-
BJS Open Mar 2023Innovative surgical procedures and devices are often modified throughout their development and introduction into clinical practice. A systematic approach to reporting... (Review)
Review
BACKGROUND
Innovative surgical procedures and devices are often modified throughout their development and introduction into clinical practice. A systematic approach to reporting modifications may support shared learning and foster safe and transparent innovation. Definitions of 'modifications', and how they are conceptualized and classified so they can be reported and shared effectively, however, are lacking. This study aimed to explore and summarize existing definitions, perceptions, classifications and views on modification reporting to develop a conceptual framework for understanding and reporting modifications.
METHODS
A scoping review was conducted in accordance with PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines. Targeted searches and two database searches were performed to identify relevant opinion pieces and review articles. Included were articles relating to modifications to surgical procedures/devices. Data regarding definitions, perceptions and classifications of modifications, and views on modification reporting were extracted verbatim. Thematic analysis was undertaken to identify themes, which informed development of the conceptual framework.
RESULTS
Forty-nine articles were included. Eight articles included systems for classifying modifications, but no articles reported an explicit definition of modifications. Some 13 themes relating to perception of modifications were identified. The derived conceptual framework comprises three overarching components: baseline data about modifications, details about modifications and impact/consequences of modifications.
CONCLUSION
A conceptual framework for understanding and reporting modifications that occur during surgical innovation has been developed. This is a first necessary step to support consistent and transparent reporting of modifications, to facilitate shared learning and incremental innovation of surgical procedures/devices. Testing and operationalization is now needed to realize the value of this framework.
Topics: Humans; Research Design; General Surgery; Inventions
PubMed: 37104755
DOI: 10.1093/bjsopen/zrad020 -
Journal of Vascular Surgery Jun 2022When introduced to a new procedure, physicians improve their performance and reduce their procedural adverse event rates rapidly during the initial cases and then...
BACKGROUND
When introduced to a new procedure, physicians improve their performance and reduce their procedural adverse event rates rapidly during the initial cases and then improvement slows, signaling that proficiency has been achieved. Determining when they have acquired proficiency has important implications for procedural innovation, education, credentialing, and patient safety. We analyzed the worldwide experience with transcarotid artery revascularization (TCAR), a hybrid approach to carotid revascularization, to identify the (1) procedural performance measures associated with clinical and technical adverse events; (2) target levels of performance measures that minimize adverse event rates; and (3) number of TCAR cases needed to achieve the target levels for the performance measures.
METHODS
The patient, lesion, and physician characteristics were collected for each TCAR procedure performed by each physician worldwide in an international quality assurance database. Four procedural performance measures were recorded for each procedure: flow-reversal time, fluoroscopy time, contrast volume, and total skin-to-skin time. Composite clinical adverse events (ie, transient ischemic attack, stroke, myocardial infarction, death) and composite technical adverse events (ie, aborted procedure, conversion to surgery, bleeding, dissection, cranial nerve injury, device failure), occurring within 24 hours were also recorded. Correlations between each performance measure and the clinical and technical adverse event rates were computed. The inflection points in the performance measures were identified at which no further improvements occurred in the adverse event rates. Finally, the minimum number of TCAR cases required to achieve the target performance measure levels was computed.
RESULTS
A total of 18,240 procedures performed by 1273 physicians were analyzed. Of the 18,240 patients, 34.9% were women and 62.5% were asymptomatic. The flow-reversal time correlated with clinical adverse events adjusted for age, sex, and symptomatic status (R = 0.91; P < .0001) and adjusted technical adverse events (R = 0.86; P < .0001). The skin-to-skin time correlated with adjusted technical adverse events (R = 0.92; P < .0001). A reduction in flow-reversal times to <13.1 minutes and the skin-to-skin time to <81 minutes did not translate into further improvements in the adverse event rates. A minimum of 26 TCAR cases was required to achieve the target flow-reversal time, and a minimum of 15 cases was required to achieve the target skin-to-skin time.
CONCLUSIONS
The flow-reversal time and skin-to-skin time are appropriate performance measures for establishing the level of expertise of physicians as they acquire skills to perform TCAR. A target time of ≤13.1 minutes for flow-reversal and 81 minutes for skin-to-skin time minimized the adverse event rates. Familiarity with the steps involved in performing TCAR was achieved after ≥15 cases, and minimizing clinical adverse events occurred after ≥26 cases.
Topics: Benchmarking; Carotid Arteries; Carotid Stenosis; Endovascular Procedures; Female; Humans; Learning Curve; Male; Retrospective Studies; Risk Factors; Stents; Stroke; Time Factors; Treatment Outcome
PubMed: 35063612
DOI: 10.1016/j.jvs.2021.12.073 -
The Journal of Education in... 2022Eye-tracking measures attention patterns, which may offer insight into evaluating procedural expertise. The purpose of this study was to determine the feasibility of...
BACKGROUND
Eye-tracking measures attention patterns, which may offer insight into evaluating procedural expertise. The purpose of this study was to determine the feasibility of using eye tracking to assess visual fixation patterns when performing an ultrasound-guided regional anesthesia procedure and to assess for differences between experienced, intermediate, and novice practitioners.
METHODS
Participants performed an ultrasound-guided sciatic nerve block 3 times on a fresh cadaver model while wearing eye-tracking glasses. Gaze fixation and dwell time on each location were compared between participants. Eye-gaze paths were used to derive a measure of entropy, or how often participants switched gaze fixations between locations.
RESULTS
Five attending anesthesiologists, 5 third-year anesthesiology residents with prior ultrasound-guided regional anesthesia experience, and 5 medical students completed the study. Individuals with more experience were more likely to successfully perform the sciatic nerve block (5/5 attendings, 5/5 residents, 0/5 students; = .002) and performed the procedure faster (average: attendings 62.6 seconds, residents 106.4 seconds, students 134.4 seconds; = .089). Participants were progressively faster with practice (Trial 1: 41.8 seconds, Trial 2: 29.2 seconds, Trial 3: 28.9 seconds; = .012), and the average number of eye shifts per trial decreased from 10.8 to 6.5 to 6 ( = .010). Attending physicians spent significantly less time fixating on the ultrasound monitor compared to trainees ( = .035). Average visual entropy progressively decreased from Trial 1 to Trial 3 ( = .03) and with greater experience ( = .15). There was a strong correlation between entropy and time on task (r(16) = 0.826, = .001).
CONCLUSIONS
Experienced providers make fewer back-and-forth visual fixations, spend less time in the procedure, and demonstrate less entropy during ultrasound-guided regional anesthesia procedures. Mobile eye-tracking has the potential to provide additional objective measures of performance that may help not only determine procedural competence but also distinguish between levels of proficiency.
PubMed: 35707014
DOI: 10.46374/volxxiv_issue1_zurca -
International Journal of Surgery... Aug 2019To assess the efficacy and safety of double J (DJ) stented, external stented and stent-less procedures in pediatric pyeloplasty by adopting a network meta-analysis (NMA). (Comparative Study)
Comparative Study Review
OBJECTIVE
To assess the efficacy and safety of double J (DJ) stented, external stented and stent-less procedures in pediatric pyeloplasty by adopting a network meta-analysis (NMA).
MATERIAL AND METHODS
Electronic databases including PubMed, Cochrane Library, Web of science and Embase database were retrieved. The trials that compared double J (DJ) stented, external stented or stent-less procedures in pediatric pyeloplasty were identified. A network meta-analysis was conducted with the software of STATA 14.0. Probability-based ranking results were performed to identify the best treatment, and publication bias was analyzed by funnel plots.
RESULTS
15 studies with 1731 participants were enrolled in the analysis, including 4 randomized controlled trials (RCT) and 11 retrospective studies. The NMA results revealed that no significant differences were detected in the outcomes of operative time, operative success, hospital stay, improvement of renal functions, overall complications and redo pyeloplasty. DJ stented and external stented procedures were associated with more postoperative pain than that of stent-less procedures [DJ stented: OR = 4.47, 95%CI(1.05,19.08); external stented: OR = 5.83, 95%CI(0.09,1.43)]. DJ stented procedure had a lower rate of urine leakage than those of external stented procedure [OR = 0.18, 95%CI (0.04, 0.76)] and stent-less procedure [OR = 0.07, 95%CI=(0.01, 0.34)]. No significant difference was observed in other types of complications such as urinary tract infection (UTI), stent migration, recurrent ureteropelvic junction obstruction (UPJO) and fever. The probabilities of ranking results indicated that the DJ stented procedure was the best treatment in the outcomes of hospital stay, operative success, improvement of renal functions, and the complication of urine leakage. Stent-less procedure showed its advantages in the outcomes of operative time, flank pain and UTI. External stented procedure had the lowest rate of overall complications and redo pyeloplasty.
CONCLUSIONS
There were no obvious differences in operative time, operative success, hospital stay, improvement of renal functions, overall complications between external stented, DJ stented and stent-less procedures for pediatric pyeloplasty. When considering the ranking results, the DJ stented procedure seemed to be more beneficial for pediatric pyeloplasty than the other methods. However, with the limitation of our study, additional high-quality studies are needed for further evaluation.
Topics: Child; Humans; Kidney Pelvis; Length of Stay; Network Meta-Analysis; Plastic Surgery Procedures; Retrospective Studies; Stents; Ureteral Obstruction; Urologic Surgical Procedures
PubMed: 31279854
DOI: 10.1016/j.ijsu.2019.07.001 -
BMC Medical Research Methodology Jul 2022Meta-analysis is a central method for quality evidence generation. In particular, meta-analysis is gaining speedy momentum in the growing world of quantitative... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Meta-analysis is a central method for quality evidence generation. In particular, meta-analysis is gaining speedy momentum in the growing world of quantitative information. There are several software applications to process and output expected results. Open-source software applications generating such results are receiving more attention. This paper uses Python's capabilities to provide applicable instruction to perform a meta-analysis.
METHODS
We used the PythonMeta package with several modifications to perform the meta-analysis on an open-access dataset from Cochrane. The analyses were complemented by employing Python's zEpid package capable of creating forest plots. Also, we developed Python scripts for contour-enhanced funnel plots to assess funnel plots asymmetry. Finally, we ran the analyses in R and STATA to check the cross-validity of the results.
RESULTS
A stepwise instruction on installing the software and packages and performing meta-analysis was provided. We shared the Python codes for meta-analysts to follow and generate the standard outputs. Our results were similar to those yielded by R and STATA.
CONCLUSION
We successfully produced standard meta-analytic outputs using Python. This programming language has several flexibilities to improve the meta-analysis results even further.
Topics: Humans; Programming Languages; Publications; Research Design; Software
PubMed: 35820854
DOI: 10.1186/s12874-022-01673-y -
Paediatrics & Child Health Oct 2021Procedural practice by paediatricians in Canada is evolving. Little empirical information is available on the procedural competencies required of general paediatricians....
BACKGROUND AND OBJECTIVES
Procedural practice by paediatricians in Canada is evolving. Little empirical information is available on the procedural competencies required of general paediatricians. Accordingly, the aim of this study was to conduct a needs assessment of Canadian general paediatricians to identify procedural skills required for practice, with the goal of informing post-graduate and continuing medical education.
METHODS
A survey was sent to paediatricians through the Canadian Paediatric Surveillance Program (CPSP) (www.cpsp.cps.ca/surveillance). In addition to demographic information about practice type and location, participants were asked to indicate the frequency with which they performed each of 32 pre-selected procedures and whether each procedure was considered essential to their practice.
RESULTS
The survey response rate was 33.2% (938/2,822). Data from participants who primarily practice general paediatrics were analyzed (n=481). Of these, 71.0% reported performing procedures. The most frequently performed procedures were: bag-valve-mask ventilation of an infant, lumbar puncture, and ear curettage, being performed monthly by 40.8%, 34.1%, and 27.7% of paediatricians, respectively. The procedures performed by most paediatricians were also those found most essential to practice, with a few exceptions. Respondents performed infant airway procedures with greater frequency and rated them more essential when compared to the same skill performed on children. We found a negative correlation between procedures being performed and difficulty maintaining proficiency in a skill.
CONCLUSIONS
This report of experiences from Canadian general paediatricians suggests a wide variability in the frequency of procedural performance. It helps establish priorities for post-graduate and continuing professional medical education curricula in the era of competency-based medical education.
PubMed: 36874401
DOI: 10.1093/pch/pxaa103 -
Memory & Cognition Apr 2024To acquire and process information, performers can frequently rely on both internal and extended cognitive strategies. However, after becoming acquainted with two...
To acquire and process information, performers can frequently rely on both internal and extended cognitive strategies. However, after becoming acquainted with two strategies, performers in previous studies exhibited a pronounced behavioral preference for just one strategy, which we refer to as perseveration. What is the origin of such perseveration? Previous research suggests that a prime reason for cognitive strategy choice is performance: Perseveration could reflect the preference for a superior strategy as determined by accurately monitoring each strategy's performance. However, following our preregistered hypotheses, we conjectured that perseveration persisted even if the available strategies featured similar performances. Such persisting perseveration could be reasonable if costs related to decision making, performance monitoring, and strategy switching would be additionally taken into account on top of isolated strategy performances. Here, we used a calibration procedure to equalize performances of strategies as far as possible and tested whether perseveration persisted. In Experiment 1, performance adjustment of strategies succeeded in equating accuracy but not speed. Many participants perseverated on the faster strategy. In Experiment 2, calibration succeeded regarding both accuracy and speed. No substantial perseveration was detected, and residual perseveration was conceivably related to metacognitive performance evaluations. We conclude that perseveration on cognitive strategies is frequently rooted in performance: Performers willingly use multiple strategies for the same task if performance differences appear sufficiently small. Surprisingly, other possible reasons for perseveration like effort or switch cost avoidance, mental challenge seeking, satisficing, or episodic retrieval of previous stimulus-strategy-bindings, were less relevant in the present study.
Topics: Humans; Cognition
PubMed: 37874485
DOI: 10.3758/s13421-023-01475-7 -
PRiMER (Leawood, Kan.) 2022Performing clinical procedures is an essential component of family medicine (FM) residency training. A referral-based procedure clinic was established at our institution...
INTRODUCTION
Performing clinical procedures is an essential component of family medicine (FM) residency training. A referral-based procedure clinic was established at our institution in 2014, and a yearly 2-week rotation was established for residents. The objective of this study was to determine the effect of a procedure clinic rotation on the numbers of procedures performed during residency training.
METHODS
We conducted a retrospective review on graduating FM residents from 2009 to 2019. Data collected include type and number of procedures performed each postgraduate year. We analyzed data as mean number of procedures per resident per year. We conducted statistical comparison with Wilcoxon-Mann-Whitney two-sample rank-sum tests.
RESULTS
Residents who participated in the procedure clinic rotation performed significantly more dermatologic procedures per year, joint and soft tissue injections and intrauterine device (IUD) insertions and removals, but did not perform significantly more circumcisions, endometrial biopsies, incision and drainages, subdermal contraceptive implant procedures, toenail removals, or vasectomies.
CONCLUSION
The establishment of a 2-week procedure clinic rotation for FM residents was associated with a significant increase in dermatologic procedures, joint and soft tissue injections, and IUD procedures. Further research can explore the impact of this rotation on procedural competency and confidence.
PubMed: 35812790
DOI: 10.22454/PRiMER.2022.962965 -
MedEdPORTAL : the Journal of Teaching... 2023Cervical intraepithelial neoplasia 3 is associated with a high degree of progression to cervical cancer. Its risk is markedly reduced after excisional treatment. Hence,...
INTRODUCTION
Cervical intraepithelial neoplasia 3 is associated with a high degree of progression to cervical cancer. Its risk is markedly reduced after excisional treatment. Hence, it is critical that providers accurately diagnose and treat this condition. We present a simulation-based module focused on resident mastery of performance of colposcopy and loop electrosurgical excision procedure (LEEP).
METHODS
Learners were obstetrics and gynecology residents. Guidelines on performance of colposcopy and LEEP were presented prior to module participation. We used pelvic task trainers, kielbasa sausages, and routine equipment for performance of colposcopy and LEEP. Colposcopy and LEEP sessions each lasted 30 minutes. Learners completed questionnaires before and after regarding comfort level on aspects of colposcopy and LEEP performance and level of agreement with statements on performing procedures independently. Comfort levels and degrees of agreement were based on 5-point Likert scales (1 = 3 = 5 = respectively).
RESULTS
Modules were held in November 2021 and May 2022. Thirty-four residents participated. Mean comfort scores significantly increased from 3.1 to 4.3 ( < .001) before and after the module for all steps. There was an increase in level of agreement with statements on being able to independently perform colposcopy (2.2 to 3.5, < .01) and LEEP (2.9 to 3.6, = .06).
DISCUSSION
Simulation-based modules on performance of colposcopy and LEEP significantly increased resident learner comfort in the performance of these procedures. Comfort in performing these procedures is important in providing comprehensive gynecologic care.
Topics: Pregnancy; Female; Humans; Colposcopy; Electrosurgery; Computer Simulation; Obstetrics; Pelvis
PubMed: 37691878
DOI: 10.15766/mep_2374-8265.11344 -
Journal of Reconstructive Microsurgery Nov 2023Preparation of the recipient vessels is a crucial step in autologous breast reconstruction, with limited opportunity for resident training intraoperatively. The...
BACKGROUND
Preparation of the recipient vessels is a crucial step in autologous breast reconstruction, with limited opportunity for resident training intraoperatively. The Blue-Blood-infused porcine chest wall-a cadaveric pig thorax embedded in a mannequin shell, connected to a saline perfusion system-is a novel, cost-effective ($55) simulator of internal mammary artery (IMA) dissection and anastomosis intended to improve resident's comfort, safety, and expertise with all steps of this procedure. The purpose of this study was to assess the effect of the use of this chest wall model on resident's confidence in performing dissection and anastomosis of the IMA, as well as obtain resident's and faculty's perspectives on model realism and utility.
METHODS
Plastic surgery residents and microsurgery faculty at the University of Wisconsin were invited to participate. One expert microsurgeon led individual training sessions and performed as the microsurgical assistant. Participants anonymously completed surveys prior to and immediately following their training session to assess their change in confidence performing the procedure, as well as their perception of model realism and utility as a formal microsurgical training tool on a five-point scale.
RESULTS
Every participant saw improvement in confidence after their training session in a minimum of one of seven key procedural steps identified. Of participants who had experience with this procedure in humans, the majority rated model anatomy and performance of key procedural steps as "very" or "extremely" realistic as compared with humans. 100% of participants believed practice with this model would improve residents' ability to perform this operation in the operating room and 100% of participants would recommend this model be incorporated into the microsurgical training curriculum.
CONCLUSION
The Blue-Blood porcine chest wall simulator increases trainee confidence in performing key steps of IMA dissection and anastomosis and is perceived as valuable to residents and faculty alike.
Topics: Humans; Swine; Animals; Internship and Residency; Clinical Competence; Education, Medical, Graduate; Simulation Training; Thorax
PubMed: 36931312
DOI: 10.1055/a-2057-0766