A novel team Familiarity Score for operating teams is a predictor of length of a procedure: A retrospective Bayesian analysis.

OBJECTIVE: The aim of our retrospective study was to assess whether a novel team Familiarity Score (FS) is associated with the length of procedure (LOP), postoperative length of stay (LOS), and complication rate after vascular procedures. METHODS: We retrospectively analyzed 326 vascular procedures performed at a tertiary care vascular surgery center between April 2012 and September 2014. Data collected included patients' age, American Society of Anesthesiologists grade, LOP, type and urgency of procedure, LOS, and complications. Familiarity Score (FS) was defined as the sum of the number of times that each possible pair of the team (vascular consultant, vascular registrar, scrub nurse, anesthetic consultant) within the team had worked together during the previous 6 months, divided by the number of possible combinations of pairs in the team. Bayesian statistics was used to analyze the data. RESULTS: FS was significantly associated with type and urgency of the procedure (Bayes factor [BF] >1000). Emergency procedures were performed by less familiar teams, and the least familiar teams were involved in the emergency aortic procedures-endovascular and open. FS was strongly associated with LOP (BF = 37) but not with LOS (BF = 4.0) and complication rate. CONCLUSIONS: FS in vascular teams was shown to be strongly associated with LOP, suggesting that more familiar teams might collaborate more efficiently.

Chronic venous insufficiency: a new concept to understand pathophysiology at the microvascular level - a pilot study.

OBJECTIVES: The real mechanism for the development of the later stages of chronic venous insufficiency still remains unclear. Venous hypervolemia and microvascular ischemia have been reported to be the consequences of venous insufficiency. The aim of this study was to investigate the effects of induced venous hypovolemia by dorsiflexion exercise in patients with venous leg ulcers. METHODS: Thirty-six participants, all of whom had an ankle brachial pressure index between 0.8 and 1.2 mmHg, were chosen for this study. The participants were divided into two groups: Group A, a non-exercise group and Group B which performed regular exercise in the form of dorsiflexion. The basic assessment, including the history and examination, ankle-brachial pressure index (ABPI), Duplex scan and tcPO2 measurements, was performed on two occasions at the beginning of the trial and after three months. RESULTS: The tcPO2 level was low in the beginning in all the subjects, but the picture was different at the end of the trial. There was a significant increase in the tcPO2 level (p<0.001) in the patients who performed exercise while there was no difference in the measurements (p>0.05) in the non-exercise group. CONCLUSIONS: Induced venous hypovolemia through regular evacuation of the peripheral venous system improved tissue oxygenation at skin level. Venous hypervolemia may be the main contributing factor for the development of venous hypoxia and microvascular ischemia.

An investigation of skin perfusion in venous leg ulcer after exercise.

INTRODUCTION: A venous leg ulcer (VLU) has a major impact on the quality of life and functional ability of individuals, but no single treatment is yet effective. This study investigates the changes induced by dorsiflexion exercise on skin perfusion in VLU patients to achieve a better understanding of venous ulcer pathophysiology. METHODS: Seventy-eight venous leg ulcer patients were randomised into four groups. The non-exercise groups included a control group (n = 18) and a compression therapy group (n = 20) and the exercise groups included an exercise-only group (n = 20) and a compression and exercise group (n = 20). The exercise groups were expected to perform exercise for three months. Measurements included transcutaneous oximetry (tcPO2) and laser Doppler flowmetry (LDF). Skin perfusion measurements for all groups were taken twice: at the beginning and end of the three-month period. RESULTS: Initially, all participants showed a low level of tcPO2. The exercise groups showed a significant increase after three months of exercise (p<0.001), the tcPO2 level remained the same in the non-exercise groups. The LDF parameters decreased significantly (p<0.001) in the compression and exercise group and decreased to a lesser extent in the exercise-only group. There were no LDF changes in the non-exercise groups. CONCLUSIONS: Perfusion measurements showed significant changes after three months of regular exercise. We conclude that exercise has a significant effect on tissue perfusion parameters in venous leg ulcer and this effect may play a role in understanding the pathophysiology of VLU.

Validation of an assessment tool for pre-operative EVAR planning.

INTRODUCTION: Current methods of teaching endovascular aortic aneurysm repair (EVAR) planning involve non-criteria-based observations that lack validity. The primary aim of this study was to validate an EVAR Planning Objective Structured Assessment of Skill (EpOSAS) tool for the assessment of pre-operative EVAR planning skills. METHODS: Content analysis was performed in order to inform the formulation of EpOSAS domains. Thirty-five participants planned two cases of infra-renal abdominal aortic aneurysm for EVAR, using the OsiriX 7 platform. EVAR planning measurements, with accompanying screenshots, were uploaded onto an electronic data collection sheet. Performance was assessed by three blinded assessors using the EpOSAS tool. Construct and concurrent validity were evaluated. RESULTS: Inter-observer reliability for the three assessors for total EpOSAS scores was high (Cronbach's α 0.89). There were statistically significant differences in total EpOSAS scores between the different experience groups, demonstrating construct validity (Novice (5.3, IQR 5-5.3), Intermediate (15.3, IQR 14.8-16.8) and Experts (17.5, IQR 17-17.7), p<0.001). A statistically significant correlation was found between total EpOSAS scores and percentage error in measurements, demonstrating concurrent validity (Spearman's rank correlation coefficient: R=-0.250, p<0.001). Receiver-operator characteristics analysis established a cut-off point of 16 out of 18 for determining competence. CONCLUSION: We have developed and validated a tool that can be used for the assessment of pre-operative EVAR planning skills.

Sources of Delay in the Acute Limb Ischemia Patient Pathway.

BACKGROUND: Acute limb ischemia (ALI) continues to pose a significant challenge to clinicians and is associated with an unacceptably high rate of morbidity and mortality. Despite its time critical nature, little is known regarding the delays encountered during the patient pathway. The aim of this study was to identify sources of delay in the patient pathway at our institution. METHODS: Sixty-seven cases of ALI of the lower extremities from 66 patients, who had presented to our center between May 2003 and April 2014, were identified for retrospective analysis. Data were retrieved from the patient records, discharge summaries and hospital laboratory, emergency department and radiology databases. RESULTS: Median time from onset of symptom to arrival at our institution was 11.35 hr (interquartile range [IQR] 6.27-72). Median cumulative time taken from arrival to vascular team review was 40 min (22.5-120), to imaging being performed was 4.75 hr (2.42-17.25), and to intervention being performed was 10.2 hr (4-31). There were significantly longer delays to presentation in those transferred from inpatient beds as compared with those transferred from the emergency department of other hospitals (66 hr [10.3-98] vs. 8 hr [5.6-14.9], P = 0.007). In total, 84.6% of patients underwent preoperative arterial imaging. Time taken from arrival to diagnostic arterial imaging was significantly longer in patients presenting out-of-ours (15 hr [6.5-20.75]) as compared with patients presenting in-hours (3.5 hr [2-6.5], P = 0.014) or during the weekend (2 hr [2-3], P = 0.022). Time from presentation to intervention was significantly shorter in patients presenting over the weekend (3.9 hr [2.6-5.1]) as compared with those presenting in-hours (14.2 hr [6.2-29], P = 0.006) and out-of-hours (16 hr [10-33], P = 0.021). Out-of-hours, a significant portion of the delay, was attributable to imaging (median time to imaging 15 hr). CONCLUSIONS: This study demonstrates the systematic nature of delays in the patient pathway from onset of symptoms to treatment. Several factors including time to patient presentation and time to imaging and delays in timely transfer to an appropriate facility contribute to this. Strategies need to be deployed to reduce time to revascularization.

The impact of a focused vascular lower limb arterial duplex (F-VLAD) scan in management decisions for acute limb ischaemia.

OBJECTIVE: To establish the diagnostic accuracy of a 'focused vascular lower limb arterial duplex scan (F-VLAD)' developed to facilitate rapid decision-making for acute limb ischaemia (ALI). METHODS: Ten cases of ALI were identified from our patient database; clinical details, history and examination findings were extracted from the clinical notes. Original 'full' duplex ultrasound (DUS) pictorial reports were 're-formatted' to include only anatomical segments included in the 'F-VLAD' scan. The series of 10 reports were emailed to 1741 vascular surgeons. Each recipient received a random mixture of full and F-VLAD scans. Participants were asked regarding next step in management and confidence in decision-making (Likert scale; 1 strongly disagree, 5 strongly agree). The cases were again sent out to the same database and respondents were asked as to the cause of ischaemia (embolic or thrombosis). RESULTS: Eighty-one participants responded to the first survey and 43 participants to the second survey. Participants felt more confident making decisions regarding management using the full duplex report compared to the F-VLAD report (4 (3-4) vs 3 (2-4), median (IQR); p<0.001). However, there was no significant difference in diagnostic accuracy (differentiating embolus from thrombosis) when comparing the F-VLAD and full DUS reports (85.4% vs 88.3%; p=0.461). F-VLAD and 'full' DUS reports had comparable sensitivity (85.1% vs 86.8%), specificity (85.6% vs 89.2%),positive predictive value (PPV) (80.4% vs 81.9%) and negative predictive value (NPV) (89.2% vs 92.2%), respectively. CONCLUSION: The F-VLAD scan has comparable accuracy to a traditional full DUS in diagnosing the underlying aetiology of ALI. This may facilitate surgeon-performed point-of-care DUS.

Potential identification of a claudicant group vulnerable to acute kidney injury.

This observational study aimed to investigate the relationship between renal injury, endothelial function and oxidative stress in claudicants undergoing maximal treadmill exercise. Twenty patients with claudication were identified in whom the urinary N-acetyl-ß-D-glucosaminidase (ß-NAG)/creatinine ratio, plasma oxidative state and endothelial function were tested pre- and post-maximal treadmill walking exercise. Of the 20 participants in this study, the urinary NAG/creatinine (Cr) rose from a pre-exercise level of 8.9, 6.7 to 14.3 (µmol/L/mmol Cr; median, IQR) to 12.9, 9.1 to 17.7 post exercise (p = 0.0003, Mann Whitney U test). Of the 20 participants, eight participants had a rise of the NAG/Cr ratio post exercise whereas 12 did not. Participants with a rise in the NAG/Cr ratio post exercise had a greater ability to increase endothelial reactivity (%; median, IQR; 2.56, 0.1 to 3.7) cf. (0.1, -4.8 to 0.9, p = 0.03); they also walked further (metres; median, IQR; 415, 208 to 908) cf. (170, 100 to 315, p = 0.04), had a lower pre-exercise H2O2 (median, IQR; 1.9, 1.4 to 2.3 cf. 2.7, 2.1 to 3.3; p = 0.04) and a greater rise in H2O2 post exercise (18.8, -1.5 to 129.7 cf., -7.7, -13.9 to -2.0, p = 0.04). The mechanism by which the phenotypically distinct sub-group of patients with intermittent claudication who experience a NAG/Cr rise involves complex interactions between systemic oxidative stress and endothelial function. Implications on cardiovascular risk in this group requires further investigation.

Randomized study of teaching ultrasound-guided vascular cannulation using a phantom and the freehand versus needle guide-assisted puncture techniques.

PURPOSE: The task of ultrasound-guided vessel cannulation can be technically difficult. Needle guides have been designed to facilitate vessel puncture. We aimed to identify and compare the learning curves of participants performing vessel puncture with conventional freehand (FH) and needle guide-assisted (NG) techniques. METHODS: Thirty-six participants were randomly allocated to either the FH or the NG group. They were asked to consecutively perform as many as 30 vessel punctures on a simulated phantom model. Quantitative metrics (time taken and number of skin and posterior-wall punctures) were recorded and compared between the two groups. The cumulative sum and moving F-test statistical methods were used to delineate the learning curves. RESULTS: There was a significantly lower rate of posterior-wall punctures in the NG group than in the FH group (15% versus 26%; p < 0.0001). Participants in the NG group also performed significantly fewer skin punctures than did those in the FH group (mean, 405 versus 515; p < 0.0001). Cumulative sum statistical method analysis showed that participants in the NG group surmounted the learning curve earlier (13 attempts; interquartile range, 10.3-17.0) than did those in the FH group (19 attempts; interquartile range, 15.0-27.5). The number of attempts to surmount the learning curve was significantly less for the FH group (7.2 versus 16 attempts; p = 0.007) when using the moving F-test. CONCLUSIONS: The NG puncture allows a greater number of trainees to cross the learning threshold and offers the advantages of fewer posterior-wall punctures and skin punctures. The use of NG puncture may result in a shorter path to proficiency, allowing trainees to attempt needle puncture earlier and with a greater degree of safety.

Training safer orthopedic surgeons. Construct validation of a virtual-reality simulator for hip fracture surgery.

BACKGROUND AND PURPOSE: Virtual-reality (VR) simulation in orthopedic training is still in its infancy, and much of the work has been focused on arthroscopy. We evaluated the construct validity of a new VR trauma simulator for performing dynamic hip screw (DHS) fixation of a trochanteric femoral fracture. PATIENTS AND METHODS: 30 volunteers were divided into 3 groups according to the number of postgraduate (PG) years and the amount of clinical experience: novice (1-4 PG years; less than 10 DHS procedures); intermediate (5-12 PG years; 10-100 procedures); expert (> 12 PG years; > 100 procedures). Each participant performed a DHS procedure and objective performance metrics were recorded. These data were analyzed with each performance metric taken as the dependent variable in 3 regression models. RESULTS: There were statistically significant differences in performance between groups for (1) number of attempts at guide-wire insertion, (2) total fluoroscopy time, (3) tip-apex distance, (4) probability of screw cutout, and (5) overall simulator score. The intermediate group performed the procedure most quickly, with the lowest fluoroscopy time, the lowest tip-apex distance, the lowest probability of cutout, and the highest simulator score, which correlated with their frequency of exposure to running the trauma lists for hip fracture surgery. INTERPRETATION: This study demonstrates the construct validity of a haptic VR trauma simulator with surgeons undertaking the procedure most frequently performing best on the simulator. VR simulation may be a means of addressing restrictions on working hours and allows trainees to practice technical tasks without putting patients at risk. The VR DHS simulator evaluated in this study may provide valid assessment of technical skill.

The feasibility and acceptability of integrating regular centralised laboratory-based skills training into a surgical training programme.

BACKGROUND: Traditional laboratory-based skills training provides mass training that does not match clinical experience and is not tailored to individual needs. This compromises the transfer and retention of skills into clinical practice. AIM: To demonstrate the feasibility of integrating a centralised programme of laboratory-based surgical skills training into a higher surgical training programme and to evaluate its effectiveness and acceptability to trainees. METHODS: Laboratory-based skills training was provided at a central site, delivered by consultants and tailored to the trainees' level of clinical experience. Each trainee was expected to attend one session a month for 11 months a year. Evaluation was conducted through attendance records, structured evaluations by participants, independent qualitative questionnaires and web interviews. RESULTS: Forty-two specialist surgical trainees in the North West London higher surgical training programme participated in laboratory-based skills sessions delivered by 19 consultants over a period of two years. The average attendance was 70.5% for trainees and 100% for trainers. All sessions were rated by trainees as well-organised and useful with an average score of more than 4 out of 5. Trainees felt that the Skills Programme can complement surgical training by allowing practice under expert supervision in a safe environment. CONCLUSIONS: Centralising laboratory-based skills training and integrating it into a clinical programme is feasible and acceptable and represents a paradigm shift in surgical training. Involvement of trainees in designing the content is valuable.

The Effect of Lower Limb Revascularization on Flow, Perfusion, and Systemic Endothelial Function: A Systematic Review.

Peripheral arterial disease (PAD) is associated with reduced lower limb blood flow and tissue perfusion. The consequent reduction in vessel wall shear stress as well as ischemia-reperfusion injury has also been associated with systemic endothelial dysfunction and inflammation. We aimed to explore the impact of lower limb revascularization on (1) lower limb blood flow, (2) tissue perfusion, and (3) systemic endothelial function. We performed a systematic literature search using the MEDLINE, Embase, and Web of Science databases. Eligible studies measured changes in lower limb blood flow, perfusion, or systemic endothelial function following revascularization for the treatment of symptomatic PAD. We found 19 eligible studies, which were limited by considerable heterogeneity. Current evidence suggests that revascularization has a positive effect on flow, perfusion, and systemic endothelial dysfunction. Any changes may take a number of weeks to become apparent. There is a need for well-designed studies to explore the association between flow, perfusion, and endothelial dysfunction.

Significant prostacyclin/thromboxane level imbalance after lower limb arterial angioplasty: a possible platelet function alteration.

PURPOSE: The authors investigated prostacyclin (PGI2) and thromboxane (TX) productions in peripheral venous blood after lower limb revascularization by percutaneous transluminal angioplasty (PTA) versus diagnostic angiography. The purpose of this study was to investigate PGI2/TX imbalance after PTA. This imbalance is of pathophysiologic importance and it is a potential sign of platelet function alteration. MATERIALS AND METHODS: Twenty-five patients requiring PTA were compared with 20 patients undergoing angiography alone from April 2004-December 2005 from a single vascular unit. Patient age range was 42-90 years, and the majority of patients were men. Prostaglandin F2-alpha (PGF2-alpha) and thromboxane B2 (TXB2) were measured sequentially (preprocedure, at 1 hour, and 24 hours after procedure). Differences between postprocedure and preprocedure level were compared statistically between angiography and PTA. RESULTS: Baseline demographics were distributed equally between the two groups except presence of critical ischemia and ankle brachial pressure index, which were two significant confounders. TXB2 was significantly higher after PTA at 1 hour and 24 hours after PTA (P = .005 and P = .014 respectively), PGF2-alpha was significantly higher 24 hours after PTA only (P = .018) (Mann-Whitney U test). CONCLUSIONS: PGI2/TX balance homeostasis is of significant pathophysiologic importance. The authors found that PTA results in significant PGI2/TX imbalance and shifts more toward increased TX production. This finding is partly suggestive of significant platelet activation. This imbalance in PGI2/TX level may have implications for future failure of PTA. Future research in reducing this platelet activation is recommended.

Percutaneous transluminal angioplasty of lower limb arteries causes a systemic inflammatory response.

BACKGROUND: Percutaneous transluminal angioplasty (PTA) of a lower limb arterial segment is a well-established treatment for suitable lesions for critical or noncritical lower limb ischemia. Our aim was to define the inflammatory response after PTA by measuring inflammatory markers. METHODS: Twenty-five patients having PTA were compared with 20 patients having angiography alone. Interleukin-6 (IL-6), IL-8, IL-10, and tumor necrosis factor-alpha (TNF-alpha) were measured sequentially. The difference between postprocedure and preprocedure baseline levels were compared statistically between angiography alone and PTA. Patients were followed up to 1 year after the procedure, and the failure rate of PTA was noted. RESULTS: IL-6 and TNF-alpha were significantly higher in PTA patients at 1 hr after PTA (p < 0.05), and the IL-6 level only was significantly higher at 24 hr post-PTA (p < 0.05) compared to angiography alone (Mann-Whitney test). IL-8 and IL-10 levels did not differ significantly in the PTA group. At 1 year after the procedure, 45% of PTAs had failed. There was no statistically significant correlation between failed PTA and inflammatory response. CONCLUSION: PTA appears to cause a significant inflammatory response compared to angiography alone. This demonstrates a systemic manifestation of localized ischemia/reperfusion injury. Further investigation of the inflammatory response due to ischemia/reperfusion injury and its correlation with restenosis is recommended.

A pilot study of preoperative heart rate variability predicting pain during local anesthetic varicose vein surgery.

OBJECTIVE: Local anesthetic endovenous procedures were shown to reduce recovery time, to decrease postoperative pain, and to more quickly return the patient to baseline activities. However, a substantial number of patients experience pain during these procedures. The autonomic nervous system modulates pain perception, and its influence on stress response can be noninvasively quantified using heart rate variability (HRV) indices. The aim of our study was to evaluate whether preoperative baseline HRV can predict intraoperative pain during local anesthetic varicose vein surgery. METHODS: Patients scheduled for radiofrequency ablation were included in the study. They had their electrocardiograms recorded from a single channel of a custom-made amplifier. Each patient preoperatively filled in forms Y-1 and Y-2 of Spielberger's State and Trait Anxiety Inventory, completed the Aberdeen Varicose Vein Questionnaire, and rated anxiety level on a numeric scale. Postoperatively, patients filled in the pain they felt during the procedure on the numeric pain intensity scale. MATLAB software (MathWorks, Natick, Mass) was used to extract R waves and to generate HRV signals, and a mathematical model was created to predict the pain score for each patient. RESULTS: In multivariable analysis, we looked into correlation between reported patient's pain score (rPPS) and Aberdeen Varicose Vein Questionnaire score, preoperative forms Y-1 and Y-2, preoperative anxiety level, and predicted patient's pain (pPPS) score. Multivariable analysis found association only between rPPS and pPPS. The pPPS was significantly correlated with rPPS (R = 0.807; P < .001) with accuracy of prediction of 65.2%, which was calculated from R2 on a linear regression model. CONCLUSIONS: This preliminary study shows that preoperative HRV can accurately predict patients' pain, allowing patients with higher predicted score to have the procedure under general anesthesia.

The influence of exercise on ulcer healing in patients with chronic venous insufficiency.

BACKGROUND: Venous leg ulcer (VLU) affects millions of people, and yet there have been no major advances in its treatment for many decades. Is it the time to change our approach, and try a multidisciplinary one that could bring about a change? The aim of this study is to evaluate whether a regular, home-based exercise could be influential in healing the VLU. METHODS: Eighty subjects (mean age: 65.13 years) were recruited for 12 weeks. The participants were randomized into a control group (N.=20), a compression therapy group (N.=20), an exercise group (N.=20) and a compression and exercise group (N.=20). The exercise comprised of 10 dorsiflexions each hour while the patient was awake. The first 2 groups did not perform any exercise while the other two did. Baseline and 3-month measurements were performed. These measurements include skin perfusion assessment and ulcer size. RESULTS: All patients showed low tcPO2 in the beginning of the study. At the point of 3 months of exercise, Laser Doppler flowmetry and ulcer size measurements showed significant decrease, P<0.001 in exercise groups, however, no real change was demonstrated in the non-exercise groups. Subjects who were performing exercise showed significant increase in tcPO2 readings after 3 months (P<0.001), whereas the tcPO2 readings remained the same in the non-exercise groups. CONCLUSIONS: We concluded that exercise had a significant effect on the VLU healing and this effect may be enhanced further with the help of the compression therapy. The tcPO2 and RF measurements may be seen as useful tools in evaluating the microvascular changes, and monitoring healing and follow up of the venous leg ulcer.

Management of peripheral arterial disease in diabetes: a national survey of podiatry practice in the United Kingdom.

BACKGROUND: We aimed to investigate podiatry practice in diagnosing peripheral arterial disease (PAD) in diabetes, decision making once PAD is suspected and limitations of referral pathways. METHODS: A survey, comprising 26 questions was distributed to podiatrists across the UK via mailing lists of collaborating organizations including the College of Podiatry (UK). Response rates were estimated based on NHS workforce data. Analysis of responses from the open-ended questions was performed using inductive content analysis. RESULTS: Data from 283 respondents were analyzed. Response rate for all NHS podiatrists across the UK was estimated to be 6%. For the detection of arterial disease only 18.8% (n = 49/260) of participants reported using a full combination of history, pulse palpation, Doppler and ABPI assessment. Self-reported confidence in detecting arterial disease was highest amongst podiatrists who felt they had received adequate training compared to podiatrists who felt they had not (median 85 (IQR 75-90) vs 67 (50-77), respectively; p < 0.001) as well as those who see > 20 diabetic patients per week compared to those who see < 20 (median 80 (IQR 70-90) vs 72 (60-82.8), respectively; p < 0.001). Over one third of respondents (35.8%, n = 93/260) were aware of missed cases of PAD in the past year and 17.5% (n = 38/217) believed that this resulted in an amputation in some cases.The survey highlighted a lack of clarity amongst podiatrists regarding referral guidelines. Additionally, 69% (n = 169/242) reported that their patients had to wait longer than 2-weeks for specialist vascular assessment and 67.6% (n = 54/80) reported similar waits for a Duplex Ultrasound scan. There was a statistically significant variation in DUS waiting time across the UK (X2 (10, N = 80) = 21.59, p = 0.017). Inability to make a direct referral to vascular services and long delays were reported as major limitations of the referral pathway. CONCLUSION: We have identified important targets for further investigation and quality improvement.

Podiatry Ankle Duplex Scan: Readily Learned and Accurate in Diabetes.

We aimed to train podiatrists to perform a focused duplex ultrasound scan (DUS) of the tibial vessels at the ankle in diabetic patients; podiatry ankle (PodAnk) duplex scan. Thirteen podiatrists underwent an intensive 3-hour long simulation training session. Participants were then assessed performing bilateral PodAnk duplex scans of 3 diabetic patients with peripheral arterial disease. Participants were assessed using the duplex ultrasound objective structured assessment of technical skills (DUOSATS) tool and an "Imaging Score". A total of 156 vessel assessments were performed. All patients had abnormal waveforms with a loss of triphasic flow. Loss of triphasic flow was accurately detected in 145 (92.9%) vessels; the correct waveform was identified in 139 (89.1%) cases. Participants achieved excellent DUOSATS scores (median 24 [interquartile range: 23-25], max attainable score of 26) as well as "Imaging Scores" (8 [8-8], max attainable score of 8) indicating proficiency in technical skills. The mean time taken for each bilateral ankle assessment was 20.4 minutes (standard deviation ±6.7). We have demonstrated that a focused DUS for the purpose of vascular assessment of the diabetic foot is readily learned using intensive simulation training.

Self-assessment of surgical ward crisis management using video replay augmented with stress biofeedback.

BACKGROUND: We aimed to explore the feasibility and attitudes towards using video replay augmented with real time stress quantification for the self-assessment of clinical skills during simulated surgical ward crisis management. METHODS: Twenty two clinicians participated in 3 different simulated ward based scenarios of deteriorating post-operative patients. Continuous ECG recordings were made for all participants to monitor stress levels using heart rate variability (HRV) indices. Video recordings of simulated scenarios augmented with real time stress biofeedback were replayed to participants. They were then asked to self-assess their performance using an objective assessment tool. Participants attitudes were explored using a post study questionnaire. RESULTS: Using HRV stress indices, we demonstrated higher stress levels in novice participants. Self-assessment scores were significantly higher in more experienced participants. Overall, participants felt that video replay and augmented stress biofeedback were useful in self-assessment. CONCLUSION: Self-assessment using an objective self-assessment tool alongside video replay augmented with stress biofeedback is feasible in a simulated setting and well liked by participants.

Effectiveness of a multicenter training programme to teach point-of-care vascular ultrasound for the detection of peripheral arterial disease in people with diabetes.

BACKGROUND: The primary aim of this study was to evaluate the effectiveness of a training programme to teach a focused bedside ultrasound scan (PAD-scan; Podiatry Ankle Duplex Scan) for the detection of arterial disease in people with diabetes. METHODS: Five podiatrists and one diabetologist across two hospitals were enrolled in a structured training programme consisting of a training course (1-day), supervised scanning (5-weeks), independent scanning (3-weeks) and a final evaluation of performance (1-day).Time, technical skills (Duplex Ultrasound Objective Structured Assessment of Technical Skills tool (DUOSATS); minimum score = 6, maximum score = 26) and accuracy (level of agreement with vascular scientist PAD-scan assessment) were assessed for every supervised scan and again for the final evaluation of performance. RESULTS: A total of 90 PAD-scans in 65 patients were performed during the supervised phase. Participants demonstrated significant improvements in median time (19 min(IQR 13.9-25.5) vs 9.3 min (IQR 7.3-10.5);p = 0.028) and DUOSATS scores (17.5 (IQR 16.8-21) vs 25 (IQR 24-25.3); p = 0.027). At the final evaluation, participants completed scans in 5.4 min (IQR 5.3-5.9), achieved full DUOSAT scores and perfect agreement with the vascular scientist. CONCLUSION: A structured training programme, integrated into diabetic foot clinics, was effective in teaching the PAD-scan.

Colour doppler ultrasound of the lumbar arteries: a novel application and reproducibility study in healthy subjects.

Lumbar arteries are important because they are the main source of blood supply to the lumbar spine structures. However, these vessels and their flow characteristics have received little attention and their role in conditions such as low back pain remains unclear. The present study 1. describes the application of duplex ultrasonography in the assessment of lumbar artery blood flow and 2. evaluates the interobserver and intraobserver reproducibility of lumbar artery Doppler velocimetry. A total of 13 healthy volunteers were evaluated by two different examiners successively on the same day and measurements repeated by the same examiners 1 week later. Peak systolic velocities of lumbar arteries were recorded at an optimal angle below 60 degrees . Overall mean peak systolic velocity (+/-SD) for lumbar arteries was 0.158 +/- 0.051 m/s, and mean Doppler angle (+/-SD) was 24.6 +/- 14.5 degrees . For interobserver variability, the coefficient of variation was 23.4% and SD of differences 0.037 m/s. Reliable results of lumbar artery Doppler velocimetry demonstrate its applicability in future clinical investigations in patients with low back disorders. (E-mail: ).