A retrospective validation of ROTEM algorithms for detecting hyperfibrinolysis demonstrates poor agreement for prediction of in-hospital mortality and transfusion requirement in a general, non-cardiac, surgical population.

INTRODUCTION: Hyperfibrinolysis diagnosed on Rotational Thromboelastography (ROTEM) is associated with increased transfusion requirements and mortality in trauma. The diagnosis and significance of hyperfibrinolysis in a mixed, non-cardiac, general surgical population has not been investigated. We aimed to measure agreement between four ROTEM algorithms for diagnosing hyperfibrinolysis and transfusion requirements and mortality in general surgical patients. These algorithms mostly incorporate measures of early or late clot amplitude reduction on the Extrinsic Clotting Pathway Test with Tissue Factor (EXTEM) channel. METHOD: Four hospital administrative data sets were linked from 2019 to 2022. Adults >18 years were included if a ROTEM was performed during their surgery (intraoperative period) or within 24-h of the surgery completion (postoperative period). The four hyperfibrinolysis criteria were applied to the ROTEM data and assessed for their agreement, intraoperative and postoperative transfusion requirements and in-patient mortality. RESULTS: We linked 933 ROTEMs to 558 patient-procedures. One algorithm identified hyperfibrinolysis on only three patients so was excluded. Agreement between the remaining three was slight (Cohens Kappa 0.18 (p < 0.001)) with hyperfibrinolysis diagnosed between 22 and 69 % of the procedures. The association between hyperfibrinolysis diagnosis and intraoperative or postoperative transfusion requirement was inconsistent between the criteria. However, an algorithm put forward by Goerling et al. was more often associated with transfusion requirement and inpatient mortality. DISCUSSION: The poor agreement between criteria suggests that some ROTEM criteria may not transfer directly to general surgical patients. Future research should focus on optimising hyperfibrinolysis cut-off values to update algorithms for bleeding general surgical patients.

Obstruction of the external auditory meatus secondary to a giant pyogenic granuloma.

Pyogenic granuloma is a benign lesion of the skin and mucosa commonly known to occur in the head and neck region. The current literature has not yet identified its occurrence within the conchal bowl, a condition that leads to obstruction of the external auditory meatus. We present the case of a 28-year-old man who presented with a history of 3-4 weeks of a rapidly enlarging pedunculated lesion within the conchal bowl of the right ear and conductive hearing loss. Initial management included excision under local anaesthesia. The histological report concluded that it was a pyogenic granuloma. Later, reoccurrence was treated with a more definitive excision under general anaesthesia. During follow-up, the operative site was seen to have healed by secondary intention without reoccurrence. Although a pyogenic granuloma within the conchal bowl is benign, early therapeutic excision is important for histological diagnosis as much as to relieve consequential secondary obstruction and conductive hearing loss.

Inhalation of a plastic wall plug: implications of foreign body characteristics in paediatric patients.

Foreign body inhalation causing asphyxiation is a significant cause of death in children under 4 years. Approximately one-fifth of the cases are inorganic industrial objects. We describe the case of an 18-month-old boy who presented with respiratory distress after inhaling a wall plug. An emergency rigid bronchoscopy was performed; however, the nature of the object and its location within the airway proved it difficult to identify at first look, causing the removal to be a challenge even in the most skilled of hands. Furthermore, its design contributed to the severity of obstruction of the airway and hence risk of death. This case prompts a discussion on the safety implications of small inorganic product designs and the measures currently being taken by manufacturers and clinicians to prevent the fatal asphyxiation in children.

Lactococcus lactis cremoris infection: not rare anymore?

A middle-aged female patient with diabetes was admitted with a right neck abscess. Ultrasound scan revealed a necrotic abscess suspicious of malignancy and biopsy showed evidence of chronic inflammation. In order to isolate the primary source of malignancy, we performed MRI and positron emission tomography scans but neither had conclusive results. Subsequently, we performed an incision and drainage of the mass in order to alleviate pressure symptoms. The ensuing histological examination revealed that the mass was caused by Lactococcus lactis cremoris. As such, the patient was treated with antibiotics and made a complete recovery. This report reinforces the scarce existing evidence that L lactis cremoris is a potential pathogen in adults. The case shows that atypical organisms should always be considered in the working diagnosis of an atypical neck abscess especially due to the rise in popularity of organic farming.

An unusual presentation of herpes infection in the head and neck.

Herpes simplex virus (HSV) is among a spectrum of viruses known to affect the upper aerodigestive tract. Gingivostomatitis and pharyngitis are the most common clinical manifestations of first-episode HSV infection, whereas recurrent herpes labialis is the most common clinical manifestation of reactivation HSV infection. Herpetic viral infections seldom attack the larynx. Laryngeal disorders provoked by the herpes virus are characterised by a large spectrum of presentations and polymorphisms, and can simulate mucous lesions such as an extensive laryngeal neoplasm (supraglottic tumour). We report a case of a 69-year-old woman, smoker, who presented with a large ulcerated supraglottic mass mimicking laryngeal cancer, requiring emergency tracheostomy for worsening stridor, which turned out to be an HSV laryngitis superimposed onto an underlying Streptococcus A lower respiratory tract infection. The patient was treated for Streptococcus A infection and her symptoms resolved following treatment. Patient's tracheotomy tube was removed on follow-up appointment.

Simulation-based surgical education.

The reduction in time for training at the workplace has created a challenge for the traditional apprenticeship model of training. Simulation offers the opportunity for repeated practice in a safe and controlled environment, focusing on trainees and tailored to their needs. Recent technological advances have led to the development of various simulators, which have already been introduced in surgical training. The complexity and fidelity of the available simulators vary, therefore depending on our recourses we should select the appropriate simulator for the task or skill we want to teach. Educational theory informs us about the importance of context in professional learning. Simulation should therefore recreate the clinical environment and its complexity. Contemporary approaches to simulation have introduced novel ideas for teaching teamwork, communication skills and professionalism. In order for simulation-based training to be successful, simulators have to be validated appropriately and integrated in a training curriculum. Within a surgical curriculum, trainees should have protected time for simulation-based training, under appropriate supervision. Simulation-based surgical education should allow the appropriate practice of technical skills without ignoring the clinical context and must strike an adequate balance between the simulation environment and simulators.

Assessment methods in surgical training in the United Kingdom / 보건의료교육평가

A career in surgery in the United Kingdom demands a commitment to a long journey of assessment. The assessment methods used must ensure that the appropriate candidates are selected into a programme of study or a job and must guarantee public safety by regulating the progression of surgical trainees and the certification of trained surgeons. This review attempts to analyse the psychometric properties of various assessment methods used in the selection of candidates to medical school, job selection, progression in training, and certification. Validity is an indicator of how well an assessment measures what it is designed to measure. Reliability informs us whether a test is consistent in its outcome by measuring the reproducibility and discriminating ability of the test. In the long journey of assessment in surgical training, the same assessment formats are frequently being used for selection into a programme of study, job selection, progression, and certification. Although similar assessment methods are being used for different purposes in surgical training, the psychometric properties of these assessment methods have not been examined separately for each purpose. Because of the significance of these assessments for trainees and patients, their reliability and validity should be examined thoroughly in every context where the assessment method is being used.

The theoretical base of e-learning and its role in surgical education.

INTRODUCTION: The advances in Internet and computer technology offer many solutions that can enhance surgical education and increase the effectiveness of surgical teaching. E-learning plays an important role in surgical education today, with many e-learning projects already available on the Internet. EDUCATIONAL THEORY: E-learning is based on a mixture of educational theories that derive from behaviorist, cognitivist, and constructivist educational theoretical frameworks. CAN EDUCATIONAL THEORY IMPROVE E-LEARNING?: Conventional educational theory can be applied to improve the quality and effectiveness of e-learning. The theory of "threshold concepts" and educational theories on reflection, motivation, and communities of practice can be applied when designing e-learning material. E-LEARNING IN SURGICAL EDUCATION: E-learning has many advantages but also has weaknesses. Studies have shown that e-learning is an effective teaching method that offers high levels of learner satisfaction. Instead of trying to compare e-learning with traditional methods of teaching, it is better to integrate in e-learning elements of traditional teaching that have been proven to be effective. CONCLUSIONS: E-learning can play an important role in surgical education as a blended approach, combined with more traditional methods of teaching, which offer better face-to-interaction with patients and colleagues in different circumstances and hands on practice of practical skills. National provision of e-learning can make evaluation easier. The correct utilization of Internet and computer resources combined with the application of valid conventional educational theory to design e-learning relevant to the various levels of surgical training can be effective in the training of future surgeons.

Securing a tracheostomy when circumferential ties may compromise flap perfusion: the 'epaulette' technique.

The use of free flaps in head and neck reconstruction raises the question of how to adequately fix a tracheostomy tube without causing local pressure to the vascular anastomosis. We describe a previously unreported technique of securing a tracheostomy tube in the immediate and early post-operative period without vascular compromise of the free flap, using the 'epaulette' technique. We undertook a PubMed literature search for articles describing similar methods of securing a tracheostomy tube in patients with head and neck free flaps, but found none. In our experience of using this method, we encountered no compromised flaps or unplanned extubations. We believe the epaulette technique to be an easy and safe method of securing a tracheostomy tube whilst simultaneously avoiding any local pressure effect on the free flap vessels and anastomosis.

Robotic surgery in ear nose and throat.

The arrival of a commercial surgical robotic platform at our institution has raised the question of its application and usefulness within the department of otolaryngology head and neck surgery. In order to answer this question, we sought to perform a qualitative review to examine the evolution of commercial surgical robotics and examine present and future applications of this emerging technology within our specialty. The main objective of this study is to examine the development and application of robotic surgery in otolaryngology, head and neck surgery. The study includes a qualitative systematic review. We have reviewed research papers and studies that specifically relate to the use of robots in otorhinolaryngology. More specifically, we have attempted to review those studies that have significantly added to the development of this field. In summary, we have examined eight animal studies, six cadaveric studies, nine human trials. Robotic surgery in ENT is a safe and feasible option. In certain procedures, it offers significant benefits over conventional surgery. Instrument and robotic arm size, and costs are limiting factors that prevent the use of robots being applied to many additional ENT procedures. We feel the development of new speciality-specific robots will yield a new era in the common use of robotics in ENT.

Arbitrary coherence in theoretical decision making about surgical training: the effect of irrelevant subliminal anchoring.

OBJECTIVE: The extent of surgical training given to undergraduates is variable and the decisions taken on the adequacy of the amount to be delivered are often made using little evidence. Therefore, these decisions are vulnerable to bias. Arbitrary coherence is a recently recognized behavior that can be induced by influencing subjects to anchor their answers to a series of questions to an unrelated anchor. We set out to assess the impact of arbitrary numerical anchors on answers given to questions concerning surgical training. DESIGN: Prospective Anchoring Study. SETTING: Nonclinical environment. PARTICIPANTS: A group of 41 fourth year medical students. MAIN OUTCOME MEASURES: Each participant was asked to write the last 2 digits of their mobile telephone numbers on the proforma. This was used as an arbitrary anchor to their decisions. They were then asked a series of questions, the answers to which required an estimate to be made. RESULTS: There was a statistically significant correlation (r = 0.36, p = 0.04) between the mean of the answers given by each student and the value of the last 2 digits of their mobile telephone number. Despite the fact that the students knew that these numbers could not be related to the questions that were asked, they were influenced by them in their responses. CONCLUSIONS: The introduction of a subliminal anchor affects decision making in participants who are given questions where estimation is required. Simple anchors will substantially sway responses in a subliminal fashion. This pilot study shows how powerful this effect can be. This effect is under-recognized and may be the source of considerable bias in research into training needs. Steps should be taken to guard against this effect in similar surveys.