Transforming the "SEAD": Evaluation of a Virtual Surgical Exploration and Discovery Program and its Effects on Career Decision-Making.

OBJECTIVE: The abrupt cessation of in-person education due to the COVID-19 pandemic has made it difficult for preclerkship students to explore a career in surgery. To supplement the lack of exposure, the Surgical Exploration and Discovery (SEAD) program was transitioned to an entirely virtual format. This study aims to describe the virtual SEAD program and evaluate its effectiveness as a career decision-making (CDM) intervention. DESIGN: The week-long program was delivered on Microsoft Teams, featured 11 surgical specialties, and comprised four activities: live demonstrations, virtual operating room observerships, career talks, and technical skills workshops. The program was evaluated using the four levels of the Kirkpatrick model: (1) reactions, (2) knowledge, (3) CDM behaviors - assessed using the Career Decision-making Difficulties Questionnaire (CDDQ) - and (4) results. The latter was indirectly assessed using CDDQ scores from an in-person SEAD program, where lower CDDQ scores indicate less difficulty with CDM. SETTING: Faculty of Medicine at the University of Ottawa in Ontario, Canada. PARTICIPANTS: Forty pre-clerkship students (27 first and 13 second year students) at the University of Ottawa RESULTS: Level 1: 97.5% of participants rated the program as good or very good. Live demonstration and technical skills workshops were the highest rated activities. Level 2: participants' scores on knowledge-based questions about a surgical career significantly increased following the program (pre: 9/25 vs post: 15/25, p = 0.008). Level 3: overall mean CDDQ scores (±SD) decreased difficulties with significantly following the program (pre: 45.6 ± 10.5 vs post: 38.8 ± 10.9, p < 0.001), which indicates decreased CDM difficulties. Level 4: Except for one sub-category, the difference in mean CDDQ scores between the virtual and in-person programs were not significantly different. CONCLUSION: The program received the positive reactions and significantly increased participants' knowledge. The change in CDDQ scores following the virtual program suggests it may reduce career decision-making difficulties in the short-term. In-person surgical exposure remains important; however, a hybrid model may be valuable in resource limited settings. WC: 300.

Risk Factors for Surgical Site Infection After Lower Limb Revascularization Surgery in Adults With Peripheral Artery Disease: Protocol for a Systematic Review and Meta-analysis.

BACKGROUND: Surgical site infections (SSIs) are common, costly, and associated with increased morbidity and potential mortality after lower limb revascularization surgery (ie, arterial bypass, endarterectomy, and patch angioplasty). Identifying evidence-informed risk factors for SSI in patients undergoing these surgeries is therefore important. OBJECTIVE: The aim of this study is to conduct a systematic review and meta-analysis of prognostic studies to identify, synthesize, and determine the certainty in the cumulative evidence associated with reported risk factors for early and delayed SSI after lower limb revascularization surgery in adults with peripheral artery disease. METHODS: We will search MEDLINE, Embase, the seven databases in Evidence-Based Medicine Reviews, review articles identified during the search, and included article bibliographies. We will include studies of adults (aged ≥18 years) with peripheral artery disease that report odds ratios, risk ratios, or hazard ratios adjusted for the presence of other risk factors or confounding variables and relating the potential risk factor of interest to the development of SSI after lower limb revascularization surgery. We will exclude studies that did not adjust for confounding, exclusively examined certain high-risk patient cohorts, or included >20% of patients who underwent surgery for indications other than peripheral artery disease. The primary outcomes will be early (in-hospital or ≤30 days) SSI and Szilagyi grade I (cellulitis involving the wound), grade II (infection involving subcutaneous tissue), and grade III (infection involving the vascular graft) SSI. Two investigators will independently extract data and evaluate the study risk of bias using the Quality in Prognosis Studies tool. Adjusted risk factor estimates with similar definitions will be pooled using DerSimonian and Laird random-effects models. Heterogeneity will be explored using stratified meta-analyses and meta-regression. Finally, we will use the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to determine certainty in the estimates of association between reported risk factors and the development of SSI. RESULTS: The protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews). We will execute the peer-reviewed search strategy on June 30, 2021, and then complete the review of titles and abstracts and full-text articles by July 30, 2021, and September 15, 2021, respectively. We will complete the full-text study data extraction and risk of bias assessment by November 15, 2021. We anticipate that we will be able to submit the manuscript for peer review by January 30, 2022. CONCLUSIONS: This study will identify, synthesize, and determine the certainty in the cumulative evidence associated with risk factors for early and delayed SSI after lower limb revascularization surgery in patients with peripheral artery disease. The results will be used to inform practice, clinical practice statements and guidelines, and subsequent research. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42021242557; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242557. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/28759.

Effect of e-Cigarettes Plus Counseling vs Counseling Alone on Smoking Cessation: A Randomized Clinical Trial.

Importance: Electronic cigarettes (e-cigarettes) for smoking cessation remain controversial. Objective: To evaluate e-cigarettes with individual counseling for smoking cessation. Design, Setting, and Participants: A randomized clinical trial enrolled adults motivated to quit smoking from November 2016 to September 2019 at 17 Canadian sites (801 individuals screened; 274 ineligible and 151 declined). Manufacturing delays resulted in early termination (376/486 participants, 77% of target). Outcomes through 24 weeks (March 2020) are reported. Interventions: Randomization to nicotine e-cigarettes (n = 128), nonnicotine e-cigarettes (n = 127), or no e-cigarettes (n = 121) for 12 weeks. All groups received individual counseling. Main Outcomes and Measures: The primary end point was point prevalence abstinence (7-day recall, biochemically validated using expired carbon monoxide) at 12 weeks, changed from 52 weeks following early termination. Participants missing data were assumed to be smoking. The 7 secondary end points, examined at multiple follow-ups, were point prevalence abstinence at other follow-ups, continuous abstinence, daily cigarette consumption change, serious adverse events, adverse events, dropouts due to adverse effects, and treatment adherence. Results: Among 376 randomized participants (mean age, 52 years; 178 women [47%]), 299 (80%) and 278 (74%) self-reported smoking status at 12 and 24 weeks, respectively. Point prevalence abstinence was significantly greater for nicotine e-cigarettes plus counseling vs counseling alone at 12 weeks (21.9% vs 9.1%; risk difference [RD], 12.8 [95% CI, 4.0 to 21.6]) but not 24 weeks (17.2% vs 9.9%; RD, 7.3 [95% CI, -1.2 to 15.7]). Point prevalence abstinence for nonnicotine e-cigarettes plus counseling was not significantly different from counseling alone at 12 weeks (17.3% vs 9.1%; RD, 8.2 [95% CI, -0.1 to 16.6]), but was significantly greater at 24 weeks (20.5% vs 9.9%; RD, 10.6 [95% CI, 1.8 to 19.4]). Adverse events were common (nicotine e-cigarette with counseling: 120 [94%]; nonnicotine e-cigarette with counseling: 118 [93%]; counseling only: 88 [73%]), with the most common being cough (64%) and dry mouth (53%). Conclusions and Relevance: Among adults motivated to quit smoking, nicotine e-cigarettes plus counseling vs counseling alone significantly increased point prevalence abstinence at 12 weeks. However, the difference was no longer significant at 24 weeks, and trial interpretation is limited by early termination and inconsistent findings for nicotine and nonnicotine e-cigarettes, suggesting further research is needed. Trial Registration: ClinicalTrials.gov Identifier: NCT02417467.

Superficial femoral artery pseudoaneurysm caused by a solitary femoral shaft osteochondroma in a young adult.

We discuss the presentation, diagnosis, and surgical management of a young man presenting with a symptomatic superficial femoral artery pseudoaneurysm caused by a solitary femoral shaft osteochondroma. We review the existing literature regarding the incidence and management of this problem.

Using Self-Reported Measures of Confidence and Anxiety to Determine the Efficacy of the Surgical Exploration And Discovery (SEAD) Program in Reducing Anxiety and Increasing Confidence in Performing Procedural Skills.

OBJECTIVE: Clerkship students feel increased anxiety and lack of confidence when it comes to surgery. This study assessed whether participation in Surgical Exploration And Discovery (SEAD), a 2-week intensive surgical program that includes career information, simulation workshops, and operating room observerships, would help decrease anxiety, increase confidence, and foster interest in a surgical career. SETTING: This study took place at The Ottawa Hospital in Ottawa, Ontario, Canada. DESIGN: Thirty first year medical students were randomly selected for the SEAD program and 32 were only given the program's instruction manual during the duration of the program serving as the control. At baseline and after the completion of SEAD, both groups were given a survey containing the State Trait Anxiety Inventory that measures self-reported anxiety levels with an adjunct that gauges confidence and interest in a surgical career. RESULTS: Students who participated in the program showed significant improvements in self-perceived knowledge and confidence for each surgical skill: scrubbing (p-value < 0.001, p-value < 0.001), maintaining sterility (p-value < 0.001, p-value < 0.001), and surgical assisting (p-value < 0.001, p-value < 0.001). However, there was no difference in the average state anxiety with procedural skills (p-value = 0.190) between students who participated in SEAD and those who did not. Students who completed SEAD had a notable increase in their interest in pursuing a career in surgery compared with their pretest (p-value = 0.020) and compared with the control group (p-value = 0.600). CONCLUSIONS: The SEAD program may increase medical students' confidence and interest in pursuing a surgical career. These results encourage offering medical students with similar opportunities that provide exposure to surgery in preclerkship.

Harvesting the 'SEAD': Long-Term Follow-Up of the Surgical Exploration and Discovery Program.

OBJECTIVE: The Surgical Exploration and Discovery (SEAD) program was established to facilitate career decision-making by providing preclerkship students with comprehensive exposure to surgical specialties. Our short-term findings demonstrated that, compared to a control group, SEAD participants showed significantly greater career-related learning. The purpose of this study was to understand the long-term impact of the SEAD program. DESIGN: This was a prospective cohort study. One group of students participated in a 2-week surgical curriculum (SEAD group) while another group read only the program manual (Manual group). Students were surveyed following their residency selection 3 years later. The outcome measures were final specialty preference (medical or surgical), program utility, and program satisfaction. SETTING: Undergraduate Medical Education, Faculty of Medicine, at the University of Ottawa in Ottawa, Ontario, Canada. PARTICIPANTS: A total of 18 medical students in the SEAD group, and 18 in the Manual group. RESULTS: Survey response rate was 100%. There was no significant difference in the number of students who pursued surgical careers in the SEAD and Manual groups. All students who pursued a surgical residency were 'very interested' in surgery prior to SEAD-initial interest in surgery had a significant influence on final residency preference. Ninety-four percent (n = 17) of SEAD participants described the SEAD program as valuable to facilitating their career decision-making. CONCLUSIONS: Although SEAD does not generate sustained new interest in surgical disciplines, graduating students believe the program is valuable in facilitating career decision-making and perceive the program as a worthwhile time investment. These findings were true for students who selected both surgical and medical specialties, suggesting that early, multifaceted, exposure to surgery is a valuable addition to career exploration even for students who ultimately don't pursue surgical specialties. Going forward, integrating a longitudinal mentorship program may further improve the value of SEAD.

Surgical Exploration and Discovery Program: Early Exposure to Surgical Subspecialties and Its Influence on Student Perceptions of a Surgical Career.

OBJECTIVE: Interest in pursuing a surgical career has been declining among North American medical students. Numerous factors are known to influence student interest in pursuing surgery as a career, such as prestige, income potential, and overall lifestyle. Given that many of these factors are rooted in bias, it may be possible to properly address several of these stereotypes through first-hand, early exposure to the field of surgery via the Surgical Exploration and Discovery (SEAD) Program. The purpose of this study is twofold: (1) to investigate whether participation in an intensive, 2-week surgical program may alter student opinion, bias, and/or preconceived assumptions of a career in surgery, and (2) to determine whether these changes in perception, if present, has an impact on student interest in pursuing a surgical career compared to baseline. DESIGN: This was a prospective cohort study. The analysis cohort consisted of 30 first-year medical students who participated in the 2-week SEAD program. The control group consisted of 29 first-year medical students who did not participate in the SEAD program. Both the SEAD and control groups completed two surveys: (1) an entry survey distributed prior to the start of the SEAD program, and (2) an exit survey distributed upon completion of the SEAD program. The surveys were designed to assess students' motivations for choosing a specialty in medicine, previous surgical experience, as well as perceptions and biases surrounding a surgical career, pre- and post-exposure. SETTING: Undergraduate Medical Education, Faculty of Medicine, at the University of Ottawa in Ottawa, Ontario, Canada. PARTICIPANTS: 30 medical students in the SEAD group, and 29 in the control group. RESULTS: Students' perceptions of the lifestyle, call schedule as a staff or resident, diversity of practice and gender changed significantly following the SEAD program compared to students in the control group. Furthermore, students' perceptions of surgeons as intimidating declined following the 2-week program (p = 0.003), however they were more likely to view surgery as a field requiring physical strength (p = 0.022). Overall, there was no significant change with regards to desire to pursue a career in surgery in the treatment group (p = 0.625) or in the control group (p = 1.00). CONCLUSIONS: Early exposure to surgery through the SEAD program alters student perceptions of surgical specialties, yet it does not significantly influence students to pursue a career in the surgical field. Nonetheless, participation in the SEAD program continues to assist medical students with career decision making.

Break out of the Classroom: The Use of Escape Rooms as an Alternative Teaching Strategy in Surgical Education.

OBJECTIVE: To implement and assess the impact of a Vascular Surgery-themed Escape Room on medical student motivation, satisfaction, and engagement in CanMEDS roles. DESIGN: The authors designed an Escape Room combining Vascular Surgery objectives, knowledge-based problems and technical skills into Vascular Surgery-themed stations. Groups of 3 to 4 medical students participated in the activity. Data collected included time to escape, CanMEDS roles covered during the activity, debriefing interview session, and satisfaction survey. SETTING: The Escape Room was installed at the University of Ottawa Skills and Simulation Centre at the Ottawa Hospital, a tertiary care center. PARTICIPANTS: Medical students in their preclerkship years of study were invited to participate in the Escape Room. In total, 13 medical students completed the experience, divided into 4 groups. RESULTS: Thirteen medical students divided into 4 groups participated in the Escape Room. Two teams used a collaborative strategy to complete the activity and successfully escaped with an average time of 53.6 minutes, whereas only 1 of the 2 teams completing the experience employing an individualistic strategy successfully escaped. Following the experience, 83% of participants stated that the experience motivated them to prepare beforehand and believed that the experience consolidated the knowledge that they had read. All the participants also reported that the experience encouraged the use of the CanMEDS communicator and collaborator roles. As well, 76.9% of students mentioned that they enjoyed the practical exercises incorporated into the experience and 53.8% stated that they would like to see the Escape Room format included in the medical curriculum. CONCLUSIONS: By combining knowledge-based problems, key learning objectives, technical skills, and CanMEDS themes into the Escape Room, the authors have developed a learning platform that may be more enjoyable and provide an adjunct to traditional didactic lectures.

Impact of visualization on simulation training for vascular anastomosis.

OBJECTIVE: There is mounting evidence supporting the benefit of surgical simulation on the learning of skills independently and in a patient-safe environment. The objective of this study was to examine the effect of visualization of surgical steps via instructional media on performance of an end-to-side microvascular anastomosis. METHODS: Thirty-two first- and second-year surgical trainees from the University of Ottawa received an expert-guided, didactic lecture on vascular anastomosis and performed an end-to-side anastomosis on a procedural model to assess baseline skills. Assessments were performed by 2 blinded, expert observers using validated measurements of skill. Subjects were then proctored to perform anastomoses using the model. Subjects were then randomized to watch an instructional video on performance of vascular anastomosis using visualization as the education strategy. One week later, subjects were again assessed for technical skill on the model. The primary outcome was the score achieved on the Objective Structured Assessment of Technical Skill (OSATS) scale. Secondary outcomes included an anastomosis-specific End-Product Rating Score and time to completion. RESULTS: Compared with residents who received expert-guided simulator training alone, those who used the supplementary multimedia scored significantly greater on OSATS (17.4 ± 2.9 vs 14.2 ± 3.2, P = .0013) and on End-Product Rating Score (11.24 ± 3.0 vs 7.4 ± 4.1, P = .011). However, performance time did not differ between groups (15.7 vs 14.3 minutes, P = .79). CONCLUSIONS: Residents with supplemental instructional media performed an end-to-side anastomosis more proficiently as assessed by OSATS and with a greater quality end-product. This suggests that both didactic simulation training as well as use of visualization multimedia improves learning and performance of vascular anastomosis and should be incorporated into surgical curricula.

The effect of 22.5 kHz low-frequency contact ultrasound debridement (LFCUD) on lower extremity wound healing for a vascular surgery population: A randomised controlled trial.

The aim of this study was to compare changes in wound size and appearance and health complication rates in patients with vasculopathy and lower-extremity wounds treated with or without low-frequency contact ultrasound debridement (LFCUD) This study was a randomised controlled trial. The study was conducted in a vascular surgery service, including outpatient wound clinic and inpatient ward, in a tertiary care academic centre. In total, 70 patients with vasculopathy and lower-extremity wounds of mixed aetiology were enrolled in the trial; 68 completed the study. Patients were randomised to receive LFCUD plus usual care (n = 33) or usual care (n = 37) at 4 weekly visits, and were followed thereafter for up to 12 wk. The main outcome measures included closed wounds, change in wound surface area (WSA), and wound appearance by the revised Photographic Wound Assessment Tool (revPWAT). After 4 weekly LFCUD treatments, patients in the LFCUD group had significantly better wound appearance (total revPWAT score) compared with the control group treated only with usual care (P = <0.05). LFCUD-treated wounds also had a significant reduction in WSA over 4 wk that was not found in the UC group. LFCUD treatment was also associated with a greater number of healed wounds, odds ratio 5.00 (95% CI 1.24-20.25), and fewer instances of wound deterioration. Weekly LFCUD applications to patients with significant vasculopathy resulted in superior healing outcomes when compared with current usual wound care practice.

Internal iliac coverage during endovascular repair of abdominal aortic aneurysms is a safe option: A preliminary study.

Endovascular aneurysm repairs lacking suitable common iliac artery landing zones occasionally require graft limb extension into the external iliac artery, covering the internal iliac artery origin. The purpose of this study was to assess incidence of type II endoleak following simple coverage of internal iliac artery without embolization during endovascular aneurysm repair. Three hundred eighty-nine endovascular aneurysm repairs performed by a single surgeon (2004-2015) were reviewed. Twenty-seven patients underwent simple internal iliac artery coverage. Type II endoleak was assessed from operative reports and follow-up computed tomography imaging. No patient suffered type II endoleak from a covered internal iliac artery in post-operative computed tomography scans. Follow-up ranged from 0.5 to 9 years. No severe pelvic ischemic complications were observed. In conclusion, for selected cases internal iliac artery coverage without embolization is a safe alternative to embolization in endovascular aneurysm repairs, where the graft must be extended into the external iliac artery.

Predicting the need for vascular surgeons in Canada.

OBJECTIVE: With the introduction of direct entry (0+5) residency programs in addition to the traditional (5+2) programs, the number of vascular surgery graduates across Canada is expected to increase significantly during the next 5 to 10 years. Society's need for these newly qualified surgeons is unclear. This study evaluated the predicted requirement for vascular surgeons across Canada to 2021. A program director survey was also performed to evaluate program directors' perceptions of the 0+5 residency program, the expected number of new trainees, and faculty recruitment and retirement. METHODS: The estimated and projected Canadian population numbers for each year between 2013 and 2021 were determined by the Canadian Socio-economic Information and Management System (CANSIM), Statistics Canada's key socioeconomic database. The number of vascular surgery procedures performed from 2008 to 2012 stratified by age, gender, and province was obtained from the Canadian Institute for Health Information Discharge Abstract Database. The future need for vascular surgeons was calculated by two validated methods: (1) population analysis and (2) workload analysis. In addition, a 12-question survey was sent to each vascular surgery program director in Canada. RESULTS: The estimated Canadian population in 2013 was 35.15 million, and there were 212 vascular surgeons performing a total of 98,339 procedures. The projected Canadian population by 2021 is expected to be 38.41 million, a 9.2% increase from 2013; however, the expected growth rate in the age group 60+ years, who are more likely to require vascular procedures, is expected to be 30% vs 3.4% in the age group <60 years. Using population analysis modeling, there will be a surplus of 10 vascular surgeons in Canada by 2021; however, using workload analysis modeling (which accounts for the more rapid growth and larger proportion of procedures performed in the 60+ age group), there will be a deficit of 11 vascular surgeons by 2021. Program directors in Canada have a positive outlook on graduating 0+5 residents' skill, and the majority of programs will be recruiting at least one new vascular surgeon during the next 5 years. CONCLUSIONS: Although population analysis projects a potential surplus of surgeons, workload analysis predicts a deficit of surgeons because it accounts for the rapid growth in the 60+ age group in which the majority of procedures are performed, thus more accurately modeling future need for vascular surgeons. This study suggests that there will be a need for newly graduating vascular surgeons in the next 5 years, which could have an impact on resource allocation across training programs in Canada.

Growing the 'SEAD': Expansion of the Surgical Exploration and Discovery Program.

BACKGROUND: The declining popularity of surgical specialties among North American medical students has been attributed partially to limited early exposure and minimal involvement of surgeons in preclerkship education; in response, the Surgical Exploration and Discovery (SEAD) program was developed at the University of Toronto in 2012. SEAD is a 2-week curriculum that provides first-year medical students comprehensive exposure to surgical specialties through operating room observerships, simulation workshops, and career discussions. This study is the first to examine implementation of the SEAD program at another site. METHODS: This prospective cohort study evaluated the effectiveness of the SEAD program in improving surgical knowledge and facilitating career decision making when compared with a control group. In all, 18 students participated in the SEAD program, and 18 students from the same class read only the program's instructional manual; both the groups completed multiple-choice tests and questionnaires at baseline and at completion to assess knowledge acquisition and career-related learning. RESULTS: Both the groups significantly improved their surgical knowledge, but there was no difference between groups. SEAD participants made significantly greater progress in refining their career decisions when compared with the control group; all but one SEAD participant either gained interest in or ruled out a surgical specialty as a potential career choice compared with only 10 of the participants reading the manual only. CONCLUSIONS: The SEAD program provides a meaningful opportunity for medical students to explore surgical careers during preclerkship and to make better-informed career decisions. This expansion demonstrates that the program can be successfully reproduced at another institution.

Wait times among patients with symptomatic carotid artery stenosis requiring carotid endarterectomy for stroke prevention.

BACKGROUND: Current Canadian and international guidelines suggest patients with transient ischemic attack (TIA) or nondisabling stroke and ipsilateral internal carotid artery stenosis of 50% to 99% should be offered carotid endarterectomy (CEA) ≤ 2 weeks of the incident TIA or stroke. The objective of the study was to identify whether these goals are being met and the factors that most influence wait times. METHODS: Patients who underwent CEA at the Ottawa Hospital for symptomatic carotid artery stenosis from 2008 to 2010 were identified. Time intervals based on the dates of initial symptoms, referral to and visit with a vascular surgeon, the decision to operate, and the date of surgery were recorded for each patient. The influence of various factors on wait times was explored, including age, sex, type of index event, referring physician, distance from the surgical center, degree of stenosis, and surgeon assigned. RESULTS: Of the 117 patients who underwent CEA, 92 (78.6%) were symptomatic. The median time from onset of symptoms to surgery for all patients was 79 days (interquartile range [IQR], 34-161). The shortest wait times were observed in stroke patients (49 [IQR, 27-81] days) and inpatient referrals (66 [IQR, 25-103] days). Only 7 of the 92 symptomatic patients (8%) received care within the recommended 2 weeks. The median surgical wait time for all patients was 14 days (IQR, 8-25 days). In the multivariable analysis, significant predictors of longer wait times included retinal TIA (P = .003), outpatient referrals (P = .004), and distance from the center (P = .008). Patients who presented to the emergency department had the shortest delays in seeing a vascular surgeon and subsequently undergoing CEA (P < .0001). There was no difference between surgeons for wait times to be seen in the clinic; however, there were significant differences among surgeons once the decision was made to proceed with CEA. CONCLUSIONS: Our wait times for CEA currently do not fall within the recommended 2-week guideline nor does it appear feasible within the current system. Important factors contributing to delays include outpatient referrals, living farther from the hospital, and presenting with a retinal TIA (amaurosis fugax). Our findings also suggest better scheduling practices once a decision is made to operate can modestly improve overall and surgical wait times for CEA.

A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: the role of deliberate practice.

OBJECTIVES: There is mounting evidence supporting the benefit of surgical skills practice in a simulated environment. However, the use of simulation in cardiac surgical training has been limited. The purpose of the current trial was to examine the effect of independent and deliberate simulator practice, during nonclinical time, on the performance of an end-to-side microvascular anastomosis in an in vivo model. METHODS: This single-blinded, randomized controlled trial received institutional review board approval. Thirty-nine first- and second-year surgical trainees were randomized to an expert-guided tutorial on a procedural trainer or to the expert-guided tutorial combined with self-directed practice on the same procedural trainer. Self-directed practice consisted of 10 anastomoses performed on the procedural trainer: a low-fidelity, commercially available bench model using 4-mm polytetrafluoroethylene graft as simulated blood vessel. Two weeks after the tutorial, subjects performed an end-to-side anastomosis in a live porcine model, under realistic operating room conditions. Assessment of outcomes was performed by 2 blinded, expert observers, uings validated measurements of technical skill. The primary outcome was the score on the Objective Structured Assessment of Technical Skill (OSATS) scale. Secondary outcomes included an anastomosis-specific end-product evaluation and time to completion. Statistical analysis was conducted using nonparametric, univariate techniques. RESULTS: Compared with residents who received expert-guided simulator training alone, those who in addition practiced on a simulator independently after hours scored significantly higher on the OSATS scale (23.7 ± 4.7 vs 18.5 ± 3.9, P = .003). Residents who practiced independently also scored significantly higher on the end-product evaluation (11.4 ± 3.2 vs 8.9 ± 2.1, P = .02) and performed the anastomosis significantly faster (777 seconds vs 977 seconds, P = .04). Interrater reliability was high between the expert observers (intraclass correlation coefficient = 0.8). CONCLUSIONS: Residents who had the opportunity for self-directed simulator practice performed an end-to-side anastomosis more adeptly, more quickly, and with a higher quality end product. The results of this randomized trial suggest that independent training on a procedural trainer did transfer to improved performance in an operating room environment. Simulator training should be incorporated into cardiovascular surgical curricula and residents should have access to this modality for independent after-hours practice to improve operating room performance.

Mycobacterium bovis abdominal aortic and femoral artery aneurysms following intravesical bacillus Calmette-Guérin therapy for bladder cancer.

BACKGROUND: Infectious complications of intravesical bacillus Calmette-Guérin (BCG) therapy are rare, but these have included a handful of cases of mycotic aneurysm. METHODS AND RESULTS: We present the case of a patient with a ruptured abdominal aortic aneurysm and a femoral artery aneurysm who had previously received intravesical BCG therapy for bladder carcinoma. Histopathologic examination of resected tissue revealed numerous acid-fast bacilli, and subsequent mycobacterial culture of blood and resected tissue revealed BCG strain Mycobacterium bovis. CONCLUSIONS: Clinicians should be aware of the possible extravesical complications, albeit rare, of BCG therapy. Therapy should consist of combined medical and surgical management.

Nurse clinic versus home delivery of evidence-based community leg ulcer care: a randomized health services trial.

BACKGROUND: International studies report that nurse clinics improve healing rates for the leg ulcer population. However, these studies did not necessarily deliver similar standards of care based on evidence in the treatment venues (home and clinic). A rigorous evaluation of home versus clinic care is required to determine healing rates with equivalent care and establish the acceptability of clinic-delivered care. METHODS: Health Services RCT was conducted where mobile individuals were allocated to either home or nurse clinic for leg ulcer management. In both arms, care was delivered by specially trained nurses, following an evidence protocol. PRIMARY OUTCOME: 3-month healing rates. SECONDARY OUTCOMES: durability of healing (recurrence), time free of ulcers, HRQL, satisfaction, resource use. Data were collected at base-line, every 3 months until healing occurred, with 1 year follow-up. Analysis was by intention to treat. RESULTS: 126 participants, 65 randomized to receive care in their homes, 61 to nurse-run clinics. No differences found between groups at baseline on socio-demographic, HRQL or clinical characteristics. mean age 69 years, 68% females, 84% English-speaking, half with previous episode of ulceration, 60% ulcers at inclusion < 5 cm2 for < 6 months. No differences in 3-month healing rates: clinic 58.3% compared to home care at 56.7% (p = 0.5) or in secondary outcomes. CONCLUSION: Our findings indicate that organization of care not the setting where care is delivered influences healing rates. Key factors are a system that supports delivery of evidence-based recommendations with care being provided by a trained nursing team resulting in equivalent healing rates, HRQL whether care is delivered in the home or in a community nurse-led clinic. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Registration System: NCT00656383.

Health-related quality of life in survivors of open ruptured abdominal aortic aneurysm repair: a matched, controlled cohort study.

OBJECTIVE: The objective of this study was to document the health-related quality of life (HRQOL) for patients who survived operative repair of a ruptured abdominal aortic aneurysm (RAAA) and to compare this with a matched group of patients who survived elective operative repair of an abdominal aortic aneurysm (EAAA). METHODS: A matched, controlled cohort study of HRQOL was used to compare patients surviving RAAA with an EAAA control group. The study was conducted at two university-affiliated vascular tertiary care referral centers. Survivors of RAAA and EAAA during an 8.5-year period were identified and followed up. The RAAA and EAAA control patients were matched for age, serum creatinine concentration, gender, and duration of follow-up since surgery. HRQOL was measured with the Medical Outcomes Study Short Form-36 Health Survey (SF-36). Scores for the EAAA and RAAA cohorts were also compared with age-corrected SF-36 population scores. RESULTS: Of 267 patients operated for RAAA during the study period, 130 (49%) survived to hospital discharge. Death after discharge was documented in 35 patients, leaving a potential study population of 95 RAAA survivors. Thirteen were lost to follow-up, seven refused to participate, and four patients were not able to participate. The SF-36 was completed by 71 RAAA patients (75% of surviving RAAA patients). The 71 RAAA survivors and 189 EAAA control patients were similar for seven of eight domains of the SF-36: Physical Function, Role-Physical, Bodily Pain, General Health, Vitality, Mental Health, and Role-Emotional. There was also no difference in the Physical Health Summary and Mental Health Summary scores. The social function component of the SF-36 demonstrated a statistically significant decline in the EAAA group. Both the EAAA and RAAA SF-36 individual and summary scores compared favorably with population norms that were adjusted only for age. CONCLUSION: Long-term survivors of RAAA enjoy a HRQOL that does not differ significantly from EAAA survivors. Scores for both groups compare favorably with population scores adjusted only for age.

Leg-ulcer care in the community, before and after implementation of an evidence-based service.

BACKGROUND: Leg ulcers usually occur in older patients, a growing population for which increasing health care resources are required. Treatment is mainly provided in patients' homes; however, patients often receive poorly integrated services in multiple settings. We report the results of a prospective study of a community-based care strategy for leg ulcers. METHODS: International practice recommendations and guidelines were adapted to make a new clinical protocol. The new model, for a dedicated service staffed by specially trained registered nurses, established initial and ongoing assessment time frames and provided enhanced linkages to medical specialists. Data were collected for 1 year before and after implementation; outcome measures included 3-month healing rates, quality of life and resource usage. RESULTS: Three-month healing rates more than doubled between the year before implementation (23% [18/78]) and the year afterward (56% [100/180]). The number of nursing visits per case declined, from a median of 37 to 25 (p = 0.041); the median supply cost per case was reduced from 1923 dollars to 406 dollars (p = 0.005). INTERPRETATION: Reorganization of care for people with leg ulcers was associated with improved healing and a more efficient use of nursing visits.