Teaching Chest Tube Insertion by Blended Learning: A Multi-Dimensional Analysis.

BACKGROUND: Emerging technologies are being incorporated in surgical education. The use of such technology should be supported by evidence that the technology neither distracts nor overloads the learner and is easy to use. To teach chest tube insertion, we developed an e-learning module, as part of a blended learning program delivered prior to in-person hands-on simulation. This pilot study was aimed to assess learning effectiveness of this blended learning, and cognitive load and the usability of e-learning. METHODS: The interactive e-learning module with multimedia content was created following learning design principles. In advance of the standard simulation, 13 first-year surgical residents were randomized into two groups: 7 received the e-learning module and online reading materials (e-learning group); 6 received only the online reading materials (controls). Knowledge was evaluated by pre-and post-tests; technical performance was assessed using a Global Rating Scale by blinded assessors. Cognitive load and usability were evaluated using rating scales. RESULTS: The e-learning group showed significant improvement from baseline in knowledge (P = .047), while controls did not (P = .500). For technical skill, 100% of residents in the e-learning group reached a predetermined proficiency level vs 60% of controls (P = .06). The addition of e-learning was associated with lower extrinsic and greater germane cognitive load (P = .04, .03, respectively). Usability was evaluated highly by all participants in e-learning group. CONCLUSION: Interactive e-learning added to hands-on simulation led to improved learning and desired cognitive load and usability. This approach should be evaluated in teaching of other procedural skills.

Measurement and Management of Cognitive Load in Surgical Education: A Narrative Review.

BACKGROUND: Cognitive load should be considered in designing optimal educational programs in health care. Despite the highly demanding nature of surgery and surgical education, a consensus on how to manage cognitive load has not been established. The objective of this review is to map out how recent surgical education research incorporates cognitive load. METHODS: A literature search was performed using keywords related to cognitive load and digital education up to December 2021. Studies published in English relevant to assessment and management of cognitive load in surgical education were included. Terminology, assessment tools, association with different surgical procedures and training modalities, and programs considering cognitive load were reported. RESULTS: We identified several terms to describe cognitive load. Cognitive load was measured by subjective, self-reported questionnaires and by objective measurements, such as physiological parameters or estimated by reaction time to secondary tasks. Subjective measurements reported cognitive load in one or multiple dimensions. Correlations between subjective and objective measurements were shown in multiple studies. Overall, higher cognitive load was observed in training for more complex tasks and high-fidelity modalities, and among less experienced trainees. Cognitive load theory has been lately incorporated into designing teaching programs. CONCLUSIONS: A broad range of terms and assessment tools were identified for cognitive load. To maximize the learning outcome, management of cognitive load is necessary in surgical education. This review summarizes the current knowledge in assessment and management of cognitive load in surgical education and provides suggestions for future studies.

Sleep Duration and Timing in the Medium- to Long-Term Post-Bariatric Surgery.

Sleep duration improves short-term following bariatric surgery; however, little is known about its association with bodyweight medium- to long-term post-surgery. The purpose of this study was to describe sleep duration and its relationship with BMI and body composition. Forty-nine individuals, with a BMI of 36.6 ± 9.8 kg/m2, regained 26.4 ± 17.8% of their lost weight 9.5 ± 3.3 years post-surgery (range 3-16 years). Sleep logs and ActivPAL3 accelerometers were used to assess sleep duration. Participants averaged 7.9 ± 1.6 h/day and 8.5 ± 1.7 h/day of sleep for weekdays and weekends, respectively (P < 0.01). A positive association between delta weekend-weekday sleep timing midpoint with BMI (ß = 0.03, 95% CI = 0.01, 0.06; P = 0.01) was noted in the multivariable-adjusted model. On average, this sample achieved recommended sleep durations medium- to long-term post-surgery. Having an earlier sleep timing midpoint during the weekend may be associated with lower BMI.

Effect of Employment Status on Physical Activity and Sedentary Behavior Long-Term Post-Bariatric Surgery.

INTRODUCTION: Inactivity and weight regain are serious problems post-bariatric surgery. Nearly half of waking time is spent at work, representing an opportunity to accumulate physical activity and help avoid weight regain. PURPOSE: The purpose of this study is to evaluate potential differences in physical activity and sedentary time by employment status post-bariatric surgery. METHODS: A total of 48 adults (employed (n = 19), unemployed (n = 29)) aged 50.7 ± 9.4 years, BMI = 34.4 ± 10.1 kg/m2, and 10 ± 3 years post-surgery participated. ActivPAL accelerometers measured transitions, steps, and sedentary time for 7 days. RESULTS: Participants worked on average 8.7 ± 1.8 h/day. Twenty-one percent of employed met step/day guidelines on work-days compared to 10% of unemployed. Employed persons transitioned from sitting-to-standing more on work-days (58.6 ± 17.8) than unemployed (45.0 ± 15.4). Employment status did not influence activity or sedentarism on weekend/non-working-days. CONCLUSION: Employment status may be associated with meaningful improvements in activity post-bariatric surgery.

Eccentric Ergometer Training Promotes Locomotor Muscle Strength but Not Mitochondrial Adaptation in Patients with Severe Chronic Obstructive Pulmonary Disease.

Eccentric ergometer training (EET) is increasingly being proposed as a therapeutic strategy to improve skeletal muscle strength in various cardiorespiratory diseases, due to the principle that lengthening muscle actions lead to high force-generating capacity at low cardiopulmonary load. One clinical population that may particularly benefit from this strategy is chronic obstructive pulmonary disease (COPD), as ventilatory constraints and locomotor muscle dysfunction often limit efficacy of conventional exercise rehabilitation in patients with severe disease. While the feasibility of EET for COPD has been established, the nature and extent of adaptation within COPD muscle is unknown. The aim of this study was therefore to characterize the locomotor muscle adaptations to EET in patients with severe COPD, and compare them with adaptations gained through conventional concentric ergometer training (CET). Male patients were randomized to either EET (n = 8) or CET (n = 7) for 10 weeks and matched for heart rate intensity. EET patients trained on average at a workload that was three times that of CET, at a lower perception of leg fatigue and dyspnea. EET led to increases in isometric peak strength and relative thigh mass (p < 0.01) whereas CET had no such effect. However, EET did not result in fiber hypertrophy, as morphometric analysis of muscle biopsies showed no increase in mean fiber cross-sectional area (p = 0.82), with variability in the direction and magnitude of fiber-type responses (20% increase in Type 1, p = 0.18; 4% decrease in Type 2a, p = 0.37) compared to CET (26% increase in Type 1, p = 0.04; 15% increase in Type 2a, p = 0.09). EET had no impact on mitochondrial adaptation, as revealed by lack of change in markers of mitochondrial biogenesis, content and respiration, which contrasted to improvements (p < 0.05) within CET muscle. While future study is needed to more definitively determine the effects of EET on fiber hypertrophy and associated underlying molecular signaling pathways in COPD locomotor muscle, our findings promote the implementation of this strategy to improve muscle strength. Furthermore, contrasting mitochondrial adaptations suggest evaluation of a sequential paradigm of eccentric followed by concentric cycling as a means of augmenting the training response and attenuating skeletal muscle dysfunction in patients with advanced COPD.

Effects of Neighborhood Walkability on Physical Activity and Sedentary Behavior Long-Term Post-Bariatric Surgery.

ᅟ: Chronic inactivity and weight regain are serious health concerns following bariatric surgery. Neighborhood walkability is associated with higher physical activity and lower obesity rates in normal weight populations. PURPOSE: Explore the influence of neighborhood walkability on physical activity and sedentarism among long-term post-bariatric surgery patients. METHODS: Fifty-eight adults aged 50.5 ± 9.1 years, with a BMI of 34.6 ± 9.7 kg/m2 having undergone surgery 9.8 ± 3.15 years earlier participated in this study. Participants were asked to wear an ActivPAL™ tri-axial accelerometer attached to their mid-thigh for 7-consecutive days, 24 hours/day. The sample was separated into those that live in Car-Dependent (n = 23), Somewhat Walkable (n = 14), Very Walkable (n = 16), and Walker's Paradise (n = 5) neighborhoods as defined using Walk Score®. ANCOVA was performed comparing Walk Score® categories on steps and sedentary time controlling for age and sex. RESULTS: Neighborhood walkability did not influence either daily steps (F (3, 54) = 0.921, p = 0.437) or sedentary time (F (3, 54) = 0.465, p = 0.708), Car-Dependent (6359 ± 2712 steps, 9.54 ± 2.46 hrs), Somewhat Walkable (6563 ± 2989 steps, 9.07 ± 2.70 hrs), Very Walkable (5261 ± 2255 steps, 9.97 ± 2.06 hrs), and Walker's Paradise (6901 ± 1877 steps, 10.14 ± 0.815 hrs). CONCLUSION: Walkability does not appear to affect sedentary time or physical activity long-term post-surgery. As the built-environment does not seem to influence activity, sedentarism, or obesity as it does with a normal weight population, work needs to be done to tailor physical activity programming after bariatric surgery.

Validity and reliability of Fitbit activity monitors compared to ActiGraph GT3X+ with female adults in a free-living environment.

OBJECTIVES: Inexpensive activity monitors have recently gained popularity with the general public. Researchers have evaluated these consumer-based monitors in laboratory-conditions. Given the current wide-spread consumer use of these devices, it is important to ensure users are attaining accurate information compared to previously validated measures. This study investigates the accuracy of Fitbit One and Flex activity monitors in measuring steps, sedentary time, and time spent in light, moderate, and vigorous intensity activities with ActiGraph GT3X+ with female adults in free-living conditions. DESIGN: Cross-sectional study. METHODS: Twenty-two women, 21.23±1.63 years, BMI: 22.35±2.34kg/m2 wore two Fitbit Ones (bra and waist), one Fitbit Flex on the wrist, and one ActiGraph GT3X+ on the waist for seven-consecutive days. Repeated measures ANOVA was used to explore differences in steps, sedentary time, and time spent in light, moderate and vigorous intensity activities among the four devices. RESULTS: No differences were found in number of steps recorded across the four devices. Fitbit One, waist and bra, overestimated time spent in light intensity activities. Fitbit One (waist) and Fitbit Flex overestimated time spent in moderate intensity activities. Fitbit One, waist and bra, and Fitbit Flex overestimated time spent in vigorous intensity activities. All Fitbit activity monitors overestimated MVPA and underestimated sedentary time compared to the ActiGraph. CONCLUSIONS: Regardless of wear-location all Fitbit devices provide similar activity monitoring and users can wear the devices wherever best accommodates their lifestyle or needs. Users should not rely solely on these monitors when tracking vigorous and MVPA activities.

Physical activity and sedentary behavior in bariatric patients long-term post-surgery.

BACKGROUND: To measure sedentary behaviors and physical activity using accelerometry in participants who have undergone bariatric surgery 8.87 ± 3.78 years earlier and to compare these results with established guidelines. METHODS: Participants' weight and height were measured, an ActivPAL™3 accelerometer and sleeping journal were used to determine day sedentary time, transitions from sitting to standing, as well as steps/day, and participants were asked to indicate if they felt that they were currently less, the same, or more active than before surgery. RESULTS: Participants averaged 48 ± 15 transitions/day, 6375 ± 2690 steps/day, and 9.7 ± 2.3 h/day in sedentary positions. There was a negative correlation between steps/day and sedentary time (r = -.466, p ≤ .001), 11.27 % of participants achieved 10,000 steps/day. Participants who reported being more active prior to surgery averaged 6323.4 ± 2634.79 steps/day, which was not different from the other two groups of self-perceived change in level of physical activity (F (2, 68) = .941, p ≤ .05) from pre- to post-surgery. CONCLUSIONS: Participants were inadequately active and overly sedentary compared to established guidelines and norms. Healthcare workers should be taking physical activity and sedentary time into account when creating post-surgical guidelines for this population to ensure the best long-term weight loss maintenance and health outcomes.

Keeping the weight off: physical activity, sitting time, and weight loss maintenance in bariatric surgery patients 2 to 16 years postsurgery.

BACKGROUND: Bariatric surgery patients often exhibit low levels of physical activity (PA), despite the presumed importance of PA as an adjunct to surgery for successful weight loss. Little is known regarding the associations of PA and sedentary behaviors to weight loss outcomes in the long term following surgery. The objective of the study was to assess the associations of PA and sitting time with weight status, weight loss, and weight maintenance outcomes in bariatric patients 2-16 years postsurgery. METHODS: A total of 303 Roux-en-Y Gastric Bypass patients (73% female; mean age 47 ± 10 years, mean 7 ± 4 years since surgery) completed a telephone questionnaire. Patients reported moderate-to-vigorous PA (MVPA: # sessions/week ≥30 min) and average daily sitting time (h/day). Associations with various weight outcomes were assessed. RESULTS: Only 48% of patients reported ≥1 session/week MVPA, and mean reported sitting time was 7 ± 4 h/day. Neither MVPA nor sitting time was associated with weight loss outcomes at patients' lowest weight postsurgery. However, both MVPA and sitting time were independently positively and inversely, respectively, associated with total (kg) weight loss, % weight loss, and % excess weight loss at current weight, as well as weight loss maintained vs. regained, controlling for age, sex, surgery type, presurgery BMI, total initial weight loss, and time since surgery. CONCLUSIONS: Results demonstrate associations between MVPA and high sitting time and weight loss outcomes among bariatric patients in the long term. The implications for long-term weight management and concomitant health outcomes highlight the need for appropriate follow-up and interventions in this unique high-risk patient population.

Precision of the iDXA for visceral adipose tissue measurement in severely obese patients.

UNLABELLED: A new measurement tool, the automated software CoreScan, for the GE Lunar iDXA, has been validated for measuring visceral adipose tissue (VAT) against computed tomography in normal-weight populations. However, no study has evaluated the precision of CoreScan in measuring VAT among severely obese patients. PURPOSE: The purpose of the study was to evaluate the precision of CoreScan for VAT measurements in severely obese adults (body mass index > 40 kg·m(-2)). METHODS: A total of 55 obese participants with a mean age of 46 ± 11 yr, body mass index of 49 ± 6 kg·m(-2), and body mass of 137.3 ± 21.3 kg took part in this study. Two consecutive iDXA scans with repositioning of the total body were conducted for each participant. The coefficient of variation, the root-mean-square averages of SD of repeated measurements, the corresponding 95% least significant change, and intraclass correlations were calculated. RESULTS: Precision error was 8.77% (percent coefficient of variation), with a root-mean-square SD of 0.294 kg and an intraclass correlation of 0.96. Bland-Altman plots demonstrated a mean precision bias of -0.08 ± 0.41 kg, giving a coefficient of repeatability of 0.82 kg and a bias range of -0.890 to 0.725 kg. CONCLUSIONS: When interpreting VAT results with the iDXA in severely obese populations, clinicians should be aware of the precision error for this important clinical parameter.

In vivo precision of the GE lunar iDXA for the assessment of lumbar spine, total hip, femoral neck, and total body bone mineral density in severely obese patients.

No study has evaluated the precision of the GE Lunar iDXATM (GE Healthcare) in measuring bone mineral density (BMD) among severely obese patients. The purpose of the study was to evaluate the precision of the GE Lunar iDXATM for assessing BMD, including the lumbar spine L1-L4, L2-L4, the total hip, femoral neck, and total body in a severely obese population (body mass index [BMI]>40 kg/m(2)). Sixty-four severely obese participants with a mean age of 46 ± 11 yr, BMI of 49 ± 6 kg/m(2), and a mean body mass of 136.8 ± 20.4 kg took part in this investigation. Two consecutive iDXA scans (with repositioning) of the total body (total body BMD [TBBMD]), lumbar spine (L1-L4 and L2-L4), total hip (total hip BMD [THBMD]), and femoral neck (femoral neck BMD [FNBMD]) were conducted for each participant. The coefficient of variation (CV), the root mean square (RMS) averages of standard deviations of repeated measurements, the corresponding 95% least significant change, and intraclass correlations (ICCs) were calculated. In addition, analysis of bias and coefficients of repeatability were calculated. The results showed a high level of precision for total body (TBBMD), lumbar spine (L1-L4), and total hip (THBMD) with values of RMS: 0.013, 0.014, and 0.011 g/cm(2); CV: 0.97%, 1.05%, and 0.99%, respectively. Precision error for the femoral neck was 2.34% (RMS: 0.025 g/cm(2)) but still represented high reproducibility. ICCs in all dual-energy X-ray absorptiometry measurements were 0.99 with FNBMD having the lowest at 0.98. Coefficients of repeatability for THBMD, FNBMD, L1-L4, L2-L4, and TBBMD were 0.0312, 0.0688, 0.0383, 0.0493, and 0.0312 g/cm(2), respectively. The Lunar iDXA demonstrated excellent precision for BMD measurements and is the first study to assess reproducibility of the GE Lunar iDXA with severely obese adults.

In vivo precision of the GE iDXA for the assessment of total body composition and fat distribution in severely obese patients.

OBJECTIVE: To evaluate the precision of the iDXA for total body composition and fat distribution measurements in severely obese patients. DESIGN AND METHODS: Sixty-five severely obese participants with a mean age of 46 ± 11 years, BMI of 49 ± 6 kg/m(2) , and a mean body mass of 137.3 ± 20.9 kg took part in this investigation. Two consecutive iDXA scans with repositioning of the total body were conducted for each participant. The coefficient of variation (CV), the root-mean-square (RMS) averages of standard deviations of repeated measurements, the corresponding 95% least significant change, and Intraclass Correlations (ICC) were calculated. RESULTS: Precision expressed as % CV, for total body bone mineral content, fat free mass, total body fat, total body lean, and % total body fat were 1.08%, 0.94%, 0.90%, 1.00%, 0.79%, respectively. Precision was 1.44% for gynoid fat distribution and 1.64% for android fat (AF) distribution. The ICCs in all DXA measurements were 0.99 with % AF having the lowest at 0.96. CONCLUSIONS: The GE Lunar iDXA™ demonstrated excellent precision for total body composition assessments and is the first study to assess reproducibility in severely obese individuals.