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.

Evaluating the efficacy of self-study videos for the surgery clerkship rotation: an innovative project in undergraduate surgical education.

Background: Educational videos have become valuable resources and can address some of the pitfalls of traditional learning. To ensure clerkship students have adequate exposure to curriculum objectives, a series of objective-aligned self-directed learning video podcasts covering core surgical concepts were developed by medical students and surgical residents. The objective of the study was to evaluate the efficacy of the video podcasts in the surgery clerkship rotation. Methods: Nineteen video podcasts were created, housed at www.surgicaleducationportal.com, and distributed to third-year medical students completing their surgical clerkship. A 10-question multiple-choice quiz was administered before and after students viewed each video, and they were also asked to complete a satisfaction survey. Results: A total of 302 paired pretests and posttests were completed. There was a mean increase of 2.7 points in posttest scores compared with pretest scores (p < 0.001). On a Likert scale from 1 to 5, with 5 being excellent, students rated the usefulness of the videos as 4.3, the quality of the content as 4.3 and the quality of the video as 4.2. Ninety-eight percent of students would recommend these videos to their classmates. Conclusion: Video podcasts are an effective modality for engaging medical students and may improve standardization of learning during their surgical clerkship.

Contexte: Les vidéos de formation sont devenues d'inestimables ressources et elles peuvent combler certaines des lacunes de l'enseignement traditionnel. Pour que les résidents bénéficient d'une exposition adéquate aux objectifs curriculaires, une série de balados vidéo d'autoapprentissage centrés sur des objectifs reliés aux principaux concepts de chirurgie a été réalisée par des étudiants en médecine et des résidents en chirurgie. L'objectif de l'étude était d'évaluer l'efficacité des balados pour les stages de chirurgie. Méthodes: Dix-neuf balados vidéo ont été réalisés (accessibles en anglais au www.surgicaleducationportal.com) et distribués à des étudiants de troisième année de médecine qui effectuent leur stage de chirurgie. Un questionnaire en 10 points à choix multiples leur a été administré avant et après le visionnement de chaque vidéo; ils ont ensuite été invités à répondre à un questionnaire d'évaluation. Résultats: En tout 302 pré- et post-tests appariés ont été effectués. On a observé une augmentation de 2,7 points aux scores post-test, comparativement aux scores pré-test (p < 0,001). Sur une échelle de Likert allant de 1 à 5, 5 correspondant à excellent, les étudiants ont accordé un score de 4,3 pour l'utilité des balados vidéo et de 4,2 pour leur qualité. Quatre-vingt-dix-huit pour cent des étudiants recommanderaient ces balados vidéo à leurs camarades. Conclusion: Les balados vidéo sont une modalité efficace pour mobiliser les étudiants en médecine et pourraient faciliter l'uniformisation de l'apprentissage lors des stages de chirurgie.

A clampless and atraumatic technique for surgical preclosure of peripheral arteries.

Peripheral vascular access and closure are fundamental skills in cardiovascular surgery, especially in the era of transcatheter and minimally invasive surgical techniques. Conventional arterial access via surgical cutdown typically requires vascular clamps for surgical control and primary closure. We have been utilizing a surgical preclosure technique that does not require vascular clamping. The technique utilizes 4 to 5 full-thickness Prolene sutures placed in an interrupted fashion at the site of access instead of traditional purse-string sutures. These sutures are placed prior to vascular access. The sutures are not tied down until the procedure is complete and the vascular sheath is removed. This technique allows for adequate control and closure of the peripheral access artery without the use of vascular clamps and avoids traumatic manipulation of the artery.

Development of a median sternotomy simulation model for cardiac surgery training.

OBJECTIVE: We sought to develop a simulation model to train resident physicians in the performance of a median sternotomy. METHODS: A modified Delphi consensus process was used with cardiac surgery staff to develop a 20-point checklist for the safe performance of a median sternotomy. Thirteen junior cardiac surgery trainees from across Canada participated in this study to assess the simulation model. Trainees performed the sternotomy before and after reviewing an instructional video. Two senior cardiac surgery resident physicians assessed the participants with the checklist during each session. An entry and exit questionnaire was given to the participants to evaluate the simulation model. RESULTS: Participants scored higher after the training (14.3 ± 2.0) compared with before training (8.0 ± 3.1) (P < .001). The mean duration of time for participants to complete the sternotomy was shorter before training (188 ± 52 seconds vs 228 ± 58 seconds; P = .003). The checklist interrater reliability was κ = 0.47 (moderate) for before training and κ = 0.37 (fair) for after training. All study participants rated the simulation sessions as very useful or extremely useful. CONCLUSIONS: Using the simulation model, training video, and checklist, trainees were able to improve their skill in performing a median sternotomy. This improvement was associated with longer times to complete all procedure steps. Rater training may further improve interrater reliability. Our median sternotomy checklist and simulation model can be adopted for the technical skills training of future cardiac surgery trainees.

A technical skills elective program for pre-clerkship medical students reduces levels of high anxiety for performing technical skills.

BACKGROUND: We investigated the effect of a simulation-based technical skills course on rates of high anxiety reported by pre-clerkship medical students for basic and advanced technical skills. METHODS: Twenty-two second year medical students reported levels of anxiety by electronic survey for 21 technical skills before and after the course. A peer group of 75 students were invited to complete the survey for comparison. RESULTS: We received 21 (95.5%) responses before and after the course, and 12 (57.1%) in a three-month follow-up. Rates of high anxiety ranged from 19 to 86% across skills before the course and 0-48% afterward. There was no statistically significant difference in high anxiety reported in a three-month follow-up survey. The rates of high anxiety reported were reduced across all skills for course participants compared to the responding peer group of 32 (42.7%), reaching a statistically significant difference for 15/21 skills (P < 0.05). CONCLUSIONS: Participation in this technical skills course was associated with decreased reports of high anxiety by pre-clerkship medical students regarding the performance of basic and advanced technical skills.

Mechanical circulatory support in the context of coronary artery bypass grafting.

PURPOSE OF REVIEW: With the continuous innovation in mechanical circulatory support as an option for the management of patients in cardiogenic shock from myocardial infarction, it is important to understand the current evidence and recommendations for the use of these devices for patients who require or underwent coronary artery bypass surgery. RECENT FINDINGS: The use of mechanical circulatory support (MCS) in patients with cardiogenic shock who require or underwent coronary artery bypass surgery has not been well studied. Observational studies have shown that the use of intra-aortic balloon pump or percutaneous ventricular assist devices prior to revascularization lead to better survival. Extracorporeal membrane oxygenation (ECMO) still carries significant risk of mortality and complications; the use of additional MCS devices for left ventricular unloading during ECMO improves outcomes. SUMMARY: MCS will continue to play an important role in coronary artery surgery patients. Multidisciplinary Cardiac Shock Team can assist in proper patient selection and device choice, whereas prospective clinical trials are required to provide evidence-based guidance towards the management of these patients.

Exposure to the RXR Agonist SR11237 in Early Life Causes Disturbed Skeletal Morphogenesis in a Rat Model.

Longitudinal bone growth occurs through endochondral ossification (EO), controlled by various signaling molecules. Retinoid X Receptor (RXR) is a nuclear receptor with important roles in cell death, development, and metabolism. However, little is known about its role in EO. In this study, the agonist SR11237 was used to evaluate RXR activation in EO. Rats given SR11237 from post-natal day 5 to post-natal day 15 were harvested for micro-computed tomography (microCT) scanning and histology. In parallel, newborn CD1 mouse tibiae were cultured with increasing concentrations of SR11237 for histological and whole-mount evaluation. RXR agonist-treated rats had shorter long bones than the controls and developed dysmorphia of the growth plate. Cells invading the calcified and dysmorphic growth plate appeared pre-hypertrophic in size and shape, in correspondence with p57 immunostaining. Additionally, SOX9-positive cells were found surrounding the calcified tissue. The epiphysis of SR11237-treated bones showed increased TRAP staining and additional TUNEL staining at the osteo-chondral junction. MicroCT revealed morphological disorganization in the long bones of the treated animals. This study suggests that stimulation of RXR causes irregular ossification, premature closure of the growth plate, and disrupted long bone growth in rodent models.

Transcatheter vs Surgical Aortic Valve Replacement for Aortic Stenosis in Low-Intermediate Risk Patients: A Meta-analysis.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has emerged as the treatment of choice for patients with severe aortic stenosis at high surgical risk; the role of TAVR compared with surgical aortic valve replacement (SAVR) in the low-intermediate surgical risk population remains uncertain. Our primary objective was to determine differences in 30-day and late mortality in patients treated with TAVR compared with SAVR at low-intermediate risk (Society of Thoracic Surgeons Predicted Risk of Mortality < 10%). METHODS: Medline and Embase were searched from 2010 to March 2017 for studies that compared TAVR with SAVR in the low-intermediate surgical risk population, restricted to randomized clinical trials and matched observational studies. Two investigators independently abstracted the data and a random effects meta-analysis was performed. RESULTS: Four randomized clinical trials (n = 4042) and 9 propensity score-matched observational studies (n = 4192) were included in the meta-analysis (n = 8234). There was no difference in 30-day mortality between TAVR and SAVR (3.2% vs 3.1%, pooled risk ratio: 1.02; 95% confidence interval, 0.80-1.30; P = 0.89; I2 = 0%) or mortality at a median of 1.5-year follow-up (incident rate ratio: 1.01; 95% confidence interval, 0.90-1.15; P = 0.83; I2 = 0%). There was a higher risk of pacemaker implantation and greater than trace aortic insufficiency in the TAVR group whereas the risk of early stroke, atrial fibrillation, acute kidney injury, cardiogenic shock, and major bleeding was higher in the SAVR group. CONCLUSIONS: Although there was no difference in 30-day and late mortality, the rate of complications differed between TAVR and SAVR in the low-intermediate surgical risk population.

Maternal protein restriction leads to enhanced hepatic gluconeogenic gene expression in adult male rat offspring due to impaired expression of the liver X receptor.

Epidemiological studies demonstrate that the link between impaired fetal development and glucose intolerance in later life is exacerbated by postnatal catch-up growth. Maternal protein restriction (MPR) during pregnancy and lactation in the rat has been previously demonstrated to lead to impaired glucose tolerance in adulthood, however the effects of protein restoration during weaning on glucose homeostasis are largely unknown. Recent in vitro studies have identified that the liver X receptor α (LXRα) maintains glucose homeostasis by inhibiting critical genes involved in gluconeogenesis including G6pase (G6pc), 11ß-Hsd1 (Hsd11b1) and Pepck (Pck1). Therefore, we hypothesized that MPR with postnatal catch-up growth would impair LXRα in vivo, which in turn would lead to augmented gluconeogenic LXRα-target gene expression and glucose intolerance. To examine this hypothesis, pregnant Wistar rats were fed a control (20%) protein diet (C) or a low (8%) protein diet during pregnancy and switched to a control diet at birth (LP). At 4 months, the LP offspring had impaired glucose tolerance. In addition, LP offspring had decreased LXRα expression, while hepatic expression of 11ß-HSD1 and G6Pase was significantly higher. This was concomitant with decreased binding of LXRα to the putative LXRE on 11ß-Hsd1 and G6pase. Finally, we demonstrated that the acetylation of histone H3 (K9,14) surrounding the transcriptional start site of hepatic Lxrα (Nr1h3) was decreased in LP offspring, suggesting MPR-induced epigenetic silencing of the Lxrα promoter. In summary, our study demonstrates for the first time the important role of LXRα in mediating enhanced hepatic gluconeogenic gene expression and consequent glucose intolerance in adult MPR offspring.