Adverse event profile of a mature voluntary medical male circumcision programme performing PrePex and surgical procedures in Zimbabwe

Introduction : The frequency of adverse events (AEs) is a widely used indicator of voluntary medical male circumcision (VMMC) programme quality. Though over 11.7 million male circumcisions (MCs) have been performed, little published data exists on the profile of AEs from mature, large‐scale programmes. No published data exists on routine implementation of PrePex, a device‐based MC method. Methods : The ZAZIC Consortium began implementing VMMC in Zimbabwe in 2013, supporting services at 36 facilities. Aggregate data on VMMC outputs are collected monthly from each facility. Detailed forms are completed describing the profile of each moderate and severe AE. Bivariate and multivariable analyses were conducted using log‐binomial regression models. Results : From October 2014 through September 2015, 44,868 clients were circumcised with 156 clients experiencing a moderate or severe AE. 96.2% of clients had a follow‐up visit within 14 days of their procedure. AEs were uncommon, with 0.3% (116/41,416) of surgical and 1.2% (40/3,452) of PrePex clients experiencing a moderate or severe AE. After adjusting for VMMC site, we found that PrePex was associated with a 3.29‐fold (95% CI: 1.78–6.06) increased risk of experiencing an AE compared to surgical procedures. Device displacements, when the PrePex device is intentionally or accidentally dislodged during the 7‐day placement period, accounted for 70% of PrePex AEs. The majority of device displacements were intentional self‐removals. Overall, infection was the most common AE among VMMC clients. Compared to clients aged 20 and above, clients aged 10–14 were 3.07‐fold (95% CI: 1.36–6.91) more likely to experience an infection and clients aged 15–19 were 1.80‐fold (95% CI: 0.82–3.92) more likely to experience an infection, adjusted for site. Conclusions : This exploratory analysis found that clients receiving PrePex were more likely to experience an AE than surgical circumcision clients. This is largely attributable to the occurrence of device displacements, which require prompt access to corrective surgical MC procedures as part of their clinical management. Most device displacements were self‐removals which are preventable if client behaviour could be modified through counselling interventions. We also found that infection after MC is more common among younger clients, who may benefit from additional counselling or increased parental involvement.     

The impact of didactic read‐aloud action cards on the performance of cannula cricothyroidotomy in a simulated ‘can't intubate can't oxygenate’ scenario

Significant benefits have been demonstrated with the use of peri‐operative checklists. We assessed whether a read‐aloud didactic action card would improve performance of cannula cricothyroidotomy in a simulated ‘can't intubate, can't oxygenate’ scenario. A 17‐step action card was devised by an expert panel. Participants in their first 4 years of anaesthetic training were randomly assigned into ‘no‐card’ or ‘card’ groups. Scenarios were video‐recorded for analysis. Fifty‐three participants (27 no‐card and 26 card) completed the scenario. The number of steps omitted was mean (SD) 6.7 (2.0) in the no‐card group vs. 0.3 (0.5); p < 0.001 in the card group, but the no‐card group was faster to oxygenation by mean (95% CI) 35.4 (6.6–64.2) s. The Kappa statistic was 0.84 (0.73–0.95). Our study demonstrated that action cards are beneficial in achieving successful front‐of‐neck access using a cannula cricothyroidotomy technique. Further investigation is required to determine this tool's effectiveness in other front‐of‐neck access situations, and its role in teaching or clinical management.     

Relationships between a critical life event and eating behaviour in high-school students

This study describes the impact of a major school examination on eating behaviour in 225 high-school students 15–19 years old where each student served as his own control. Food eaten was recorded on the day of an examination (D0) and on a control day (D7) identical to the former but without a stressful school event. Results revealed that the total energy intake (2225 ± 49 kcal vs 2074 ± 48 kcal; p ? 0.01) and amount of fat in the diet (38.3 ± 0.5 per cent vs 36.8 ± 0.6 per cent; p ? 0.05) were significantly increased on the day of the examination. Energy intake in girls was affected by the stressful event (+ 135 kcal; p ? 0.05) while the level of fat in the diet was modified in boys (+ 1.9 per cent; p ? 0.05) on day D0. The ninetieth and tenth percentiles for the energy variable showed that students who had low-energy intake on the control day increased their intake on the day of the examination while students whose energy input was high on the control day decreased consumption on the day of the examination. These results suggest that a major stressful event in school may induce significant changes in eating habits in high-school students.     

Battling COVID-19: critical care and peri-operative healthcare resource management strategies in a tertiary academic medical centre in Singapore

In December 2019, a cluster of atypical pneumonia cases were reported in Wuhan, China, and a novel coronavirus elucidated as the aetiologic agent. Although most initial cases occurred in China, the disease, termed coronavirus disease 2019, has become a pandemic and continues to spread rapidly with human-to-human transmission in many countries. This is the third novel coronavirus outbreak in the last two decades and presents an ensuing healthcare resource burden that threatens to overwhelm available healthcare resources. A study of the initial Chinese response has shown that there is a significant positive association between coronavirus disease 2019 mortality and healthcare resource burden. Based on the Chinese experience, some 19% of coronavirus disease 2019 cases develop severe or critical disease. This results in a need for adequate preparation and mobilisation of critical care resources to anticipate and adapt to a surge in coronavirus disease 2019 case-load in order to mitigate morbidity and mortality. In this article, we discuss some of the peri-operative and critical care resource planning considerations and management strategies employed in a tertiary academic medical centre in Singapore in response to the coronavirus disease 2019 outbreak.     

The impact of COVID-19 on anaesthesia and critical care services in the UK: a serial service evaluation*

Between October 2020 and January 2021, we conducted three national surveys to track anaesthetic, surgical and critical care activity during the second COVID-19 pandemic wave in the UK. We surveyed all NHS hospitals where surgery is undertaken. Response rates, by round, were 64%, 56% and 51%. Despite important regional variations, the surveys showed increasing systemic pressure on anaesthetic and peri-operative services due to the need to support critical care pandemic demands. During Rounds 1 and 2, approximately one in eight anaesthetic staff were not available for anaesthetic work. Approximately one in five operating theatres were closed and activity fell in those that were open. Some mitigation was achieved by relocation of surgical activity to other locations. Approximately one-quarter of all surgical activity was lost, with paediatric and non-cancer surgery most impacted. During January 2021, the system was largely overwhelmed. Almost one-third of anaesthesia staff were unavailable, 42% of operating theatres were closed, national surgical activity reduced to less than half, including reduced cancer and emergency surgery. Redeployed anaesthesia staff increased the critical care workforce by 125%. Three-quarters of critical care units were so expanded that planned surgery could not be safely resumed. At all times, the greatest resource limitation was staff. Due to lower response rates from the most pressed regions and hospitals, these results may underestimate the true impact. These findings have important implications for understanding what has happened during the COVID-19 pandemic, planning recovery and building a system that will better respond to future waves or new epidemics.     

Advances in the medical management of differentiated thyroid carcinoma and their impact on the surgical approach

The introduction of recombinant human TSH and neck ultrasonography has refined the management of differentiated thyroid cancer, leading to the publication of new guidelines by the American Thyroid Association (ATA) and a consensus report by the European Thyroid Association (ETA) in 2006. In this paper, we give an overview of the current medical management of differentiated thyroid cancer (pre-surgical, post-surgical), of how the advances have been integrated into the recent 2006 ATA guidelines and ETA consensus and finally, of the impact on the surgical management (first surgery, treatment of cervical lymph nodes) of differentiated thyroid cancer.     

Self-assessment of performance among surgical trainees during simulated procedures in a simulated operating theater

BACKGROUND: The ability of surgeons to assess their own performance is essential for training and self-regulation. The latter is based on the premise that they recognize their weaknesses and seek remedial action accordingly. METHODS: Twenty-seven surgical trainees performed a simulated saphenofemoral high-tie on a synthetic model in a simulated operating theater. The performance assessment consisted of blinded rating of technical skills and a global rating of team skills by a human factors expert and a trained surgical research fellow. Subjects also were asked to assess their own performance using the same methods. Spearman's rho was used for data analysis. RESULTS: There was a strong correlation between the experts rating of technical skills and self-assessment (rho = .64). However, the correlation improved with increasing experience. It was .24 for junior trainees, .43 for those with intermediate experience, and .52 for senior trainees. There was a low correlation between the self-assessment and the expert scores for human factors skills (rho = .31). The correlation was higher for the 2 junior groups compared with the senior trainees. CONCLUSIONS: Unlike other studies on self-assessment, this study found that senior surgical trainees are accurate in their self-assessment of technical skills. However, this was not true in the case of human factors skills.     

谷氨酰胺并肠外营养支持在外科术后危重患者中的应用

目的 观察谷氨酰胺并肠外营养支持在外科术后危重患者中的应用价值.方法 外科术后危重患者50例,随机分为观察组和对照组,每组各25例.两组患者均于术后第1天行肠外营养支持,观察组在对照组的基础上加用加丙氨酰-谷氨酰胺20 9(商品名:力太注射液,华瑞制药).治疗后检测两组患者营养指标、免疫指标.结果 观察组治疗第7天营养指标及免疫指标均较对照组明显改善.结论 加用谷氨酰胺的肠外营养支持能明显改善外科术后危重患者的营养状况及免疫功能.     

The impact of neurophysiological intraoperative monitoring on surgical decisions: a critical analysis of 423 cases

OBJECT: The aim of this observational clinical study was to analyze the impact of neurophysiological intraoperative monitoring (IOM) on the surgical procedure and to assess the benefits of such monitoring. METHODS: Data for 423 patients who underwent neurophysiological IOM with somatosensory evoked potentials and brainstem auditory evoked potentials during neurosurgical procedures were collected prospectively. The patients were classified into one of five groups according to the findings of IOM, the intervention following a monitoring alarm, and the patient's postoperative neurological condition. These groups were as follows: patients with true-positive findings with intervention (42 cases, 9.9%), those with true-positive findings without intervention (42 cases, 9.9%), those with false-positive findings (nine cases, 2.1%), those with false-negative findings (16 cases, 3.8%), and those with true-negative findings (314 cases, 74.2%). Different interventions followed an event identified with monitoring. These interventions were related to dissection in 17 cases, to perfusion pressure in 11, to a limitation of the surgical procedure in five, to vessel clipping in four, to vasospasm in three, and to retraction in one case. In one case the surgical procedure was abandoned. A critical analysis and cautious estimation of the interventions revealed that IOM was helpful in preventing a postoperative deficit in 5.2% of the monitored cases. CONCLUSIONS; For critical analysis of the benefits of IOM one must evaluate not only the findings of IOM and the patient's postoperative neurological condition but also the intraoperative findings and surgical interventions following a monitoring alarm. Evidence is presented that IOM is helpful in preventing a postoperative deficit.     

The changing face of trauma management and its impact on surgical resident training

BACKGROUND: The management of trauma patients has become increasingly nonoperative, especially for solid abdominal organ injuries. However, the Residency Review Committee (RRC) still requires an operative trauma experience deemed essential for graduating general surgical residents. The purpose of this study was to review the trauma volume and mix of patients at two trauma centers and determine the major operative trauma cases available to residents involved in the care of these patients. METHODS: A retrospective chart review was conducted at the two trauma centers used by the Michigan State University surgery residency. Both of the trauma centers are American College of Surgeons verified. Surgical residents are involved with the care of every trauma patient at each of the hospitals. Cumulative data were collected and analyzed from January 1, 1997, through December 31, 1999. Age, gender, mechanism of injury (blunt vs. penetrating), Injury Severity Score, length of stay, operative interventions, and patients managed nonoperatively were reviewed. RESULTS: There were 434 patients selected for this study from 2,340 patients admitted to the trauma services. Male patients accounted for 66% of patients and female patients accounted for 34% of patients. Blunt trauma was the mechanism in 89% of patients, with penetrating trauma accounting for the other 11% of patients. Of the total number of patients, motor vehicle crashes accounted for the majority of cases, 325 of 434 (75%). Overall, 85% (370 of 434) of patients were managed without an index trauma surgical procedure according to RRC guidelines. Only 14.7% (64 of 434) of patients underwent operative intervention that qualified as index trauma surgical cases identified by the RRC. The spleen and small bowel were the two most commonly injured organs found at laparotomy. Nonoperative intervention of many patients with solid abdominal organ injuries did not meet the operation requirements expected by the RRC. CONCLUSION: Our residency program had 10 graduating chief residents over the 3-year time period. With only 64 operative trauma cases, this yields an average of 6.4 trauma cases per resident. This falls significantly short of the 16-case minimum requirement in trauma surgery established by the RRC. The operative trauma requirements established by the RRC for graduating residents may be unattainable in many residency programs because of the high incidence of blunt trauma and the changing patterns of trauma management.     

The development of physician confidence during surgical and medical internship

BACKGROUND: While much research has addressed physician competency, the development of confidence has not been studied. We sought to identify which elements of internship residents feel most contributed to building their confidence. METHODS: By anonymous survey, University of Pennsylvania residents rated 104 internship elements for contribution to building physician confidence and reported their subjective confidence during and since internship. RESULTS: Two hundred ten residents in 18 specialties participated. Detailed ratings for all 104 elements are provided. Generally, independent decision-making items and good back-up support were equally highly valued, as was developing work efficiency. Poorly valued items included high patient loads, long hours, and abusive interactions. Surgical and medical residents agreed. Mean confidence increased during internship from 12 to 32 (1-100 scale) but remained in the 50s during residency for most specialties. CONCLUSIONS: Faculty should make informed, deliberate attempts to provide those elements identified as most fostering the development of physician confidence.     

Role of simulation in surgical education and training

There are several challenges facing surgical education and training that simulation may help to address. A conceptual framework is required to allow the appropriate application of simulation to a given level and type of surgical skill and this should be driven by educational imperatives and not by technological innovation. Simple simulation is required for core skills training. Cognitive simulation is introduced as a way in which procedural skills training can be achieved. Virtual world simulation opens up significant opportunities for team skills training. A role for simulation in surgical education and training appears assured, but its success will be determined by the extent to which it is integral to high quality curricula, its importance determined by its contribution to both learning and assessment, and its sustainability determined by evidence of its advantages and cost‐effectiveness.     

An analysis of critical incidents in a teaching department for quality assurance A survey of mishaps during anaesthesia

A prospective survey was conducted from April 1984-January 1985 and April 1985-January 1986 to study the frequency of critical incidents and factors associated with them. Eighty-six mishaps were reported in the first period, the majority of which were because of human error (80.3%); the most common were the transmission of gases and vapours and errors in drug administration. Factors frequently associated with these mishaps were failure to perform a normal check and lack of familiarity with equipment or technique. An anaesthesia equipment checklist was incorporated in the survey during the second period and 43 mishaps were reported. This decrease in incidence may have resulted from the anaesthesia apparatus checklist, awareness of mishaps since they were discussed regularly at departmental meetings, and new anaesthesia machines (eight older machines were replaced during the first period and 11 at the beginning of the second).