In vivo Simulation-Based Learning for Undergraduate Medical Students: Teaching and Assessment.

An increasing emphasis on simulation has become evident in the last three decades following fundamental shifts in the medical profession. Simulation-based learning (SBL) is a wide term that encompasses several means for imitating a skill, attitude, or procedure to train personnel in a safe and adaptive environment. A classic example has been the use of live animal tissue, named in vivo SBL. We aimed to review all published evidence on in vivo SBL for undergraduate medical students; this includes both teaching concepts as well as focused assessment of students on those concepts. We performed a systematic review of published evidence on MEDLINE. We also incorporated evidence from a series of systematic reviews (eviCORE) focused on undergraduate education which have been outputs from our dedicated research network (eMERG). In vivo SBL has been shown to be valuable at undergraduate level and should be considered as a potential educational tool. Strict adherence to 3R (Reduce, Refine, Replace) principles in order to reduce animal tissue usage, should always be the basis of any curriculum. In vivo SBL could potentially grant an extra mile towards medical students' inspiration and aspiration to become safe surgeons; however, it should be optimised and supported by a well-designed curriculum which enhances learning via multi-level fidelity SBL.

Suturing Skills for Medical Students: A Systematic Review.

AIM: This systematic review aimed to identify all published evidence on teaching suturing skills for medical students. We aimed to outline significant positive teaching outcomes and devise a comprehensive framework for the optimal teaching of suturing skills for medical students. MATERIALS AND METHODS: We searched MEDLINE® (via Ovid), EMBASE and SCOPUS databases until July 2019 with no language restriction using predefined 'Population, Intervention, Comparison, Outcome (PICO)' criteria. Data were summarised in discrete thematic axes using a qualitative synthesis approach. RESULTS: Our search yielded a total of 2,562 articles, out of which 25 were included in the final data synthesis. We provide a structured breakdown of educational interventions including participants, instructors and nature of teaching intervention. We also describe discrete means for assessment of performance and retention of suturing skills. Based on those we propose a standardised framework on teaching suturing skills for novices. CONCLUSION: To our knowledge this is the first systematic review investigating teaching interventions used to teach suturing skills in medical students. After extraction of individual positive teaching outcomes and utilising widely known learning theories and principles, we devised a comprehensive framework for more efficient and cost-effective teaching of suturing skills to medical students in the future.

Is the H2 economy realizable in the foreseeable future? Part III: H2 usage technologies, applications, and challenges and opportunities.

Energy enthusiasts in developed countries explore sustainable and efficient pathways for accomplishing zero carbon footprint through the H2 economy. The major objective of the H2 economy review series is to bring out the status, major issues, and opportunities associated with the key components such as H2 production, storage, transportation, distribution, and applications in various energy sectors. Specifically, Part I discussed H2 production methods including the futuristic ones such as photoelectrochemical for small, medium, and large-scale applications, while Part II dealt with the challenges and developments in H2 storage, transportation, and distribution with national and international initiatives. Part III of the H2 economy review discusses the developments and challenges in the areas of H2 application in chemical/metallurgical industries, combustion, and fuel cells. Currently, the majority of H2 is being utilized by a few chemical industries with >60% in the oil refineries sector, by producing grey H2 by steam methane reforming on a large scale. In addition, the review also presents the challenges in various technologies for establishing greener and sustainable H2 society.

Team performance training for medical students: Low vs high fidelity simulation.

OBJECTIVES: The aim of this study is to evaluate a simulation-based team performance course for medical students and compare its low- and high-fidelity components. STUDY DESIGN: This is a prospective crossover observational study. Groups participated in one low- and one high-fidelity session twice. Low-fidelity scenarios included management of an emergency case on a simulated-patient, whereas high-fidelity scenarios constituted of multiple-trauma cases where simulated-patients wore a hyper-realistic suit. Team performance was assessed objectively, using the TEAM™ tool, and subjectively using questionnaires. Questionnaires were also used to assess presence levels, stress levels and evaluate the course. RESULTS: Participants' team performance was higher in the low-fidelity intervention as assessed by the TEAM™ tool. An overall mean increase in self-assessed confidence towards non-technical skills attitudes was noted after the course, however there was no difference in self-assessed performance between the two interventions. Both reported mean stress and presence levels were higher for the high-fidelity module. Evaluation scores for all individual items of the questionnaire were ≥4.60 in both NTS modules. Students have assessed the high-fidelity module higher (4.88 out of 5, SD = 0.29) compared to low-fidelity module (4.74 out of 5, SD = 0.67). CONCLUSIONS: Both the low- and high-fidelity interventions demonstrated an improvement in team performance of the attending medical students. The high-fidelity intervention was more realistic, yet more stressful. Furthermore, it proved to be superior in harvesting leadership, teamwork and task management skills. Both modules were evaluated highly by the students, however, future research should address retention of the taught skills and adaptability of such interventions.

Introducing In Vivo Dissection Modules for Undergraduate Level Trainees: What Is the Actual Benefit and How Could We Make It More Efficient?

Essential Skills in the Management of Surgical Cases (ESMSC) is an international wet lab simulation course aimed at undergraduate students. It combines basic science workshops, case-based lectures and ex vivo skills modules, as well as in vivo dissections using a swine model. This study aims to evaluate the effectiveness of high-fidelity In Vivo Simulation-Based Learning for undergraduate level trainees. Also our goal was to compare the skill-based performance of final year students vs. more junior-level ones. Forty undergraduate delegates at clinical rotation level (male = 28, female = 12, mean age = 23.12, 22-24, SD = 0.69) attended this 2-day course in Athens. N = 1 (2.5 %) was year 3, N = 4 (10 %) were year 4, N = 23 (57.5 %) were year 5 and N = 12 (30 %) were year 6. N = 30 (75 %) came from Hellenic universities, N = 8 (20 %) from the UK and N = 2 (5 %) from Germany. N = 20 (50 %) attended the in vivo dissections module first, and then the ex vivo one (type A rotation), whereas N = 20 followed the reverse training sequence with the ex vivo dissection first, followed by the in vivo one (type B rotation). The mean global rating scores for type A rotation were better in both the in vivo by 0.10 (2.40 vs. 2.30) and ex vivo modules by 0.15 (2.85 vs. 2.70), though it did not reach statistical significance (p > 0.05). Furthermore, the mean improvement of performance, in the laparoscopic skills station for the type A rotation, was better compared to type B by 0.351 (2.00 vs. 1.65, p = 0.003). Year 6 students performed better in the laparoscopic station (2.00 vs. 1.75, p = 0.059), whereas years 3, 4 and 5 performed better in the in vivo (2.42 vs. 2.16, p = 0.157) as well as the ex vivo dissections (2.78 vs. 2.75, p = 0.832), though none of those comparisons reached statistical significance. Delegates seemed to appreciate and enjoy the in vivo dissections as reflected in the feedback (8.67/10, min = 6 and max = 10, SD = 1.79). Although medical students seem to appreciate in vivo dissections modules, currently, further evidence is needed to support their recommendation in the undergraduate level. Surgical skills should be part of the undergraduate curriculum to improve final year students' performance in the theatre.

A lateral tarsorrhaphy with forehead hitch to pre-empt and treat burns ectropion with a contextual review of burns ectropion management.

INTRODUCTION: Facial burns around the eyes and eyelid ectropion can lead to corneal exposure, irritation, dryness, epiphora, infection or visual loss. We undertook a review of the published articles describing management of eyelid burns as well as methods to treat or prevent ectropion. We describe early experience of a surgical technique that we have found to mitigate ectropion in facial burns with peri-ocular involvement. MATERIALS AND METHODS: Two illustrative cases with our surgical technique is described from our experience of three cases. We reviewed the literature using the PubMed and EMBASE databases using the search terms 'burn' and 'ectropion'. RESULTS: The literature review produced a total of 17 relevant papers. Treatment options for eyelid burns were varied and were invariably level 4 or 5 evidence. Various techniques were used to treat eyelid burns including the use of a full thickness skin graft with or without concurrent scar contracture release but also use of a local flap reconstruction with or without a tissue expander or release of the underlying muscle. Other techniques included canthoplasty, Z-plasty, forehead flaps, fat transfer, and tarsorrhaphy with full thickness skin grafting. In general, the focus of articles was therapeutic and reconstructive rather than pre-emptive/preventative management. PROCEDURE: We describe our early experience of a novel technique for temporary lateral tarsorrhaphy with forehead hitch which protexts the globe and counters the scar- and gravity-related ectropic effects on the lower eyelids. DISCUSSION: Facial burns pose a difficult problem to the burn surgeon, especially when the eyelids are affected, both directly or indirectly. The optimal surgical management of eyelid burns remains unclear and the literature base lies mainly in the domain of case series. We review the literature on this subject and tabulate our findings and also describe our contribution to this area with a method of lateral and lower lid elevator that we have found valuable.

Developing an International Combined Applied Surgical Science and Wet Lab Simulation Course as an Undergraduate Teaching Model.

BACKGROUND: Essential Skills in the Management of Surgical Cases (ESMSC) is an international, animal model-based course. It combines interactive lectures with basic ex vivo stations and more advanced wet lab modules, that is, in vivo dissections and Heart Transplant Surgery on a swine model. MATERIALS AND METHODS: Forty-nine medical students (male, N = 27, female N = 22, and mean age = 23.7 years) from King's College London (KCL) and Greek Medical Schools attended the course. Participants were assessed with Direct Observation of Procedural Skills (DOPS), as well as Multiple Choice Questions (MCQs). Paired t-test associations were used to evaluate whether there was statistically significant improvement in their performance. AIM: To evaluate the effectiveness of a combined applied surgical science and wet lab simulation course as a teaching model for surgical skills at the undergraduate level. RESULTS: The mean MCQ score was improved by 2.33/32 (P < 0.005). Surgical skills competences, as defined by DOPS scores, were improved in a statically significant manner (P < 0.005 for all paired t-test correlations). CONCLUSIONS: ESMSC seems to be an effective teaching model, which improves the understanding of the surgical approach and the basic surgical skills. In vivo models could be used potentially as a step further in the Undergraduate Surgical Education.

The Introduction of Standard Operating Procedures to Improve Burn Care in the United Kingdom.

United Kingdom (UK) burn units face substantial new obstacles in delivering high quality care because of the advent of full-shift working patterns, cross-specialty cover arrangements, and increased trainee turnover. Junior trainees rely heavily on senior colleagues, who may not be readily accessible. The authors therefore proposed the introduction of standard operating procedures (SOPs), detailed written instructions used to achieve uniformity in performance and to improve outcomes. After undertaking a preliminary strength, weaknesses, opportunities, and threats analysis of their use locally and nationally, the authors set out to systematically develop burn-specific SOPs. The authors first mapped our existing local SOPs to the newly introduced UK national burn care pathway to specify gaps in coverage. The authors then administered a questionnaire to other UK burn units to identify SOPs already used elsewhere. Finally, the authors developed and piloted a robust pathway for the development, introduction, and auditing of new SOPs. The strength, weaknesses, opportunities, and threats analysis identified significant benefits and minimal risks. The mapping exercise identified specific deficiencies in our coverage of the national pathway. All 26 UK burn units responded to our questionnaire; only 12 had one or more SOPs (mean, 2.1). These covered initial assessment, inhalational injuries, drug prescribing, wound care, and gastric protection; none were audited. Locally, the authors have begun to develop the additional SOPs required. SOPs have not been instituted widely in the UK, despite the shift toward a standardized national care pathway and their association with improved outcomes. The authors hope that the systematic approach to their development and implementation demonstrates the feasibility of their wider use within UK regional burn centers and beyond.

Blood loss and transfusion rates in DIEP flap breast reconstruction. Introducing a new predictor.

BACKGROUND: The popularity of the DIEP flap has increased over the last decade. However, there is little information regarding the transfusion rates of this complex procedure. The current study reports the transfusion rates in patients who underwent DIEP flap reconstruction in our unit with an attempt to correlate significant blood loss with potential predictors such as the abdominal flap weight. METHODS-MATERIAL: A retrospective review of 131 patients who underwent DIEP reconstruction was performed. Patients' characteristics, risk factors, incidence of blood transfusions, Hb drop and complications were reviewed. For statistical analysis the two-tailed Student t-test, chi-squared significance test and multiple regression model were used. RESULTS: 12 patients (9.1%) were transfused compared to 80.3% and 18.8% described in the literature. Definite association was found between the presence of a complication and transfusion. No correlation was found between age, obesity, chemotherapy and/or radiotherapy or tamoxifen treatment and blood loss. However, operation duration, complications and weight all found to have significant correlation. On average, every additional hour of surgery adds 0.25 g of Hb drop; the presence of a complication adds 0.45 g of Hb drop, and every extra gram of tissue removed from the abdomen adds an extra 0.001 g of Hb drop. CONCLUSION: The different transfusion rates published reflect variations in surgical strategies, different operative technical details but mostly transfusion protocols applied in each unit. As a correlation with complications was found, it is quite important to identify predictors for significant blood loss to optimise the operation outcome which in our study are additional time of surgery, the presence of complication and increased flap weight.

Primary squamous cell carcinoma of the nipple: a diagnosis of suspicion.

There has been only one documented case in the English literature with the diagnosis of primary Squamous Cell Carcinoma (SCC) of the nipple; we present a further case of a primary SCC of the nipple, thus raising awareness to the skin or breast specialist of this possible presentation for SCC. We present the case of a 34 year old lady who presented to our plastic surgery unit with an erythematous, scaly lesion on her right Nipple Areola Complex (NAC). The lesion was histologically confirmed on biopsy to be an SCC and subsequently formally excised. Histology confirmed complete excision of the lesion with adequate margins with no lymphovascular or perineural invasion. This case report describes a rare presentation of a primary moderately differentiated SCC of the nipple. Although SCC of the nipple is a rare diagnosis, in view of its similar presentation to Paget disease of the nipple, it must be considered and careful examination of the histology must be performed in order to ascertain a definitive diagnosis. Patients presenting with lesions of the NAC cannot be assumed to have either Paget's disease or SCC and biopsy should be performed before arranging further investigations or treatment, as the pathways for the two conditions can be very different.