Perceptions and behaviors of learner engagement with virtual educational platforms.

BACKGROUND: The COVID-19 pandemic has increased utilization of educational technology for surgical education. Our aim was to determine attitudes and behaviors of surgical education champions towards virtual educational platforms and learner engagement. METHODS: An electronic survey was distributed to all Association of Surgical Education members addressing i) methods of engagement in virtual learning ii) ways to improve engagement and iii) what influences engagement. Stratified analysis was used to evaluate differences in responses by age, gender, level of training and specialty. RESULTS: 154 ASE members completed the survey (13% response rate). 88% respondents accessed virtual learning events at home. Most (87%) had joined a virtual learning event and then participated in another activity. 1 in 5 who did this did so "always" or "often". Female respondents were more likely than males to join audio and then participate in another activity (62.3% v 37.7%, p = 0.04). CONCLUSIONS: Virtual platforms do not automatically translate into increased learner engagement. Careful design of educational strategies is essential to increase and maintain learner engagement when utilizing virtual surgical education.

Medical students' perception of what embodies an effective surgeon educator.

BACKGROUND: Effective surgeon educators likely help medical students develop competency and may inspire pursuit of surgical training. We sought to determine the qualities medical students believe embody effective surgical educators. METHODS: Mixed-methods study of nationally electronically recruited 3rd-year medical students using virtual semi-structured interviews and anonymous quantitative survey to determine the most critical and most frequently encountered qualities of effective surgical educators. Thematic analysis using grounded theory was undertaken. RESULTS: Data saturation occurred after 9 interviews. Themes of effective surgical educators included: engagement (acknowledging student, knowing their name, talking to the student), fostering a positive learning environment (non-threatening, non-shaming questioning), inclusion (giving responsibility/appropriate autonomy), and understanding how to teach a novice (teaching the student how to learn, adapt to learner). On quantitative analysis of Likert based survey, encouraging, promoting a positive learning climate, timely constructive feedback, and questioning were ranked as most critical. CONCLUSION: Students highly value positive learning climate and inclusion. Faculty Development to promote these traits may improve clerkship learning and experience.

Assessing learner engagement with virtual educational events: Development of the Virtual In-Class Engagement Measure (VIEM).

BACKGROUND: The COVID-19 pandemic has necessitated virtual education, but effects on learner engagement are unknown. We developed a virtual in-class engagement measure (VIEM) to assess learner engagement in online surgical education events. METHODS: Using the STROBE, an observer collected tool to document student engagement, as a template an ASE committee workgroup developed the VIEM. The VIEM had two parts: observer assessment and learner self-assessment of engagement. Trained observers collected engagement data from two institutions using the VIEM. Surgical attendings, fellows and residents were observed during virtual learning events. Educator attitudes towards online teaching were also assessed via survey. RESULTS: 22 events with 839 learners were observed. VIEM distinguished between sessions with low and high engagement. 20% of learners pretended to participate. Half of instructors were comfortable with virtual teaching, but only 1/3 believed was as effective as in-person. 2/3 of teachers believed video learners were more engaged than audio learners. CONCLUSIONS: Virtual platforms do not automatically translate into increased engagement. Standard tools such as VIEM may help with assessment of engagement during virtual education.

Utility of endoscopic therapy in the management of Boerhaave syndrome.

Background/aims: The optimal intervention for Boerhaave perforation has not been determined. Options include surgical repair with/without a pedicled muscle flap, T tube placement, esophageal resection or diversion, or an endoscopic approach. All management strategies require adequate drainage and nutritional support. Our aim was to evaluate outcomes following Boerhaave perforation treated with surgery, endoscopic therapy, or both. Patients and methods: We performed a 10-year review of our prospectively maintained databases of adult patients with Boerhaave perforations. We documented clinical presentation, extent of injury, primary intervention, "salvage" treatment (any treatment for persistent leak), and outcome. Results were analyzed using the Fisher's exact and Kruskal - Wallis tests. Results: Between October 2004 and October 2014, 235 patients presented with esophageal leak/fistula with 17 Boerhaave perforations. Median age was 68 years. Median length of perforation was 1.25 cm (range 0.8 - 5 cm). Four patients presented with systemic sepsis (two treated with palliative stent and two surgically). Primary endotherapy was performed for eight (50 %) and primary surgery for eight (50 %) patients. Two endotherapy patients required multiple stents. Median stent duration was 61 days (range 56 - 76). "Salvage" intervention was required in 2/8 (25 %) endotherapy patients and 1/8 (13 %) surgery patient (stent). All patients healed without resection/reconstruction. There were no deaths in the surgically treated group and two in the endotherapy group (stented with palliative intent due to poor systemic condition). Readmission within 30 days occurred in 3/6 of alive endotherapy patients (50 %) and 0/8 surgery patients. Re-intervention within 30 days was required for one endotherapy patient. Conclusion: Endoscopic repair of Boerhaave perforations can be useful in carefully selected patients without evidence of systemic sepsis. Endoscopic therapy such as stenting is particularly valuable as a "salvage" intervention. The benefits of endoscopic therapy and esophageal preservation are offset against an increased risk of readmission in patients primarily treated endoscopically.

Functional and physiological outcomes following repair of obstetrics anal sphincter injury. A case.

INTRODUCTION: Obstetric anal sphincter injury has important psychosocial implications and impact on subsequent pregnancies. Sound operative repair is essential, yet between 14 and 61% patients with obstetric anal sphincter injuries report incontinence symptoms. Objective assessment of the outcome following repair can be performed using anorectal manometry and endoanal ultrasonography. The aim of this study was to assess functional and physiological outcome in patients undergoing operative repair of third or fourth degree tears. METHODS: Demographic information and obstetric details were collected retrospectively for patients who sustained a third or fourth degree anal sphincter injury between the periods of 1st January 2008-31st December 2009. All patients were followed up by the Colorectal Nurse Specialist in a dedicated clinic. A detailed history, examination, anorectal manometry (AM) and endoanal ultrasound (EAU) were performed. RESULTS: Of 210 patients identified data was available for 190 (90%). Median age was 29 years and 74% of the patients were primagravida. Twenty one (11%) patients had grade 3 tear, 81 (43%) grade 3a, 63 (33%) grade 3b, 15 (8%) grade 3c and 10 (5%) patients had grade 4 tears. All patients underwent primary repair: where data was available for operative technique 68 (36%) patients underwent end-to-end and 96 (51%) had overlap repair. 177 (93%) of the repairs were performed by Registrars. Median follow up was 3 months and data was available for 142 (75%) patients. 29 (20%) patients exhibited symptoms of incontinence. Anal resting and squeeze pressure were reduced in patients experiencing incontinence symptoms (66 mHg vs 58 mmHg and 120 mmHg vs 98 mmHg respectively). EAU revealed one EAS (external anal sphincter)/IAS (internal AS) defect, seven IAS defects and 33 thinning of IAS. One quarter of patients with IAS thinning or defect exhibited incontinence symptoms. CONCLUSION: One fifth of patients experienced some incontinence following repair of obstetric anal sphincter injury, but only 2 patients were incontinent of faeces at 3 month follow up. This represents some improvement in outcome compared to results from the last two decades. Anal pressures in patients experiencing incontinence were reduced, and thinning of the IAS was more common in patients with incontinence symptoms. Efforts to identify occult IAS injury and repair this as well as the EAS may improve patient outcome.

The physiological effects of short-term smoking cessation in claudicants.

INTRODUCTION: Smoking contributes to atherosclerosis and causes significant postoperative morbidity. New antismoking law forces short-term pre-operative abstinence. Demonstrable clinical benefit might motivate complete cessation. Our aim was to determine the effects of 24-hr smoking cessation on cardiorespiratory function and claudication distance. METHODS: Smoking claudicants were randomized to 24hr smoking or abstinence. Following these separate periods, cardiopulmonary exercise testing was performed. Pre- and post-exercise, serum lactate and ankle brachial pressure index (ABPI) were measured. During exercise, cardiorespiratory function, initial and absolute claudication (IC,AC) distances and visual analogue scores (VAS) of pain were recorded. RESULTS: 16 patients completed both tests. IC, AC and VAS were unchanged with abstinence (P = .43, .66, .96, .83). ABPI drop post-exercise was unchanged with abstinence (P = .08, .09). Cardiorespiratory function was not affected by smoking cessation. CONCLUSION: Cardiorespiratory function and claudication symptoms are unchanged following 24-hr smoking cessation. No deterioration in respiratory function is important when considering anaesthetic administration. However, lack of symptomatic improvement may discourage patients from abstaining. Further investigation should determine correlation between short-term abstinence and postoperative morbidity.

The surgical application of point-of-care haemostasis and platelet function testing.

BACKGROUND: Disordered coagulation complicates many diseases and their treatments, often predisposing to haemorrhage. Conversely, patients with cardiovascular disease who demonstrate antiplatelet resistance may be at increased thromboembolic risk. Prompt identification of these patients facilitates optimization of haemostatic dysfunction. Point-of-care (POC) tests are performed 'near patient' to provide a rapid assessment of haemostasis and platelet function. METHODS: This article reviews situations in which POC tests may guide surgical practice. Their limitations and potential developments are discussed. The paper is based on a Medline and PubMed search for English language articles on POC haemostasis and platelet function testing in surgical practice. RESULTS: POC tests identifying perioperative bleeding tendency are already widely used in cardiovascular and hepatic surgery. They are associated with reduced blood loss and transfusion requirements. POC tests to identify thrombotic predisposition are able to determine antiplatelet resistance, predicting thromboembolic risk. So far, however, these tests remain research tools. CONCLUSION: POC haemostasis testing is a growing field in surgical practice. Such testing can be correlated with improved clinical outcome.

Predicting chronic post-operative pain following laparoscopic inguinal hernia repair.

BACKGROUND: Chronic post-operative pain (CPP) following laparoscopic inguinal hernia repair (LIHR) may cause significant morbidity and be more problematic than recurrence. Determining pre-operative risk may reduce morbidity. Our aim was to determine prevalence of CPP following LIHR and identify risk factors for its development. METHODS: Data from patients undergoing LIHR (1996-2004) at one District General Hospital were collected, including demographics, body mass index, pre-operative pain, LIHR type (TEP or TAPP, primary/recurrent, unilateral/bilateral) and post-operative complications including CPP (pain lasting > or = 1 year). RESULTS: A total of 881 patients underwent LIHR (1,029 hernias). Of these, 523 (60%) patients completed the questionnaire, and 72/523 (13.8%) patients experienced CPP. Presence of pre-operative pain (P < 0.001), recurrent LIHR (P = 0.021) and age < 50 years (P < 0.001) were significantly correlated with CPP. CONCLUSION: Chronic post-operative pain following LIHR is more prevalent than recurrence. Pre-operative pain, surgery for recurrent inguinal hernias (following anterior repair) and younger age at surgery predict development of CPP. Identification of 'high-risk' patients may improve management, reducing morbidity and cost.