An online case-based teaching and assessment program on clinical history-taking skills and reasoning using simulated patients in response to the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has created unprecedented challenges for medical students and educators worldwide. Groups 1, 2 and 3 of year 3, semester 2 medical students at the Royal College of Surgeons in Ireland (n = 275) had only completed 2, 5 and 7 weeks, respectively, of their scheduled 10-week clinical medicine and surgery attachments, prior to the Irish shutdown of all in-person non-essential activities, including medical student education. METHODS: We developed and delivered an online case-based program, focused on history-taking skills and clinical reasoning, using simulated patients and video technologies. 12 tutorials were delivered over 6 weeks to 35 subgroups of 8 students in line with program learning outcomes. Both simulated patients (n = 36), and tutors (n = 45, from retired clinical professors to newly graduated physicians), were rapidly upskilled in Blackboard Collaborate and Microsoft Teams, and also in the provision of constructive feedback. We evaluated this newly developed program by the following three criteria: student attendance, achieved grades, and student feedback. RESULTS: Attendance at the 12 tutorials was higher amongst group 1 and 2 students (75 and 73%) by comparison with group 3 students (60%) (p = < 0.001). Of the 273 students that sat the Year 3 Semester 2 online long case assessment, 93% were successful. Despite group 1 students having the least prior clinical experience, results were similar to those of groups 2 and 3 (1st honors, 2nd honors, pass, and fail grades for group 1, 39%, 33%, 23% and 6%; group 2, 34%, 41%, 17% and 8%; group 3, 39%, 25%, 28% and 7%) (p = 0.48). An increased attendance rate at tutorials was associated with higher numbers of honors grades (p = < 0.001). Anonymous feedback from the students demonstrated considerable satisfaction with program: > 85% agreed that the online program was interactive and very educational. CONCLUSIONS: Use of online video technology, tutors of varied experience, and simulated patients were demonstrated to replicate patient encounters, and to facilitate the development of clinical skills remotely during the COVID-19 pandemic.

Outpatient management of acute uncomplicated appendicitis after laparoscopic appendectomy: a randomized controlled trial.

OBJECTIVE: To confirm the safety and efficacy of outpatient management of laparoscopic appendectomy, with an enhanced recovery after surgery (ERAS) protocol, in adult patients with uncomplicated acute appendicitis. Outpatient laparoscopic appendectomy is feasible and secure in selected patients in observational studies. The benefits include reduced length of stay (LOS) and postoperative complications. This is the first randomized controlled trial of outpatient management following ERAS protocol. METHODS: Patients admitted from the emergency department with acute appendicitis were randomized into one of two groups: standard care within the hospital (HG) or the outpatient group (OG). An ERAS protocol was followed for both groups. Patients in the HG were admitted to the surgical ward. Patients in the OG were referred to the day-surgery unit. The primary endpoint was the length of stay. RESULTS: Ninety-seven patients were included: 49 in the OG and 48 in the HG. LOS was significantly shorter in the OG (mean 8.82 h) than in the HG (mean 43.53 h), p < 0.001. There was no difference in readmission rates (p = 0.320); we observed only one readmission in the OG. No further emergency consultations or complications were observed. The cost saving was $516.52/patient as a result of the intervention. CONCLUSION: Outpatient management of appendectomy is safe and feasible procedure in selected patients. This approach could become the standard of care for patients with uncomplicated appendicitis, showing fewer complications, lower LOS and cost. TRIAL REGISTRATION: Registration: www. CLINICALTRIALS: gov (NCT05401188) Clinical Trial ID: NCT05401188.

Options in Bariatric Surgery: Modeled Decision Analysis Supports One-Anastomosis Gastric Bypass as the Treatment of Choice when Type 2 Diabetes Is Present.

BACKGROUND: Obesity and type 2 diabetes mellitus (T2DM) represent significant healthcare burdens. Surgical management is superior to traditional medical therapy. Laparoscopic sleeve gastrectomy (LSG) and gastric bypass (both Roux-en-Y (RYGB) and one anastomosis gastric bypass (OAGB) are the most commonly performed metabolic procedures. It remains unclear which gives the optimal quality-of-life pay-off in the context of T2DM. This study compares LSG, RYGB, and OAGB in the management of T2DM and obesity using modeled decision analysis. Alternative approaches were assessed considering efficacy of interventions, post-operative complications, and quality of life outcomes to determine the optimal approach. METHODS: Modeled decision analysis was performed from the patent's perspective comparing best medical management (MM), SG, RYGB, OAGB, and LAGB. The base case is a 40-year-old female with a body mass index (BMI) of 40 and T2DM. Input variables were calculated based on published decision analyses and a literature review. Utilities were based on previous studies. Sensitivity analysis was performed. The payoff was quality-adjusted life years (QALYs) 5 years from intervention. TreeAge Pro modeling software was used for analysis. RESULTS: In 5-years post-procedure, OAGB gave the optimal QALY payoff of 3.65 QALYs (reviewer 2). RYGB gave 3.47, SG gave 3.08, LAGB gave 2.62 and MM 2.45 QALYs. Three input variables proved sensitive. RYGB is optimal if its metabolic improvement rates exceed 86%. It is also optimal if metabolic improvement rates in OAGB drop below 71.8% or if the utility of OAGB drops below 0.759. CONCLUSION: OAGB gives the optimal QALY payoff in treatment of T2DM. RYGB and SG also improve metabolic outcomes and remain viable options in selected patients.

The effect of a pre- and post-operative exercise programme versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): Study protocol for a randomised controlled trial.

BACKGROUND: Advances in peri-operative oncological treatment, surgery and peri-operative care have improved survival for patients with oesophagogastric cancers. Neoadjuvant cancer treatment (NCT) reduces physical fitness, which may reduce both compliance and tolerance of NCT as well as compromising post-operative outcomes. This is particularly detrimental in a patient group where malnutrition is common and surgery is demanding. The aim of this trial is to assess the effect on physical fitness and clinical outcomes of a comprehensive exercise training programme in patients undergoing NCT and surgical resection for oesophagogastric malignancies. METHODS: The PERIOP-OG trial is a pragmatic, multi-centre, randomised controlled trial comparing a peri-operative exercise programme with standard care in patients with oesophagogastric cancers treated with NCT and surgery. The intervention group undergo a formal exercise training programme and the usual care group receive standard clinical care (no formal exercise advice). The training programme is initiated at cancer diagnosis, continued during NCT, between NCT and surgery, and resumes after surgery. All participants undergo assessments at baseline, post-NCT, pre-surgery and at 4 and 10 weeks after surgery. The primary endpoint is cardiorespiratory fitness measured by demonstration of a 15% difference in the 6-min walk test assessed at the pre-surgery timepoint. Secondary endpoints include measures of physical health (upper and lower body strength tests), body mass index, frailty, activity behaviour, psychological and health-related quality of life outcomes. Exploratory endpoints include a health economics analysis, assessment of clinical health by post-operative morbidity scores, hospital length of stay, nutritional status, immune and inflammatory markers, and response to NCT. Rates of NCT toxicity, tolerance and compliance will also be assessed. DISCUSSION: The PERIOP-OG trial will determine whether, when compared to usual care, exercise training initiated at diagnosis and continued during NCT, between NCT and surgery and then during recovery, can maintain or improve cardiorespiratory fitness and other physical, psychological and clinical health outcomes. This trial will inform both the prescription of exercise regimes as well as the design of a larger prehabilitation and rehabilitation trial to investigate whether exercise in combination with nutritional and psychological interventions elicit greater benefits. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03807518 . Registered on 1 January 2019.

Over-admission and over-treatment of patients with cellulitis: a 5-year audit against international guidelines.

BACKGROUND/AIMS: Application of evidence-based guidelines in the management of cellulitis is poorly studied in Ireland and it is observed that current admission and prescription practices in this country vary widely from internationally accepted standards of care. We aimed to examine the management of cellulitis with regard to hospital admission and initial antibiotic therapy. METHODS: A retrospective audit of patients admitted with cellulitis from 2013 to 2017 in an Irish district general hospital. Exclusion criteria included specialist regions of the body and surgical site infections. Appropriateness of admission and management was compared against international guidelines (Clinical Research Efficiency Support Team (CREST) and Infectious Disease Society of America (IDSA)). RESULTS: Five hundred twenty emergency admissions with cellulitis were analysed. Thirty-five percent (n = 182) were deemed inappropriate admissions compared with CREST and IDSA guidelines, with an estimated cost of €152,203 per annum. Ninety-six percent (n = 501) of patients with cellulitis were treated with a combination of flucloxacillin and benzylpenicillin, despite level 1 evidence showing combination therapy to provide no benefit over appropriate monotherapy. CONCLUSIONS: There is a significant discrepancy between current clinical practice and international guidelines for the management of cellulitis in Ireland; local guidelines are not in keeping with newer evidence and there is a lack of national guidelines for this common condition. Closer adherence to international guidelines would significantly reduce costs by reducing unnecessary admissions and initial monotherapy would improve antibiotic stewardship. This study shows a clear need for local institutions to re-examine antibiotic guidelines to ensure the HSE provides effective evidence-based treatment in the correct setting.

Perioperative prehabilitation and rehabilitation in esophagogastric malignancies: a systematic review.

Cancers of the esophagus and stomach are challenging to treat. With the advent of neoadjuvant therapies, patients frequently have a preoperative window with potential to optimize their status before major resectional surgery. It is unclear as to whether a prehabilitation or optimization program can affect surgical outcomes. This systematic review appraises the current evidence for prehabilitation and rehabilitation in esophagogastric malignancy. A literature search was performed according to PRISMA guidelines using PubMed, EMBASE, Cochrane Library, Google Scholar, and Scopus. Studies including patients undergoing esophagectomy or gastrectomy were included. Studies reporting on at least one of aerobic capacity, muscle strength, quality of life, morbidity, and mortality were included. Twelve studies were identified for inclusion, comprising a total of 937 patients. There was significant heterogeneity between studies, with a variety of interventions, timelines, and outcome measures reported. Inspiratory muscle training (IMT) consistently showed improvements in functional status preoperatively, with three studies showing improvements in respiratory complications with IMT. Postoperative rehabilitation was associated with improved clinical outcomes. There may be a role for prehabilitation among patients undergoing major resectional surgery in esophagogastric malignancy. A large randomized controlled trial is warranted to investigate this further.

Virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: a randomised controlled trial.

BACKGROUND: It is standard practice to review all patients following discharge at a follow-up clinic but demands on all health services outweigh resources and unnecessary review appointments may delay or deny access to patients with greater needs. AIMS: This randomised trial aimed to establish whether a virtual outpatient clinic (VOPC) was an acceptable alternative to an actual outpatient clinic (OPC) attendance for a broad range of general surgical patients following a hospital admission. PATIENTS AND METHODS: All patients admitted under one general surgical service over the study period were assessed. If eligible for inclusion the rationale, randomisation and follow-up methods were explained, consent was sought and patients randomised to receive either a VOPC or an OPC appointment. RESULTS: Two-hundred and nine patients consented to study inclusion, of which 98/107 (91.6%) in the VOPC group and 83/102 (81.4%) in the OPC group were successfully contacted. Only 6 patients in the OPC group and 10 in the VOPC group reported ongoing issues. A further follow-up indicated 78 of 82 (95%) VOPC patients were very happy with their overall experience compared with 34/61 (56%) in the actual OPC group (p<0.001). A significant proportion of both cohorts-68/82 (83%) in VOPC group and 41/61 (67%) in OPC group (p = 0.029)-preferred a VOPC appointment as their future follow-up of choice. CONCLUSIONS: The majority of patients discharged from a surgical service could be better followed up by a virtual clinic with a significant proportion of patients reporting a preference for and a greater satisfaction with such a service.