Safer surgical practice: a guide for surgeons (not just for pandemics)

The surgical working environment has changed considerably since the World Health Organisation (WHO) declared the coronavirus outbreak, COVID-19 (SARS-CoV-2), a pandemic on 11 March 2020. Measures remain in place to reduce the risk of spread from patients to surgeons, nosocomial infection and amongst healthcare workers. However, despite these protective measures, healthcare staff are at risk with the number of health workforce deaths increasing worldwide. This article sets out to explore the roles and responsibilities of the surgeon during these extraordinary times and discuss how we can improve our practice to reduce the risk of harm to patients, surgical staff, and ourselves. (c) 2021 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Optimizing Radiologic Detection of COVID-19: Test Set Technologies and Artificial Intelligence

COVID-19 has had a huge impact globally. This chapter examines the role that test set technologies coupled with artificial intelligence can transform clinical educational strategies. Using AI to streamline a methodology that has been around for decades enables education that is tailored to each clinician, acknowledges each individual's weaknesses, and is available instantly wherever in the world the clinician is available. Cautionary notes are also provided. © Springer Nature Switzerland AG 2022.

How has the mental health of junior staff been negatively affected by the current COVID-19 climate?

While pandemics are widely recognised and remembered for their devastating physical effects on human and/or animal life, previously a less talked about but recognised effect is that on mental health. This audit aimed to measure the negative effects COVID-19 has had on the mental wellbeing of junior staff working in hospitals, specifically the Dental Core Trainees (DCT) throughout the Thames Valley and Wessex (TVW) Deanery. 40% of the respondents used the intervention, with meditation and mindfulness found most useful. The overall mental health of the DCT improved with increased scores seen in all areas of personal life. Leisure activity/hobbies increased as well as positive behaviours which resulted in anxiety levels decreasing significantly. There was an overall reduction in all stressors except 'workload/responsibilities', which increased from 40 to 80%. Dissatisfaction with senior support which was not in line with what the DCT wanted or needed. Responses still showed that 'family/friends health' continues to be of higher importance than 'personal health'. The intervention was partly successful, with increased satisfaction levels and improved mental wellbeing. A lack of perceived internal support from Trusts and poor communication from senior colleagues with no specific guidance on how their role was changing despite the second intervention.Copyright © 2021 The Authors

NISO plus 2022 Miles Conrad lecture: The role of a library in a world of unstructured data

Throughout its nearly two hundred year existence, the National Library of Medicine (NLM) (https://www.nlm.nih.gov/) has advanced biomedicine and public health by acquiring, organizing, preserving, and disseminating knowledge essential to health and medicine. NLM has devised many innovations including standard terminologies and messaging formats such as the Journal Article Tag Suite (https://dtd.nlm.nih.gov/) to organize and manage biomedical literature. While scientific communication largely relied on books and journals over the last two hundred years, digital data are quickly forming the substrate of scientific communications. Data come in forms with much less structure than that afforded by publications, and these can vary from observations made during carefully controlled clinical trials to streams of genomic sequences to the counts of footfalls captured by personal devices. Coincidently, an increasingly diverse set of users - from clinicians to laypeople to public health to big pharma to scientists - bring unique perspectives as they draw meaning from new sets of scientific output. How does a modern library meet its mission to acquire, organize, preserve, and disseminate the many outputs of contemporary science? What role do standards play? How does NLM help this diverse set of stakeholders derive meaning from its resources? © 2022 - The authors. Published by IOS Press.

A novel Australian online radiology teaching program for medical students

Purpose: To evaluate the effectiveness, uptake and improved learning of medical students following the introduction of a novel online radiology teaching program integrated within a medical student curriculum. Background(s): Traditional medical student teaching usually consists of system (anatomy, physiology, etc) or problem-based learning1, meaning that specific radiology teaching can be not focussed on as much as other specialties. This is supported by the literature that suggests that the lack of focus on radiology teaching in medical schools2 has often led to new medical graduates feeling ill-prepared for clinical practice3 when interpretation of medical images is required. The authors of this paper in collaboration with an Australian-based radiology education provider, DetectedX, have attempted to address this by creating an online, personalized chest Xray interpretation tool for medical students. Chest X-rays were prioritised in this project since they are the most ordered radiographic scan, have widespread relevancy across many specialties, and evidently there is an expectation that most graduating students should be able to interpret them4. Method(s): Pre-clinical medical students at a single tertiary institution were given several online modules that provided teaching on developing an approach to chest X-rays and recognising common pathology. Students were given access to these and were able to access these multiple times "on-demand" to create a personalized and selfdirected approach to their learning. Assessments on knowledge and surveys on the student's perception were performed prior to and at the conclusion of the module. Finding(s): Preliminary findings amongst medical students have found several benefits. Overall students have indicated that an online teaching program with set learning objectives, provided a more effective way to learn when compared to previous models. Additionally, the self-directed pace, as well as the ability to return to modules to revise topics further improved retention of, and reinforced interpretation principles. Preliminary survey findings report an increased willingness from students to use this online tool and increased receptiveness to further online, self-directed teaching modules. Students also reported better understanding when pathology was demonstrated within a clinical context reflecting alignment with other teaching that is problem-based. Conclusion(s): Traditional teaching often requires the student's physical presence at a scheduled location and time;however, the impact of Covid-19 has urged deliverers of medical education to consider effective online approaches. Our experience shows medical student willingness for further radiology teaching, and the use of an online, self-paced tool, demonstrates improved learning of concepts and retention of knowledge.

Determinants of turnaround time in a rapid genome sequencing program

Previous studies of genome sequencing (GS) in critically ill childrenhave made use of either modified hardware or working procedureswhich would be difficult, if not impossible, to integrate into existingclinical workflows1. Our lab’s transition from exome sequencing (ES) to GS offered an opportunity to implement in-house rapid genomesequencing (rGS) in critically ill children in a manner which couldintegrate with existing clinical workflows. We conducted a feasibilityand implementation pilot by offering rGS to child-parent triosconcurrently undergoing clinical rapid ES (rES) via a reference lab.The purpose of this study was to identify and address operationalbarriers to implementation of a rGS program capable of communicatinga preliminary result within 7 days of consent. We consideredthis time span to be more reflective of clinical realities than lab-quotedturnaround times (TAT) which typically start at sample receipt andthus do not account for challenges in sample acquisition and pre-testcounseling in a critical care setting, nor the impact of shipping times.Here we present data on TAT and lessons learned from the first 27subjects enrolled.Using rapid cycle improvement methodologies, we identified fourdistinct but inter-related workflows requiring optimization:1. Pre-analytic: patient identification through acquisition ofsamples2. Wet-lab: extraction through sequencing3. Bioinformatics: secondary and tertiary analysis as well as rapididentification of causal variants4. Return of resultsFigure 1 summarizes TAT across cases, demonstrating the markedimprovements in TAT with our programmatic approach to improvement.We used our first 9 cases to determine a baseline TAT for theentire process and to delineate the 4 main workflows (above). Atbaseline, excluding cases delayed by COVID-19 restrictions, mean TATwas 17.12 days (3 sequential deviant range: 7.05–27.19 days).Following deployment of our programmatic approach to rGS, meanTAT fell to 6.19 days (3 sequential deviant range: 0.51–11.87 days).Table 1 summarizes the observations and insights, by workflow, whichimpacted upon TAT and/or implementation. The single biggest impacton TAT was optimization of bioinformatics by removing all manualsteps between starting sequencing and producing human interpretable,filtered, annotated output of high-priority variants for interpretation.The second biggest source of improvement was optimization ofthe sequencing itself as well as prioritizing sample processing for andaccess to sequencing runs. While variant ranking is helpful in identifying causal variants, in 9/10 cases with a diagnostic findingthe causal variant(s)were obvious to the study teamwithin minutes ofviewing the annotated variant list, regardless of variant rank. (Figure Presented) As time required for sequencing and analytic workflows fell, therelative contribution of other workflows to overall TAT shifted and itbecame more obvious that early identification and utilization of thisapproach is very important in lowering overall time to diagnosis(Figure 2). In 6/10 cases with a diagnostic finding, the initial approachof the clinical team was NOT rES (and thus patients were not eligiblefor rGS on a research basis). Had rGS been the initial diagnosticmodality chosen, a diagnosis could have been reached in a median 12days sooner (range 2–28 days). There were also several cases wheresequencing was delayed when one or both parents did not present tothe lab to provide a blood sample in a timely manner. Optimization ofsequencing or analytic workflows cannot meaningfully improveoutcomes either of these situations.Our findings suggest some important considerations for institutionsdeveloping or seeking to improve rapid sequencing programs for acuteand critically ill children: (Table Presented) • Optimization of computational resource utilization and phenotypecuration saves more time than improved variant filtering orprioritization.• Obtaining samples from parents is non-trivial.• Even trained geneticists may fail to recognize appropriatecandidates for rGS.

Dual surgeon operating to improve patient safety.

The COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or 'layoff period') can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of 'currency' may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.

Optimisation of the evening surgical handover process in a large tertiary surgical department-a quality improvement project

Introduction: The aim of the project was to improve the quality and effectiveness of the evening surgical handover in a large tertiary surgical department, incorporating up to 150 patients. Method: Audit standards were derived from GMC and RCSEng guidelines. An initial audit of the evening handover was conducted over a period of two weeks. Following this, a standard operating protocol (SOP) was introduced, with re-audit 4-weeks following implementation. Results: The initial audit identified an inconsistent format and significant variability. Few handovers commenced with all team members present (11%) and were uninterrupted (33%). A laminated handover SOP checklist was produced and a new proforma was introduced to document tasks or reviews required overnight. A mandatory evening surgical HDU round was invoked and a “watchers” system was introduced to identify patients at highest risk of deterioration. Re-audit demonstrated significant improvements in all domains to>85%. ICU referrals overnight decreased from 6% to 2%. Further improvements measures were implemented in the form of a dynamic virtual handover document. Conclusions: A structured SOP improved the consistency of the handover process. A night review of all HDU patients reduced the rate of ICU referrals. Implementation of virtual handover processes may be required in the COVID-era.

Cutting edge selection: learning from high reliability organisations for virtual recruitment in surgery during the COVID-19 pandemic.

INTRODUCTION: National selection for higher surgical training (ST3+) recruitment in the UK is competitive. The process must prioritise patient safety while being credible, impartial and fair. During the COVID-19 pandemic, all face-to-face interviews were cancelled. Selection was based on a controversial isolated self-assessment score with no evidence checking taking place. From 2021, selection will take place entirely online. Although this has cost and time advantages, new challenges emerge. METHODS: We review surgical selection as it transitions to an online format and suggest validated methods that could be adapted from High Reliability Organisations (HRO). FINDINGS: Virtual selection methods include video interviewing, online examinations and aptitude testing. These tools have been used in business for many years, but their predictive value in surgery is largely unknown. In healthcare, the established online Multi-Specialty Recruitment Assessment (MSRA) examines generic professional capabilities. Its scope, however, is too limited to be used in isolation. Candidates and interviewers alike may have concerns about the technical aspects of virtual recruitment. The significance of human factors must not be overlooked in the online environment. Surgery can learn from HROs, such as aviation. Pilot and air traffic control selection is integral to ensuring safety. These organisations have already established digital selection methods for psychological aptitude, professional capabilities and manual dexterity. CONCLUSION: National selection for higher surgical training (ST3+) can learn from HROs, using validated methods to prioritise patient safety while being acceptable to candidates, trainers and health service recruiters.

COVID-19 vaccination and low cervical lymphadenopathy in the two week neck lump clinic - a follow up audit.

The UK COVID vaccination programme has progressed at an astonishing rate since the first patients received their doses in December 2020. It is well known that other vaccines including influenza and human papilloma virus (HPV) can result in reactive lymphadenopathy in the axilla and/or neck. Patients are now presenting via the two week wait neck lump clinic with supraclavicular fossa and low neck lymphadenopathy related to COVID vaccination, and to similar one stop breast clinics with axillary lymph nodes. In an audit of 80 patients seen over a period of one month, we found COVID vaccine-related low neck lymphadenopathy in four cases (5%), with an additional rectal cancer patient thought to have metastatic disease who presented with a Virchow type node. COVID vaccine-related lymphadenopathy should be considered in the differential diagnosis of low-neck nodes if they occurred shortly after vaccination, but it is important to exclude sinister disease using ultrasound and other investigations as necessary.

Suspected cauda equina syndrome: no reduction in investigation, referral and treatment during the COVID-19 pandemic.

INTRODUCTION: Compression of the cauda equina can lead to bladder, bowel and sexual dysfunction with lower limb pain, numbness and weakness. Urgent surgical decompression aims to prevent progressive neurological deficit. Symptoms of cauda equina syndrome (CES), such as back pain, sciatica and bladder dysfunction are common in the population, but the majority of those investigated do not have radiological cauda equina compression. However, a missed diagnosis can have significant medical, social and legal consequences. We investigated the effect of the COVID-19 pandemic on presentation and management of suspected CES. METHODS: This retrospective cohort study analysed referral, investigation and treatment of CES in a regional neurosurgical centre during the initial COVID-19 surge between March and May 2020 compared with March to May 2019. RESULTS: Referrals for suspected CES were similar during the COVID-19 pandemic (n = 275) compared with 2019 (n = 261, p = 0.596) despite a significant (19%) decrease in total emergency neurosurgical referrals (1248 in 2020 vs 1544 in 2019, p < 0.001). Nineteen (7%) of the suspected CES referrals underwent decompression in 2020, similar to 16 (6%) in 2019 (p = 0.867). There were no differences in outcomes or complications and no evidence of delays in presentation or treatment. CONCLUSIONS: Unlike other emergency neurosurgical conditions, the number of referrals for suspected CES and the percentage of referrals with radiological cauda equina compression were unchanged during the COVID-19 pandemic. The persistence of CES referrals when many people stayed away from hospital highlights the distress and worry caused by suspected CES and its symptoms to both patients and healthcare providers.

Supraclavicular lymphadenopathy following COVID-19 vaccination: an increasing presentation to the two-week wait neck lump clinic?

The first COVID-19 vaccination was given in December 2020 and there is an effort to vaccinate the international population on a massive scale. Common side effects from the vaccine include headache and tiredness. Regional lymphadenopathy has been described in relation to other vaccines. We describe two cases of supraclavicular reactive lymphadenopathy presenting in patients who had the COVID vaccination in the ipsilateral arm. Awareness of this diagnosis is important for patients presenting to the neck lump clinic.

Safer Surgical Practice: A Guide for Surgeons (not just for pandemics)

The surgical working environment has changed considerably since the World Health Organisation (WHO) declared the coronavirus outbreak, COVID-19 (SARS-CoV-2), a pandemic on 11 March 2020. Measures remain in place to reduce the risk of spread from patients to surgeons, nosocomial infection and amongst healthcare workers. However, despite these protective measures, healthcare staff are at risk with the number of health workforce deaths increasing worldwide. This article sets out to explore the roles and responsibilities of the surgeon during these extraordinary times and discuss how we can improve our practice to reduce the risk of harm to patients, surgical staff and ourselves.

Comparison of provision of maxillofacial emergency service during the two COVID-19 national lockdowns in the United Kingdom.

We previously published a study on the provision of emergency maxillofacial services during the first UK COVID-19 pandemic national lockdown. We repeated the study during the second lockdown and now present our findings that highlight the main differences and learning issues as the services have evolved.