Non-technical attributes and surgical experience: A cross-sectional study comparing communication styles and attitudes in surgical staff, trainees and applicants.

BACKGROUND: This monocentric study aimed to explore whether key non-technical attributes can be reliably measured in a mixed population of candidates applying for surgical training, surgical trainees and staff and to identify any differences between these groups. MATERIALS & METHODS: Candidates applying for surgical training, surgical trainees and staff from four surgical specialties (general surgery, orthopedics, plastic surgery or urology) at a tertiary academic teaching hospital were all sent an online self-report questionnaire. The Communication Styles Inventory (CSI, 96 items) was used to assess a six-dimensional behavioral model of participant communication styles (expressiveness, preciseness, verbal aggressiveness, questioningness, emotionality and impression manipulativeness). Attitudes toward uncertainty and risks were assessed with the Physicians' Reaction toward Uncertainty (PRU, 15 items) and Physician Risk Attitudes (PRA, 6 items) scales respectively. Data was encoded and analyzed using parametric testing. RESULTS: The questionnaire was completed by 177 participants (110 candidates; 42 trainees; 25 staff). All scales had very good internal consistency (Cronbach's alpha >0.80). After controlling for gender-based differences, surgical candidates scored significantly higher on 'expressiveness' (P = 0.012) and were significantly less risk-averse (P = 0.006) than trainees and staff. Surgical trainees scored lowest on the CSI 'questioningness' subscale (P = 0.019) and had significantly more difficulties dealing with uncertainty, characterized by their highest scores on the 'concern about bad outcome' (P = 0.021) and reluctance to disclose uncertainty to patients' (P = 0.05) subscales. Multiple subscales revealed gender-based differences in candidate and trainee groups, which were not noted for surgical staff. CONCLUSIONS: Meaningful differences in non-technical attributes of surgical staff, trainees and candidates have been identified, which may be explained by differences in clinical experience and learning and may suggest that these develop over time. Further research on assessment of non-technical attributes during surgical selections and the role of both technical and non-technical attributes in surgery at large is needed.

Endovascular Training Using a Simulation Based Curriculum is Less Expensive than Training in the Hybrid Angiosuite.

OBJECTIVE/BACKGROUND: This study aimed to determine the cost-effectiveness of a PROficiency based StePwise Endovascular Curricular Training (PROSPECT) program, including e-learning and hands on virtual reality simulation. METHODS: A prospective, single blinded, randomised controlled trial (RCT) was carried out to evaluate the impact of a PROSPECT training program on real life operative performance. Under supervision, all subjects performed two endovascular interventions on patients with symptomatic iliac and/or superficial femoral artery stenosis. Primary outcomes were technical performance (Global Rating Scale, Examiner Checklist), operative metrics, and patient outcomes, adjusted for case difficulty and the trainee's experience. Additionally, an analysis of costs and savings related to implementation of this endovascular training program was performed. Thirty-two general surgery trainees were randomised into three groups: group 1 (n = 11) received e-learning and simulation training (PROSPECT program); group 2 (n = 10) only had access to e-learning; group 3 (n = 11) did not receive supplementary education besides clinical training. Developmental cost, implementation cost, training time cost, and the operational cost of PROSPECT were determined. Time spent studying and practicing was converted to indirect saving of operating time. The costs of logistics, faculty time supervising simulation sessions, and 30 day complication rates were registered. Sensitivity analysis was performed to assess the robustness of the results. RESULTS: Fifty-eight peripheral endovascular interventions, performed by 29 surgical trainees (three dropouts) were included in this RCT from October 2014 to February 2016. Annual costs from the perspective of the hospital were €6589 for curriculum design, €31,484 for implementation, and €1143 in operational costs. Per trainee, simulation based training until proficiency cost €3806. In comparison, if endovascular proficiency levels were obtained with conventional training only, this may have cost €5001 per trainee. CONCLUSION: Simulation based training in endovascular procedures may be cost saving, because training occurs outside the angiosuite. It is possible that cost savings are underestimated as, in contrast to the literature, prevented costs related to complications could not be defined.

Defining the Key Competencies in Radiation Protection for Endovascular Procedures: A Multispecialty Delphi Consensus Study.

OBJECTIVES: Radiation protection training courses currently focus on broad knowledge topics which may not always be relevant in daily practice. The goal of this study was to determine the key competencies in radiation protection that every endovascular team member should possess and apply routinely, through multispecialty clinical content expert consensus. METHODS: Consensus was obtained through a two round modified Delphi methodology. The expert panel consisted of European vascular surgeons, interventional radiologists, and interventional cardiologists/angiologists experienced in endovascular procedures. An initial list of statements, covering knowledge skills, technical skills and attitudes was created, based on a literature search. Additional statements could be suggested by the experts in the first Delphi round. Each of the statements had to be rated on a 5- point Likert scale. A statement was considered to be a key competency when the internal consistency was greater than alpha = 0.80 and at least 80% of the experts agreed (rating 4/5) or strongly agreed (rating 5/5) with the statement. Questionnaires were emailed to panel members using the Surveymonkey service. RESULTS: Forty-one of 65 (63.1%) invited experts agreed to participate in the study. The response rates were 36 out of 41 (87.8%): overall 38 out of 41(92.6%) in the first round and 36 out of 38 (94.7%) in the second round. The 71 primary statements were supplemented with nine items suggested by the panel. The results showed excellent consensus among responders (Cronbach's alpha = 0.937 first round; 0.958 s round). Experts achieved a consensus that 30 of 33 knowledge skills (90.9%), 23 of 27 technical skills (82.1%), and 15 of 20 attitudes (75.0%) should be considered as key competencies. CONCLUSIONS: A multispecialty European endovascular expert panel reached consensus about the key competencies in radiation protection. These results may serve to create practical and relevant radiation protection training courses in the future, enhancing radiation safety for both patients and the entire endovascular team.

Complication Rate after Carotid Endarterectomy Comparing Patch Angioplasty and Primary Closure.

BACKGROUND: Carotid endarterectomy (CEA) reduces the risk for stroke in patients with internal carotid artery stenosis. The optimal surgical technique remains subject of debate. Literature suggests patch angioplasty reduces complication risk. However, primary closure shortens cross-clamp times and eliminates graft-specific complications. This study aimed to assess complication rate after CEA with selective patching. METHODS: A total of 213 consecutive CEAs over a 3-year period from January 5th, 2011 to December 19th, 2013 were retrospectively analyzed. Postoperative complications were evaluated within 1 month after surgery. RESULTS: Primary closure was used in 110 operations and patch angioplasty in 103 procedures. Primary closure was performed when the carotid artery had a diameter above 5 mm, when there was a high carotid bifurcation, and when the contralateral carotid artery was occluded. After primary closure, we found 4 (3.6%) complications: 2 (1.8%) bleeding and 2 (1.8%) cranial nerve damage. After patch angioplasty 5 (4.9%) complications occurred: 1 (1.0%) bleeding, 2 (1.9%) cranial nerve damage, 1 (1.0%) cerebrovascular event, and 1 (1.0%) cerebral hyperperfusion resulting in mortality. There was no higher complication risk after primary closure (P = 0.68). Clamp time was significantly longer when using patch angioplasty (P < 0.001). CONCLUSIONS: Primary closure appears to be an equivalent closure technique compared with patch angioplasty when used in selected patients.

Development of a PROficiency-Based StePwise Endovascular Curricular Training (PROSPECT) Program.

OBJECTIVES: Focus on patient safety, work-hour limitations, and cost-effective education is putting pressure to improve curricula to acquire minimally invasive techniques during surgical training. This study aimed to design a structured training program for endovascular skills and validate its assessment methods. DESIGN: A PROficiency-based StePwise Endovascular Curricular Training (PROSPECT) program was developed, consisting of e-learning and hands-on simulation modules, focusing on iliac and superficial femoral artery atherosclerotic disease. Construct validity was investigated. Performances were assessed using multiple-choice questionnaires, valid simulation parameters, global rating scorings, and examiner checklists. Feasibility was assessed by passage of 2 final-year medical students through this PROSPECT program. SETTING: Ghent University Hospital, a tertiary clinical care and academic center in Belgium with general surgery residency program. PARTICIPANTS: Senior-year medical students were recruited at Ghent University Hospital. Vascular surgeons were invited to participate during conferences and meetings if they had performed at least 100 endovascular procedures as the primary operator during the last 2 years. RESULTS: Overall, 29 medical students and 20 vascular surgeons participated. Vascular surgeons obtained higher multiple-choice questionnaire scores (median: 24.5-22.0 vs. 15.0-12.0; p < 0.001). Students took significantly longer to treat any iliac or femoral artery stenosis (3.3-14.8 vs. 5.8-30.1min; p = 0.001-0.04), whereas in more complex cases, fluoroscopy time was significantly higher in students (8.3 vs. 21.3min; p = 0.002; 7.3 vs. 13.1min; p = 0.03). In all cases, vascular surgeons scored higher on global rating scorings (51.0-42.0 vs. 29.5-18.0; p < 0.001) and examiner checklist (81.5-75.0 vs. 54.5-43.0; p < 0.001). Hence, proficiency levels based on median expert scores could be determined. There were 2 students who completed the program and passed for each step within a 3-month period during their internships. CONCLUSIONS: A feasible and construct validated surgical program to train cognitive, technical, and nontechnical endovascular skills was developed. A structured, stepwise, proficiency-based valid endovascular program to train cognitive, technical, and human factor skills has been developed and proven to be feasible. A randomized controlled trial has been initiated to investigate its effect on performances in real life, patient outcomes, and cost-effectiveness.

Autonomic function in migraine patients: ictal and interictal pupillometry.

OBJECTIVE AND BACKGROUND: Pupillometric investigations into migraine have suggested that an autonomic disturbance is part of the pathogenesis of that condition. This observation is controversial, however, which may reflect that the putative sympathetic hypofunction is either subtle or transient. In this study, we assessed the sympathetic function of migraine patients and controls during both a symptom-free phase and a migraine attack, and challenged patients with apraclonidine to reveal small changes in autonomic function. METHODS: Infrared pupillometry was used to measure pupillometric parameters in 37 controls and 46 migraine patients in the interictal phase of disease. Fifteen migraine patients were also studied during a migraine attack. In addition, 26 controls and 18 migraine patients were tested interictally both with and without apraclonidine. Of these 18 migraine patients, seven were also tested with and without apraclonidine during a migraine attack. RESULTS: We found no significant differences between migraine patients and controls in the interictal phase. Additionally, no differences in pupil parameters were detected during the migraine attack. However, after administration of apraclonidine, migraine patients had a longer latency of the light reflex compared with controls. This increase in latency was more pronounced ictally (oculus dexter: P = .046, oculus sinister: P = .023) than interictally (oculus dexter: P = .075, oculus sinister: P = .021). CONCLUSIONS: We conclude that there is evidence for a subtle pupillary sympathetic hypofunction in migraine patients, observed as a prolonged latency to light reflex, which is revealed after the administration of apraclonidine.

Apraclonidine and my pupil.

PURPOSE: Used in the diagnosis of Horner's syndrome, apraclonidine 1% dilatates the involved eye due to denervation supersensitivity. Recent literature suggests that in healthy volunteers, apraclonidine provokes a mild miotic effect. Since the comparison of both the pathologic and the non-pathologic eye is important, we wanted to further investigate the effect of apraclonidine on the healthy eye. By measuring the effect on the pupil intermittently over a few hours, we tried to determine the best moment for evaluation after instillation with apraclonidine. Therefore, the effect of apraclonidine on pupillary parameters was investigated in 14 healthy volunteers. METHODS: Infrared pupillography was used to measure the scotopic pupil diameter and the dynamic pupil responses to light. The first measurements were performed prior to instillation of apraclonidine. Measurements were retaken 30, 60, 90, 120, 180, 240, 300 and 360 min after random instillation of one eye with one drop of 1% apraclonidine. RESULTS: The anisocoria after dark adaptation and at minimum pupil diameter differed significantly for the measurements obtained 30 and 60 min after instillation with apraclonidine. The eye with apraclonidine drops showed relative miosis and an increased amplitude of constriction to light. No significant influence was found on the latency, the constriction velocity and redilation velocity. CONCLUSIONS: Instillation of apraclonidine 1% in healthy subjects causes relative miosis, which is most pronounced after 30-60 min. The amplitude of constriction to light also differs significantly. The relative miotic effect of apraclonidine could be explained by the α-2 receptor agonistic effect which is more pronounced than the α-1 agonistic effect in healthy subjects. In patients with Horner's syndrome, the α-1 agonistic effect will dominate because of the supersensitivity of the α-1 receptors, resulting in relative mydriasis. These findings stress the necessity to instill the unaffected eye in diagnosing a suspected Horner's pupil.