Bench and Bedside? Surgeons’ views on the role of research in surgical training

Aims

Internationally, surgical training is facing the challenge of balancing research and clinical experience in the context of reduced working hours. This study aimed to investigate trainees and trainers’ views on surgeons participating in full-time research during surgical training.

Methods

An anonymous voluntary survey was conducted of surgical trainers and trainees in two training systems. To examine surgeons’ views across two different training schemes, surgeons were surveyed in Ireland (Royal College of Surgeons in Ireland) and in a Canadian centre (University of Toronto) between January 2009 and September 2010 (n = 397 respondents).

Results

The majority of respondents felt that time spent in research by trainees was important for surgery as a specialty, while 65 % felt that research was important for surgical trainees (trainers 79 %, trainees 60 %, p = 0.001). A higher proportion of Canadian surgeons reported that they enjoyed their time spent in research, compared to Irish surgeons (84 vs. 66 %, p = 0.05). Financial worries and loss of clinical time were common demotivating factors. Full-time research was more popular than part-time options to obtain a post-graduate degree.

Conclusions

Most agree that research remains an important component of surgical training. However, there are significant differences in opinion among surgeons in different countries on the precise role and structure of research in surgical training.     

A survey of upper and lower limb tourniquet use among Irish orthopaedic surgeons

Background

Tourniquet use in orthopaedic surgery is common practice. However, the technique varies among Irish orthopaedic surgeons and there are no standard guidelines.

Aim

To analyse trends in tourniquet use among Irish orthopaedic surgeons.

Methods

Ninety-two Irish orthopaedic consultants were sent a 15-survey question about tourniquet use by post.

Results

Sixty respondents returned a completed survey, of which 49 (81 % of respondents) used both upper arm and thigh tourniquets. A variation in tourniquet pressure settings and techniques used was reported. Thirty-nine surgeons (65 % of respondents) use a tourniquet pressure range of 201–250 mmHg for the upper arm and 30 surgeons (50 % of respondents) use a range of 251–300 mmHg for the thigh. Thirty-six surgeons (60 % of respondents) experienced a complication secondary to tourniquet use, the most common complications being nerve and skin injury.

Conclusions

Based on published studies of limb occlusion pressures, this study suggests that some of the tourniquet cuff inflation pressures used may be higher than necessary. Guidelines for optimising cuff pressure and technique should be established to minimise the risk of complications. This study may help determine direction for future research on tourniquet use.     

Postgraduate training in Ireland: expectations and experience

Background

Postgraduate medical training in Ireland has been compared unfavourably with training abroad and blamed for an “exodus” of graduates of Irish medical schools. Exploration of features of a good training environment and development of tools to measure it have been the focus of much published research. There have been no Irish studies examining training environment using such validated tools.

Aim

The aim of this study was to use a validated tool, to examine the expectations and experience of training, amongst those training under the Royal College of Physicians of Ireland (RCPI).

Method

The Dutch Residency Education Climate Test (D-RECT) is a 50 item tool to measure postgraduate learning environments. D-RECT was sent to all new entrants to RCPI training programmes in July 2012 (n = 527) and completed in regard to expectations of training (response rate 80.6 %). In March 2013, D-RECT was sent to all RCPI trainees (n = 1,246) to complete in relation to the post held on 1 March (response rate 32.6 %). Data were analysed in SPSS version 18.

Results

Experience fell short of expectations for basic specialist training, however, scores for experience rose with greater seniority to match expectations. Positive aspects were teamwork, consultant willingness to discuss patients and respectful treatment of trainees. Areas of weakness were provision of feedback and time to learn new skills.

Conclusion

Measurement of learning environment at a national level using a quantitative tool provides useful information for quality assurance and improvement of training.     

Prevalence of left-sided melanomas in an Irish population

Background

A predominance of melanomas on the left side of the body has recently been described. No associations between tumour laterality and gender, age or anatomical site have been identified.

Aim

The aim of this study was to investigate the prevalence of left-sided melanomas in an Irish population and to examine potential associations with various patient and tumour characteristics.

Methods

A retrospective chart review of patients with cutaneous melanoma who were treated over a 10-year period was carried out. Lateral distribution of melanoma on either side of the body was compared using χ² analysis and evaluated by gender, age group, anatomic location, histologic subtype and Breslow depth.

Results

More melanomas occurred on the left side (57%, P = 0.015), and this finding was particularly significant in females. For both genders combined, there were no statistically significant differences in laterality by age group, anatomic location, type of melanoma and Breslow depth. There were significantly more superficial spreading melanomas on the left side in both men and women.

Conclusions

This study demonstrates a predominance of left-sided melanomas in Irish patients. While a number of demographic and molecular associations have been proposed, further research is required to fully explain this phenomenon.     

Preoperative tests: an Irish perspective

Introduction

We sought to investigate whether hospital doctors in Ireland order too many expensive, unnecessary tests and analyse their motives for so doing.

Methods

A series of test patients modelled along guidelines as outlined by the National Institute for Clinical Excellence were presented to doctors in two university teaching hospitals. For each case, they were asked to identify the appropriate investigations.

Results

Fifty-three interns on a surgical rotation completed the questionnaires. Forty-four percent (n = 50) of interns ordered the tests based on influences from the consultant leading their team, with only 24% citing their medical training as the critical reason for ordering a preoperative investigation. No intern considered cost to have any influence on their decision to book preoperative tests.

Discussion

This study demonstrates that the previously well-documented international practice of overuse and unexplained variation in preoperative testing is also the norm in Ireland.     

When Irish eyes are smiling: income and happiness in Ireland, 2003–2009

Background

Ireland’s economic fortunes rose and fell in dramatic fashion between 2000 and 2010, as an unprecedented boom was followed by economic crisis.

Aims

We hypothesised that (a) these dramatic changes in economic circumstances did not substantially change self-rated happiness in Ireland, but (b) social and psychological correlates of happiness may have changed, both within Ireland and compared to other European countries.

Methods

We studied data from the European Social Survey relating to self-rated happiness and social and psychological correlates of happiness in Ireland in 2003 (n = 2,046), 2005 (n = 2,274), 2007 (n = 1,794) and 2009 (n = 1,764).

Results

There was a slight decline in happiness between 2005 and 2009, as mean self-rated happiness score changed from 7.94 (2005) to 7.55 (2009) (0: “extremely unhappy”; 10: “extremely happy”). Linear regression models accounted for only 16.6–20.2 % of inter-individual variation in happiness at each time-point. Satisfaction with health had the strongest association with happiness in 2003, 2005 and 2007. Satisfaction with income, relative to other variables, increased over time and in 2009 had the strongest association with happiness.

Conclusion

Overall, despite dramatic changes in economic circumstances and a slight decline in happiness, the Irish continued an historic tradition of rating ourselves as generally very happy.     

Helicobacter pylori resistance rates for levofloxacin, tetracycline and rifabutin among Irish isolates at a reference centre

Introduction

Helicobacter pylori eradication rates using conventional triple therapies are falling, making viable second-line and rescue regimens necessary. Levofloxacin, tetracycline and rifabutin are three efficacious antibiotics for rescue therapy.

Aim

We aimed to assess the resistance rates for H. pylori against these antibiotics in an Irish cohort.

Methods

Gastric biopsies were collected from 85 patients infected with H. pylori (mean age 46 years) in the Adelaide and Meath Hospital, Dublin in 2008 and 2009. Susceptibility to antibiotics was tested using the Etest. Clinical information was obtained from endoscopy reports and chart review.

Results

50.6 % of patients were females. Mean age was 47 years. Ten had prior attempts at eradication therapy with amoxicillin-clarithromycin-PPI, two had levofloxacin-based second-line therapy. 11.7 % [95 % CI (6.5–20.3 %)] (N = 10) had strains resistant to levofloxacin. There were no strains resistant to rifabutin or tetracycline. Levofloxacin resistance in the under 45 age group was 2.6 % (1/38) compared to 19.1 % (9/47) of above 45 age group (p = 0.02).

Discussion

The levofloxacin rates illustrated in this study are relatively low by European standards and in line with other studies from the United Kingdom and Germany, with younger patients having very low levels of resistance. Levofloxacin, tetracycline and rifabutin are all valid options for H. pylori eradication in Irish patients but the importance of compliance cannot be underestimated.     

The effect of behavioural risk factors on osteoporosis in Irish women

Background

Osteoporosis constitutes a major public health concern and its underlying pathogenesis is complex and multifactorial. Although hereditary factors strongly contribute to bone health, behavioural factors can modulate the genetically determined pattern of skeletal modelling and remodelling.

Aim

The aim of this study was to investigate the effect(s) of behavioural risk factors on osteoporosis in Irish women.

Methods

Pre- and post-menopausal adult women (n = 189; 44 ± 15 years) participated in this cross-sectional study. Demographic, anthropometric and lifestyle data were collected during a single clinic visit. Dietary calcium intake and lifetime physical activity (PA) were assessed for each subject. Lumbar and femoral bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (DXA). Multivariate analysis was used to determine the independent predictors of low BMD.

Results

Low BMD was present in 59 % of subjects (42 % pre- and 77 % post-menopausal). Smoking was the strongest behavioural predictor of lumbar and femoral BMD. Age, height, family history, smoking, metabolic (MET) and mechanical (MECH) PA (lifetime) and weight (body mass) accounted for 39 % of the variance in lumbar BMD. Age, height, family history, alcohol consumption, MET and MECH PA (lifetime) and weight accounted for 41 % of the variance in femoral BMD.

Conclusions

Prevalence of osteopenia and osteoporosis is high in Irish women and is associated with modifiable risk factors. A clearer focus should be paid to educate Irish women on preventative health behaviours for osteoporosis to curb the prevalence of this disease and the human and fiscal costs associated with it.     

The Irish National Joint Registry: where are we now?

Background

Ireland is currently in the process of establishing a National Joint Registry.

Aim

We aim to determine which implants and surgical techniques are currently being used by Irish orthopaedic surgeons and to examine the impact that a National Joint Registry may have on arthroplasty practice in Ireland.

Methods

The study consisted of a postal questionnaire sent to all public service consultant orthopaedic surgeons in The Republic of Ireland.

Results

We had a response rate of 76.6 %. Of this 76.6, 86.4 % regularly perform total hip arthroplasty (THA) and 84.7 % perform total knee arthroplasty. Of those who perform THA, 86.3 % use different implants in younger patients. Thirteen different femoral implants are used, and seven different knee implants. We conservatively estimate that at least 3,918 total hip arthroplasties and 2,604 total knee arthroplasties are performed in Ireland each year. At present we have no way to precisely monitor the number of arthroplasty procedures being performed, and we have no way of accurately monitoring the short- or long-term outcomes of the many implants used.

Conclusions

The establishment of a National Joint Registry for Ireland would benefit the Irish orthopaedic community, and given the large number of procedures being performed, may also be of benefit to the international orthopaedic community.     

Explaining the increase in breastfeeding at hospital discharge in Ireland, 2004–2010

Background

Despite a steady increase in the rate of breastfeeding in Ireland over the period 2004–2010 (from 46.8 % in 2004 to 55.7 % in 2010), Irish rates of breastfeeding are still low by international standards. Over this period, the characteristics of mothers and babies changed, with mothers increasingly older, having fewer children and increasingly born outside the Republic of Ireland.

Aims

The purpose of this paper is to understand the extent to which changing maternal and birth characteristics explained the increase in the breastfeeding rate in Ireland over the period 2004–2010.

Methods

We apply non-linear decomposition techniques to micro-data from the 2004–2010 Irish National Perinatal Reporting System to examine this issue. The technique allows us to quantify the extent to which the increase in the breastfeeding rate over the period 2004–2010 is due to changing maternal and birth characteristics.

Results

We find that between 55 and 74 % of the increase over the period can be explained by changing characteristics, with the increasing share of mothers from Eastern Europe, and increasing maternal age the most important contributors.

Conclusions

These findings suggest that the existing policy initiatives have been relatively ineffective in increasing breastfeeding rates in Ireland, i.e. most of the observed increase occurred simply because the characteristics of mothers were changing in ways that made them increasingly likely to breastfeed.     

The impact of abdominal aortic aneurysm surgery on intensive care unit resources in an Irish tertiary centre

Background

The potential impact of surgical service reconfiguration on intensive care unit (ICU) resources needs to be assessed.

Aims

To determine the resources required to provide post-operative ICU care to patients undergoing open abdominal aortic aneurysm (AAA) repair or endovascular aneurysm repair (EVAR) at a specialist centre in the HSE South area

Methods

For 198 patients, we calculated: (1) ICU bed-days; (2) organ support required; and (3) monetary cost of ICU care.

Results

In total, 82.8 % (101/122) of patients undergoing open AAA repair required post-operative ICU care (52 emergency and 49 elective). Emergency cases required more ICU bed-days (median 4.2 vs. 1.9, p < 0.0005) and were more likely to require ventilation (odds ratio, OR 11.7, p < 0.0001), inotropes (OR 3.1, p = 0.01) or enteral nutrition (OR 23.3, p < 0.0001). Mean cost per patient was €3,956 for elective cases and €16,419 for emergency cases. No patient required ICU admission after EVAR (n = 76).

Conclusions

Open AAA surgery places significant demands on ICU resources. The planned reconfiguration of surgical services in Ireland must provide for parallel investment in ICU facilities and expertise.     

Deprivation in cold weather increases the risk of hospital admission with hypothermia in older people

Background

Material deprivation in cold weather may increase the risk of hypothermia and contribute to excess winter mortality. To date, there were no local data to support the potential contribution of material deprivation to the incidence of hypothermia in Irish older people.

Aim

To contribute evidence from a hospital-based perspective.

Methods

Patient series from St James’s Hospital Dublin, Ireland. Of all patients aged ≥65 years experiencing their last medical admission between 1 January 2002 and 31 December 2010, we selected those who presented with a body temperature of <35 °C. Their clinical characteristics were compared with those of a random sample of 200 age and gender-matched non-hypothermic patients. Multivariate logistic regression was used to identify predictors of presentation with hypothermia. The following predictors were considered: age, gender, mean air temperature on the day of admission, year of admission, comorbidity, major diagnostic categories, and material deprivation as per the Irish National Deprivation Index (NDI).

Results

Eighty patients presented with hypothermia over the period. They presented in colder days (mean 8.8 vs. 10.8 °C, P < 0.001) were less likely to present in summer (P < 0.002), more likely to present in winter (P = 0.010), and their mortality was high (50 vs. 17 %, P < 0.001). The interaction NDI* air temperature was a significant multivariate predictor of hypothermia (OR = 1.03, 95 % CI 1.01–1.06, P = 0.033).

Conclusions

The NDI could be an adequate tool to target fuel poverty in older people.     

The detrimental impact of the implementation of the European working time directive (EWTD) on surgical senior house officer (SHO) operative experience

Background

Concerns have been voiced regarding the impact of the European Working Time Directive (EWTD) on surgical training. Following its introduction (August 2009) in Wexford General Hospital, Ireland Surgical Senior House Officers (SSHOs) are required to leave the hospital at 10 a.m. the morning after on-call duty. This study investigates the consequences of this practice on operative experience gained by six SSHOs in comparison to their predecessors.

Methods

A prospectively maintained database of surgical procedures was interrogated. Operative experience of SSHOs over a 5-month period (August–December 2009) was compared with that of colleagues 1 year earlier. The primary endpoint was overall operative volume of SSHOs. Subgroup analysis was performed of cases by primary operator versus assistant, intermediate versus minor procedures and by team. Comparison was made of operative volume between Group 1 (pre-EWTD) and Group 2 (post-EWTD).

Results

Operative volume for Group 1 (pre-EWTD) was 461 cases. Group 2 (post-EWTD) was involved in a total of 349 operations, showing a decrease of 24 % (P = 0.006). SSHOs in Group 1 (pre-EWTD) had been the primary operator in 109 cases compared to 87 in Group 2 (post-EWTD), demonstrating a reduction of 20 % (P = 0.06). Most worryingly, there was a reduction of 63 % (P = 0.04) in the intermediate cases performed as operating surgeon in Group 2 (post-EWTD).

Conclusions

The present data set demonstrates a significant reduction in operative experience gained by SSHOs after local implementation of the EWTD. A major challenge facing Irish surgical training over the next decade is reduced operative exposure in the clinical setting.     

Pancreatic metastasectomy: experience of the Irish National Surgical Centre for Pancreatic Cancer

Background

Metastatic tumours of the pancreas are rare and the optimal management of these tumours remains unclear, given the paucity of data existing in the literature. We report our experience of pancreatic metastasectomy.

Methods

Data were reviewed on all patients who underwent pancreatic resection for pathologically confirmed metastatic lesions over a consecutive 7-year period.

Results

Seven patients (two men and five women) underwent a pancreatectomy for a metastatic pancreatic tumour. The primary tumours were renal cell carcinoma (n = 3), colorectal carcinoma (n = 2) and leiomyosarcoma (n = 2). There was no operative mortality. Postoperative morbidities occurred in two patients. The median follow-up was 49 months (range 17–76). Overall 1- and 2-year survivals were 100 and 86 %, respectively, with a 2-year disease-free survival of 72 %.

Conclusions

Our series further supports that pancreatic metastasectomy can be performed safely and achieves acceptable survival outcomes.     

Attitudes towards patients with mental illness in Irish medical students

Background

A positive attitude to patients with mental illness is important in all branches of medicine, as it can impact on the quality of care patients receive from doctors. Attitudes of preclinical medical students is an under researched area.

Aims

This study aims to (1) assess the attitudes of preclinical and clinical medical students to patients with mental illness and (2) assess the effect of two modules taught using different teaching methods on students’ attitudes to patients with mental illness.

Methods

During the same academic year all students (N = 394) completing the year 3 preclinical psychiatry module and the final year psychiatry module completed an attitudinal questionnaire at the beginning and following completion of the module. Seventy-two percent of students completed both pre- and post-module questionnaires in full (n = 285).

Results

There was no significant difference in attitudes displayed by preclinical and clinical medical students prior to starting their respective modules. An association was found between female gender and more tolerant attitudes (r = 0.20, p = 0.02). Students who knew someone with experience of mental illness were associated with more tolerant attitudes (r = 0.32, p < 0.001). Final year students who completed the clinical module demonstrated a positive attitudinal shift (p < 0.001), and the attitudes of third and final year male students improved significantly following the module (p < 0.05).

Conclusions

Given the high rates of physical illness in patients with mental health problems, specific educational initiatives to address medical student’s attitudes to patients with mental health problems should be an educational priority in medical school.     

Publication rates of presentations at the Irish Orthopaedic Association annual meeting

Background

Presentation of scientific research at national and international meetings is an important forum for the dissemination of knowledge. Subsequent publication of a full-text paper in a peer-reviewed journal is the expected outcome of such presentations. The publication rate from these meetings is highly variable.

Aims

To determine the publication rate of abstracts presented at the Irish Orthopaedic Association’s Annual Conference and to determine which factors are associated with progression to full-text publication.

Methods

We reviewed the proceedings from the Irish Orthopaedic Association’s National Meeting over a 4 year period. We searched the Pubmed database using author names, institution names, and keywords from each abstract’s title, to determine how many presented articles progressed to full-text publication.

Results

Sixty-six of 203 were published, 97 % within 5 years of presentation. Laboratory based studies presenting novel or innovative findings were more likely to be published than clinical studies. Clinical studies were more likely to be published if they were prospective and had a longer period of follow-up. Retrospective audits were less likely to be published, even with a large cohort size. Changes in authorship of presented papers were related to a longer delay in time to full-text publication.

Conclusions

Thorough planning of research studies is essential to ensure a timely progression to full-text publication in a peer-reviewed journal. Most studies will be published within 5 years of initial presentation.     

The surgical safety checklist survey: a national perspective on patient safety

Background

In 2008, the World Health Organisation (WHO) recommended practices to ensure the safety of patients worldwide. This led to the development of the Surgical Safety Checklist (SSC). Ireland has endorsed the SSC (www.hiqa.ie/press-release/2008-06-17-health-information-and-quality-authority-launches-world-health-organization, 10).

Objectives

We aimed to determine (i) whether SSC is being implemented, (ii) whether it promotes a safer surgical environment and (iii) identify problems associated with its introduction and on-going implementation.

Methods

All hospitals in Ireland with operating departments (n = 61) were invited to participate in an online survey.

Results

The response rate was 67 %. The WHO SSC or modified version is in place in 78 % (mean time: 20 months) of operating departments that responded. Partaking in Time Out as a team was reported as occurring in 57 % of cases. Greater than 60 % of respondents reported that the SSC was difficult to introduce and implement and that its introduction was time consuming. Further training in using the SSC was reported as desirable by 84 % of respondents. The introduction of the SSC was reported to be associated with an improvement in team communication (72 %), a positive change in team behaviour (63 %), an increase in the consistency of patient care (82 %) and a positive culture of safety in theatre (81 %).

Conclusion

The SSC has not been implemented throughout all operating departments in Ireland. Where it has been introduced there has been a perceived positive change in safety culture. However, overall greater education, endorsement, teamwork, and communication will be required to optimise the potential benefits associated with this safety instrument. In order to properly determine the benefit of the SSC following its implementation, a formal audit of morbidity and mortality is required.     

Reproductive health in Irish female renal transplant recipients

Objective

To report the pregnancy outcomes in Irish female renal transplant recipients on modern maintenance immunosuppression.

Methods

The Republic of Ireland transplant database was accessed to identify the patient cohort in question. All female renal transplant recipients whose transplantation was in Ireland before or during their reproductive years were included. A questionnaire was sent to the identified women. A chart review was performed for those women who reported a pregnancy following renal transplantation.

Results

Two hundred and ten women met the inclusion criteria. There was a response rate of 70% (n?=?148). Eighteen women reported 29 pregnancies. The live birth rate was 76%. The mean gestation of the live births was 36.2?weeks with a mean birth weight of 3.0?kg. There were six cases of pre-eclampsia. Twin pregnancies and those entering pregnancy with a creatinine greater than 135???mol/l had particularly complicated clinical courses. Four women had not conceived post transplant despite actively trying for over 1?year. Two women utilised assisted fertility methods (in vitro fertilisation), one of whom became pregnant.

Conclusions

A significant proportion of women who attempt to conceive following renal transplantation are successful, without the use of assisted fertility. Pregnancy in this setting warrants meticulous multidisciplinary care.     

Late presentation of HIV despite earlier opportunities for detection, experience from an Irish Tertiary Referral Institution

Objectives

Late presentation of HIV continues to undermine advances in the management of HIV. Opportunities to detect HIV at an earlier stage are often missed. Current estimates suggest that undiagnosed individuals comprise approximately one quarter of all people in the western world living with HIV. ‘Testing-and-treating’ this group has been proposed as a means to curb the HIV epidemic. In this study we assessed the characteristics of individuals newly diagnosed with HIV, and their utilisation of healthcare services in Ireland prior to their diagnosis.

Methods

A retrospective review was undertaken of all patients newly diagnosed with HIV over a 27-month period. Patient demographics were recorded, as were details of healthcare contacts in the year preceding diagnosis. Individuals detected via screening of recent immigrants/asylum seekers were excluded.

Results

In the period studied 114 patients received a new diagnosis of HIV, 59 met inclusion criteria. The majority (54 %) fulfilled the European consensus definition for late presenters (CD4 < 350 cells/µl). ‘Late presenters’ were significantly more likely to be symptomatic at diagnosis (OR = 4.62; 95 % CI 1.45–14.67; p = 0.015), diagnosed by acute tertiary hospital services (p = 0.015), and 56 % reported heterosexual mode of acquisition (OR = 2.12; 95 % CI 0.73–6.16; p = 0.19). Patients detected via screening had significantly higher CD4 counts at diagnosis compared with those diagnosed due to symptoms (Median CD4 422 cells/µl; IQR 285–594 vs. 142 cells/µl; IQR 62–333; p = 0.0007). ‘Symptomatic’ patients were significantly more likely to report prior healthcare contacts (OR 4.71; 95 % CI 1.32–16.79; p = 0.013).

Conclusion

Current screening activities are inadequate. Unfortunately newly diagnosed HIV patients continue to be symptomatic, at advanced stages of disease, to acute hospital services. Heterosexual groups in particular are at risk for late detection.