Self-Directed Interactive Video-Based Instruction Versus Instructor-Led Teaching for Myanmar House Surgeons: A Randomized, Noninferiority Trial.

OBJECTIVE: To compare self-directed interactive video-based instruction (IVBI) with instructor-led teaching in the acquisition of basic surgical skills by House Surgeons at University of Medicine 1, Yangon. DESIGN: A prospective, 1:1 randomized controlled trial was conducted. Participants were randomized into 2 teaching arms: (1) self-directed IVBI or (2) instructor-led teaching. Self-directed IVBI participants were provided with a portable DVD player that could play, fast forward, rewind, and skip through skills modules. Participants in the instructor-led teaching group were taught in small groups by standardized instructors. Pretesting and posttesting of 1-handed knot tie, 2-handed knot tie, vertical mattress suture, and instrument tie was performed using the Objective Structured Assessment of Technical Skills (OSATS). Students randomized to self-directed IVBI completed an exit survey to assess satisfaction. Demographic data were collected of all participants. SETTING: University of Medicine 1, Yangon, Myanmar. PARTICIPANTS: Fifty participants were randomly selected from 78 eligible House Surgeons who were enrolled in their basic surgery rotation. RESULTS: Demographic characteristics and baseline skills were comparable in participants randomized to IVBI and instructor-led teaching. Mean OSATS score increased from pretest to posttest in both groups (p < 0.001). The mean posttest OSATS score of the IVBI group was 0.72 points below that of the instructor-led teaching group (90% CI: -3.8 to 5.2), with the 90% CI falling below the a priori noninferiority margin, satisfying criteria for noninferiority. More than 90% of students marked either "agree" or "strongly agree" to the following statements on the exit survey: further expansion of IVBI into other skills modules and integration of IVBI into training curriculum. CONCLUSION: IVBI is noninferior to instructor-led teaching of surgical skills based on OSATS scores. House Surgeons highly rated self-directed IVBI. Self-directed IVBI has the potential to significantly reduce the personnel required for skills teaching and may serve as a long-term learning adjunct in low-resource settings.

Awareness of racial/ethnic disparities in surgical outcomes and care: factors affecting acknowledgment and action.

BACKGROUND: Studies have demonstrated racial/ethnic disparities in surgical outcomes and care. Surgeon awareness and its association with institutional action remain unclear. The study sought to assess surgeons' awareness of racial/ethnic disparities, ascertain whether demographic and practice factors influence acknowledgement of disparities, and determine whether surgeons are seeking to mitigate disparities. METHODS: Anonymous online survey was administered to a random sample of American College of Surgeons (ACS) general surgeons (July 2013 to March 2014). Responses were weighted for nonresponse and risk-adjusted using logistic regression. RESULTS: 172 surgeons completed the survey. Levels of acknowledged disparities were low. Less than one half reported institutional efforts to address disparities, and less than one fourth had taken efforts to investigate disparities in their personal practice. Several respondent factors including Academic Medical Center affiliation, awareness of the ACS statement on optimal access, and year of medical school graduation significantly associated with expressed acknowledgment of disparities. CONCLUSIONS: Such associations speak to the need for continued efforts to promote enhanced provider awareness and participation. As the field of surgical disparities moves from understanding to action, we must acknowledge the contributing role that providers play.

Troponin elevations only detected with a high-sensitivity assay: clinical correlations and prognostic significance.

OBJECTIVES: With clinical use of high-sensitivity troponin I (hsTnI), more frequent troponin elevations will occur. However, the burden and implications of these elevations are not well understood. The authors quantified the prevalence of elevated hsTnI in patients presenting with possible acute coronary syndrome (ACS) who do not have elevated troponin with a current generation assay (cardiac troponin I [cTnI]) and determined the association of these newly detected elevations with a composite of all-cause mortality and subsequent cardiac hospitalization. METHODS: This was a prospective observational study of 808 subjects evaluated for possible ACS and followed for up to 1 year. Troponin values were measured with hsTnI (Abbott Laboratories) and cTnI (Abbott and Beckman Coulter). Cardiac hospitalization was defined as hospitalization for ACS, revascularization, acute heart failure (AHF), or tachy/brady arrhythmia that occurred after the index emergency department (ED) visit or hospital discharge. RESULTS: Forty subjects (5%) were diagnosed with ACS (26 myocardial infarction and 14 unstable angina). On the initial sample, the prevalence of elevated hsTnI among subjects with nonelevated cTnI was 9.2% using a gender-neutral cutoff (95% confidence interval [CI] = 7.1% to 11.4%) and 11.1% using a gender-specific cutoff (95% CI = 8.8% to 13.4%). Adjudicated diagnoses for subjects whose initial samples had elevated hsTnI but nonelevated cTnI (gender-neutral cutoff) were as follows: three (4.6%) ACS, 15 (23.1%) AHF, three (4.6%) volume overload etiology unclear/noncardiac, three (4.6%) cardiac (non-ACS), and 41 (63.1%) other. Of the 65 patients whose initial samples had hsTnI but nonelevated cTnI, eight developed cTnI elevation on subsequent serial sampling. After traditional cardiovascular risk factors and renal function were adjusted for, subjects with elevated initial hsTnI but nonelevated cTnI (initial and serial sampling) had a higher risk of all-cause mortality and subsequent cardiac hospitalization than subjects with both nonelevated hsTnI and nonelevated cTnI (hazard ratio [HR] = 1.91, 95% CI = 1.14 to 3.19). CONCLUSIONS: On the initial sample, 9% to 11% of subjects without cTnI elevation had hsTnI elevation. Although the majority of the patients with these newly detected hsTnI elevations did not have ACS, they had a higher risk for all-cause mortality and subsequent cardiac hospitalization.