Redeployment of Surgical Trainees to Intensive Care During the COVID-19 Pandemic: Evaluation of the Impact on Training and Wellbeing.

OBJECTIVE: The aim of this study was to evaluate the impact of redeployment of surgical trainees to intensive care units (ICUs) during the COVID-19 pandemic-in terms of transferrable technical and nontechnical skills and wellbeing. DESIGN: This was a survey study consisting of a 23-point questionnaire. SETTING: The study involved surgical trainees that had been redeployed to the (ICU) across all hospitals in London during the COVID-19 pandemic. PARTICIPANTS: The survey was sent to 90 surgical trainees who were between postgraduate years 2 to 4. Trainees in specialty training programs (>5 years after graduation) were not included. Thirty-two trainees responded to the questionnaire and were included in the study results. RESULTS: All respondents spent between 4 and 8 weeks working in ICU. Prior to redeployment, 78% of participants had previous experience of ICU or an affiliated specialty, and >90% had attended at least 1 educational course with relevance to ICU. There were statistically significant increases in confidence performing central venous cannulation and peripheral arterial catheterisation (p < 0.05). With regards to clinical skills, respondents reported feeling more confident managing ventilated patients, patients on noninvasive ventilation, dialysis, and circulatory failure patients after working in ICU. Respondents (97%) felt that the experience would be beneficial to their future careers but 53% felt the redeployment had a negative impact on their mental health. CONCLUSIONS: Redeployment of surgical trainees to ICU led to increased confidence in a number of technical and nontechnical skills. However, proactive interventions are needed for training surgeons with regard to their psychological wellbeing in these extraordinary circumstances and to improve workforce planning for future pandemics.

Management of hand fractures.

Hand fractures are the most common fractures of the upper extremity, with a reported incidence of 3.7 per 1000 per year for men and 1.3 per 1000 per year for women. Understanding the diagnosis and management of these injuries is vital for any clinician working in the emergency department, plastic or orthopaedic surgery or providing community care. This review identifies the most common presentations and outlines how to assess and manage such fractures appropriately, with an emphasis on clinical and radiographic examination. The majority of hand fractures are managed conservatively and operative management should be carefully considered on a case-by-case basis with analysis of patient and fracture-related factors, in order to achieve optimal hand function following treatment.

Secondary free tissue transfer in head and neck reconstruction.

BACKGROUND: The incidence of head and neck cancer (H&N) continues to increase together with the need for reconstructive surgery. Head and Neck microsurgeons are likely to encounter challenging secondary free flap surgery on the background of failed primary flaps, radiotherapy treatment or recurrence. The aim of this study was to review our experience of treating such cases in a tertiary referral centre in the United Kingdom. METHODS: We performed a retrospective analysis of all patients undergoing sequential free flap surgery for head and neck defects in our unit during 2010-2017. Parameters recorded included indication for surgery, type and sequence of reconstruction, recipient vessel use and post-operative complications. RESULTS: We identified 17 patients who underwent 39 free tissue transfers for the reconstruction of head and neck defects (five transfers were performed at other units). The radial forearm and anterolateral thigh flaps were most commonly used. Almost a quarter of patients underwent three or more free flap reconstructive procedures. In over a third, the same vein and artery were used for subsequent anastomoses, and we used five vein grafts over 68 anastomoses. There were no flap failures recorded. CONCLUSIONS: Secondary free flaps in the head and neck are required for a variety of aetiologies and can have success rates similar to those for primary free tissue transfers with minimal morbidity and mortality. Free tissue transfer is the best reconstructive option in H&N patients and should still be considered the first choice option in salvage cases until the patient's donor sites have been depleted.

Candesartan- and atenolol-based treatments induce different patterns of carotid artery and left ventricular remodeling in hypertension.

BACKGROUND AND PURPOSE: Angiotensin receptor blocker (ARB)-based treatment reduces cardiovascular events and stroke more than does beta-blocker-based treatment despite similar blood pressure (BP) reduction. We investigated whether these treatments have different effects on cardiac and large-artery remodelling and evaluated the relation of arterial remodelling to hemodynamic changes in subjects with hypertension. METHODS: We compared the treatment effects of an ARB (candesartan cilexetil)-based regimen and a beta-blocker (atenolol)-based regimen for 52 weeks on common carotid artery (CCA) and left ventricular structure in hypertensive patients in a randomized, double-blind study. Clinic brachial BP and 24-hour ambulatory BP, carotid BP, left ventricular mass index, CCA intima-media thickness, lumen diameter, intima-media area, and carotid blood flow were measured. Distensibility, circumferential tensile stress, Young's elastic modulus (E(m)), and shear stress (tau) in the CCA were also calculated. RESULTS: Both candesartan and atenolol reduced intima-media thickness and intima-media area and increased distensibility to similar extents after 52 weeks of treatment. Despite similar reductions in BP, treatment with atenolol resulted in a lesser reduction in left ventricular mass index, a decrease in lumen diameter, and a reduction in carotid blood flow compared with candesartan. CONCLUSIONS: BP-independent effects of ARB on cardiac and arterial structure may contribute to the beneficial effects of these agents on cardiovascular disease.

Metachronous melanoma in breast reconstruction patients.

The incidence and mortality due to malignant melanoma has increased three- to four-fold across males and females in England and Wales over the past thirty years. Ninety percent of patients with primary melanoma have no clinical evidence of lymphadenopathy at presentation. In this paper we describe our management of impalpable axillary melanoma deposits in a patient with a pedicled latissimus dorsi (LD) flap reconstruction to the ipsilateral breast. No such case has been previously described in the literature.