Hirudo Medicinalis and the plastic surgeon.

Medicinal leech therapy is an ancient craft that dates back to ancient Egypt and the beginnings of civilisation. The popularity of Hirudo Medicinalis has varied throughout history, reaching such a peak in Europe in the early 19th century that supplies were exhausted. During the latter half of the 19th century, their use fell out of favour, as they did not fit in with the emerging concepts of modern medicine. Leeches have enjoyed a renaissance in the world of reconstructive microsurgery during recent years, and their first reported use in alleviating venous engorgement following flap surgery was reported in this journal [M Derganc, F Zdravic, Venous congestion of flaps treated by application of leeches, Br J Plast Surg 13 (1960) 187]. Contemporary plastic and reconstructive surgeons in units throughout the United Kingdom and Ireland continue to use leeches to aid salvage of failing flaps. We carried out a survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland to assess the current extent of use, and to investigate current practice. We have shown that the majority of plastic surgery units in the UK and Ireland use leeches post-operatively and that the average number of patients requiring leech therapy was 10 cases per unit per year. Almost all units use antibiotic prophylaxis, but the type of antibiotic and combination used is variable. We outline current practice and suggest a protocol for the use of leeches. Whilst the use of leeches is widespread, the plastic surgery community has progressed little in defining indications for their use or in achieving an accepted protocol for their application in units throughout the UK and Ireland.     

Training in pediatric anesthesia for registrars – UK National survey

Background:  The aim of this National survey was to review the training provided in pediatric anesthesia to all registrars across all deaneries in the United Kingdom. The Royal College of Anaesthetists (RCA) recognizes training in pediatric anesthesia as an important training module for specialist registrars in years 1 and 2 of their training and recommends that this training should be delivered in 1–3-month blocks.
Methods:  This was a simple online survey ( http://www.esurveyspro.com ). We aimed to contact all registrars via the Association of Paediatric Anaesthetists of Great Britain and Ireland and the RCA.
Results:  Our survey indicated that there is wide variation in the duration of modular training across all deaneries. Three hundred and sixty-two registrars (65.5%) thought that the implementation of the European working time directives (EWTD) would hamper training in this specialty. One hundred and sixty-seven trainees (42.7%) spent more than 75% of their time doing pediatric anesthesia during their training module. Only 34 trainees (6.4%) had the opportunity to anesthetize children every week in District General Hospitals (DGHs), while 280 trainees (53.03%) said they did not have regular pediatric lists in DGHs.
Conclusions:  It will be necessary to increase the duration of modular training with the implementation of EWTD. Modular training in pediatric anesthesia should be provided as a dedicated and protected module. Training opportunities in DGHs are limited. There is also a need for new guidelines, as current guidelines regarding pediatric anesthesia training will be outdated with the implementation of EWTD.     

The place of plastic surgery in the undergraduate surgical curriculum

This paper reports the findings of a national survey of Medical Schools and Plastic Surgery Units. The survey has shown that plastic surgery is included in the undergraduate curriculum of 78% of the Medical Schools in the United Kingdom, and that this teaching load is shared by 77% of the Plastic Surgery Units in the United Kingdom. The results of a survey of medical students from the University of Oxford are also presented.     

The impact of junior surgical jobs in cardiothoracic surgery on career choice in the United Kingdom

Objectives

Cardiothoracic surgery is a small specialty, often with a limited presence on the undergraduate curriculum. In the past, there was a heavy reliance on postgraduate exposure to inform career choice. Recent changes in recruitment to the specialty in the United Kingdom may reduce exposure of the best trainees to the specialty, and reduce the quality of future surgeons. This study will evaluate the impact of junior surgical jobs on future career preferences.

Methods

We asked all 126 core surgical trainees in the Northern Ireland Deanery their surgical specialty preferences over 2 years. Trainees were asked for their first and second preferences on each occasion. In total 502 first and second preferences were declared. Past and present postings were then correlated with this information to see if working in a cardiothoracic unit impacted on specialty preference choices.

Results

Cardiothoracic surgery is the least popular of all the surgical specialties amongst junior surgical trainees (3.6%)—with general surgery, breast surgery, and orthopaedic surgery, drawing 53% of trainees. In trainees who had previously worked in cardiothoracic surgery, 75% expressed a wish to return to the specialty, making it the most dominant.

Conclusions

The role of junior surgical jobs in the specialty is immensely important on career choice. Moving to a more junior recruitment may exclude excellent candidates who have simply not experienced cardiothoracic surgery.

     

Transplant surgeons in training: is anybody out there?

There is a long-standing recognition that there is an organ donor shortage in the United Kingdom and Ireland (UK&E) that limits transplant activity. However, the fact that, at present, there are several unfilled consultant vacancies would suggest that a shortage of trained surgeons may soon be an equally important limiting factor. The aim of this current study was to identify all transplant trainees in the UK&E and to determine their career aspirations. A list of all trainees intending to practice as transplant surgeons was compiled. A combination of postal questionnaire and telephone interview was used to construct a database on past and present training in transplantation, and preferred type of consultancy was assessed both by direct questioning and by using a visual analogue scale to grade desirability of various posts. Of 110 potential trainees identified, 50 (45%) replied and indicated a desire to pursue a career in transplant surgery. Thirty-one intended practising in the UK&E (19 UK&E graduates and 12 overseas). The preferred consultancy (27/31) was transplantation (Tx) together with a second specialty while only four wanted a multivisceral practice. The mean score (0-10) for desirability of a multivisceral transplant post was 4.7, for renal transplant and vascular access it was 3.6 and for transplantation and a second specialty it was 8.4. We conclude that the majority of trainees do not wish to apply for pure transplant posts, either single organ or multivisceral, and that the majority wish to practice transplantation with a second specialty. In addition, there is still a major shortage of trainees and further studies are required to identify reasons why trainees fail to pursue a career in transplantation.     

Syringe labels in anaesthetic induction rooms

A survey of 35 hospitals in the United Kingdom has uncovered a wide variety of syringe drug labels. Use of different systems in different hospitals may result in wrong drug administrations, particularly when trainees move from one hospital to another. There is an urgent need to standardise the colour coding of syringe labels in the United Kingdom. Such standards are already in place in Australia, New Zealand and in the United States of America. This survey of syringe drug labels highlights the existing risks and recommendations for change are made.     

Plastic surgical trainees’ perspectives toward burn surgery in Australia and New Zealand: Changes in the last 17 years?

IntroductionAn emerging amount of literature emphasises the ever-growing shortage of burn surgeons worldwide. Despite burn surgery being a fundamental competency in the Australia and New Zealand plastic and reconstructive surgery training curriculum, a perceived lack of interest amongst trainees exists. The aim of this study was to investigate Australasian plastic surgery trainees’ interest in burn surgery as a career and compare with the Brown and Mills survey in 2004.MethodsAn electronic survey was distributed to all Australian and New Zealand plastic and reconstructive surgery trainees during the March 2021 registrar trainee conference. This anonymous survey was adapted from the original survey conducted by Brown and Mills in 2004, with additional questions to determine the perceived importance of burns surgery as a subspecialty of plastic and reconstructive surgery, and to elicit possible solutions to the issue of workforce shortage. A reminder email was sent one month following the conference to improve the response rate. The survey was hosted by Survey Monkey (San Mateo, California, USA).ResultsThe survey was distributed to all 121 trainees and 71 (58.7%) responded. An increase in interest amongst trainees in pursuing a career in burn surgery was found, with 34 trainees (48.6% of respondents) interested, mostly on a half time or sessional basis. The three most common barriers to practising burn surgery remain unchanged, and were nature of burn operations, nature of burn care and on-call commitments; inadequacy of exposure or training ranked fourth. We found a strong overall response that burn surgery and burn care remained an important component of plastic and reconstructive surgery.DiscussionInadequate exposure or training has evolved to present a bigger barrier in this study compared to a similar study conducted 17 years ago. Burn units and training bodies may offer additional job placements to address these feelings of insufficient exposure. Facilitating employment of burn surgeons on a half-time or sessional capacity is a sustainable model, and will arguably improve clinical service provision. Strong and early mentorship and allocation of commensurate resources and funding will help to address the high workload.ConclusionsInterest in burn surgery has improved over the last 17 years and the most common deterrents persist, namely nature of burn operations, nature of burn care and on-call commitments. However, many of these issues are modifiable or amenable to change. The opportunity exists for relevant stakeholders to address some of these concerns raised, and thereby addressing the issue of burn surgeon shortage.     

Thromboprophylaxis for radical prostatectomy: a comparative analysis of present practice between the USA, the UK, and Ireland

BACKGROUND: A clinical dilemma exists in the management of patients undergoing radical prostatectomy (RP) whereby measures taken to reduce the risk of thrombotic events may adversely affect efforts to limit blood loss. No consensus exists in the literature on the ideal management of thromboprophylaxis in these patients. Our aim is to examine and compare current thromboprophylactic policy and practice between the centres involved in performing RP. METHODS: A questionnaire was forwarded to all urology residency programmes in Ireland, the United Kingdom, and the United States, regarding their current practice with respect to thromboprophylaxis in RP. Completed questionnaire were returned by fax and the data entered into a computer database. RESULTS: An overall response rate of 60% was achieved. The questionnaires demonstrated a significant difference in clinical practice between Urologists in the United States and the United Kingdom. Just 24% of American Urologists use pharmacological thromboprophylaxis in contrast to 100% of British Urologists. There was no difference in the use of non-pharmacological thromboprophylaxis. Pharmacological thromboprophylaxis is mainly administered by units, mostly in the United Kingdom, doing fewer radical prostatectomies. CONCLUSIONS: While there have been studies advocating the use of pharmacological thromboprophylaxis in patients undergoing major pelvic surgery, there is no consensus on it is use in urological practice. This study has demonstrated significant differences in the management of thromboprophylaxis between the USA and the UK/Ireland. Units performing the largest number of radical prostatectomies, mostly in the USA, do not use pharmacological thromboprophylaxis and most do not use compression boots.     

Attitudes of surgical trainees towards transplantation surgery as a career

At present there are a number of unfilled consultant posts in transplantation surgery in the United Kingdom, particularly within the field of kidney transplantation. Unless the current shortfall is addressed, it seems highly probable that the number of unfilled consultant posts will continue to increase. This survey aimed to highlight the reasons underlying trainees' reluctance to enter the field of transplantation surgery and to assess how the specialty might be changed to attract new trainees. Questionnaires were sent to 102 surgical trainees requesting details on age, sex, training grade, research interests and chosen specialty. They were asked to consider nine specified reasons commonly thought to influence a trainee's decision on whether or not he/she would enter their chosen specialty and to grade each of these according to their relative importance in the context of considering a career in transplantation. The survey then suggested five changes in training/structure, and the trainees were again asked to grade the relative importance of each with regard to whether it would attract them towards transplantation surgery. Replies were received from 61 trainees (60 %). Trainees were deterred from transplantation surgery because of the on-call commitment, unpredictable workload, lack of exposure and a lack of information on the specialty. A reduced on-call commitment, increased income, increased exposure, improved training structure and increased information would all serve to attract new trainees to the specialty. To attract new trainees to transplantation surgery, there must be exposure to the specialty at an earlier stage in training, and a proactive stance must be adopted in providing information for the trainees. In addition, there needs to be ongoing commitment to improvements in training structure. The issues of increased income and an acceptable on-call commitment must be addressed. Received: 20 October 1998 Received after revision: 30 April 1999 Accepted: 3 May 1999     

The Impact of COVID-19 on Plastic Surgery Training in the United Kingdom,Canada and Australia—A Cross-Sectional Study

Background Surgical trainees worldwide have been thrust into a period of uncertainty, with respect to the implications COVID-19 pandemic will have on their roles, training, and future career prospects. It is currently unclear how plastic surgery trainees are being affected by COVID-19. This study examined the experience of plastic surgery trainees in Canada, the UK, and Australia to determine trainee roles during the early COVID-19 emergency response and how training changed during this time. Methods A cross-sectional survey-based study was designed for plastic surgery trainees in the UK, Canada and Australia. In total, 110 trainees responded to the survey. Statistical tests were conducted to determine differences in responses, based on year of training and country of residence. Results In total, 9.7% (10/103) of respondents reported being deployed to cover another service. There was a significant difference between redeployment based on country ( p = 0.001). Within the UK group, 28.9% of respondents were redeployed. For trainees not deployed, 95.5% (85/89) reported that there has been a reduction in operative volume. Ninety-seven (94.1%) respondents reported that there were ongoing teaching activities offered by their program. The majority of trainees (66.4%) were concerned about their training. There was a significant difference between overall concern and country ( p < 0.05). Conclusion In these unprecedented times, training programs in plastic surgery should be aware of the major impact that COVID-19 has had on trainees and will have on their training. The majority of plastic surgery trainees have experienced a reduction in surgical exposure but have maintained some form of regular teaching.     

Survey of arrangements for anaesthesia for interventional neuroradiology for aneurysmal subarachnoid haemorrhage

The management of patients with subarachnoid haemorrhage following rupture of an intracranial aneurysm is changing. The recent introduction of endovascular occlusion of the aneurysm using detachable coils offers an alternative to craniotomy and clipping of the aneurysm for the prevention of recurrent aneurysmal haemorrhage. The aim of this survey was to evaluate the current provision of peri-operative care for patients with an aneurysmal subarachnoid haemorrhage in the United Kingdom and Republic of Ireland. A survey was conducted of the 34 neuroscience centres which provide an adult neurosurgery service in the United Kingdom and Republic of Ireland. Most centres reported an increasing role for coiling, and a decreasing role for clipping in the management of aneurysmal subarachnoid haemorrhage. The provision of peri-operative care for patients undergoing interventional neuroradiology procedures varied greatly between centres. Neurovascular services in the UK are being reorganised and adequate staff and facilities should be available for the peri-operative care of patients undergoing interventional neuroradiology procedures.     

Supervision of trainee anaesthetists: a survey of opinions and practices

This questionnaire survey investigated the different degrees of supervision of trainee anaesthetic senior house officers (SHOs) in hospitals across the United Kingdom, and compared it with past practices as well as with The Royal College of Anaesthetists' recommendations at that time. It is apparent that the duration of intensive supervision of new anaesthetic trainees has increased over the last 25 years. This study assesses these changes in order to evaluate whether or not these reforms have achieved their intended outcomes.     

Marked Variation in Venous Thromboprophylaxis Management for Abdominal Aortic Aneurysm Repair; Results of Survey Amongst Vascular Surgeons in the United Kingdom

Objectives

We aimed to survey the current management of venous thromboprophylaxis in patients undergoing elective surgery for abdominal aortic aneurysm (AAA) by vascular surgeons in the United Kingdom.

Design

A questionnaire was designed to investigate anticoagulation strategies in the perioperative period of elective AAA repair, both open and endovascular. This included both chemical and mechanical prophylaxis. A total of 395 questionnaires was posted to the members of the Vascular Society of Great Britain and Ireland.

Results

One hundred and seventy-two (44%) valid responses were received. Half of the respondents administered pre-operative chemical prophylaxis at a mean of 13 h prior to AAA surgery. There was a high level of concordance in administration of heparin during surgery and in thromboprophylaxis post-operatively, with 97% giving some form of thromboprophylaxis. However there was a variation in the dose and timing, if administered, of chemical and mechanical prophylaxis.

Conclusion

The survey revealed diversity in perioperative thromboprophylaxis strategies among vascular surgeons. This suggests that standardisation of pre-operative and post-operative mechanical and chemical thromboprophylaxis may be required which could potentially improve the outcomes in elective management of AAA in the UK.     

Do Cosmetic Surgeons Consider Estrogen-Containing Drugs to Be of Significant Risk in the Development of Thromboembolism?

Background  Well-documented evidence shows that estrogen increases the risk of deep vein thrombosis (DVT), and that the effects of DVT are compounded by the stress of surgery and an anesthetic. Methods  This study sought to determine the current views and practice of plastic surgeons regarding combined oral contraceptive and surgery. In the United Kingdom, 285 consultant plastic surgeons were identified, and postal questionnaires were distributed to each surgeon. Results  Of 286 postal questionnaires distributed to consultant plastic surgeons, 53% were returned and analyzed. Most of the surgeons considered combined oral contraceptive and surgery to be a risk factor for DVT, although only 54% discontinued it before surgery. Approximately 50% believed hormone-replacement therapy (HRT) is a risk, but fewer than a one-fourth of surgeons stopped its use before surgery. There was a range of distribution for the length of time HRT was discontinued for surgery. The majority of consultants discontinue HRT use for 5 to 6 weeks before surgery and until full ambulation after surgery. Data retrieved were used to compare documented evidence relating to combined oral contraceptive and surgery and its association with DVT. Conclusion  This survey shows that the management of patients taking estrogen-containing medication before plastic surgery varies, and guidelines regarding this should be sought.     

Regional anaesthesia for limb surgery: a review of anaesthetists' beliefs and practice in the Oxford region

We conducted a postal survey of 210 anaesthetists in the Oxford region to determine their views and practice regarding the timing of regional anaesthesia when combined with general anaesthesia for adults undergoing limb surgery and to compare the results with those obtained in a similar survey conducted in 2001. Of the 151 respondents (72% response rate), 102 (68%) regularly combined regional and general anaesthesia for adult limb surgery. Over 80% believed that central neuraxial blocks should be performed before general anaesthesia. This matched their current practice, marking a change from 2001. Significantly fewer anaesthetists believed it necessary to perform peripheral nerve blocks before general anaesthesia than in 2001, marking another significant change in practice. Overall, the results indicate an increased popularity of regional blocks in combination with general anaesthesia when compared with 2001 practice, which we believe is related to high quality advanced training modules now on offer to senior trainees in the Oxford region.     

Survey of minimally invasive general surgery fellows training in robotic surgery

Minimally invasive surgery fellowships offer experience in robotic surgery, the nature of which is poorly defined. The objective of this survey was to determine the current status and opportunities for robotic surgery training available to fellows training in the United States and Canada. Sixty-five minimally invasive surgery fellows, attending a fundamentals of fellowship conference, were asked to complete a questionnaire regarding their demographics and experiences with robotic surgery and training. Fifty-one of the surveyed fellows completed the questionnaire (83 % response). Seventy-two percent of respondents had staff surgeons trained in performing robotic procedures, with 55 % of respondents having general surgery procedures performed robotically at their institution. Just over half (53 %) had access to a simulation facility for robotic training. Thirty-three percent offered mechanisms for certification and 11 % offered fellowships in robotic surgery. One-third of the minimally invasive surgery fellows felt they had been trained in robotic surgery and would consider making it part of their practice after fellowship. However, most (80 %) had no plans to pursue robotic surgery fellowships. Although a large group (63 %) felt optimistic about the future of robotic surgery, most respondents (72.5 %) felt their current experience with robotic surgery training was poor or below average. There is wide variation in exposure to and training in robotic surgery in minimally invasive surgery fellowship programs in the United States and Canada. Although a third of trainees felt adequately trained for performing robotic procedures, most fellows felt that their current experience with training was not adequate.     

The practice of the first check cystoscopy following radiotherapy for the treatment of muscle-invasive (T3N0M0) bladder cancer: a UK national survey

Objectives  

To determine the current trends in the follow-up of patients with muscle-invasive bladder cancer following radiotherapy, among consultants in the United Kingdom and the republic of Ireland in terms of cystoscopic survey and imaging of the upper tracts.     

Prehospital airway management in Ambulance Services in the United Kingdom

A postal survey of the 38 Ambulance Services in the United Kingdom was undertaken to find out what equipment is provided for paramedic crews to aid tracheal intubation and to confirm tracheal placement. The response rate to our survey was 100%. Fourteen (37%) ambulance services provided neither stylet nor bougie to facilitate difficult intubation. The laryngeal mask airway was available to 15 (40%) ambulance services. Seventeen (45%) ambulance services had use of a needle cricothyroidotomy set. Twenty-nine (76%) ambulance services had no type of device other than a stethoscope to confirm tracheal tube placement. This survey showed wide variations in the equipment for airway management available to paramedic crews in the United Kingdom. We recommend provision of a standard set of airway management equipment to all paramedic crews in the United Kingdom together with introduction of appropriate training programmes.     

A Strategy to Improve Quality of Outpatient Education for Residents and Medical Students on a Vascular Surgery Service

In the current era of same-day admissions and decreased length of hospitalization for major vascular operations, education of residents and medical students in the outpatient setting has become an increasingly challenging problem. We developed a strategy to provide improved outpatient experience for advanced vascular surgery residents (VSRs), general surgery residents (GSRs), and medical students (MSs) on a vascular surgery service. A survey of program directors and VSRs at accredited vascular surgery fellowships in the United States and Canada was undertaken to determine the manner in which outpatient education was accomplished and the amount of time devoted to pre- and postoperative patient evaluation. The survey revealed that VSRs, GSRs, and MSs spent 1 or more days in clinic at approximately half of accredited vascular surgery programs. There were no appreciable differences in time spent in clinic for different levels of trainees. VSRs preoperatively evaluated at least half of their patients at approximately two-thirds of the programs, while at the other third of the programs they preoperatively evaluated one-quarter or less of their patients before surgery. GSRs preoperatively evaluated at least half of their patients at 50% of programs, according to program directors, and at 69% of programs, according to VSRs. Because of recent changes in health care delivery and the effect of these changes on resident training, outpatient education of VSRs, GSRs, and MSs will require increased attention on the part of vascular surgeons involved with their education. increasing time demands and decreasing reimbursements for vascular surgeons as a result of managed health care may make this goal increasingly difficult to accomplish. Improved strategies and extra efforts are necessary to ensure that trainees obtain sufficient experience to evaluate vascular patients pre- and postoperatively and maintain high quality of care for vascular surgery patients.     

Antibiotic prophylaxis in cardiothoracic surgery in the United Kingdom: current practice.

A survey was conducted of the current practice of antibiotic prophylaxis in cardiac surgery throughout the United Kingdom. Most surgeons (84%) use a regimen covering a broad spectrum of bacterial species that is continued for two to three days after the operation. The most used regimens are a combination of beta lactamase resistant penicillin with an aminoglycoside (44%) or a single broad spectrum cephalosporin (30%). Just 16% of surgeons preferred a narrow spectrum regimen effective against only the Gram positive organisms commonly responsible for postoperative infection in these patients. Antibiotic prophylaxis has been adopted by all cardiac surgeons in the United Kingdom but is sometimes continued longer than is indicated by the clinical or experimental evidence.