of thoracic surgical skills and procedures, although validation evidence is frequently inadequate. Simulation models may be able to provide training in basic surgical and procedural skills; however, further assessment of validity needs to be undertaken before consideration of their integration into training programs.

Recommendations for the use of coronary and valve simulators in cardiac surgical training: a systematic review.

OBJECTIVES: The aim of this study was to systematically review the simulators that are currently available for coronary artery bypass graft and valve surgery and, in addition, to review the validation evidence supporting them and to recommend several simulators for training based on the analysis of results. METHODS: A systematic literature search of the MEDLINE® (1946 to May 2021) and EMBASE® (1947 to May 2021) databases was performed to identify simulators for coronary artery and valvular procedures in cardiothoracic surgery. A selection of keywords and MeSH terms was used to execute the literature search. After identification of relevant articles, data were extracted and analysed. RESULTS: Thirty-seven simulators were found in 31 articles. Simulators were found for coronary artery bypass graft (n = 24) and valve surgery (n = 13). The majority of models were either benchtop (n = 28) or hybrid (n = 8) modalities. Evidence of validity was demonstrated in 15 (40.5%) simulators. Twenty-two (59.5%) simulators had no validation evidence, and 1 (2.7%) simulator had 3 or more elements of validity established. CONCLUSIONS: Two simulators were recommended for supplemental training in cardiothoracic surgery. Low-fidelity models can provide a broad foundation for surgical skills' development whereas high-fidelity simulators can be used for immersive training scenarios and appraisals. These should be utilized in early training, at which point the learning curve of trainees is steepest.

Loperamide: an emerging drug of abuse and cause of prolonged QTc.

Loperamide is an over-the-counter medication which is commonly used to treat diarrhoea. In excessive doses, loperamide acts as an opioid on the central nervous system, which contributes to its increasing popularity as an alternative substance for opiate addictions. High doses for prolonged periods can cause prolonged QTc and provoke life-threatening arrhythmias, such as ventricular fibrillation. We report the case of a young female who developed dangerous arrhythmias as a result of chronic loperamide overdosing. Following syncopal episodes at rest, she was admitted for a period of monitored observation and later discharged with a plan to taper her loperamide in the community. Upon second presentation, her loperamide was replaced with buprenorphine patches, which were then weaned successfully in the community. Despite this, she passed away several months later, most likely from an underlying congenital cardiac arrhythmia which was unmasked by excessive use of loperamide.

Validity assessment of a simulation module for robot-assisted thoracic lobectomy.

BACKGROUND: Training for robot-assisted thoracic lobectomy remains an issue, prompting the development of virtual reality simulators. Our aim was to assess the construct and face validity of a new thoracic lobectomy module on the RobotiX Mentor, a robotic surgery simulator. We also aimed to determine the acceptability and feasibility of implementation into training. METHODS: This prospective, observational, and comparative study recruited novice (n = 16), intermediate (n = 9), and expert (n = 5) participants from King's College London, the 25th European Conference on General Thoracic Surgery, and the Society of Robotic Surgery conference 2018. Each participant completed two familiarization tasks followed by the Guided Robotic Lobectomy module and an evaluation questionnaire. Outcome measures were compared using Mann-Whitney U tests. RESULTS: Construct validity was demonstrated in 12/21 performance evaluation metrics. Significant differences between groups were found in all metrics including: time taken to complete module, vascular injury, respect for tissue, number of stapler firings, time instruments out of view, number of instrument collisions, and number of movements. Participants deemed aspects of the simulator (mean 3/5) and module (3/5) as realistic and rated the simulator as both acceptable (3.8/5) and feasible (3.8/5) for robotic surgical training. CONCLUSIONS: Face validity, acceptability, and feasibility were established for the thoracic lobectomy module of the RobotiX Mentor simulator. Moderate evidence of construct validity was also demonstrated. With further work, this simulation module could help to reduce the initial part of the learning curve for trainees and decrease the risk of errors during live training.

Validation of the RobotiX Mentor Robotic Surgery Simulator.

OBJECTIVES: To assess face, content, and construct validity of the RobotiX Mentor virtual reality simulator, to assess its acceptability as a robotic surgery training tool and feasibility of its use, and to develop a supplementary training curriculum. SUBJECTS AND METHODS: This prospective, observational, and comparative study recruited novice (n = 20), intermediate (n = 15), and expert (n = 11) robotic surgeons as participants from institutions across the United Kingdom and at the 30th European Association of Urology Annual Meeting. Each participant completed nine surgical tasks across two modules on the simulator, followed by a questionnaire to evaluate subjective realism (face validity), task importance (content validity), feasibility, and acceptability. Outcome measures of novice, intermediate, and expert groups were compared using Mann-Whitney U-tests to assess construct validity. RESULTS: Construct validity was demonstrated in a total of 17/25 performance evaluation metrics (p < 0.001). Experts performed better than intermediates with regard to time taken to complete the first (p = 0.002) and second (p = 0.043) module, number of instrument collisions (p = 0.040), path length (p = .049), number of cuts >2 mm deep (p = 0.033), average distance from suture target (p = 0.015), and number of suture breakages (p = 0.038). Participants determined both the simulator console and psychomotor tasks as highly realistic (mean: 3.7/5) and important for surgical training (4.5/5), with system pedals (4.2/5) and knot tying task (4.6/5) scoring highest, respectively. The simulator was also rated as an acceptable (4.3/5) tool for training and its use highly feasible (4.3/5). CONCLUSION: Construct, face, and content validity was established for the RobotiX Mentor, and feasibility and acceptability of incorporation into surgical training were ascertained. The RobotiX Mentor shows potential as a valuable tool for training and assessment of trainees in robotic skills. Investigation of concurrent and predictive validity is necessary to complete validation, and evaluation of learning curves would provide insight into its value for training.

Teamwork Assessment Tools in Modern Surgical Practice: A Systematic Review.

Introduction. Deficiencies in teamwork skills have been shown to contribute to the occurrence of adverse events during surgery. Consequently, several teamwork assessment tools have been developed to evaluate trainee nontechnical performance. This paper aims to provide an overview of these instruments and review the validity of each tool. Furthermore, the present paper aims to review the deficiencies surrounding training and propose several recommendations to address these issues. Methods. A systematic literature search was conducted to identify teamwork assessment tools using MEDLINE (1946 to August 2015), EMBASE (1974 to August 2015), and PsycINFO (1806 to August 2015) databases. Results. Eight assessment tools which encompass aspects of teamwork were identified. The Nontechnical Skills for Surgeons (NOTSS) assessment was found to possess the highest level of validity from a variety of sources; reliability and acceptability have also been established for this tool. Conclusions. Deficits in current surgical training pathways have prompted several recommendations to meet the evolving requirements of surgeons. Recommendations from the current paper include integration of teamwork training and assessment into medical school curricula, standardised formal training of assessors to ensure accurate evaluation of nontechnical skill acquisition, and integration of concurrent technical and nontechnical skills training throughout training.