Generating a Prioritized List of Operative Procedures for Simulation-based Assessment of General Surgery Trainees Through Consensus.

OBJECTIVE: To develop appropriate content for high-stakes simulation-based assessments of operative competence in general surgery training through consensus. BACKGROUND: Valid methods of summative operative competence assessment are required by competency-based training programs in surgery. METHOD: An online Delphi consensus study was conducted. Procedures were derived from the competency expectations outlined by the Joint Committee on Surgical Training Curriculum 2021, and subsequent brainstorming. Procedures were rated according to their perceived importance, perceived procedural risk, how frequently they are performed, and simualtion feasibility by a purposive sample of 30 surgical trainers and a 5-person steering group. A modified Copenhagen Academy for Medical Education and Simulation Needs Assessment Formula was applied to the generated data to produce ranked procedural lists, which were returned to participants for re-prioritization. RESULTS: Prioritized lists were generated for simulation-based operative competence assessments at 2 key stages of training; the end of 'phase 2' prior to the development of a sub-specialty interest, and the end of 'phase 3', that is, end-of-training certification. A total of 21 and 16 procedures were deemed suitable for assessments at each of these stages, respectively. CONCLUSIONS: This study describes a national needs assessment approach to content generation for simulation-based assessments of operative competence in general surgery using Delphi consensus methodology. The prioritized procedural lists generated by this study can be used to further develop operative skill assessments for use in high-stakes scenarios, such as trainee progression, entrustment, and end-of-training certification, before subsequent validity testing.

Augmentation Therapy for Severe Alpha-1 Antitrypsin Deficiency Improves Survival and Is Decoupled from Spirometric Decline-A Multinational Registry Analysis.

Rationale: Intravenous plasma-purified alpha-1 antitrypsin (IV-AAT) has been used as therapy for alpha-1 antitrypsin deficiency (AATD) since 1987. Previous trials (RAPID and RAPID-OLE) demonstrated efficacy in preserving computed tomography of lung density but no effect on FEV1. This observational study evaluated 615 people with severe AATD from three countries with socialized health care (Ireland, Switzerland, and Austria), where access to standard medical care was equal but access to IV-AAT was not. Objectives: To assess the real-world longitudinal effects of IV-AAT. Methods: Pulmonary function and mortality data were utilized to perform longitudinal analyses on registry participants with severe AATD. Measurements and Main Results: IV-AAT confers a survival benefit in severe AATD (P < 0.001). We uncovered two distinct AATD phenotypes based on an initial respiratory diagnosis: lung index and non-lung index. Lung indexes demonstrated a more rapid FEV1 decline between the ages of 20 and 50 and subsequently entered a plateau phase of minimal decline from 50 onward. Consequentially, IV-AAT had no effect on FEV1 decline, except in patients with a Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2 lung index. Conclusions: This real-world study demonstrates a survival advantage from IV-AAT. This improved survival is largely decoupled from FEV1 decline. The observation that patients with severe AATD fall into two major phenotypes has implications for clinical trial design where FEV1 is a primary endpoint. Recruits into trials are typically older lung indexes entering the plateau phase and, therefore, unlikely to show spirometric benefits. IV-AAT attenuates spirometric decline in lung indexes in GOLD stage 2, a spirometric group commonly outside current IV-AAT commencement recommendations.

Radiographic Absence of the Left Humeral Head.

An older patient with history of surgical decompression for syringomyelia, poor mobility, and frequent falls presented with pain, numbness, and paresthesias in his left upper extremity. Radiograph showed complete absence of the left humeral head. What is the diagnosis, and what would you do next?

Direct Common Carotid Artery Puncture for Endovascular Treatment of Acute Large Vessel Ischemic Stroke in a Patient with Aortic Coarctation.

Coarctation of the aorta is a condition that typically presents in childhood as a congenital malformation. This report describes a case of acute right middle cerebral artery ischemic stroke, which occurred in a patient with aortic coarctation that remained undiagnosed until her eighth decade. Complex anatomical variant presented a significant technical challenge in establishing endovascular access for mechanical thrombectomy using standard femoral, brachial, or radial artery approaches. Direct right common carotid puncture was performed successfully with subsequent reperfusion and full neurological recovery. Direct carotid artery puncture represents an alternative to standard transfemoral access in the event of stroke in a patient with difficult anatomy.

Prevalence of prescribing in pregnancy using the Irish primary care research network: a pilot study.

BACKGROUND: To establish the prevalence and patterns of prescribing to pregnant women in an Irish primary care setting. METHODS: We reviewed electronic healthcare records routinely collected in primary care, of pregnant women attending nine Dublin-based General Practices affiliated to the Irish Primary Care Research Network (IPCRN) for antenatal care between January 2007 and October 2013 (n = 2,361 pregnancies). RESULTS: Excluding folic acid, 46.8% (n = 1,104) of pregnant women were prescribed at least one medication. Amoxicillin (11.1%, n = 263) and co-amoxiclav (8.0%, n = 190) were the most commonly prescribed medication followed by topical clotrimazole (4.9%, n = 117), salbutamol inhalers (4.1%, n = 96) and paracetamol (4.0%, n = 95). General Medical Services (GMS) patients were more likely to receive a prescription than private patients (OR 2.81; 95%CI (2.28, 3.47)). We applied the US FDA pregnancy-risk categories as a proxy measure of prescribing appropriateness, with FDA Category D and X medications considered inappropriate. FDA Category D drugs were prescribed in 5.9% (n = 140) of pregnancies. FDA Category X drugs were prescribed in 4.9% (n = 116) of pregnancies but after exclusion of oral contraceptives, progestogens, infertility treatments Category X medications were prescribed in 0.6% (n = 13) of pregnancies. After the initial antenatal consultation the prescribing prevalence of FDA Category D medications reduced to 4.7% (n = 110) and Category X to 3.1% (n = 72). CONCLUSIONS: The overall prevalence of prescribing to pregnant women in our cohort is low compared to studies internationally, however similar levels of prescribing for FDA Category D and X were found. Following the initial antenatal consultation levels of prescribing of the FDA Category D and X medications reduced, however there is potential to further reduce their use in early pregnancy. The IPCRN database has provided valuable information on the current practice of antenatal prescribing within this pilot group of practices however it is limited by the absence of morbidity and pregnancy outcome data.

Design and utilisation of a novel, high-fidelity, low-cost, hybrid-tissue simulation model to facilitate training in robot-assisted partial nephrectomy.

Robot-assisted partial nephrectomy (RAPN) has rapidly evolved as the standard of care for appropriately selected renal tumours, offering key patient benefits over radical nephrectomy or open surgical approaches. Accordingly, RAPN is a key competency that urology trainees wishing to treat kidney cancer must master. Training in robotic surgery is subject to numerous challenges, and simulation has been established as valuable step in the robotic learning curve. However, simulation models are often both expensive and suboptimal in fidelity. This means that the number of practice repetitions for a trainee may limited by cost restraints, and that trainees may struggle to reconcile the skills obtained in the simulation laboratory with real-world practice in the operating room. We have developed a high-fidelity, low-cost, customizable model for RAPN simulation based on porcine tissue. The model has been utilised in teaching courses at our institution, confirming both feasibility of use and high user acceptability. We share the design of our model in this proof-of-concept report.

Developing a clamshell thoracotomy training model to support hybrid teaching in simulation-based education.

OBJECTIVE: Thoracotomy is an acute, time-sensitive procedure. Simulation-based education provides a safe-learning platform to learn these techniques under close supervision. METHODS: We used the spiral model and concepts of functional fidelity to guide the evolutionary design and fabrication of a hybrid thoracotomy simulator. RESULTS: This model simulates a clamshell thoracotomy that physically integrates with bespoke manikins and adds a high-fidelity technical skills element to immersive team-based simulation training. CONCLUSIONS: We describe the creation of a thoracotomy simulation model that allows trainees to practice these techniques in a safe-learning environment.

Remote feedback in endovascular simulation training: a mixed-methods study.

BACKGROUND: There is an increasing need to increase simulation-based learning opportunities for vascular surgery residents in endovascular skills training. This study aims to explore the effectiveness of remote expert instructional feedback of endovascular simulation-based education, as a means of increasing training opportunities in this area for vascular surgery residents. METHODS: A mixed-methods study design was adopted. Twelve vascular surgery residents from Ireland were tasked with completing two endovascular renal artery procedures: one with in-person expert feedback and the other with remote instruction. Participants ranged in experience levels from second year to final year of residency. Following the training activities, interviews and a questionnaire were employed to gather information on the usefulness of remote feedback. RESULTS: There was no significant difference reported by participants using a post-event validated questionnaire between remote and in-person feedback. During the interviews, participants expressed mixed feelings about the presence of the educator while practicing, but they eventually saw no limiting factors to their practice when the trainer provided remote feedback. When receiving performance feedback remotely, clear communication and a shared knowledge of the task development are critical to success. CONCLUSIONS: We believe these findings can inform the design and development of remote learning and assessment of endovascular skills training and ultimately provide increased opportunities for more skills practice for vascular surgical residents.

Collating evidence to support the validation of a simulated laparotomy incision and closure-training model.

BACKGROUND: It is essential to evaluate the functionality of surgical simulation models, in order to determine whether they perform as intended. In this study, we assessed the use of a simulated laparotomy incision and closure-training model by collating validity evidence to determine its utility as well as pre and post-test interval data. METHOD: This was a quantitative study design, informed by Messick's unified validity framework. In total, 93 participants (surgical trainees â€‹= â€‹80, experts â€‹= â€‹13) participated in this study. Evaluation of content validity and the models' relationships with other variables was conducted, along with a pre and post-test confidence assessment. RESULTS: The model was deemed realistic and useful as a teaching tool, providing strong content validity evidence. In assessment of relationships with other variables, the expert group out-performed the novice group conclusively. Pre and post-test evaluation reported a statistically significant increase in confidence levels. CONCLUSION: We present strong validity evidence of a novel laparotomy incision and closure simulation-training model.

A Mixed Methods Study Identifying the Competencies of Health Care Simulation Technicians.

INTRODUCTION: Health care simulation technicians (HSTs), also referred to as simulation operations specialists, are essential to the delivery of simulation-based education. The HST role draws on a broad range of knowledge, skills, and attitude competencies. However, because of the neoteric nature of the HST role and the ambiguity surrounding the core responsibilities of the position, it has proved difficult to identify the competencies required to perform this role successfully. This study aims to identify the knowledge, skills, and attitude competencies required by HSTs. METHODS: A mixed methods approach was used in this study. Data were collected from (1) online searches of HST job descriptions and (2) semistructured interviews about the competencies required by HSTs with 10 HSTs, 10 health care simulation educators, and 10 health care simulation center managers/director. The data from the job descriptions and interviews were analyzed using thematic analysis, using a framework method to guide the coding. RESULTS: A total of 59 competencies were identified from the job descriptions and 65 competencies from the interviews. This analysis resulted in the identification of 9 competency domains: 3 knowledge domains (technical, clinical, and pedagogic), 4 skills domains (resourcefulness, pedagogic, team, and technical), and 2 attitudes domains (professional and "can-do" mentality). CONCLUSIONS: The identification of the competencies required by HSTs will support the selection of candidates with the attributes that will allow them to be successful in this role and guide continuous professional development opportunities for current and future HSTs.

Direct carotid puncture for endovascular thrombectomy in acute ischemic stroke.

BACKGROUND: Mechanical thrombectomy is the standard of care for acute ischemic strokes with proximal intracranial occlusion. Arterial access is commonly achieved with femoral artery puncture, although this is not always possible. In this case series, we describe 11 cases of anterior circulation stroke where direct carotid puncture was used to obtain vascular access. METHODS AND MATERIALS: A review of a prospectively maintained thrombectomy database over a 2-year period (August 2016 - August 2018) was undertaken to identify cases where direct carotid access was performed. CT and angiographic imaging were reviewed. Indications for carotid access, techniques used, technical success of procedure, recanalization rates, procedure-related complications, and patient outcomes were assessed. RESULTS: Eleven patients out of 498 overall thrombectomy procedures (2.2% thrombectomies) underwent direct carotid access. Median National Institutes of Health Stroke Scale was 20. Seventy three percent of patients received intravenous thrombolysis. The direct carotid approach was performed following the failed femoral approach due to unfavorable aortic arch anatomy, vessel tortuosity, and severe atherosclerotic disease. Direct carotid puncture was successful in 10 patients, and unsuccessful in one. Successful recanalization (TICI 2b-3) was achieved in eight patients. One patient had spontaneously recanalized on angiography. There was failed recanalization in one patient with tandem ICA and M1 occlusion. Carotid access complications included one patient with both neck hematoma and asymptomatic ICA dissection, and one of delayed central retinal artery occlusion. CONCLUSION: This case series highlights direct carotid puncture as a successful alternative when the femoral approach is not possible, allowing thrombectomy in patients who would otherwise be unsuitable.

Concentric and Eccentric Target MRI Signs in a Case of HIV-Associated Cerebral Toxoplasmosis.

Cerebral toxoplasmosis is one of the most common causes of focal brain lesions in immunocompromised patients, such as those with human immunodeficiency virus (HIV). Differentiating toxoplasmosis from other central nervous system (CNS) lesions provides a significant clinical challenge. Magnetic resonance (MR) imaging of the brain is key to prompt diagnosis and treatment of cerebral toxoplasmosis. Several specific signs on MRI of brain have been described in recent literature including the "concentric target sign" and "eccentric target sign." We report a case of successfully treated HIV-associated cerebral toxoplasmosis in which both MRI signs were present simultaneously.

The role of leukotriene receptor antagonists in exercise induced bronchoconstriction in children.

Exercise induced bronchoconstriction (EIB) may complicate childhood asthma. Leukotriene receptor antagonists (LTRAs), such as montelukast, may be beneficial in protecting against EIB. Our aim was to systematically review the role of LTRAs in the treatment of asthmas complicated by exercise induced bronchoconstriction and to assess various clinical factors which may influence the therapeutic outcome. Electronic searches were performed in the following databases: PubMed, CENTRAL, and the US National Institutes of Health Clinical Trial database. Following selection according to clearly defined inclusion and exclusion criteria and in accordance with the PRISMA statement; 5 double-blind, randomized, placebo-controlled trials of montelukast as monotherapy or add-on therapy in childhood asthma and 2 review articles were analysed in this systematic review. Treatment with LTRAs provides protection from EIB, when used as both monotherapy and add-on therapy. However, disease variables and aetiological factors may impact on the extent of clinical improvement. Genetic variability may influence leukotriene production and subsequent response to LTRAs. This issue could be addressed in further studies.