Training for excellence: using a multimodal videoconferencing platform to coach surgeons and improve intraoperative performance.

INTRODUCTION: Continuing Professional Development opportunities for lifelong learning are fundamental to the acquisition of surgical expertise. However, few opportunities exist for longitudinal and structured learning to support the educational needs of surgeons in practice. While peer-to-peer coaching has been proposed as a potential solution, there remains significant logistical constraints and a lack of evidence to support its effectiveness. The purpose of this study is to determine whether the use of remote videoconferencing for video-based coaching improves operative performance. METHODS: Early career surgeon mentees participated in a remote coaching intervention with a surgeon coach of their choice and using a virtual telestration platform (Zoom Video Communications, San Jose, CA). Feedback was articulated through annotating videos. The coach evaluated mentee performance using a modified Intraoperative Performance Assessment Tool (IPAT). Participants completed a 5-point Likert scale on the educational value of the coaching program. RESULTS: Eight surgeons were enrolled in the study, six of whom completed a total of two coaching sessions (baseline, 6-month). Subspecialties included endocrine, hepatopancreatobiliary, and surgical oncology. Mean age of participants was 39 (SD 3.3), with mean 5 (SD 4.1) years in independent practice. Total IPAT scores increased significantly from the first session (mean 47.0, SD 1.9) to the second session (mean 51.8, SD 2.1), p = 0.03. Sub-category analysis showed a significant improvement in the Advanced Cognitive Skills domain with a mean of 33.2 (SD 2.5) versus a mean of 37.0 (SD 2.4), p < 0.01. There was no improvement in the psychomotor skills category. Participants agreed or strongly agreed that the coaching programs can improve surgical performance and decision-making (coaches 85%; mentees 100%). CONCLUSION: Remote surgical coaching is feasible and has educational value using ubiquitous commercially available virtual platforms. Logistical issues with scheduling and finding cases aligned with learning objectives continue to challenge program adoption and widespread dissemination.

Perceptions of the multidisciplinary operative team on intraoperative telecoaching among surgeons.

Telecoaching, intraoperative coaching through videoconference, has been suggested as a tool to overcome logistical barriers with in-person coaching. However, little is known about the operative team's perception of telecoaching and its unique set of challenges. This qualitative study explores the perceptions of the multidisciplinary operative team on surgical telecoaching. A telecoaching program between peer surgeons was implemented using the Karl Storz Visitor1 remote presence system (Karl Storz, Germany). Semistructured interviews were conducted with the 12 operative team members present during 2 telecoaching sessions completed during the study period. Twelve participants were interviewed. The 4 central themes that emerged from the data were effective communication and collaboration, improving performance, operating room workflow, and culture and optics. Participating surgeon mentees reported that the session met expectations and learning goals and revealed concerns about negative perception of their autonomy and expertise by colleagues and patients. Conversely, team members unanimously reported a positive impression of surgeon mentees for taking additional measures to improve their performance and for patient outcomes. The operative team members reported that telecoaching was conducive to their own learning and relevant for complex cases. Considerations for future implementation of telecoaching include robust privacy standards for patients and staff, strong internet connectivity, coordinating with the operative team, and space constraints. Operative team participants viewed the intervention favorably and identified practical considerations for its continued use in an operating room environment. However, more work is needed on surgical culture as a contributor to low adoption and its impact on coaching programming activity.

Local FK506 drug delivery enhances nerve regeneration through fresh, unprocessed peripheral nerve allografts.

OBJECTIVE: Nerve allografts offer many advantages in the reconstruction of peripheral nerve gaps: they retain their native microstructure, contain pro-regenerative Schwann cells, are widely available, and avoid donor site morbidity. Unfortunately, clinical use of nerve allografts is limited by the need for systemic immunosuppression and its adverse effects. To eliminate the toxicity of the systemic immunosuppressant FK506, we developed a local FK506 drug delivery system (DDS) to provide drug release over 28 days. The study objective was to investigate if the local FK506 DDS enhances nerve regeneration in a rodent model of nerve gap defect reconstruction with immunologically-disparate nerve allografts. METHODS: In male Lewis rats, a common peroneal nerve gap defect was reconstructed with either a 20 mm nerve isograft from a donor Lewis rat or a 20 mm fresh, unprocessed nerve allograft from an immunologically incompatible donor ACI rat. After 4 weeks of survival, nerve regeneration was evaluated using retrograde neuronal labelling, quantitative histomorphometry, and serum cytokine profile. RESULTS: Treatment with both systemic FK506 and the local FK506 DDS significantly improved motor and sensory neuronal regeneration, as well as histomorphometric indices including myelinated axon number. Rats with nerve allografts treated with either systemic or local FK506 had significantly reduced serum concentrations of the pro-inflammatory cytokine IL-12 compared to untreated vehicle control rats with nerve allografts. Serum FK506 levels were undetectable in rats with local FK506 DDS. INTERPRETATION: The local FK506 DDS improved motor and sensory nerve regeneration through fresh nerve allografts to a level equal to that of either systemic FK506 or nerve isografting. This treatment may be clinically translatable in peripheral nerve reconstruction or vascularized composite allotransplantation.

A single session of brief electrical stimulation enhances axon regeneration through nerve autografts.

Nerve graft reconstruction of gap defects may result in poor clinical outcomes, particularly with long regeneration distances. Electrical stimulation (ES) of nerves may improve outcomes in such patients. A single session of ES at 20 Hz for 1 h significantly enhances axon regeneration in animals and human subjects after nerve crush or nerve transection and repair. The objectives of this study were to evaluate if ES enhances axon regeneration through nerve grafts and if there is added benefit of a second, delayed session of ES (serial ES) on axon regeneration as compared to a single session only of ES. In female rats, a gap defect was created in the hindlimb common peroneal (CP) nerve and immediately reconstructed with a 10 mm nerve autograft (Experiment 1) or a 20 mm nerve autograft (Experiment 2). In Experiment 1, rats were randomized to 1 h of CP nerve ES or sham stimulation. In Experiment 2, rats were randomized to control (sham ES + sham ES), single ES (ES + sham ES), or serial ES (ES + ES), which consisted of an initial 1 h session of either ES or sham stimulation of the CP nerve, followed by a second 1 h session of ES or sham stimulation of the CP nerve 4 weeks later. In both experiments, after a 6 week period of nerve regeneration, CP neurons that had regenerated axons distal to the autograft were retrograde labelled for enumeration, and the CP nerve distal to the autograft was harvested for histomorphometry. In Experiment 1, rats that received CP nerve ES had statistically significantly more motor (p < .05) and sensory (p < .05) neurons that regenerated axons distal to the 10 mm nerve autograft, with more myelinated axons on histomorphometry (p < .001). Similarly, in Experiment 2, significantly more motor (p < .01) and sensory (p < .05) neurons regenerated axons distal to the 20 mm nerve autograft after a single session or two sessions of CP nerve ES. There was no significant difference in the number of regenerated motor or sensory neurons between rats with 20 mm CP nerve autografts receiving either one or two sessions of CP nerve ES (p > .05). In conclusion, a single session of ES enhances axon regeneration following nerve autografting with no added effect of a second, delayed session of ES. These findings support previous studies in animals and humans of the robust effect of a single session of ES in promoting nerve regeneration following injury and repair.

Origin of the Zika virus revealed: a historical journey across the world.

BACKGROUND: Zika virus (ZIKV) is an arbovirus within the Flaviviridae family, the recent spread of which has promoted public concern. METHODS: This study outlines the clinical features, potential for teratogenicity, diagnosis, and treatment of ZIKV infection. RESULTS: Zika virus is transmitted through the bite of an infected Stegomyia (= Aedes) mosquito, blood transfusion, sexual intercourse, and perinatal routes. Infection has been characterized as mildly symptomatic. Symptoms include mild fever, headache, arthralgia, myalgia, non-purulent conjunctivitis, and a pruritic maculopapular rash. It is rarely life-threatening, but both Guillain-Barré syndrome and fetal microcephaly have been reported. ZIKV belongs to the same family as bovine viral diarrhea virus, which causes hydrocephalus and microcephaly in newborn calves, and hepatitis C virus, which can be vertically transmitted in human pregnancies, and hence there remains concern for potential similarities. Diagnostic methods include polymerase chain reaction performed in blood samples during infection, and in urine and saliva. Pregnant women undergo antibody testing for immunoglobulin M. Treatment involves supportive care, and acetaminophen and antihistamines to control symptoms. CONCLUSIONS: Although there was no evidence of the circulation of ZIKV in the Western hemisphere prior to 2014, the global spread of Stegomyia aegypti and increases in urban populations and international travel have fostered its evolution. Adherence to current guidelines for the prevention of ZIKV transmission is especially relevant in regions experiencing ongoing outbreaks. Concern for microcephaly in newborns warrants further investigation into the potential long-term effects of ZIKV infection, especially in relation to reproductive health and mother-fetus transmission.