Psychosocial correlates of depression following spinal injury: A systematic review

Objectives

Spinal cord injury (SCI) studies have identified a range of psychosocial risk and protective factors for depression post-injury. This study presents the first systematic and quantitative review of this body of research.

Methods

Twenty-four studies (N = 3172 participants) were identified through electronic database searches. Studies were evaluated according to recommended guidelines on Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). The significance and magnitude of the relationships between standardised measures of depression and psychosocial outcome were examined using Pearson''s effect size r, 95% confidence intervals and fail-safe Ns. Effect sizes were categorised according to the ICF psychosocial domains.

Results

STROBE ratings indicated discrepancies in procedural detail and statistical analyses. Individual personal variables including affective feelings, and thoughts and beliefs specific to SCI demonstrated the strongest relationship with depression self-ratings. Life satisfaction, disability acceptance, environmental supports and community participation had a medium to strong association, helping to reduce vulnerability to depression. Longitudinal studies revealed that symptoms of depression continued to impact on psychosocial outcome up to 10 years post-injury, although this was based on limited data.

Conclusions

Assessment of psychosocial factors in the acute stages of SCI rehabilitation can inform evidence-based interventions to treat and manage depressive symptomatology in the short to longer-term. Future studies would benefit from adopting a unified approach to the measurement of depression post-SCI to help inform targeted treatment.     

Weight gain following spinal cord injury: a pilot study

Study design

Retrospective chart review.

Objective

To define the temporal course of weight gain in persons with new spinal cord injury (SCI), and to identify predictors of weight gain in this population.

Setting

A United States Department of Veterans Affairs (VA) SCI Unit.

Methods

A retrospective chart review in a VA SCI Unit was conducted. Participants (n = 85) included all persons with new SCI completing initial rehabilitation at the center between 1998 and 2006. Outcome measures were mean change in body mass index (BMI) between rehabilitation admission and final follow-up, time of greatest BMI change, and distribution of participants by BMI classification. These measures were also examined relative to SCI level, American Spinal Injury Association Impairment Scale (AIS) grade, primary mode of mobility, and age at rehabilitation admission.

Results

Mean BMI increased by 2.3 kg/m² between rehabilitation admission (mean 45 days post-injury) and final follow-up (mean 5 years post-injury). The distribution of participants shifted from lower BMI classifications at rehabilitation admission to higher BMI classifications at final follow-up. For participants transitioning from normal to overweight or obese, the greatest increase occurred during the first year after acute rehabilitation. Neurological level, impairment category, primary mode of mobility, and age at rehabilitation admission did not significantly predict BMI change. BMI at rehabilitation admission correlated significantly with BMI at final follow-up (P < 0.0005).

Conclusions

These findings confirm a significant increase in BMI after new SCI and suggest that persons with new SCI are at greatest weight gain risk during the first year following acute rehabilitation.     

Obesity as defined by waist circumference but not body mass index is associated with higher renal mass complexity

Objectives

Obesity, typically defined as a body mass index (BMI)≥30 kg/m², is an established risk factor for renal cell carcinoma (RCC) but is paradoxically linked to less advanced disease at diagnosis and improved outcomes. However, BMI has inherent flaws, and alternate obesity-defining metrics that emphasize abdominal fat are available. We investigated 3 obesity-defining metrics, to better examine the associations of abdominal fat vs. generalized obesity with renal tumor stage, grade, or R.E.N.A.L. nephrometry score.

Evaluation of bone mineral loss in patients with chronic traumatic spinal cord injury in Iran

Objectives

We described the associations between demographic and injury-related factors on bone mineral density (BMD) of the spine and the hip among adult patients with chronic spinal cord injury (SCI).

Design

BMD in spinal and femoral bone sites were assessed. Multivariate analysis was performed to evaluate the relationship between anthropometric and injury-related factors with BMD. Serum level and amount of dietary intake of calcium, phosphor, and 25-hydroxy vitamin D were measured.

Setting

A referral tertiary rehabilitation center in Iran.

Participants

Patients with SCI who had no previous history of endocrine disorders and were not on specific medications entered the investigation. Those with non-traumatic SCI, pregnant, or with substance dependency were excluded as well.

Interventions

No interventions were applied.

Main study outcome measures

Dual X-ray absorptiometry was performed to estimate BMD. Body mass index was positively associated with higher femoral (P < 0.01, r = 0.56) and hip (P < 0.0001, r = 0.82) BMD only in female participants. The high prevalence of vitamin D deficiency (60%) was noticeable.

Results

Older male patients revealed lower BMD only in spinal vertebrae (P < 0.02, r = −0.21). A significant higher BMD loss in lumbar vertebras in male patients with complete spinal cord lesion (P < 0.009) was detected. Spinal reduction of BMD was more severe when the level of injury was above T6 (P < 0.02).

Conclusion

Along with the clarification of age, gender, post injury duration, and the other factors'' effect on the BMD in the SCI patients, here we have also shown the noticeable prevalence of the 25-hydoxy vitamin D deficiency in these patients which needs attention.     

Impact of body mass index on outcome in patients undergoing coronary artery bypass grafting and/or valve replacement surgery

Objective

This study aimed to analyze the impact of body mass index on outcomes of 101 patients undergoing coronary artery bypass grafting, valve replacement, or combined valve/ coronary artery bypass grafting surgery in a private hospital in Belo Horizonte, Brazil.

Methods

This was a prospective cross-sectional study of patients undergoing cardiac surgery from May 2009 to December 2012. All patients were followed up from the first day of admission until discharge or death. Patients were divided into three groups according to BMI: normal weight, overweight, and obese. The main outcome measure was the association between BMI and postoperative morbidities and mortality.

Results

Multivariate analysis identified obesity as an independent predictor of increased risk of surgical reintervention (odds ratio [OR] 13.6; 95%CI 1.1 - 162.9; P=0.046) and reduced risk of bleeding (OR 0.05; 95% CI 0.09 - 0.69; P=0.025). Univariate analysis showed that obesity was associated with increased frequency of wound dehiscence (P=0.021). There was no association between BMI and other complications or mortality in univariate analysis. There was also no association between body mass index and duration of cardiopulmonary bypass, aortic clamping, mechanical ventilation, and intensive care unit or hospital stay.

Conclusion

Obese individuals undergoing coronary artery bypass grafting, valve replacement, or combined surgery have a higher postoperative risk of surgical reintervention and lower chances of bleeding.     

The acromial index is not predictive for failed rotator cuff repair

Background

The main objective of this study was to evaluate the association between the acromial index (AI) and the incidence of recurrent tears of the rotator cuff (RC) in a cohort of patients with full thickness tears who underwent arthroscopic primary repair.

Methods

A prognostic study of a prospective case series of 103 patients with full thickness RC tears was undertaken. The average age was 59.5 years (39–74) and follow-up was 30.81 months (12–72). True anterior–posterior X-rays were obtained during the pre-operative evaluation. Pre and post-operative magnetic resonance imaging (MRI) were recorded.

Results

Eighteen cases with recurrent tears (17.4 %) were seen on post-operative MRI. The average AI for patients with recurrent tears was 0.711 ± 0.065 and for patients without recurrent tears 0.710 ± 0.064 (p < 0.05). A positive association between age and recurrent tears of the RC was noted (average ages: recurrent tears group 63 ± 5.9 years; group without recurrent tears 58.8 ± 7.5 years) (r = −0.216; p = 0.029). We did not find an association between size of the primary tear and recurrent tears (r = −0.075; p < 0.05) or between degrees of retraction of the primary and recurrent tears of the cuff (r = −0.073; p < 0.05). We observed that 38.9 % of the recurrent tears cases presented with more than one tendon affected before the arthroscopy. At follow-up, none of these recurrent tears showed more than one tendon affected on MRI evaluation.

Conclusion

In this study, we found that the AI radiological measurement is not a predictor for recurrent tears of the RC after primary arthroscopic repair.     

Team size in spinal cord injury inpatient rehabilitation and patient participation in therapy sessions: The SCIRehab Project

Context/objective

Rehabilitation teams generally are described as consisting of a single representative of 6–8 disciplines, but research suggests that the number of individuals involved may be much larger. This study aimed to determine the size of teams in spinal cord injury (SCI) rehabilitation, and the effect of team size on patients'' active participation in their treatment sessions.

Design

Prospective observational study.

Setting

Six SCI rehabilitation centers.

Participants

A total of 1376 patients with traumatic SCI admitted for first rehabilitation.

Interventions

Not applicable.

Outcome measures

Number of treatment sessions, by discipline and overall clinician rating of active participation of the patient; Treatment Concentration Index (TCI) calculated as Σp_k² (where p refers to the proportion of treatment sessions delivered by team member k).

Results

The average patient was treated by 39.3 different clinicians. The numbers were especially high for physical therapy (mean: 8.8), occupational therapy (7.2), and nursing (16.1). TCI was 0.08 overall; it varied by discipline. TCI was negatively correlated with length of stay, except for psychology. Participation ratings were minimally affected by the number of sessions the patient and the therapist had worked together.

Conclusions

In SCI rehabilitation, teams are at least as large as suggested by previous research. However, this may not mean lack of familiarity of patient and therapist with one another, or alternatively, the possibly weak therapeutic alliance does not affect the patients'' active participation in their sessions. Further research is needed to determine whether there are negative effects on rehabilitation outcomes.     

Influence of motor complete spinal cord injury on visceral and subcutaneous adipose tissue measured by multi-axial magnetic resonance imaging

Objective

Abdominal obesity conveys substantial health risks, in association with high levels of visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT) and an increased proportion of VAT to SAT. The purposes were to determine the influence of spinal cord injury (SCI) on the associations between single axial cross-sectional area (CSA) slices and the average CSA or volumes of VAT and SAT across multi-axial slices of magnetic resonance imaging (MRI); and the relationships relative to the whole body composition and anthropometrics.

Methods

Thirteen healthy male participants with traumatic motor complete SCI underwent fast spin-echo MRI to measure VAT and SAT across multi-axial slices, followed by dual-energy X-ray absorptiometry to measure whole body fat-free mass (FFM) and fat mass (FM). Waist circumference (WC) was also measured in the seated position.

Results

The trunk CSAs of VAT and SAT were 99 ± 51 and 164 ± 69 cm², respectively, and the ratio of VAT to SAT was 0.68 ± 0.33. The CSAs of VAT and SAT at a single slice strongly predicted the average CSA and modestly predicted the volumes across multi-axial slices. VAT and SAT represented 5.7 ± 1.8% and 9.7 ± 3.2% of the total body FM, respectively. Percent body FFM was negatively related to VAT and SAT volumes, but not to a single axial CSA.

Conclusion

A single slice CSA can modestly predict the volume of multi-axial slices in individuals with SCI, yet it is not related to any of the body composition variables. Increased percent FFM is associated with a reduction in VAT and SAT volumes measured across multi-axial slices. The ratio of VAT to SAT is greater than 0.4, suggesting that individuals with SCI are at high risk of developing metabolic sequelae.     

Association between alendronate,serum alkaline phosphatase level,and heterotopic ossification in individuals with spinal cord injury

Context/objective

Only sparse evidence exists regarding the effectiveness of oral alendronate (ALN) in the prevention of heterotopic ossification (HO) in patients with spinal cord injury (SCI). The objective of this study is to investigate the protective effect of oral ALN intake on the appearance of HO in patients with SCI.

Study design

Retrospective database review.

Setting

A Spinal Cord Unit at a Rehabilitation Hospital.

Participants

Two hundred and ninety-nine patients with SCI during acute inpatient rehabilitation.

Interventions

Administration of oral ALN.

Outcome measures

The incidence of HO during rehabilitation was compared between patients with SCI receiving oral ALN (n = 125) and patients with SCI not receiving oral ALN (n = 174). The association between HO and/or ALN intake with HO risk factors and biochemical markers of bone metabolism were also explored.

Results

HO developed in 19 male patients (6.35%), however there was no significant difference in the incidence of HO in patients receiving oral ALN or not. The mean odds ratio of not developing versus developing HO given ALN exposure was 0.8. Significant correlation was found between abnormal serum alkaline phosphatase (ALP) levels and HO appearance (P < 0.001) as well as normal serum ALP and ALN intake (P < 0.05).

Conclusion

Even though there was no direct prevention of HO in patients with SCI by oral ALN intake, abnormal serum ALP was found more frequently in patients with HO development and without oral ALN intake. This evidence could suggest that ALN may play a role in preventing HO, especially in patients with acute SCI with increasing levels of serum ALP.     

Magnetic Resonance Imaging of Pressure Sores in Spinal Cord Injured Patients: Accuracy in Predicting Osteomyelitis

Objective:

Identify key magnetic resonance imaging (MRI) features that have a significant correlation with osteomyelitis of pressure ulcers in spinal injury patients.

Design:

Retrospective review study.

Participants:

Adult patients admitted to the National Spinal Injuries Centre with spinal cord injury (SCI) and signs of pressure ulceration investigated with MRI.

Methods:

Analysis of MRI examinations and clinical records collected over a 4-year period. Images were independently assessed by 2 experienced radiologists for osteomyelitis based on assigned predictive indicators including cortical bone erosion, soft tissue edema, deep collections, heterotopic new bone, hip effusion, and abnormal signal change of the marrow.

Results:

Thirty-seven patients underwent 41 MRI scans. The prevalence of osteomyelitis was highly correlated with cortical bone erosion (r = 0.84) and abnormal bone marrow changes on T1-weighted images (r = 0.82).     

Effects of reduction in shoulder pain on quality of life and community activities among people living long-term with SCI paraplegia: a randomized control trial

Objective/background

People with spinal cord injury (SCI) paraplegia can develop shoulder problems over time, which may also cause pain. Shoulder pain may complicate or interfere with a person''s daily activities, social events, and their overall quality of life (QOL). The purpose of this study was to examine changes in social interaction and QOL after an exercise treatment for shoulder pain in people with SCI paraplegia.

Design

Fifty-eight participants with SCI paraplegia who were also experiencing shoulder pain were selected and randomized to either an exercise treatment or a control group. Participants in the treatment group participated in a 12-week, at-home, exercise and movement optimization program designed to strengthen shoulder muscles and modify movements related to upper extremity weight bearing.

Methods

Participants filled out self-report measures at baseline, 12 weeks later at the end of treatment, and at a 4-week follow-up.

Outcome measures

The Wheelchair User''s Shoulder Pain Index (WUSPI), the Social Interaction Inventory (SII), and the Subjective Quality of Life Scale.

Results

From the baseline to the end of treatment, repeated-measures analysis of variance revealed a significant interaction between WUSPI and SII scores, P < 0.001, and between WUSPI and QOL scores, P < 0.001.

Conclusion

Reductions in shoulder pain were related to significant increases in social participation and improvements in QOL. However, increases in social participation did not significantly affect improvements in QOL.     

Muscle spasticity associated with reduced whole-leg perfusion in persons with spinal cord injury

Objective

To determine the association between peripheral blood flow and spasticity in individuals with spinal cord injury (SCI).

Design

A cross-sectional study with measurements of muscle spasticity and whole-limb blood flow in individuals with SCI.

Setting

University of Texas at Austin and Brain & Spine Recovery Center, Austin, TX, USA.

Participants

Eighteen individuals (14 males and 4 females) with SCI were classified into high (N = 7), low (N = 6), and no (N = 5) spasticity groups according to the spasticity levels determined by the modified Ashworth scale scores.

Interventions

Whole-limb blood flow was measured in the femoral and brachial arteries using Doppler ultrasound and was normalized to lean limb mass obtained with dual-energy X-ray absorptiometry.

Outcome measures

Limb blood flow and muscle spasticity.

Results

Age, time post-SCI, and the American Spinal Injury Association impairment scale motor and sensory scores were not different among groups with different muscle spasticity. Femoral artery blood flow normalized to lean leg mass was different (P = 0.001) across the three spasticity groups (high 78.9 ± 16.7, low 98.3 ± 39.8, no 142.5 ± 24.3 ml/minute/kg). Total leg muscle spasticity scores were significantly and negatively correlated with femoral artery blood flow (r = −0.59, P < 0.01). There was no significant difference in brachial artery blood flow among the groups.

Conclusions

Whole-leg blood flow was lower in individuals with greater spasticity scores. These results suggest that a reduction in lower-limb perfusion may play a role, at least in part, in the pathogenesis leading to muscle spasticity after SCI.     

Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions

Context

Despite evidence that healthcare providers have implicit biases that can impact clinical interactions and decisions, implicit bias among physicians caring for individuals with spinal cord injury (SCI) has not been examined.

Objective

Conduct a pilot study to examine implicit racial bias of SCI physicians and its association with functioning and wellbeing for individuals with SCI.

Design

Combined data from cross-sectional surveys of individuals with SCI and their SCI physicians.

Setting

Four national SCI Model Systems sites.

Participants

Individuals with SCI (N = 162) and their SCI physicians (N = 14).

Outcome measures

SCI physicians completed online surveys measuring implicit racial (pro-white/anti-black) bias. Individuals with SCI completed questionnaires assessing mobility, physical independence, occupational functioning, social integration, self-reported health, depression, and life satisfaction. We used multilevel regression analyses to examine the associations of physician bias and outcomes of individuals with SCI.

Results

Physicians had a mean bias score of 0.62 (SD = 0.35), indicating a strong pro-white/anti-black bias. Greater physician bias was associated with disability among individuals with SCI in the domain of social integration (odds ratio = 4.80, 95% confidence interval (CI) = 1.44, 16.04), as well as higher depression (B = 3.24, 95% CI = 1.06, 5.41) and lower life satisfaction (B = −4.54, 95% CI= −8.79, −0.28).

Conclusion

This pilot study indicates that SCI providers are susceptible to implicit racial bias and provides preliminary evidence that greater implicit racial bias of physicians is associated with poorer psychosocial health outcomes for individuals with SCI. It demonstrates the feasibility of studying implicit bias among SCI providers and provides guidance for future research on physician bias and patient outcomes.     

PROFILE OF PATIENTS WHO SEEK THE BARIATRIC SURGERY

Background :

Nowadays obesity is a chronic disease considered one of the greatest problems in public healthy. Showing to be effective in a short and long term, the bariatric surgery has emerged as an optional treatment for morbid obesity.

Aim:

Identify the profile of patients seeking bariatric surgery.

Methods:

Were interviewed 100 patients in preoperative nutritional monitoring of bariatric surgery. The study was conducted by applying a questionnaire prepared according to the research objectives.

Results:

From the individuals that were seeking bariatric surgery, 78% were female, 62% were married and 69% reported physical activity. The average age of those surveyed was 37±10.83 years and mean body mass index (BMI) was 43.51± 6.25 kg/m². The comorbidity more prevalent in this group was high blood pressure (51%). In previous treatments for weight reduction, 92% have already done hypocaloric diet followed by anorectic drug (83%). The success of these treatments was reported by 92% of patients; however, the weight lost was recovered in less than one year of 75%. Patients with diabetes mellitus and dyslipidemia had higher BMI values. The patients with comorbidities showed lower levels of BMI.

Conclusion:

The profile of patients who sought surgical treatment for their obesity were predominantly women with a family background of obesity and obesity-related comorbidities, especially hypertension and diabetes mellitus.     

Assessment of passive knee stiffness and viscosity in individuals with spinal cord injury using pendulum test

Objective

Stiffness and viscosity represent passive resistances to joint motion related with the structural properties of the joint tissue and of the musculotendinous complex. Both parameters can be affected in patients with spinal cord injury (SCI). The purpose of this study was to measure passive knee stiffness and viscosity in patients with SCI with paraplegia and healthy subjects using Wartenberg pendulum test.

Design

Non-experimental, cross-sectional, case–control design.

Setting

An outpatient physical therapy clinic, University of social welfare and Rehabilitation Science, Iran.

Patients

A sample of convenience sample of 30 subjects participated in the study. Subjects were categorized into two groups: individuals with paraplegic SCI (n = 15, age: 34.60 ± 9.18 years) and 15 able-bodied individuals as control group (n = 15, age: 30.66 ± 11.13 years).

Interventions

Not applicable.

Main measures

Passive pendulum test of Wartenberg was used to measure passive viscous-elastic parameters of the knee (stiffness, viscosity) in all subjects.

Results

Statistical analysis (independent t-test) revealed significant difference in the joint stiffness between healthy subjects and those with paraplegic SCI (P = 0.01). However, no significant difference was found in the viscosity between two groups (P = 0.17). Except for first peak flexion angle, all other displacement kinematic parameters exhibited no statistically significant difference between normal subjects and subjects with SCI.

Conclusions

Patients with SCI have significantly greater joint stiffness compared to able-bodied subjects.     

Do vascular risk factors contribute to the prevalence of pressure ulcer in veterans with spinal cord injury?

Objective

The overall goal of this observational study was to determine whether modifiable vascular risk factors contribute to the prevalence of pressure ulcers (PrU) in veterans with traumatic spinal cord injury (SCI).

Background

Given the increasingly limited financial resources in hospitals and clinics, identifying risk factors associated with the development of PrU in persons with SCI will be a major step in reducing the cost of care for these individuals, and may improve their quality of life.

Method

We retrospectively reviewed the electronic charts of 87 veterans with SCI who are being followed regularly in our SCI clinic and are enrolled in the SCI registry. The data collected included the basic demographics, presence of modifiable vascular risk factors such as hypertension, diabetes mellitus, hyperlipidemia, and current smoking; presence of incontinence and depression; and results from blood drawn for hemoglobin level, blood urea nitrogen, creatinine, and albumin levels and lipid profile on veteran''s initial enrollment. Local Institution Review Board approval was obtained for the protocol.

Results

Of the 87 veterans with SCI, 27 had PrU. Comparisons between those with and without PrU found no significant differences for the demographic variables of age, gender, age of SCI onset, or SCI duration, but there was a trend for the groups to differ in ethnicity (P = 0.05). Similarly, the presence of modifiable vascular risk factors including hypertension, diabetes mellitus, hyperlipidemia, and current smoking did not differ between those with and without PrU. There were 36 pressure ulcer sites observed in 27 people. The proportion of pressure ulcer sites (of the 36) significantly differed by SCI severity based on the American Spinal Injury Association (ASIA) score (P < 0.0001).

Conclusion

This study suggests that the presence of PrU was influenced by the severity of the SCI without any contribution from modifiable vascular risk factors.     

Testing the feasibility of training peers with a spinal cord injury to learn and implement brief action planning to promote physical activity to people with spinal cord injury

Objective

The present study tested the feasibility of training peers with spinal cord injury (SCI) to learn brief action planning (BAP), an application of motivational interviewing principles, to promote physical activity to mentees with SCI.

Method

Thirteen peers with SCI attended a half-day BAP workshop. Using a one-arm, pre-, post-test design, feasibility to learn BAP was assessed in terms of peers'' (1) BAP and motivational interviewing spirit competence; (2) training satisfaction; and (3) motivations to use BAP as assessed by measures of the theory of planned behavior constructs. Measures were taken at baseline, immediately post-training, and 1 month follow up.

Results

Following the training, participants'' BAP and motivational interviewing competence significantly increased (P''s < 0.05, d''s > 2.27). Training satisfaction was very positive with all means falling above the scale midpoint. Participants'' perceived behavioral control to use BAP increased from baseline to post (P < 0.05, d = 0.91) but was not maintained at follow up (P > 0.05).

Conclusion

Training peers with a SCI to learn to use BAP is feasible.

Practical implications

BAP is a tool that can be feasibly learned by peers to promote physical activity to their mentees.     

Impact of body mass index on perioperative outcomes during the learning curve for robot-assisted radical prostatectomy

Introduction:

Previous studies of robotic-assisted radical prostatectomy (RARP) have suggested that obesity is a risk factor for worse perioperative outcomes. We evaluated whether body mass index (BMI) adversely affected perioperative outcomes.

Methods:

A prospective database of 153 RARP (single surgeon) was analyzed. Obesity was defined as BMI ≥ 30 kg/m²; normal BMI < 25 kg/m²; and overweight as 25 to 30 kg/m². Two separate analyses were performed: the first 50 cases (the initial learning curve) and the entire cohort of 153 RARP.

Results:

In the initial cohort of 50 cases (14 obese patients), there was no statistically significant difference with regards to operative times, port-placement times and estimated blood loss (EBL). Length of stay (LOS) was longer in the obese group (4.3 vs. 2.9 days); BMI remained an independent predictor of increased LOS on multivariate linear regression analysis (p = 0.002). There was no statistically significant difference in the postoperative outcomes of leak rates, margin rates and incisional herniae. In the entire cohort, when comparing obese patients to those with a normal BMI, there was no statistically significant difference in operative times, EBL, LOS, or immediate postoperative outcomes. However, on multivariate linear regression analysis, BMI was an independent predictor of increased operative time (p = 0.007).

Conclusion:

Obese patients do not have an increased risk of blood loss, positive margins or the postoperative complications of incisional hernia and leak during the learning curve. They do, however, have slightly longer operative times; we also noted an increased LOS in our first 50 cases.     

Self-assessment of technical skill in surgery: the need for expert feedback

INTRODUCTION

Technical skill has been formally assessed in the Fellow of the European Board of Vascular Surgery Examinations (FEBVS) since 2002. The aim of this study was to examine the relationship between expert assessment and trainee self-assessment.

MATERIALS AND METHODS

Forty-two examination candidates performed a saphenofemoral junction (SFJ) ligation and an anterior tibial anastomosis on a synthetic simulation. Each candidate was rated by two examiners using a validated rating scale for their generic surgical skill for both procedures. Candidates then anonymously rated their own performance using the same scale. Parametric tests were used in the statistical analysis; a P-value <0.05 was considered significant.

RESULTS

The maximum mark in each assessment was 40; 24 was considered a competent score. The interobserver correlation for examiners marks were high (SFJ ligation, α = 0.68; distal anastomosis, α = 0.76). Examiners'' marks were averaged. The mean examiner score for the SFJ ligation station was 27.8 (SD = 4.1) with 36 candidates (85.8%) attaining a competent score. The mean self-assessment score for this station was 30.7 (SD = 4.66). The mean examiners'' marks for the distal anastomosis station was 29.2 (SD = 4.2); 39 candidates (92.8%) attained a competent score. The mean self-assessment score was 32.1 (SD = 4.0). There was no correlation between examiner and self-assessment scores in either station (Pearson''s correlation coefficient: SFJ, r = 0.045, P = NS); distal anastomosis, r = 0.089, P = NS). Bland and Altman plots assessed the agreement between examiner and self-assessment. These showed candidates marked themselves higher than examiners with a mean difference of 2.9 marks in each station.

CONCLUSIONS

Candidates'' self-assessment and expert independent assessment correlate poorly. Trainees overestimate their ability according to independent assessment; regular technical feedback during training is, therefore, essential.