Extended-Duration Work Shifts in Surgical Specialties: A Systematic Review.

INTRODUCTION: There has been widespread international implementation of duration-hour restrictions to prevent surgical resident burnout and promote patient safety and wellbeing of doctors. A variety of Extended-Duration Work Shifts (EDWS) have been implemented, with a variety of studies examining the effect of shift systems on both surgical performance and the stress response unestablished in the literature. METHODS: This was a systematic review evaluating the impact of extended working hours on surgical performance, cognitive impairment, and physiological stress responses. The review used PubMed, Ovid Medline, Embase, and Google Scholar search engines between September and October 2021 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Filters including studies carried out after 2002 and published in the English language were applied. RESULTS: In total, 30 studies were included for analysis. General surgery was the most commonly studied rotation, with Neurosurgical, Orthopedic, and ear, nose and throat specialties also included. The majority of studies found no difference or a significant improvement in post-EDWS on simulated performance. EDWS appeared to have the greatest impact on physiological stress markers in junior surgical trainees. CONCLUSIONS: Experience appears to confer a protective element in the postcall period, with preservation of skill demonstrated. More experienced clinicians yielded lower levels of physiological markers of stress, although variability in hierarchical workload should be considered. Heterogeneity of findings across physiological, cognitive, and psychomotor assessments highlights the need for robust research on the optimum shift pattern prevents worker burnout and promotes patient safety. Future research to evaluate correlation between stress, on-call workload, and performance in the postcall period is warranted.

Impact of Mentoring for Underrepresented Groups in Undergraduate Medical Education: A Systematic Review.

OBJECTIVES: Despite efforts to mitigate challenges to advance underrepresented groups (URG) groups' representation in medical education, diversity remains underwhelming. In response to this several mentoring programs to increase diversification within medical education have been implemented. However, the impact of these programs on URG representation across disciplines is unknown. The aim of this review is to evaluate the impact of structured mentoring programs on URGs in undergraduate medical education. DESIGN: Systematic review. METHODS: A comprehensive search strategy was performed of electronic databases including PubMed, Ovid Medline, and EMBASE between January and September 2022 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Both qualitative and quantitative outcomes including characteristics of the mentoring structure explored within each study were collected, and differences in study outcomes analyzed. RESULTS: In total 17 studies were included for analysis. Mentoring within URGs resulted in an increase in research opportunities, exam performance, medical specialty applications, and residency matching. Structured feedback yielded positive experiences by both mentors and mentees participating in programs, with both emotional and cultural competence issues explored across studies included for analysis. CONCLUSIONS: Mentoring for medical students underrepresented in medicine across mentoring relationships including peer, senior, formal, and informal structures yield positive outcomes within research, academic modules, and career pathways. Future applications of mentoring programs should consider the use of tandem mentoring from both senior and peer mentors to optimize benefits URG students derive from each mentoring relationship.

Surgical Priming Improves Operative Performance in Surgical Trainees: A Crossover Randomized Control Trial.

OBJECTIVE: The aim of this study was to evaluate the impact of a surgical warm-up using a virtual reality simulator on operative performance. DESIGN: This was a single-blinded cross-over randomized control trial in a single tertiary Orthopedic training center. PARTICIPANTS: Orthopedic trainees were recruited, and each morning participants rostered to theatre were randomized to either undergo a simulated surgical procedure on a virtual reality simulation system prior to their first case as primary operator (priming arm), or to perform their usual preparatory routine for surgery (control arm). Consultant orthopedic trainers were recruited within the orthopedic unit to carry out subjective surgical performance assessments using a validated global rating scale tool on the first case the participant performed on the list as primary operator. RESULTS: Over 3 study periods a total of 151 data points were collected, with 49 matched data points across priming status and procedural level of difficulty. Subjective assessment tools consistently demonstrated improved operative performance by participants following surgical priming (p = 0.001). CONCLUSION: This study highlights that introduction of preoperative priming to improve operative preparation, and optimizes operative performance. This has not only implications for improved resident training, but also signals towards beneficial downstream effects on patient outcomes, and theatre list planning.

Preoperative priming results in improved operative performance with surgical trainees.

BACKGROUND: Preoperative warm-up regimens are increasingly utilised in the surgical field, however no consensus on benefits of priming across surgical experience has been realised. The aim of this study was to evaluate the impact of simulation preoperative priming on operative performance across levels of resident experience. METHODS: A single-blinded randomised control trial was carried out in a regional surgical training centre. Volunteers were randomised to undergo simulated surgical warm-up procedure prior to their first case as primary operator or proceed directly to surgery. RESULTS: Performances of 147 operative procedures were collected over an 18 month period, experience ranging from PGY2-PGY 7. Senior participants consistently outperformed junior residents in unprimed operative cases (p = 0.005). In primed operative performances no significant difference in aggregate performance scores was found (p = 0.07). CONCLUSION: Priming confers a greater advantage to junior residents with particular regard to generic surgical skills. Senior residents demonstrate improved self-efficacy scores measured following priming.

Evaluating the Impact of Supervision on Surgical Trainees Stress Response During Simulated Surgical Procedures; A Crossover Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate the cumulative impact of supervision on technical skills and surrogate stress markers in surgical trainees. DESIGN: This was a quasi-experimental crossover study to evaluate the impact of attending supervision on orthopedic trainee stress response during a simulated surgical procedure. Enrolled residents performed a proximal femoral nail module with the Precision OS system twice; once independently, and once under direct attending supervision, whilst wearing a heart rate monitor. Mean and maximum heart rates were recorded. Simulated performance was assessed using validated simulator-based metrics. Student's t-test was used to evaluate the impact of supervision on trainee heart rate, and performance ranking. SETTING: Tertiary trauma center in a Regional Orthopedic Unit PARTICIPANTS: Orthopedic interns and residents within our institution were invited to participate, with 20 participants included for analysis. RESULTS: Both supervised and unsupervised mean heart rate was significantly higher (p = 0.001) than baseline recorded heart rates. Supervised mean and maximum HR were significantly higher than unsupervised HR during module completion (p = 0.015; p = 0.001). Calories burned demonstrated correlation to surrogate stress markers, significantly higher in supervised sessions (p = 0.004). Performance metrics demonstrated superior performance in senior-level participants, with a decrement in performance during supervision, failing to reach significance. CONCLUSION: The development of accretion of technical and non-technical skills required in surgical training pathways may derive benefit from the use of simulation-based training in surgical residents with both supervised and unsupervised sessions.

Use of procedure specific preoperative warm-up during surgical priming improves operative outcomes: A systematic review.

BACKGROUND: Preoperative warm-up in preparation for surgery is a technique used in recognition of similarities between surgeons and performance based professionals. The aim of this review was to evaluate the use of simulation-based preoperative warm-up on surgical performance in the operating room and its impact on both clinical and patient outcomes. MATERIALS AND METHODS: A systematic review of the literature was carried out in accordance with PRISMA guidelines between August-September 2021. In total 15 studies were retrieved. RESULTS: Seven studies across general surgery, urology, and vascular surgery used a procedure specific warm-up, with significant improvement in operative performance, rate of errors, radiological and patient-based outcomes. Variables including level of experience and specialty appeared to have no impact on the merits of preoperative warm-up demonstrated. CONCLUSIONS: While heterogeneity in the benefit of generic warm-up procedures was noted, procedure specific warm-up methods consistently resulted in significantly better operative outcomes.

Rates of complications in Achilles tendon rupture repair using absorbable and nonabsorbable suture material; A systematic review.

BACKGROUND: The impact of suture type on tensile strength, re-rupture rates and infection risk in Achilles tendon rupture repair is not been well established. The aim of this review is to evaluate existing literature on the associated risk of postoperative infection with absorbable and non-absorbable suture materials in Achilles tendon rupture repair. METHODS: A systematic review of search databases PubMed; Google Scholar; and OVID Medline was made to identify studies related to complications associated with Achilles tendon rupture repair. PRISMA guidelines were utilised for this review. Meta-analysis was used to compare rupture rates and infections following rupture repair. RESULTS: 12 studies with a total of 460 patients, 230 in both nonabsorbable and absorbable suture groups were included for analysis. Risk of wound complications was significantly higher in patients with non-absorbable sutures (p < 0.001). CONCLUSION: Nonabsorbable braided sutures is associated with the highest risk of postoperative wound complications following Achilles tendon rupture repair.

Hand dominance and experience improve bimanual performance on arthroscopic simulator task.

PURPOSE: The aim of this study was to identify if experience in arthroscopy confers ambidexterity to the operator and the role of baseline characteristics in arthroscopic simulator performance. METHODS: A prospective comparative study was carried out across four regional Orthopaedic training centres. Participants were divided into novice, intermediate or experienced groups based on arthroscopic experience. Baseline demographics including age, sex, handedness, and gaming history were also collected. Following familiarisation with the procedure, participants were asked to complete a simulated task requiring bimanual control consisting of visualisation with camera control and manipulation of highlighted objects using a grasping instrument. One attempt using camera control and grasping accuracy per hand was performed by each participant, with scores for each hand collected for analysis. Performance scores for camera alignment, camera path length, grasper path length and grasping efficiency were collected. Time taken to completion was also noted for each attempt. RESULTS: Fifty-six participants were recruited to the study. A significant difference in grasping efficiency between groups in the dominant hand was demonstrated (p = 0.013). Novices demonstrated laterality with superior performance in grasping efficiency in the dominant hand (p = 0.001). No significant difference was noted between dominant and non-dominant hand performance in the experienced group. CONCLUSION: Arthroscopic simulation-based training is a valuable learning tool for orthopaedic training. This study demonstrated that experienced orthopaedic surgeons have a greater degree of ambidexterity than intermediate or novice groups, hypothesised by authors to be conferred through conventional orthopaedic training. Dedicated bimanual control tasks to reduce laterality in trainees should be incorporated in simulated surgical curricula. LEVEL OF EVIDENCE: III.

Postoperative Infection Risk in Total Joint Arthroplasty After Perioperative IV Corticosteroid Administration: A Systematic Review and Meta-Analysis of Comparative Studies.

BACKGROUND: Perioperative corticosteroid administration is associated with reduced postoperative nausea, pain, and enhanced recovery after surgery. However, potential complications including wound and periprosthetic joint infections remain a concern for surgeons after total joint arthroplasty (TJA). METHODS: A systematic review of the search databases PubMed, Google Scholar, and EMBASE was made in January 2021 to identify comparative studies evaluating infection risk after perioperative corticosteroid administration in TJA. PRISMA guidelines were used for this review. Meta-analysis was used to assess infection risk in accordance with joint and corticosteroid dosing regimen used. RESULTS: 201 studies were returned after initial search strategy, with 29 included for review after application of inclusion and exclusion criteria. Studies were categorized as using low- or high-dose corticosteroid with single or repeat dosing regimens. Single low-dose corticosteroid administration was not associated with an increased risk of infection (P = .4; CI = 0.00-0.00). Single high-dose corticosteroid was not associated with an increased infection risk (P = .3; CI = 0.00-0.01) nor did repeat low-dose regimens result in increased risk of infection (P = .8; CI = -0.02-0.02). Studies assessing repeat high-dosing regimens reported no increased infection, with small numbers of participants included. No significant risk difference in infection risk was noted in hip (P = .59; CI = -0.03-0.02) or knee (P = .2; CI = 0.00-0.01) arthroplasty. Heterogeneity in patient profiles included in studies to date was noted. CONCLUSION: Use of perioperative corticosteroid in TJA does not appear to be associated with increased risk of postoperative infection in patients with limited comorbidities. Further research is warranted to evaluate postoperative complications after TJA in these at-risk patient populations.

Upscaling Virtual Fracture Clinic Use Is a Safe, Effective Measure in the Delivery of Trauma Care.

The Virtual Fracture Clinic (VFC) has proved beneficial in reducing footfall within the hospital setting, improving the cost of running a trauma service, while satisfying the majority of referred patients. The mandatory upscaling of telemedicine use, specifically the enhancement of the VFC, amidst the COVID-19 pandemic, was analyzed. The remit of the VFC within our hospital was expanded so as to include all referred ambulatory trauma. Outcomes of our VFC review over the 6-week period following the introduction of the national Irish COVID-19-related restrictions were gathered. These outcomes were analyzed and compared with the corresponding 6-week period from 2019. A 77.2% increase in the VFC referral volume was observed throughout the COVID-19-related period. Patients were directly discharged in 55.2% of cases in 2020, as opposed to 47.8% in 2019 (P = 0.044); referred directly for physiotherapy in 32.9% of cases in 2020, as opposed to 28.9% in 2019 (P = 0.173); and referred to a fracture clinic in 11.9% of cases in 2020, as opposed to 23.7% in 2019 (P < 0.001). Also, 3.0% of patients returned to the clinic after discharge in 2020, compared with 4.4% in 2019 (P = 0.237); 4.5% of patients were referred for surgery in 2020, as opposed to 2.2% in 2019 (P = 0.105). The VFC proved to be an efficient tool in managing ambulatory trauma throughout the pandemic. Upscaling the VFC to include all ambulatory trauma is a safe, effective method in reducing clinic attendances and hospital footfall, whilst ensuring that high care standards are maintained. LEVEL OF EVIDENCE:: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Qualitative and Quantitative Comparative Analysis of Commercial and Independent Online Information for Hip Surgery: A Bias in Online Information Targeting Patients?

BACKGROUND: Direct to consumer (DTC) advertising, targeting the public over the physician, is an increasingly pervasive presence in medical clinics. It is trending toward a format of online interaction rather than that of traditional print and television advertising. METHODS: We analyze patient-focused Web pages from the top 5 companies supplying prostheses for total hip arthroplasties, comparing them to the top 10 independent medical websites. Quantitative comparison is performed using the Journal of American Medical Association benchmark and DISCERN criteria, and for comparative readability, we use the Flesch-Kincaid grade level, the Flesch reading ease, and the Gunning fog index. Content is analyzed for information on type of surgery and surgical approach. RESULTS: There is a statistically significant difference between the independent and DTC websites in both the mean DISCERN score (independent 74.6, standard deviation [SD] = 4.77; DTC 32.2, SD = 10.28; P = .0022) and the mean Journal of American Medical Association score (Independent 3.45, SD = 0.49; DTC 1.9, SD = 0.74; P = .004). The difference between the readability scores is not statistically significantly. The commercial content is found to be heavily biased in favor of the direct anterior approach and minimally invasive surgical techniques. CONCLUSION: We demonstrate that the quality of information on commercial websites is inferior to that of the independent sites. The advocacy of surgical approaches by industry to the patient group is a concern. This study underlines the importance of future regulation of commercial patient education Web pages.