Neuro- and cognitive diversity in surgery and allied professions: celebrating difference and optimising performance.

Neurotypicality (NT) and neurodiversity (ND) are two terms used to describe separate ways of thinking and experiencing the world. The prevalence of ND within surgery and allied professions is poorly studied or understood but is likely to be significant and increasing. If our aim is to be truly inclusive, ND's effects on teams and our willingness and ability to adapt adequately must improve.

Strategic organisational skills predict surgical training success.

INTRODUCTION: Surgical career progression is determined by examination success and Annual Review of Competence Progression (ARCP) outcome, yet data on organisational skills are sparse. This study aimed to determine whether organisational skills related to Core Surgical Training (CST) outcome. Primary outcome measures include operative experience, publications, examination success (Membership of the Royal College of Surgeons or the Diploma in Otolaryngology-Head and Neck Surgery (MRCS/DO-HNS)) and ARCP outcome. METHODS: The study was conducted prospectively at three consecutive CST induction boot camps (2017-2019) providing clinical and simulation training for 125 trainees. Arrival time at course registration was the selected surrogate for organisational skills. Trainees were advised to arrive promptly at 8:45 for registration and that the course would start at 9:00. Trainee arrival times were grouped as follows: early (before 8:45), on time (8:45-8:59am) or late (after 9:00). Arrival times were compared with primary outcome measures. SETTING: Health Education and Improvement Wales' School of Surgery, UK. RESULTS: Median arrival time was 8:53 (range 7:55-10:03), with 29 trainees (23.2%) arriving early, 63 (50.4%) on-time and 33 (26.4%) late. Arrival time was associated with operative experience (early vs late; 206 vs 164 cases, p=0.012), publication (63.2% vs 18.5%, p=0.005), MRCS/DO-HNS success (44.8% vs 15.2%, p=0.029), ARCP outcome (86.2% vs 60.6% Outcome 1, p=0.053), but not National Training Number success (60.0% vs 53.3%, p=0.772). CONCLUSIONS: Better-prepared trainees achieved 25% more operative experience, were four-fold more likely to publish and pass MRCS, which aligned with consistent desirable ARCP outcome. Timely arrival at training events represents a skills-composite of travel planning and is a useful marker of strategic organisational skills.

The Leaning Tower of Pasta: Lessons in Team Performance and Creativity From a Core Surgical Training Boot Camp Design Challenge.

AIMS: Unity of effort is an important component of strategic leadership and management theory associated with Core Surgical Training (CST) outcome. The aim was to determine the impact of team diversity on task completion: a creative design challenge, during CST Boot camp. METHODS: Attendees (n = 44) at a single Statutory Education Body's CST Boot camp were stratified into teams related to specialty theme, and set a design challenge as described by Peter Skillman, to build the tallest free-standing tower out of spaghetti (20 pieces), tape (1 m), and string (1 m), with a marshmallow on top in 18 minutes. Primary outcome measure was tower height. RESULTS: Five teams (50%) completed the task with the tallest tower measuring 70 cm (median 51, range 0-70). Median satisfaction with the simulation exercise was 4 (2-5) on a scale of 0 to 5, with 5 corresponding with highest satisfaction. Successful task completion was associated with team surgical specialty (p = 0.032), ethnicity ratio (p = 0.010,), and gender ratio (p = 0.003), respectively. On multivariable analysis, only team gender ratio was independently associated with tower height (Hazard ratio 0.515, 95% confidence interval 0.350-0.759, p = 0.001). CONCLUSION: Modern leadership theory emphasizes the important dynamic relationship between individual team members, the team, and task completion. General surgery themed teams with a gender mix were most successful in completing the design challenge; whether relative simulation performance predicts strategic organizational skill and career progression will be the next question.

Biosensors, Biomarkers and Biometrics: a Bootcamp Perspective.

Introduction: Competitive physical performance is routinely monitored by wearable technology (biosensors), yet professional healthcare is not, despite high prevalence of trainee stress and burnout, notwithstanding the corresponding risk to patient safety. This study aimed to document the physiological stress response of UK Core Surgical Trainees (CSTs) during simulation training. Methods: CSTs (n=20, 10 male) were fitted with Vital Scout Wellness Monitors (VivaLNK, Campbell, California, USA) for an intensive 3-day training bootcamp. In addition to physiological parameters, CST demographics, event diaries and Maslach Burnout Inventory scores were recorded prospectively during exposure to three scenarios: interactive lectures, clinical skills simulation and non-technical (communication) training. Results: Baseline heart rate (BHR, 60 bpm (range 39-81 bpm)) and baseline respiratory rate (14/min (11-18/min)) varied considerably and did not correlate (rho 0.076, p=0.772). BHR was associated with weekly exercise performed (66 bpm (<1 hour) vs 43 bpm (>5 hour), rho -0.663, p=0.004). Trainee response (standardised median heart rate vs BHR) revealed heart rate was related proportionately to lectures (71 bpm, p<0.001), non-technical skills training (79 bpm, p<0.001) and clinical skills simulation (88 bpm, p<0.001). Respiratory rate responded similarly (p<0.001 in each case). Heart rate during clinical skills simulation was associated with emotional exhaustion (rho 0.493, p=0.044), but maximum heart rate was unrelated to CSTs' perceived peak stressors. Discussion: Stress response, as derived from positive sympathetic heart rate drive varied over two-fold, with a direct implication on oxygen uptake and energy expenditure, and highlighting the daily physical demands placed upon clinicians.

Stress and Burnout in Training; Requiem for the Surgical Dream.

OBJECTIVE: Burnout among trainee doctors is common with as many as two-thirds reporting poor health. This study aimed to assess burnout in a cohort of UK core and higher general surgical trainees. DESIGN: The Maslach Burnout Inventory for Medical Personnel was distributed to 158 surgical trainees to evaluate emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). High EE (≥27) and DP (≥10), low PA (≤33) scores were taken to indicate burnout. SETTING: A single UK (Wales) Deanery. PARTICIPANTS: One hundred responses were received; 65 core surgical trainees, 31 Higher Surgical Trainees (HST), and 4 not specified. RESULTS: Median EE, DP, and PA scores were 22.0 (range 2-50), 7.5 (0-25), and 36.0 (19-47), respectively. High burnout by domain was: EE (n = 33), DP (n = 39), PA (n = 34), with 59% of trainees demonstrating burnout in ≥1 one domain, with strong interdomain correlation (EE:DP r = 0.351, p < 0.001; EE:PA r = -0.455, p < 0.001; DP:PA r = -0.446, p < 0.001). Female gender (p = 0.020), core surgical training grade (p = 0.012), and being childless (p = 0.033) were independently associated with higher levels of EE; whereas HST grade (p = 0.007), age >30 years (p = 0.010), married/partner status (p = 0.001), and parenthood (p = 0.015), were associated with lower levels of burnout with regard to DP. Binary logistic regression revealed lower burnout in all domains to be associated with HST status (hazard ratio 0.116, 95% confidence interval 0.014-0.980, p = 0.048) and male gender (hazard ratio 4.365, (1.246-15.293), p = 0.021). CONCLUSIONS: Burnout among surgical trainees was common in at least 1 Maslach Burnout Inventory domain. Urgent counter measures are required to protect the health and wellbeing of trainees at risk, which ought to be associated with commensurate improvement in patient safety.

Pancreas Volume Declines During the First Year After Diagnosis of Type 1 Diabetes and Exhibits Altered Diffusion at Disease Onset.

OBJECTIVE: This study investigated the temporal dynamics of pancreas volume and microstructure in children and adolescents with recent-onset type 1 diabetes (T1D) and individuals without diabetes, including a subset expressing autoantibodies associated with the early stages of T1D. RESEARCH DESIGN AND METHODS: MRI was performed in individuals with recent-onset stage 3 T1D (n = 51; median age 13 years) within 100 days after diagnosis (mean 67 days), 6 months, and 1 year postdiagnosis. Longitudinal MRI measurements were also made in similarly aged control participants (n = 57) and in autoantibody-positive individuals without diabetes (n = 20). The MRI protocol consisted of anatomical imaging to determine pancreas volume and quantitative MRI protocols interrogating tissue microstructure and composition. RESULTS: Within 100 days of diabetes onset, individuals with T1D had a smaller pancreas (median volume 28.6 mL) than control participants (median volume 48.4 mL; P < 0.001), including when normalized by individual weight (P < 0.001). Longitudinal measurements of pancreas volume increased in control participants over the year, consistent with adolescent growth, but pancreas volume declined over the first year after T1D diagnosis (P < 0.001). In multiple autoantibody-positive individuals, the pancreas volume was significantly larger than that of the T1D cohort (P = 0.017) but smaller than that of the control cohort (P = 0.04). Diffusion-weighted MRI showed that individuals with recent-onset T1D had a higher apparent diffusion coefficient (P = 0.012), suggesting a loss of cellular structural integrity, with heterogeneous pancreatic distribution. CONCLUSIONS: These results indicate that pancreas volume is decreased in stages 1, 2, and 3 of T1D and decreases during the first year after diabetes onset and that this loss of pancreatic volume is accompanied by microstructural changes.

Transmissibility of the 2009 H1N1 pandemic in remote and isolated Canadian communities: a modelling study.

OBJECTIVES: During the first wave of the 2009 influenza pH1N1, disease burden was distributed in a geographically heterogeneous fashion. It was particularly high in some remote and isolated Canadian communities when compared with urban centres. We sought to estimate the transmissibility (the basic reproduction number) of pH1N1 strain in some remote and isolated Canadian communities. DESIGN: A discrete time susceptible-exposed-infected transmission model was fit to infection curves simulated from laboratory-confirmed case counts for pH1N1 on each day. The sampling from Poisson distribution was used to estimate the basic reproduction number, R(0), of pH1N1 during the spring wave for five different communities in Manitoba and Nunavut, Canada, where remote and isolated communities experienced a high incidence of infection, and high rates of hospitalisation and intensive care unit admission. SETTING: Remote and isolated communities in Northern Manitoba, Nunavut, and the largest urban centre (Winnipeg) in the province of Manitoba, Canada. RESULTS: Using published values of the exposed and infectious periods specific to H1N1 infection, corresponding to the average generation time of 2.78 days, we estimated a mean value of 2.26 for R(0) (95% CI 1.57 to 3.75) in a community located in northern Manitoba. Estimates of R(0) for other communities in Nunavut varied considerably with higher mean values of 3.91 (95% CI 3.08 to 4.87); 2.03 (95% CI 1.50 to 3.19); and 2.45 (95% CI 1.68 to 3.44). We estimated a lower mean value of 1.57 (95% CI 1.35 to 1.87) for R(0) in the Winnipeg health region, as the largest urban centre in Manitoba. CONCLUSIONS: Influenza pH1N1 appears to have been far more transmissible in rural and isolated Canadian communities than other large urban areas. The differential severity of the pandemic in these regions may be explained partly by differential transmissibility, and suggests the need for more nuanced, targeted or population-specific control strategies in Canada.

Effect of pathogen-resistant vectors on the transmission dynamics of a vector-borne disease.

A model is introduced for the transmission dynamics of a vector-borne disease with two vector strains, one wild and one pathogen-resistant; resistance comes at the cost of reduced reproductive fitness. The model, which assumes that vector reproduction can lead to the transmission or loss of resistance (reversion), is analyzed in a particular case with specified forms for the birth and force of infection functions. The vector component can have, in the absence of disease, a coexistence equilibrium where both strains survive. In the case where reversion is possible, this coexistence equilibrium is globally asymptotically stable when it exists. This equilibrium is still present in the full vector-host system, leading to a reduction of the associated reproduction number, thereby making elimination of the disease more feasible. When reversion is not possible, there can exist an additional equilibrium with only resistant vectors.

The treatment of disc-herniation-induced sciatica with infliximab: one-year follow-up results of FIRST II, a randomized controlled trial.

STUDY DESIGN: A randomized controlled trial. OBJECTIVES: To evaluate the long-term efficacy of infliximab, a monoclonal antibody against tumor necrosis factor alpha (TNF-alpha), in patients with acute/subacute sciatica secondary to herniated disc. SUMMARY OF BACKGROUND DATA: The results of experimental studies and our open-label trial support the use of infliximab in sciatica. Here we report the 1-year results of a randomized controlled trial (FIRST II, Finnish Infliximab Related STudy) evaluating the efficacy and safety of a single infusion of infliximab for sciatic pain. METHODS: Inclusion criteria were unilateral sciatic pain with a disc herniation concordant with the symptoms and signs of radicular pain. Patients had to be candidates for discectomy. Criteria for discectomy included (in addition to a symptomatic disc herniation on MRI) neural entrapment (straight leg raising [SLR] < or =60 degrees ) with either a short-term (2-4 weeks) severe or long-term (4-12 weeks) moderate leg pain. Forty patients were allocated to a single intravenous infusion of either infliximab 5 mg/kg or placebo. Differences in the clinical examination parameters (straight leg raise [SLR], muscle strength, sensory defects, tendon reflexes), patient-reported symptoms (leg and back pain using a visual analog scale [VAS], Oswestry disability, quality-of-life [RAND-36]), sick leaves, number of discectomies, and adverse effects between the two treatment groups over the 1-year follow-up were compared using Mann-Whitney U test or Student's t test, repeated-measures analysis, or Cox proportional hazards model. Logistic regression was used to assess the predictors of good response. RESULTS: Sixty-seven percent of patients in the infliximab group reported no pain at 52 weeks compared with 63% in the control group (P = 0.72). Similar efficacy was observed between treatment groups for other outcomes. Eight patients in each group required surgery. Three nonserious adverse reactions were encountered in the infliximab group. The response (irrespective of the treatment) was significantly better with shorter symptom duration and less SLR restriction at baseline. Patients in the infliximab group appeared to especially benefit in cases of a L4-L5 (or L3-L4) herniation and if a Modic change was colocalized at the symptomatic level. CONCLUSIONS: Although the long-term results of this randomized trial do not support the use of infliximab compared with placebo for lumbar radicular pain in patients with disc herniation-induced sciatica, further study in a subgroup of patients with L4-L5 or L3-L4 herniations, especially in the presence of Modic changes, appears to be warranted.

Modelling strategies for controlling SARS outbreaks.

Severe acute respiratory syndrome (SARS), a new, highly contagious, viral disease, emerged in China late in 2002 and quickly spread to 32 countries and regions causing in excess of 774 deaths and 8098 infections worldwide. In the absence of a rapid diagnostic test, therapy or vaccine, isolation of individuals diagnosed with SARS and quarantine of individuals feared exposed to SARS virus were used to control the spread of infection. We examine mathematically the impact of isolation and quarantine on the control of SARS during the outbreaks in Toronto, Hong Kong, Singapore and Beijing using a deterministic model that closely mimics the data for cumulative infected cases and SARS-related deaths in the first three regions but not in Beijing until mid-April, when China started to report data more accurately. The results reveal that achieving a reduction in the contact rate between susceptible and diseased individuals by isolating the latter is a critically important strategy that can control SARS outbreaks with or without quarantine. An optimal isolation programme entails timely implementation under stringent hygienic precautions defined by a critical threshold value. Values below this threshold lead to control, but those above are associated with the incidence of new community outbreaks or nosocomial infections, a known cause for the spread of SARS in each region. Allocation of resources to implement optimal isolation is more effective than to implement sub-optimal isolation and quarantine together. A community-wide eradication of SARS is feasible if optimal isolation is combined with a highly effective screening programme at the points of entry.

Gutta-percha obturation of lateral grooves and depressions.

The purpose of this study was to evaluate the movement of gutta-percha into lateral grooves and depressions in the apical 7 mm of a root canal by using the System B Heat Source for the continuous wave of condensation and the Obtura II for the backfill. A split-tooth model was constructed with lateral grooves and dentin depressions prepared at 1, 3, 5, and 7 mm from working length (WL). The study included three experimental groups with 10 obturations in each group: group A-System B Fine heat plugger used at 5 mm from WL; group B-System B Fine heat plugger used at 4 mm from WL; and group C-System B Fine heat plugger used at 3 mm from WL. Group C had statistically better movement of gutta-percha into the 1-mm dentin depression than either group A (p = 0.0005) or group B (p = 0.0025) and better movement of guttapercha into the 3-mm dentin depression than group A. A significant difference in gutta-percha flow into the lateral grooves was seen at 3 mm from WL with group C (p < 0.0001). Group C demonstrated gutta-percha in the grooves, whereas both groups A and B had no gutta-percha in the grooves.