Society for Simulation in Healthcare Guidelines for Simulation Training.

BACKGROUND: Simulation has become a staple in the training of healthcare professionals with accumulating evidence on its effectiveness. However, guidelines for optimal methods of simulation training do not currently exist. METHODS: Systematic reviews of the literature on 16 identified key questions were conducted and expert panel consensus recommendations determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. OBJECTIVE: These evidence-based guidelines from the Society for Simulation in Healthcare intend to support healthcare professionals in decisions on the most effective methods for simulation training in healthcare. RESULTS: Twenty recommendations on 16 questions were determined using GRADE. Four expert recommendations were also provided. CONCLUSIONS: The first evidence-based guidelines for simulation training are provided to guide instructors and learners on the most effective use of simulation in healthcare.

Outcome comparison between primary and revisional bariatric surgery: A propensity-matched analysis.

BACKGROUND: Revisional bariatric procedures for weight recurrence are rising but are considered higher risk and less effective than primary bariatric procedures. This study aimed to compare clinical outcomes between primary and revisional bariatric surgery for weight recurrence. METHODS: Prospectively collected data from adult patients who underwent revisional or primary bariatric surgery from 2016 to 2020 in an academic institution were reviewed. Roux-en-Y gastric bypass and sleeve gastrectomy were performed primarily or as conversion procedures after laparoscopic adjustable gastric band, vertical banded gastroplasty, and sleeve gastrectomy. 1:1 propensity score matching was performed between revisional bariatric surgery and primary bariatric surgery, and logistic regression analysis was used to compare up to 2-year weight loss and comorbidity resolution outcomes. RESULTS: A total of172 cases (86 revisional bariatric surgery versus 86 primary bariatric surgery) were included. Groups were matched for age, sex, preoperative body mass index, bariatric procedure, diabetes, hypertension, and obstructive sleep apnea. Procedure duration (203 ± 78 vs 154 ± 69 minutes; P < .001) and length of stay (2.3 ± 2.1 vs 1.7 ± 1 days; P = .02) were longer for revisional bariatric surgery versus primary bariatric surgery, respectively. Total weight loss was less in revisional bariatric surgery compared with primary bariatric surgery at 1 year (23 ± 10% vs 32 ± 9%; P < .001) and 2 years (21 ± 12.% vs 32 ± 10%; P < .001) of follow-up; however, no differences were detected in postoperative occurrences, emergency department visits, readmissions, reintervention and reoperation rates, and comorbidity resolution. CONCLUSION: Although revisional bariatric surgery was associated with longer operation times, prolonged hospitalization, and lower weight loss than primary bariatric surgery, it was accomplished safely and led to substantial weight loss and comorbidity resolution. This information can guide patient counseling before revisional surgery for weight recurrence.

Relationship between stress and resident non-technical skills during interdisciplinary trauma simulations.

BACKGROUND: Non-technical skills, such as communication and situation awareness, are vital for patient care and effective surgical team performance. Previous research has found that residents' perceived stress is associated with poorer non-technical skills; however, few studies have investigated the relationship between objectively assessed stress and non-technical skills. Accordingly, the purpose of this study was to assess the relationship between objectively assessed stress and non-technical skills. METHODS: Emergency medicine and surgery residents voluntarily participated in this study. Residents were randomly assigned to trauma teams to manage critically ill patients. Acute stress was assessed objectively using a chest-strap heart rate monitor, which measured average heart rate and heart rate variability. Participants also evaluated perceived stress and workload using the 6-item version of the State-Trait Anxiety Inventory and the Surgery Task Load Index. Non-technical skills were assessed by faculty raters using the non-technical skills scale for trauma. Pearson's correlation coefficients were used to examine relationships between all variables. RESULTS: Forty-one residents participated in our study. Heart rate variability (where higher values reflect lower stress) was positively correlated with residents' non-technical skills overall and leadership, communication, and decision-making. Average heart rate was negatively correlated with residents' communication. CONCLUSION: Higher objectively assessed stress was associated with poorer non-technical skills in general and nearly all non-technical skills domains of the T-NOTECHS. Clearly, stress has a deleterious effect on residents' non-technical skills during trauma situations, and given the importance of non-technical skills in surgical care, educators should consider implementing mental skills training to reduce residents' stress and optimize non-technical skills during trauma situations.

Venous thromboembolism (VTE) prophylaxis after bariatric surgery: a national survey of MBSAQIP director practices.

BACKGROUND: Venous thromboembolism (VTE) is the most common cause of death following metabolic/bariatric surgery (MBS), with most events occurring after discharge. The available evidence on ideal prophylaxis type, dosage, and duration after discharge is limited. OBJECTIVES: Assess metabolic/bariatric surgeon VTE prophylaxis practices and define existing variability. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited centers. METHODS: The members of the ASMBS Research Committee developed and administered a web-based survey to MBSAQIP medical directors and ASMBS members to examine the differences in clinical practice regarding the administration of VTE prophylaxis after MBS. RESULTS: Overall, 264 metabolic/bariatric surgeons (136 medical directors and 128 ASMBS members) participated in the survey. Both mechanical and chemical VTE prophylaxis was used by 97.1% of the participants, knee-high compression devices by 84.7%, enoxaparin (32.4% 40 mg every 24 hours, 22.7% 40 mg every 12 hours, 24.4% adjusted the dose based on body mass index) by 56.5%, and heparin (46.1% 5000 units every 8 hours, 22.6% 5000 units every 12 hours, 20.9% 5000 units once preoperatively) by 38.1%. Most surgeons (81.6%) administered the first dose preoperatively, while the first postoperative dose was given on the evening of surgery by 44% or the next morning by 42.2%. Extended VTE prophylaxis was prescribed for 2 weeks by 38.7% and 4 weeks by 28.9%. CONCLUSIONS: VTE prophylaxis practices vary widely among metabolic/bariatric surgeons. Variability may be related to limited available comparative evidence. Large prospective clinical trials are needed to define optimal practices for VTE risk stratification and prophylaxis in bariatric surgery patients.

Iliac vein stenting in a patient with lower extremity swelling resulting from diffuse pelvic mass: A case report.

We report a 66-year-old male patient with severe right lower extremity swelling resulting from diffuse pelvic mass with compression on right external iliac vein. The patient had papillary urothelial carcinoma of bladder seven years ago and radical cystectomy and ureterostomy was performed. Recurrence of malignancy had occurred five years after the operation. The patient had also bilateral diffuse lung metastasis. The external iliac vein had severe stenosis and invasion of pelvic mass into the vein was evident on venography. Venoplasty of external iliac vein was performed throughout the stenosis. A venous stent of 80 mm length and 12 mm diameter was introduced over the guidewire and deployed in the external iliac vein. Dramatic clinical response was evident since postoperative day two. Swelling of right lower extremity was resolved dramatically on three-month and six-month follow-up visits. We believe that endovascular venous recanalization of iliac veins is feasible and safe in patients with unresectable and diffuse pelvic masses.

Comparing open conventional carpal tunnel release with mini-incision technique in the treatment of carpal tunnel syndrome: A non-randomized clinical trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy which is the result of the compression of the median nerve in the wrist. Currently, there is no consensus about the best treatment option. The purpose of this clinical trial was to compare the clinical outcomes of patients undergoing open CT release with mini-incision CT release. PATIENTS AND METHODS: This clinical trial included 75 patients with CTS who were divided into two groups of 45 and 30 patients to undergo open-CT release or mini incision CT release respectively. Patients were evaluated pre-operatively, days after the surgery and then five months after the operation to record outcomes. At follow-up, the visual analogue scale (VAS) scores for pain, patients' satisfaction, return to work, length of scar, paresthesia, grip and opposition strength were measured. RESULTS: A total of 75 patients (mean age: 52.13 years, 73.3% female) underwent CTS surgery. Forty-five patients (60%) had open-CT release and 30 patients (40%) had mini-incision CT release. Postoperative pain and scar length were significantly lower in the mini incision group compared to open group (p < 0.001). The mini-incision CT group returned to work earlier than open group with higher satisfaction (p < 0.001). No significant differences were observed between two groups in respect to the improvement of the opposition, grip and paresthesia (p > 0.05). CONCLUSION: Our study demonstrated that mini-incision CT release improves pain more effectively and has better quality of life because of smaller length of scar, immediate return to work and higher overall satisfaction. Neurosensory and motor improvements were also seen in both techniques with the same clinical impact.

Acute right upper extremity ischemia resulting from true aneurysmof right brachial artery: A case report.

We report a case of 66-year-old woman with true aneurysm of the right brachial artery. She presented with acute upper extremity ischemia. The hand was cold and parenthesized and distal pulses were absent. CT angiography (CTA) revealed a 20*25 mm true brachial artery aneurysm. The aneurysm was thrombosed without distal run-off. We excised the aneurysm and reestablished the arterial flow by a reverse saphenous interposition graft. The postoperative course was uneventful.

The educating enigma: Does training level impact postoperative outcome in bariatric surgery?

BACKGROUND: Bariatric procedures are complex, and the acceptance of complications by the general public is exceedingly low. Using the database of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, outcomes in bariatric surgery were evaluated to determine the effect of trainees. METHODS: The following data on postoperative complications for patients undergoing bariatric surgery in 2015 were collected: surgical site infections, sepsis, urinary tract infection, duration of hospital stay, operative time, renal failure, pulmonary embolus, deep vein thrombosis, pneumonia, and re-operation. These were analyzed against presence and level of trainees, using analysis of variance after normalizing the data. RESULTS: Of 168,093 procedures, 125,078 were performed without trainees, 14,883 were performed with a fellow, and 28,132 were performed with a resident. Cases without trainees were 25% Roux-en-Y gastric bypass, 59% sleeve gastrectomy, and 16% other. Cases with fellows were 35% Roux-en-Y gastric bypass, 51% sleeve gastrectomy, and 13% other; cases with residents were 27% Roux-en-Y gastric bypass, 59% sleeve gastrectomy, and 15% other. Patient demographics were similar. Average operative time differed between groups as follows: without trainees, 85 minutes; with residents, 105 minutes; and with fellows, 117 minutes (P < .001). Although not dramatically so, infections tended to be a bit more likely with fellows (2% vs 1%; P < .001), and the rate of urinary tract infection and hospital stay tended to be greater with either fellows or residents (1% vs 0%; P < .001; 2.0 days vs 2.1 days vs 1.8 days; P < .001, respectively). CONCLUSION: Fellow involvement resulted in the greatest operative times, and the rate of infections, urinary tract infections, and prolonged hospital stay, although statistically greater, were only mildly increased and of questionable clinical importance. These mild increases in postoperative complications may be attributed to prolonged operating room time.

Does Sleeve Shape Make a Difference in Outcomes?

INTRODUCTION: Sleeve gastrectomy (SG) is one of the most common procedures performed for weight loss. Many seek the "perfect sleeve" with the notion that the type of calibrating device affects sleeve shape, and this in turn will affect outcomes and complications. Two major concerns after SG are amount of weight loss and acid reflux. Our aim was to determine if the various calibration methods could impact sleeve shape and thereby allow for better outcomes of weight loss and reflux. METHODS: A retrospective chart review was performed of 210 patients who underwent SG and had postoperative upper gastrointestinal (UGI) study from 2011 to 2015 in a single center by a single (fellowship-trained) bariatric surgeon. Data regarding demographics, calibrating devices and clinical outcomes at 1 year (weight loss and de novo acid reflux) were collected. UGIs were reviewed by two radiologists blinded to the clinical outcomes. Sleeve shape was classified according to a previously described classification as tubular, dumbbell, upper pouch, or lower pouch. The types of calibrating devices used to guide the sleeve size intraoperatively were endoscopy, large-bore orogastric tube, and fenestrated suction tube. RESULTS: One hundred ninety-nine patients met inclusion criteria (11 had no esophagram). Demographics revealed age 45.76 ± 10.6 years, BMI 47 ± 8.6 kg/m2, and 82% female. Calibration devices used were endoscopic guidance (7.6%), large bore orogastric tube (41.4%), and fenestrated suction tube (50.5%). Sleeve shape was reported as 32.6% tubular, 20.6% dumbbell, 39.2% lower pouch, and 7.5% upper pouch (100% interrater reliability). No correlation was seen with type of calibration used. Of patients, 62.0% had > 50% excess weight loss at 1 year. Twenty-three percent of patients remained on PPI at 1 year (of which 43.3% did not have reflux preoperatively). The lower pouch shape showed a trend toward less reflux and more weight loss. CONCLUSION: This study showed no clear association between uniformity of sleeve shape and the type of calibration device used. The study showed a trend toward decreased reflux and improved weight loss with the lower pouch shape, regardless of calibration device.

The relation between serum vitamin D levels and blood pressure: a population-based study.

Vitamin D deficiency has been proposed as an associating factor with increased blood pressure. We studied the relationship between serum vitamin D and blood pressure in a large representative sample of Iranian population. In this cross-sectional study, based on the data of 2508 adults (aged between 20 and 70 years) from the Iran Multicenter Osteoporosis Study (IMOS), the association between serum vitamin D and blood pressure was investigated. There was a significant difference between mean (±SD) vitamin D levels of the individuals with stage I hypertension and that of the three other groups (Normal: 32.9 (±27.5); Prehypertension: 34.4 (±27.2); Stage-I: 38.7 (±29.2); Stage-II: 34.7 (±24.0) ng/ml; P<0.05. In multivariate regression models, the weak positive association of vitamin D and systolic blood pressure values disappeared after age and Body Mass Index (BMI) adjustment. We found a statistically positive but weak association between vitamin D serum concentration and systolic blood pressure. Considering the difference noted between our results and previous studies, further research is needed to assess the potential effect of ethnicity and genetic factors on these findings.

The trend of national and sub-national burden of gastrointestinal and liver diseases in Iran 1990 to 2013; study protocol.

BACKGROUND: It is expected that gastrointestinal (GI) and liver diseases inflict considerable burden on health systems in Iran; therefore, highlighting the significance of GI disorders across the other most burdensome diseases requires comprehensive assessment and regular updates of the statistics of such diseases in Iran. OBJECTIVE: To assess in-depth sub-national estimates and trends for the incidence and prevalence of selected GI and liver diseases by age, gender and province over the period 1990 - 2013 in Iran. METHODS: This is a national and sub-national burden of disease study on 21 GI diseases using all available data sources, including cancer registry, death registration system data, hospital data, and all available published data. Analyses will be performed separately by gender, age groups, year, and province. We will conduct 21 separated systematic reviews of the literature for 21 diseases categories through searching online international electronic databases (i.e. the Medline database of the National Library of Medicine, Web of Science, and Scopus), Iranian search engines (i.e., IranMedex, Scientific Information Database (SID), and IRANDOC), and gray literature. We will search the medical literature published between January 1985 and December 2013. We generated two models, Spatio-temporal and Multilevel Autoregressive models, to estimate mean and uncertainty interval for the parameters of interest by gender, age, year, and province. The models will be informed by data of gender, age, year, and province. Markov Chain Monte Carlo (MCMC) methods will be used to perform Bayesian inference in both modeling framework. All programs will be written in R statistical packages (version 3.0.1). RESULTS: We will calculate and present 1990 to 2013 trends in terms of prevalence, years of life lost due to premature mortality (YLLs), years lived with disability (YLDs), and disability-adjusted life years DALYs for the 21 selected GI diseases by gender, and province. We will also quantify the uncertainty interval for the estimates of interest. CONCLUSION: Results of the present study will have implications for policy making; as they allow for understanding geographic distributions of the selected GI diseases, and identifying health disparities across provinces.

Comparison of Knifelight Surgery versus Conventional Open Surgery in the Treatment of Carpal Tunnel Syndrome.

BACKGROUND: A variety of surgical treatment methods for carpal tunnel syndrome are introduced recently, including open surgery, endoscopic and the Knifelight. It is hypothesized that Knifelight method could decrease scar tenderness and time before return to daily activities for patients and is accompanied with less disturbance to fine sensory nerves. OBJECTIVES: To compare the Knifelight instrument and open carpal tunnel release with respect to scar length, operation duration, recovery time needed before return to work and amount of pain three weeks after surgery in patients with neurophysiologically confirmed carpal tunnel syndrome. PATIENTS AND METHODS: FIFTY NINE PATIENTS WITH INDICATION FOR CARPAL TUNNEL RELEASE RANDOMLY ASSIGNED INTO TWO GROUPS: open (n=30) or Knifelight (n=29). The patients compared regarding scar length, operation duration, time to return to daily activities and amount of pain at three weeks after operation based on Visual Analog Scale. RESULTS: There was no significant differences regarding age and sex in the two groups. The scar length, operation duration and time before return to daily activities were significantly lower in the Knifelight group. Although the mean visual analogue scale of Knifelight group found to be lower than the other, it was not statistically significant. CONCLUSIONS: The Knifelight technique is accompanied with advantages over the open surgery regarding operation time, scar length and time to return to daily activities. The pain relieve based on Visual Analog Scale was not statistically different from conventional open surgery.