Ankur Khajuria

An overview of research priorities in surgical simulation: what the literature shows has been achieved during the 21st century and what remains

BACKGROUND Key research priorities for surgical simulation have been identified in recent years. The aim of this study was to establish the progress that has been made within each research priority and what still remains to be achieved. METHODS Members of the Association for Surgical Education Simulation Committee conducted individualized literature reviews for each research priority that were brought together by an expert panel. RESULTS Excellent progress has been made in the assessment of individual and teamwork skills in simulation. The best methods of feedback and debriefing have not yet been established. Progress in answering more complex questions related to competence and transfer of training is slower than other questions. A link between simulation training and patient outcomes remains elusive. CONCLUSIONS Progress has been made in skills assessment, curricula development, debriefing and decision making in surgery. The impact of simulation training on patient outcomes represents the focus of simulation research in the years to come.

Anandamide in primary sensory neurons: too much of a good thing?

The quest for possible targets for the development of novel analgesics has identified the activation of the cannabinoid type 1 (CB1) receptor outside the CNS as a potential means of providing relief from persistent pain, which currently constitutes an unmet medical need. Increasing tissue levels of the CB1 receptor endogenous ligand N‐arachidonoylethanolamine (anandamide), by inhibiting anandamide degradation through blocking the anandamide‐hydrolysing enzyme fatty acid amide hydrolase, has been suggested to be used to activate the CB1 receptor. However, recent clinical trials revealed that this approach does not deliver the expected relief from pain. Here, we discuss one of the possible reasons, the activation of the transient receptor potential vanilloid type 1 ion channel (TRPV1) on nociceptive primary sensory neurons (PSNs) by anandamide, which may compromise the beneficial effects of increased tissue levels of anandamide. We conclude that better design such as concomitant blocking of anandamide hydrolysis and anandamide uptake into PSNs, to inhibit TRPV1 activation, could overcome these problems.

Anesthetics attenuate ischemia-reperfusion induced renal injury: effects and mechanisms.

Acute kidney injury (AKI) secondary to ischemia-reperfusion injury (IRI) is a major cause of patient morbidity and mortality in the perioperative period. It can lead to new onset of chronic kidney disease and accelerate its progression. Patients with risk factors undergoing cardiac, vascular, and liver transplantation surgeries, which may inevitably involve IRI, are more susceptible to AKI. Anesthetic agents have been postulated to possess renoprotective properties. Thus, exploring the utilization of selective perioperative anesthetic agents with renoprotective properties may be a promising avenue to reduce the risk of AKI. This review discusses the effects and mechanisms of dexmedetomidine, inhalational and intravenous anesthetics, and xenon-mediated renoprotection. Although the renoprotective effects of these agents obtained in the laboratory are promising, much work especially via clinical trials is required to determine the translational value from the bench to the bedside.

What about the surgeon

The safety of the patient and its importance in a surgical setting is well recognised. However, in the literature far less emphasis is placed upon the safety of the surgeon and his/her team. This review discusses the risks to which a surgeon is exposed, including blood-borne pathogens, radiation exposure, biomechanical stresses and fatigue, and the adverse effects of diathermy fumes. Strategies addressing these risks are presented and recommendations to improve surgical team safety are offered.

Fraud in scientific research – birth of the Concordat to uphold research integrity in the United Kingdom

Fraud in research has risen exponentially and recent high profile cases may just be the tip of the iceberg. This threatens to have a major impact on public health, with policy makers and clinicians acting on erroneous data. To address this, the new research “Concordat”, a consensus statement on research misconduct, has been published. Can it hold the key to rebuilding public confidence in scientific research in the United Kingdom? This review focuses on the concept of research misconduct, highlighting prominent cases and discussing strategies in order to restore confidence in the validity of scientific research.

Public reporting of surgeon outcomes in the United Kingdom: Potential caveats

Since June 2013, the National Health Service (NHS) in the United Kingdom (UK) has begun publishing individual surgeons’ outcomes in ten different specialties as part of the new policy of the NHS Commissioning Board [1]. This aims to facilitate the exercise of patients choosing their surgeons in order to enhance their quality of care [2]. Whilst this is a commendable initiative to further bring the patient as the central focus of care, there are several points to discuss. Different procedures vary in the number of times they are performed by an individual surgeon. Procedures performed infrequently constitute a low statistical power and this may risk inadequate identification of poorly performing surgeons, thereby compromising patient safety [2]. Walker et al. (2013) [2] demonstrated that the number of procedures required to achieve different statistical power thresholds to identify poorly performing surgeons exceeded the number that is actually performed by surgeons currently in the NHS. Poor performance was defined as double the national overall mortality rate. The difference was greatest for oesophagectomy and gastrectomy, with median procedures performed being 1/10th of the numbers required to achieve 70% statistical power [2]. Likewise, it was shown that the number of surgeons who actually perform sufficient number of procedures to achieve statistical power is much lower for most procedures except hip fracture and cardiac surgery [2]. Additionally there is a concern with regards to incorrect identification of poor performance and the negative impact on the surgeon with regards to the associated stigma attached to poor performance [3]. Moreover, it is now well established that patient outcomes are influenced not just by the surgeon’s performance but by the complex interplay between several factors including individual skills, teamwork, communication within and between teams, the environment, patient age and disease severity [4]. Organizational culture and characteristics have been further correlated with safety climate and shown to influence performance and patient outcomes. Singer et al. (2009) [5] demonstrated that a higher level of group as opposed to a hierarchical culture was associated with a higher safety climate. Thus, these factors enhance the difficulty in interpreting individual surgeon outcomes. Furthermore, with low procedure numbers, patient outcomes may in fact be more greatly influenced by external factors than individual surgeons’ performance [2].

Patellofemoral joint is an under reported joint in MRI knee – A retrospective, cross-sectional study

Background Patellofemoral joint (PFJ) pathology accounts for upto 40% of cases of knee pain. It has been suggested that PFJ pathology may be underreported in Magnetic Resonance Imaging (MRI) Knee reports. The objective of this study was to elucidate whether PFJ was reported in MRI knee reports at our institution. Materials and methods A retrospective review of 103 consecutive Knee MRIs over a 2-month period was performed by an author, blinded to the reports, at our institution. We analysed whether PFJ was mentioned in MRI knee reports and whether any significant PFJ pathology was present in the scans of this cohort. Images were also reviewed for any underlying causes of PFJ pathology such as trochlear dysplasia (TD) that can result in patellar instability or maltracking. Results PFJ was not mentioned in 79/103 cases (77%). 24 cases had trochlear dysplasia. There was no association between PFJ reporting and trochlear dysplasia (p value = 0.50). Conclusion PFJ is not mentioned in the majority of Knee MRI reports. PFJ pathology is an important cause of anterior knee and should be reported.