Development of an Interactive Remote Basic Surgical Skills Mini-Curriculum for Medical Students During the COVID-19 Pandemic.

Introduction. Teaching surgical skills has historically been a hands-on activity, with instructors and learners in close physical proximity. This paradigm was disrupted by the COVID-19 pandemic, requiring innovative solutions to surmount the challenges of teaching surgical skills remotely. In this work, we describe our institution's path and early results of developing an interactive remote surgical skills course for medical students in the surgical clerkship. Methods. 31 third-year medical students were distributed a set of surgical equipment and 3D printed phone dock. Each participant completed a baseline questionnaire and underwent 3 structured interactive remote sessions on surgical instruments, knot tying, and suturing techniques. Students were instructed on sharing their first-person viewpoint and received real-time feedback on their knot tying and suturing techniques from the course instructor. Pre- and post-session surveys were conducted and analyzed. Results. All students were able to complete the remote surgical skills course successfully, as defined by visually demonstrating successful two-handed knot and simple suture techniques. Students' aggregate confidence score in their knot tying ability (pretest mean 7.9, SD 0.7 vs posttest mean 9.7, SD 0.9, t-statistic -2.3, P = .03) and suturing ability (pretest mean 8.0, SD 1.3 vs posttest mean 13.8, SD 0.9 t-statistic -5.5, P < .001) significantly improved after the intervention. Qualitative feedback from the students underscored the utility of the first-person perspective for teaching surgical technique. Conclusion. This study demonstrates that remote teaching of knot tying and simple suturing to medical students can be effectively implemented using a remote learning curriculum that was well received by the learners.

Fluctuations in appraisal over time in the context of stable versus non-stable health.

PURPOSE: This study seeks to estimate clinically significant change in quality of life (QOL) appraisal by comparing changes in appraisal over 6 months of follow-up in people with multiple sclerosis who experienced no change in symptoms versus those with worsening symptoms. This estimation is important for enabling valid interpretation of longitudinal change, both in terms of ensuring the comparison of scores and for response shift estimation. METHODS: This is a secondary analysis of longitudinal data (N = 859) of participants in the North American Research Committee on Multiple Sclerosis registry. Patient groupings were characterized on the basis of self-reported symptom change over 1 year of follow-up and compared in terms of their responses to the QOL Appraisal Profile. Bonferroni adjustments reduced the type I error rate, and interpretation was restricted to those comparisons with small or larger effect sizes using Cohen's criteria. RESULTS: The Symptoms Unchanged group evidenced more change in Frame of Reference goal delineation themes and Combinatory Algorithm, whereas the Symptoms Worse group evidenced more change in Sampling of Experience and Standards of Comparison items. The group differences were, however, not large or statistically significant in most cases, likely due to being under-powered to detect interaction effects. CONCLUSIONS: Many aspects of appraisal are relatively constant in the context of unchanging and changing symptom experience, but symptom changes led patients to make substantial shifts in what experiences they sample when thinking about their health-related QOL. These underlying cognitive processes may help people to maintain homeostasis in their perceived QOL.

Active cognitive reserve influences the regional atrophy to cognition link in multiple sclerosis.

Recent research indicates that cognitive reserve mitigates the clinical expression of neuropsychological impairment in multiple sclerosis (MS). This literature primarily uses premorbid intelligence and lifetime experiences as indicators. However, changes in current recreational activities may also contribute to the maintenance of neural function despite brain atrophy. We examined the moderation effects of current changes in recreational activity on the relationship between brain atrophy and information processing speed in 57 relapsing-remitting MS patients. Current enrichment was assessed using the Recreation and Pastimes subscale from the Sickness Impact Profile. In patients reporting current declines in recreational activities, brain atrophy was negatively associated with cognition, but there was no such association in participants reporting stable participation. The MRI metric-by-recreational activity interaction was significant in separate hierarchical regression analyses conducted using third ventricle width, neocortical volume, T2 lesion volume, and thalamic volume as brain measures. Results suggest that recreational activities protect against brain atrophy's detrimental influence on cognition.

Changing values, changing outcomes: the influence of reprioritization response shift on outcome assessment after spine surgery.

BACKGROUND: When patients experience a substantial health state change, they may undergo changes in the underlying meaning of their self-report to standardized outcome measures. These response shifts can reflect changes in the patient's internal standards, values or conceptualization of quality of life. We investigated the presence of changing values (reprioritization response shift) in a longitudinal cohort of spine surgery patients. METHODS: Spinal decompression surgery patients (mean age 52 years; 39 % female, 36 % working) provided visual analogue scale (VAS) back and leg pain items, the Short-Form-36 (SF-36v1), and the Oswestry Disability Index (ODI) data pre- and post-surgery (n pre = 169; n 6weeks = 102; n 3months = 106; n 6months = 68). Improved and No-Effect patient groups were compared using the VAS minimally important difference (±15 points) as a cutoff. Reprioritization response shift detection was based on change in the relative importance of the SF-36 domains for group discrimination pre- and post-surgery. RESULTS: The Improved group evidenced significant post-surgery differences from the No-Effect group on bodily pain, general health, physical functioning, social functioning, vitality, and the ODI. The relative importance analysis showed a differential effect with bodily pain (p < 0.01) and physical functioning (p < 0.05) becoming more important, and role physical (p < 0.01) becoming less important post-surgery in distinguishing the Improved group as compared to the No-Effect group. The Improved patients also evidenced stronger associations between bodily pain and physical functioning, vitality and general health (p < 0.05). The No-Effect group evidenced increased inter-correlations of bodily pain with social functioning, mental health, and general health (p < 0.05). CONCLUSIONS: Patients who report clinically significant change in leg and back pain post-surgery using VAS pain scores are also distinguished by increased importance of bodily pain and physical functioning, and decreased importance of role physical. Bodily pain is primarily reflective of physical item response post-surgery among Improved patients, but reflects physical, social, and emotional item response among No-Effect patients. These changes in values may reflect a "moving goal post" in outcome assessment that complicates the interpretation of mean differences over time on standard spine outcome measures.

Cognitive reserve and symptom experience in multiple sclerosis: a buffer to disability progression over time?

OBJECTIVE: To investigate the possible buffering effect of cognitive reserve on symptom experience for multiple sclerosis (MS) disease course. DESIGN: Secondary analysis of longitudinal data from the North American Research Committee on MS Registry. SETTING: Registry study and web-based supplemental survey. PARTICIPANTS: People with MS (N=859). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Two health outcome measures, the Symptom Inventory and the Performance Scales, were collected biannually over 1 and 6 years, respectively. Active and passive cognitive reserve was measured using the Stern Leisure Activities and the Sole-Padulles Childhood Enrichment tools, respectively. Linear regression, chi-square, multilevel random-effects modeling, and classification and regression tree modeling were used to compare cross-sectional means, disease course by cognitive reserve, longitudinal trajectories, and active cognitive reserve item endorsement by disability groups, respectively. RESULTS: Patients with high-active reserve had a lesser symptom burden than those with low-active reserve independent of passive reserve (P<.01). Cognitive reserve was associated with course of disease, such that high-active patients were overrepresented among relapsing-remitting patients, and underrepresented among patients with progressive disease (χ(2)=14.7, P<.03). Longitudinal modeling revealed a significant interaction of active reserve and time in mobility, fatigue, and overall disability in the whole sample (P<.05 in all comparisons). Among patients whose disability trajectories changed over time, active cognitive reserve was associated with less deterioration (P<.001). Passive cognitive reserve evidenced no effect in the longitudinal analyses. Active cognitive reserve scores across disability groups had a similar range but comprised different items, indicating that patients maintain active cognitive reserve with different activities as the disease progresses. CONCLUSIONS: Our findings suggest that active cognitive reserve is a buffer for functional limitation across disability groupings. Cognitive reserve may provide an alternative lens for thinking about the disease course of MS, providing a longer "runway" until disability accrual through cortical remodeling. Loss of cognitive reserve may explain the onset of progressive disease in MS.

The symptom inventory disability-specific short forms for multiple sclerosis: construct validity, responsiveness, and interpretation.

OBJECTIVES: To test the cross-sectional and longitudinal construct validity of the disability-specific short forms of the Symptom Inventory for multiple sclerosis, to compare its internal consistency reliability and construct validity with those of the original (1999) 29-item short form of the Symptom Inventory, and to provide for the new disability-specific short forms interpretation metrics for use in sample size calculation for future research. DESIGN: A Web-based longitudinal study, with data collected at baseline and 6 months after baseline. Correlations evaluated the overlap among disease-specific and generic patient-reported outcome measures. Responsiveness was assessed by using symptom transition scores and modified standardized response means. Interpretation guidelines were provided by using Cohen's effect size and crosswalks to the disease-specific and generic quality-of-life measures. SETTING: National Multiple Sclerosis Registry. PARTICIPANTS: People with multiple sclerosis (N=1142) who participated in the North American Research Committee on Multiple Sclerosis Registry. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Symptom Inventory; the disease-specific Performance Scales and the Patient-Determined Disease Steps; the generic Short Form 12. RESULTS: The Symptom Inventory evidenced convergent and divergent validity, and the disability-specific short forms evidenced similar psychometric performance as the 1999 short form but had slightly better alpha reliability. They also evidenced moderate responsiveness to clinically important change, with more responsiveness among those with mild and moderate disabilities than among those with severe disabilities. Effect sizes were larger among patients who reported symptom improvement, rather than deterioration, suggesting that the tool would be more useful in clinical research focused on testing whether an intervention improves symptom experience, particularly for patients with mild and moderate disabilities. Crosswalks provided graphic and numeric links between the Symptom Inventory and other patient-reported outcomes. CONCLUSIONS: The Symptom Inventory can be useful for elucidating the patient's experience, but it varies considerably across and within disability groupings. Directions for future research are discussed.