Simulation for technical skill acquisition in open vascular surgery.

BACKGROUND: Simulation has an increasingly prominent role in modern vascular surgery training. However, it is important to understand how simulation is most effectively delivered to best use the time and resources available. The aim of this narrative review is therefore to critically appraise open technical skill acquisition in the operating room environment and provide recommendations for the future development of evidence-based simulation for open vascular surgery. METHODS: A systematic search strategy was used to retrieve relevant studies from PubMed, Medline, Web of Science, EMBASE, and the Cochrane databases in July 2019. Included papers were independently screened by two reviewers. Data were subsequently extracted using a standardized proforma and thematically analyzed. RESULTS: Thirteen studies were included. All demonstrated that simulation is effective in improving confidence and/or competence in performing open technical skills when assessed by previously validated metrics. However, not all participants or course schedules achieved equal benefit, with distributed practice for junior trainees over several weeks achieving a greater improvement in technical skill compared with senior trainees or longer course schedules for some tasks. CONCLUSIONS: Simulation can be an effective adjunct to traditional operative experience for technical skill acquisition in open vascular surgery. Future work should focus on developing models to address a wider range of training needs, as well as further defining the optimum schedule for the style, content, and timing of simulation for specific learner groups.

Reducing surgical site infection rates in colorectal surgery - a quality improvement approach to implementing a comprehensive bundle.

AIM: Surgical site infections (SSIs) are a preventable cause of morbidity following surgical procedures. Strategies to reduce rates of SSI must address pre-, peri- and postoperative factors and multiple interventions can be combined into 'bundles'. Adoption of these measures can reduce SSIs, but this is dependent on high levels of compliance. The aim of this work is to assess the change in rates of SSI in elective colorectal surgery after implementing a colorectal SSI bundle. METHOD: This is a single-centre prospective cohort study. All elective colorectal procedures from 2011 until 2018 (inclusive) were included. The primary outcome was inpatient SSI. A multimodal bundle was implemented using quality improvement methodology. The bundle was altered during the timeframe of the study to optimize outcomes. Data were analysed by interrupted time series analysis assessing points at which the bundle was altered. RESULTS: In the study period, 1075 elective colorectal procedures were performed. Prior to the introduction of the colorectal SSI bundle, the SSI rate was 16.4%. During the implementation period (2013-2015), the overall rate of SSI fell from 15.9% to 9.4%, with the most significant reduction being in superficial SSI, from 8.6% to 4.7%. In the postimplementation period from 2015-2018, there was a further reduction in the overall rate of SSI (5.1%). In 2018, there were 87 consecutive cases without infection. CONCLUSION: A successful reduction in the rate of SSI following elective colorectal surgery can be achieved by adopting a comprehensive perioperative bundle. This is complemented by a process of continuous measurement and evaluation. The current bundle has achieved a significant reduction in superficial SSI.

Estimating global and regional morbidity from acute bacterial meningitis in children: assessment of the evidence.

AIM: To estimate global morbidity from acute bacterial meningitis in children. METHODS: We conducted a systematic review of the PubMed and Scopus databases to identify both community-based and hospital registry-based studies that could be useful in estimation of the global morbidity from bacterial meningitis in children. We were primarily interested in the availability and quality of the information on incidence rates and case-fatality rates. We assessed the impact of the year of study, study design, study setting, the duration of study, and sample size on reported incidence values, and also any association between incidence and case-fatality rate. We also categorized the studies by 6 World Health Organization regions and analyzed the plausibility of estimates derived from the current evidence using median and inter-quartile range of the available reports in each region. RESULTS: We found 71 studies that met the inclusion criteria. The only two significant associations between the reported incidence and studied covariates were the negative correlation between the incidence and sample size (P<0.001) and positive correlation between incidence and case-fatality rate (P<0.001). The median incidence per 100000 child-years was highest in the African region - 143.6 (interquartile range [IQR] 115.6-174.6), followed by Western Pacific region with 42.9 (12.4-83.4), the Eastern Mediterranean region with 34.3 (9.9-42.0), South East Asia with 26.8 (21.0-60.3), Europe with 20.8 (16.2-29.7), and American region with 16.6 (10.3-33.7). The median case-fatality rate was also highest in the African region (31.3%). Globally, the median incidence for all 71 studies was 34.0 (16.0-88.0) per 100000 child-years, with a median case-fatality rate of 14.4% (5.3%-26.2%). CONCLUSIONS: Our study showed that there was now sufficient evidence to generate improved and internally consistent estimates of the global burden of acute bacterial meningitis in children. Although some of our region-specific estimates are very uncertain due to scarcity of data from the corresponding regions, the estimates of morbidity and case-fatality from childhood bacterial meningitis derived from this study are consistent with mortality estimates derived from multi-cause mortality studies. Both lines of evidence imply that bacterial meningitis is a cause of 2% of all child deaths.

Risk factors for severe acute lower respiratory infections in children: a systematic review and meta-analysis.

AIM: To identify the risk factors in children under five years of age for severe acute lower respiratory infections (ALRI), which are the leading cause of child mortality. METHODS: We performed a systematic review of published literature available in the public domain. We conducted a quality assessment of all eligible studies according to GRADE criteria and performed a meta-analysis to report the odds ratios for all risk factors identified in these studies. RESULTS: We identified 36 studies that investigated 19 risk factors for severe ALRI. Of these, 7 risk factors were significantly associated with severe ALRI in a consistent manner across studies, with the following meta-analysis estimates of odds ratios (with 95% confidence intervals): low birth weight 3.18 (1.02-9.90), lack of exclusive breastfeeding 2.34 (1.42-3.88), crowding - more than 7 persons per household 1.96 (1.53-2.52), exposure to indoor air pollution 1.57 (1.06-2.31), incomplete immunization 1.83 (1.32-2.52), undernutrition - weight-for-age less than 2 standard deviations 4.47 (2.10-9.49), and HIV infection 4.15 (2.57-9.74). CONCLUSION: This study highlights the role of the above seven risk factors in the development of severe pneumonia in under-five children. In addition, it emphasizes the need for further studies investigating other potential risk factors. Since these risk factors are potentially preventable, health policies targeted at reducing their prevalence provide a basis for decreasing the burden of childhood pneumonia.

Effectiveness of seasonal influenza vaccines in children -- a systematic review and meta-analysis.

AIM: To assess the efficacy and effectiveness of seasonal influenza vaccines in healthy children up to the age of 18 years. METHODS: MedLine, EMBASE, CENTRAL, CINAHL, WHOLIS, LILACS, and Global Health were searched for randomized controlled trials and cohort and case-control studies investigating the efficacy or effectiveness of influenza vaccines in healthy children up to the age of 18 years. The studies were assessed for their quality and data on the outcomes of influenza-like illness, laboratory-confirmed influenza, and hospitalizations were extracted. Seven meta-analyses were performed for different vaccines and different study outcomes. RESULTS: Vaccine efficacy for live vaccines, using random effects model, was as follows: (i) for similar antigen, using per-protocol analysis: 83.4% (78.3%-88.8%); (ii) for similar antigen, using intention to treat analysis: 82.5 (76.7%-88.6%); (iii) for any antigen, using per protocol analysis: 76.4% (68.7%-85.0%); (iv) for any antigen, using intention to treat analysis: 76.7% (68.8%-85.6%). Vaccine efficacy for inactivated vaccines, for similar antigen, using random effects model, was 67.3% (58.2%-77.9%). Vaccine effectiveness against influenza-like illness for live vaccines, using random effects model, was 31.4% (24.8%-39.6%) and using fixed-effect model 44.3% (42.6%-45.9%). Vaccine effectiveness against influenza-like illness for inactivated vaccines, using random effects model, was 32.5% (20.0%-52.9%) and using fixed-effect model 42.6% (38.3%-47.5%). CONCLUSIONS: Influenza vaccines showed high efficacy in children, particularly live vaccines. Effectiveness was lower and the data on hospitalizations were very limited.

An evaluation of emerging vaccines for childhood meningococcal disease.

BACKGROUND: Meningococcal meningitis is a major cause of disease worldwide, with frequent epidemics particularly affecting an area of sub-Saharan Africa known as the "meningitis belt". Neisseria meningitidis group A (MenA) is responsible for major epidemics in Africa. Recently W-135 has emerged as an important pathogen. Currently, the strategy for control of such outbreaks is emergency use of meningococcal (MC) polysaccharide vaccines, but these have a limited ability to induce herd immunity and elicit an adequate immune response in infant and young children. In recent times initiatives have been taken to introduce meningococcal conjugate vaccine in these African countries. Currently there are two different types of MC conjugate vaccines at late stages of development covering serogroup A and W-135: a multivalent MC conjugate vaccine against serogroup A,C,Y and W-135; and a monovalent conjugate vaccine against serogroup A. We aimed to perform a structured assessment of these emerging meningococcal vaccines as a means of reducing global meningococcal disease burden among children under 5 years of age. METHODS: We used a modified CHNRI methodology for setting priorities in health research investments. This was done in two stages. In the first stage we systematically reviewed the literature related to emerging MC vaccines relevant to 12 criteria of interest. In Stage II, we conducted an expert opinion exercise by inviting 20 experts (leading basic scientists, international public health researchers, international policy makers and representatives of pharmaceutical companies). They answered questions from CHNRI framework and their "collective optimism" towards each criterion was documented on a scale from 0 to 100%. RESULTS: For MenA conjugate vaccine the experts showed very high level of optimism (~ 90% or more) for 7 out of the 12 criteria. The experts felt that the likelihood of efficacy on meningitis was very high (~ 90%). Deliverability, acceptability to health workers, end users and the effect on equity were all seen as highly likely (~ 90%). In terms of the maximum potential impact on meningitis disease burden, the median potential effectiveness of the vaccines in reduction of overall meningitis mortality was estimated to be 20%; (interquartile range 20-40% and min. 8%, max 50 %). For the multivalent meningococcal vaccines the experts had similar optimism for most of the 12 CHNRI criteria with slightly lower optimism in answerability and low development cost criteria. The main concern was expressed over the cost of product, its affordability and cost of implementation. CONCLUSIONS: With increasing recognition of the burden of meningococcal meningitis, especially during epidemics in Africa, it is vitally important that strategies are taken to reduce the morbidity and mortality attributable to this disease. Improved MC vaccines are a promising investment that could substantially contribute to reduction of child meningitis mortality world-wide.

Does positron emission tomography/computed tomography change management in colorectal cancer?

BACKGROUND: Positron emission tomography/computed tomography (PET/CT) is used pre-operatively in patients with metastatic or recurrent colorectal cancer to identify those who have potentially curative disease. However, a recent randomized trial questioned the added benefit of PET/CT over conventional imaging in patients with liver metastases. The aim of this study was to determine the proportion of patients with colorectal cancer in whom PET/CT altered surgical management, in a single tertiary centre. METHODS: This was a retrospective study of all patients with colorectal cancer who had a PET/CT for colorectal cancer, funded by the Canterbury District Health Board between 2010 and 2014. RESULTS: Some 111 PET/CT scans were performed on 105 patients. A total of 38% of PET/CT were for patients with known or suspected liver metastases, 23% for suspected local recurrence and 18% for known or suspected lung metastases. Five scans were for post-operative patients with a rising carcinoembryonic antigen and no attributable source on conventional imaging. PET/CT identified additional extrahepatic sites of disease in 19 of 111 (17%) scans in patients deemed to have potentially operable disease. Overall, PET/CT altered surgical management following six of 42 (14%) scans for patients with liver metastases, four of 20 (20%) scans for patients with lung metastases and six of 26 (23%) scans for patients with local recurrence. CONCLUSION: PET/CT remains a useful adjunct to conventional imaging in the pre-operative workup of patients with colorectal cancer.

Rapid access carotid endarterectomy: winning the RACE following a natural disaster.

AIMS: Rapid access carotid endarterectomy (RACE) is the gold standard for stroke prevention in symptomatic patients with 50-99% internal carotid artery stenosis. Diagnosis and referral of eligible patients may be delayed by disruption to local health services. The aim of this study was to evaluate whether service provision was maintained at an appropriate standard (<2 weeks) following a natural disaster. METHODS: Consecutive symptomatic patients who underwent carotid endarterectomy (CEA) at a tertiary hospital between January 2006 and December 2014 were identified. The timeline from initial presentation to carotid imaging, vascular review and surgery was mapped. The post-earthquake period was defined between 22nd of February 2011 until July 2012. RESULTS: Of the 404 patients that underwent CEA during the above period, 62 patients presented during the post-earthquake period and these patients comprised the primary study group. The median time between presentation and CEA was nine days. In all, 47 patients had CEA within two weeks from the index event. The number of CEA procedures doubled since 2009. CONCLUSIONS: Despite many challenges following a major natural disaster, delivery of RACE has been maintained at an acceptable standard. Some delays persist and these remain areas for improvement in future.