The Surgical Skills and Technology Elective Program and Medical Student Career Choice.

INTRODUCTION: The Surgical Skills and Technology Elective Program (SSTEP) is a bootcamp for preclinical medical students that uses simulation learning methodology to provide exposure to procedural specialties and enhance surgical skills. Despite the widespread adoption of similar bootcamps, evidence is lacking regarding their impact on students' decision to pursue surgical/procedural careers. METHODS: This exploratory analysis consisted of a retrospective, cross-sectional assessment of SSTEP involving a survey examining engagement during clerkship rotations and career decision-making was sent to all SSTEP participants since the program's inception (n = 184). In addition, publicly available data through the Canadian Resident Matching Service (CaRMS) were used to compare match data between all SSTEP participants who have participated in the CaRMS match (n = 144) and students in corresponding years who did not participate in SSTEP (n = 351). RESULTS: Seventy-four SSTEP participants (40.2%) responded to the survey. Of the respondents, the majority agreed or strongly agreed that SSTEP influenced participants to engage in more procedural opportunities during clerkship (73%) and that they felt more confident performing procedural tasks during clerkship because of SSTEP (92%). Fifty percent of participants agreed that their anxiety decreased regarding clinical specialty decision. Thirty percent of participants indicated that SSTEP influenced them to pursue a procedural career. Examination of CaRMS data showed that 42% of SSTEP participants matched into direct-entry procedural specialties compared with 32% of non-SSTEP graduating medical students at our institution (P = 0.048). CONCLUSIONS: Our analysis supports the utility of preclerkship surgical bootcamps. By providing early exposure to procedural skills, SSTEP promoted engagement with procedural skills during clerkship. Participation in SSTEP influenced student career choice, which may have contributed to the increased match rate into procedural specialties for SSTEP participants.

Objective Structured Assessment of technical skill (OSATS) in the Surgical Skills and Technology Elective Program (SSTEP): Comparison of peer and expert raters.

BACKGROUND: A major challenge with Competency Based Medical Education (CBME) is that of increased assessment burden on faculty. To reduce this burden, the accuracy and reliability of peer-assessment for surgical skills requires further exploration. METHODS: Forty-two second year medical students were video recorded while performing a simple interrupted suture and an instrument tie. Four novice raters underwent a short training session on the use of the Objective Structured Assessment of Technical Skills (OSATS) checklists. Videos of the suturing task were then independently assessed by the four novice raters and two expert raters on two occasions. Agreement between novice and expert rater scores was calculated using the intraclass correlation coefficient (ICC). RESULTS: For both simple interrupted suturing (ICC = 0.78, CI = 0.66-0.86, p < 0.001) and instrument ties (ICC = 0.87, CI = 0.80-0.92, p < 0.001), there was good agreement between novice and expert raters. CONCLUSIONS: Novice raters can be taught to use the OSATS checklists to assess peers on simple suturing and instrument tying tasks.

Prediction of patient survival following postanoxic coma using EEG data and clinical features.

Electroencephalography (EEG) is an effective and non-invasive technique commonly used to monitor brain activity and assist in outcome prediction for comatose patients post cardiac arrest. EEG data may demonstrate patterns associated with poor neurological outcome for patients with hypoxic injury. Thus, both quantitative EEG (qEEG) and clinical data contain prognostic information for patient outcome. In this study we use machine learning (ML) techniques, random forest (RF) and support vector machine (SVM) to classify patient outcome post cardiac arrest using qEEG and clinical feature sets, individually and combined. Our ML experiments show RF and SVM perform better using the joint feature set. In addition, we extend our work by implementing a convolutional neural network (CNN) based on time-frequency images derived from EEG to compare with our qEEG ML models. The results demonstrate significant performance improvement in outcome prediction using non-feature based CNN compared to our feature based ML models. Implementation of ML and DL methods in clinical practice have the potential to improve reliability of traditional qualitative assessments for postanoxic coma patients.

Overview and Diagnostic Accuracy of Near Infrared Spectroscopy in Carotid Endarterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: Carotid endarterectomy is recommended for the prevention of ischaemic stroke due to carotid stenosis. However, the risk of stroke after carotid endarterectomy has been estimated at 2% - 5%. Monitoring intra-operative cerebral oxygenation with near infrared spectroscopy (NIRS) has been assessed as a strategy to reduce intra- and post-operative complications. The aim was to summarise the diagnostic accuracy of NIRS to detect intra-operative ischaemic events, the values associated with ischaemic events, and the relative contribution of external carotid contamination to the NIRS signal in adults undergoing carotid endarterectomy. DATA SOURCES: EMBASE, MEDLINE, Cochrane Centre Register of Controlled Trials, and reference lists through May 2019 were searched. REVIEW METHODS: Non-randomised and randomised studies assessing NIRS as an intra-operative monitoring tool in carotid endarterectomy were included. Studies using NIRS as the reference were excluded. Risk of bias was assessed using the Newcastle Ottawa Scale, RoB-2, and QUADAS-2. RESULTS: Seventy-six studies were included (n = 8 480), under local (n = 1 864) or general (n = 6 582) anaesthesia. Seven studies were eligible for meta-analysis (n = 524). As a tool for identifying intra-operative ischaemia, specificity increased with more stringent NIRS thresholds, while there was unpredictable variation in sensitivity across studies. A Δ20% threshold under local anaesthesia resulted in pooled estimates for sensitivity and specificity of 70.5% (95% confidence interval, CI, 54.1 - 82.9) and 92.4% (95% CI 85.5 - 96.1) compared with awake neurological monitoring. These studies had low or unclear risk of bias. NIRS signal consistently dropped across clamping and recovered to pre-clamp values upon de-clamp in most studies, and larger decreases were observed in patients with ischaemic events. The contribution of extracranial signal to change in signal across clamp varied from 3% to 50%. CONCLUSION: NIRS has low sensitivity and high specificity to identify intra-operative ischaemia compared with awake monitoring. Extracranial signal contribution was highly variable. Ultimately, data from high quality studies are desperately needed to determine the utility of NIRS.

The Next Surgical Skills and Technology Elective Program: The "Surgical Skills and Technology Elective Program" Decreases Cognitive Load During Suturing Tasks in Second Year Medical Students.

OBJECTIVE: The Surgical Skills and Technology Elective Program (SSTEP) is a one-week, simulation-based procedural skills bootcamp for preclinical medical students. Using cognitive load (CL) as a useful framework for understanding simulation in medical education, our aims were to (1) examine the ability of SSTEP to decrease medical students' CL during procedural skills training and (2) determine the impact of SSTEP on secondary learning. METHODS: In this prospective cohort study, twenty SSTEP participants and twenty controls were recruited. CL was assessed during a simple suturing task and a clinical vignette multitasking activity, where participants were required to suture and concurrently listen to a clinical vignette. CL was measured using the validated Subjective Rating of Mental Effort (SRME) and its impact on working memory was assessed using a knowledge test about the clinical vignette. RESULTS: Participants reported lower SRME scores while suturing following SSTEP, which persisted at 3 months (p = 0.002) and were significantly lower than controls (p = 0.031). Participants also reported lower SRME scores during the clinical vignette multitasking activity (p = 0.011), despite no improvement among controls (p = 0.63). Participants significantly outperformed controls on the clinical vignette knowledge test (p = 0.02). CONCLUSIONS: Surgical skills training through SSTEP was associated with lower reports of mental effort and increased performance on secondary learning tasks. Procedural skills bootcamps may better prepare students for the complex learning environments encountered during clinical clerkship.

Surgical outcomes in children with bottom-of-sulcus dysplasia and drug-resistant epilepsy: a retrospective cohort study.

OBJECTIVE: Bottom-of-sulcus dysplasia (BOSD) is challenging to identify radiologically. The aim of this study was to explore seizure outcomes after resective surgery or MR-guided laser interstitial thermal therapy (MRgLITT) in children with BOSD. METHODS: Children with radiologically defined BOSD who underwent resective surgery or MRgLITT, with at least 1 year of follow-up were included. Clinical, radiological, neurophysiological, and histological data were extracted from medical records. Invasive video EEG (IVEEG) was used to evaluate the ictal onset zone or motor/language mapping, wherever appropriate. Histology of MRI-visible BOSD, including the overlying and adjacent cortex, was also evaluated. RESULTS: Forty-one children with BOSD underwent surgical treatment. The lesion was initially overlooked on MRI in 20 patients (48.8%). Of 34 patients who underwent IVEEG and who had available ictal data, the ictal onset zone extended beyond the MRI-visible BOSD in 23 patients (67.6%). Surgical treatment included lesionectomy (24 patients), extended lesionectomy (12 patients), lobectomy (1 patient), and ablation of BOSD (4 patients). The pathology in 37 patients who underwent resection showed focal cortical dysplasia type IIB and type IIA in 21 (53.8%) and 16 patients (41%), respectively. Seizure freedom was achieved in 32 patients (78.1%) after a mean follow-up of 4.3 years. CONCLUSIONS: Seizure outcomes after resective surgery or MRgLITT in children with BOSD were generally favorable. The authors found that the neurophysiological abnormality and pathology often extended beyond the MRI-visible BOSD.

Magnetic Resonance Imaging Findings Are Associated with Long-Term Global Neurological Function or Death after Traumatic Brain Injury in Critically Ill Children.

The identification of children with traumatic brain injury (TBI) who are at risk of death or poor global neurological functional outcome remains a challenge. Magnetic resonance imaging (MRI) can detect several brain pathologies that are a result of TBI; however, the types and locations of pathology that are the most predictive remain to be determined. Forty-two critically ill children with TBI were recruited prospectively from pediatric intensive care units at five Canadian children's hospitals. Pathologies detected on subacute phase MRIs included cerebral hematoma, herniation, cerebral laceration, cerebral edema, midline shift, and the presence and location of cerebral contusion or diffuse axonal injury (DAI) in 28 regions of interest were assessed. Global functional outcome or death more than 12 months post-injury was assessed using the Pediatric Cerebral Performance Category score. Linear modeling was employed to evaluate the utility of an MRI composite score for predicting long-term global neurological function or death after injury, and nonlinear Random Forest modeling was used to identify which MRI features have the most predictive utility. A linear predictive model of favorable versus unfavorable long-term outcomes was significantly improved when an MRI composite score was added to clinical variables. Nonlinear Random Forest modeling identified five MRI variables as stable predictors of poor outcomes: presence of herniation, DAI in the parietal lobe, DAI in the subcortical white matter, DAI in the posterior corpus callosum, and cerebral contusion in the anterior temporal lobe. Clinical MRI has prognostic value to identify children with TBI at risk of long-term unfavorable outcomes.

Photopolymerized Starchstarch Nanoparticle (SNP) network hydrogels.

Starch is an attractive biomaterial given its low cost and high protein repellency, but its use in forming functional hydrogels is limited by its high viscosity and crystallinity. Herein, we demonstrate the use of fully amorphous starch nanoparticles (SNPs) as functional hydrogel building blocks that overcome these challenges. Methacrylation of SNPs enables hydrogel formation via photopolymerization, with the low viscosity of SNPs enabling facile preparation of pre-gel suspensions of up to 35 wt% SNPs relative to <10 wt% with linear starch. Small angle neutron scattering indicates a significantly different microstructure in SNP-based hydrogels compared to linear starch-based hydrogels due to the balance between inter- and intra-particle crosslinks, consistent with SNPs forming denser and stiffer hydrogels. Functionalized SNPs are highly cytocompatible at degree of substitution values <0.25 and, once gelled, can effectively repel cell adhesion. The physicochemical versatility and biological functionality of SNP-based hydrogels offer potential in various applications.

Evaluating complication rates and outcomes among infants less than 5kg undergoing traditional percutaneous endoscopic gastrostomy insertion: A retrospective chart review.

PURPOSE: Percutaneous endoscopic gastrostomy (PEG) enables enteral nutrition for patients with inadequate oral intake. Laparoscopic guidance of PEG insertion is used for high-risk populations, including in infants less than 5kg at insertion. This study aimed to assess complication rates with traditional PEG tube insertion in infants less than 5kg at a single tertiary care center. METHODS: A retrospective review of patients less than 5kg who underwent PEG insertion was conducted. PEG insertion-related complications, up to four years following insertion, were collected. Outcomes were reported as counts and percentages, or median with minimum and maximum values. RESULTS: 480 pediatric gastrostomy procedures between January 1, 2009 and February 1, 2017, were screened, with 129 included for analysis. Median weight at PEG insertion was 3800g. Superficial surgical site infection (SSI) occurred in 6 (4.7%) patients, and 1 (0.8%) required readmission for intravenous antibiotics. One (0.8%) required endoscopic management for retained foreign body, 1 (0.8%) required operative management for gastrocolic fistula, and 1 (0.8%) for persistent gastrocutaneous fistula. No deep space SSI, procedure-related hemorrhage requiring readmission or transfusion, buried bumper syndrome, or procedure-related mortality occurred. CONCLUSION: Traditional PEG tube insertion in infants less than 5kg results in complication rates comparable to pediatric literature standards. LEVEL OF EVIDENCE: Level II, retrospective prognosis study.