Kapil Sugand

The Anatomy of Anatomy: A Review for Its Modernization.

Anatomy has historically been a cornerstone in medical education regardless of nation or specialty. Until recently, dissection and didactic lectures were its sole pedagogy. Teaching methodology has been revolutionized with more reliance on models, imaging, simulation, and the Internet to further consolidate and enhance the learning experience. Moreover, modern medical curricula are giving less importance to anatomy education and to the acknowledged value of dissection. Universities have even abandoned dissection completely in favor of user‐friendly multimedia, alternative teaching approaches, and newly defined priorities in clinical practice. Anatomy curriculum is undergoing international reformation but the current framework lacks uniformity among institutions. Optimal learning content can be categorized into the following modalities: (1) dissection/prosection, (2) interactive multimedia, (3) procedural anatomy, (4) surface and clinical anatomy, and (5) imaging. The importance of multimodal teaching, with examples suggested in this article, has been widely recognized and assessed. Nevertheless, there are still ongoing limitations in anatomy teaching. Substantial problems consist of diminished allotted dissection time and the number of qualified anatomy instructors, which will eventually deteriorate the quality of education. Alternative resources and strategies are discussed in an attempt to tackle these genuine concerns. The challenges are to reinstate more effective teaching and learning tools while maintaining the beneficial values of orthodox dissection. The UK has a reputable medical education but its quality could be improved by observing international frameworks. The heavy penalty of not concentrating on sufficient anatomy education will inevitably lead to incompetent anatomists and healthcare professionals, leaving patients to face dire repercussions. Anat Sci Educ 3: 83–93, 2010.

Should double lung transplant be performed with or without cardiopulmonary bypass

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether double lung transplantation should be performed with or without cardiopulmonary bypass (CPB) in order to improve postoperative clinical outcomes. Altogether 386 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All 14 papers assessed a range of postoperative outcomes and broadly speaking, six papers found significantly worse outcomes with CPB use, six found no difference and two found a mixture of both depending on the specific outcomes assessed. Dalibon et al. [J Cardiothorac Vasc Anesth 2006;20:668-672] found that mortality was significantly worse in the CPB group at 48 h, one month and one year [P = 0.001, odds ratio (OR) = 246.1; P = 0.083, OR = 2.6; P = 0.001, OR = 5.3, respectively]. Other papers revealed poor outcomes in the CPB group in a range of measures including diffuse alveolar damage (P = 0.009), chest radiograph infiltrate score (P = 0.005), longer intubation time (P = 0.002), longer intensive care unit stay (P = 0.05), and greater incidence of pulmonary reimplantation response (P = 0.03). However, Myles et al. [J Cardiothorac Vasc Anesth 1997;11:177-183] found that only acute postoperative outcomes were significantly worse in their CPB group (P < 0.001); medium- and long-term survival outcomes were not significantly different (P = 0.055). de Boer et al. [Transplantation 2002;73:1621-1627] even found that there was an improved one-year survival rate with CPB use (OR = 0.25, P = 0.038) and that the number of human leukocyte antigen DR (HLA-DR) mismatches influenced this effect. Those papers suggesting no deleterious effects of CPB generally measured similar postoperative outcomes to those mentioned above, with one study also assessing incidence of primary graft failure, which was not significantly different (P = 0.37). We conclude that CPB should continue to be used where clinically indicated for a specific reason (for example, where there is pulmonary hypertension or a requirement for concomitant cardiac repair). However, given that the evidence for using CPB for all elective cases is relatively weak, and the fact that there are strong arguments in the literature for both methods, either approach would be clinically acceptable.

Validating Touch Surgery™: A cognitive task simulation and rehearsal app for intramedullary femoral nailing.

BACKGROUND The role of simulation in orthopaedic surgical training is becoming increasingly evident, as simulation allows repeated sustained practice in an environment that does not harm the patient. Previous studies have shown that the cognitive aspects of surgery are of equal if not greater importance in developing decision making than the practical aspects. AIM To observe construct, content and face validity of four IFN modules on a cognitive simulator, Touch Surgery™. METHODS 39 novices and 10 experts were recruited to complete four simulation modules on surgical decision-making that represented the procedural steps of preparing the patient and equipment, inserting and locking an intramedullary femoral nail. Real-time objective performance metrics were obtained, stored electronically and analysed using median and Bonett-Price 95% confidence intervals from the participants primary attempt to assess for construct validity. The median score of a post-study questionnaire using 5-point Likert scales assessed face and content validity. Data was confirmed as non-parametric by the Kolmogorov-Smirnov test. Significance was calculated using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. Significance was set as 2-tailed p-value<0.05. RESULTS Experts significantly outperformed novices in all four modules to demonstrate construct validity (p<0.001). Specifically, experts scored 32.5% higher for patient positioning and preparation (p<0.0001), 31.5% higher for femoral canal preparation (p<0.0001), 22.5% higher for proximal locking (p<0.0001) and 17% higher scores for distal locking and closure (p<0.001). Both cohorts either agreed or strongly agreed that the graphics, simulated environment and procedural steps were realistic. Also, both cohorts agreed that the app was useful for surgical training and rehearsal, should be implemented within the curriculum and would want to use it to learn other surgical procedures. CONCLUSION IFN on the Touch Surgery app demonstrated construct, face and content validity. Users can demonstrate cognitive competencies prior to performing surgical procedures in the operating room. The application is an effective adjunct to traditional learning methods and has potential for curricular implementation.

Training safer orthopedic surgeons. Construct validation of a virtual-reality simulator for hip fracture surgery.

Background and purpose — Virtual-reality (VR) simulation in orthopedic training is still in its infancy, and much of the work has been focused on arthroscopy. We evaluated the construct validity of a new VR trauma simulator for performing dynamic hip screw (DHS) fixation of a trochanteric femoral fracture. Patients and methods — 30 volunteers were divided into 3 groups according to the number of postgraduate (PG) years and the amount of clinical experience: novice (1–4 PG years; less than 10 DHS procedures); intermediate (5–12 PG years; 10–100 procedures); expert (> 12 PG years; > 100 procedures). Each participant performed a DHS procedure and objective performance metrics were recorded. These data were analyzed with each performance metric taken as the dependent variable in 3 regression models. Results — There were statistically significant differences in performance between groups for (1) number of attempts at guide-wire insertion, (2) total fluoroscopy time, (3) tip-apex distance, (4) probability of screw cutout, and (5) overall simulator score. The intermediate group performed the procedure most quickly, with the lowest fluoroscopy time, the lowest tip-apex distance, the lowest probability of cutout, and the highest simulator score, which correlated with their frequency of exposure to running the trauma lists for hip fracture surgery. Interpretation — This study demonstrates the construct validity of a haptic VR trauma simulator with surgeons undertaking the procedure most frequently performing best on the simulator. VR simulation may be a means of addressing restrictions on working hours and allows trainees to practice technical tasks without putting patients at risk. The VR DHS simulator evaluated in this study may provide valid assessment of technical skill.

Training safer surgeons: How do patients view the role of simulation in orthopaedic training?

BackgroundSimulation allows training without posing risk to patient safety. It has developed in response to the demand for patient safety and the reduced training times for surgeons. Whilst there is an increasing role of simulation in orthopaedic training, the perception of patients and the general public of this novel method is yet unknown. Patients and the public were given the opportunity to perform a diagnostic knee arthroscopy on a virtual reality ARTHRO Mentor simulator. After their practice session, participants answered a validated questionnaire based on a 5-point Likert Scale assessing their opinions on arthroscopic simulation. Primary objective was observing perception of patients on orthopaedic virtual reality simulation.FindingsThere were a total of 159 respondents, of which 86% were of the opinion that simulators are widely used in surgical training and 94% felt that they should be compulsory. 91% would feel safer having an operation by a surgeon trained on simulators, 87% desired their surgeon to be trained on simulators and 72% believed that additional simulator training resulted in better surgeons. Moreover, none of the respondents would want their operation to be performed by a surgeon who had not trained on a simulator. Cronbach’s alpha was 0.969.ConclusionsThere is also a clear public consensus for this method of training to be more widely utilised and it would enhance public perception of safer training of orthopaedic surgeons. This study of public perception provides a mandate to increase investment and infrastructure in orthopaedic simulation as part of promoting clinical governance.

The Transferability of Generic Minimally Invasive Surgical Skills: Is There Crossover of Core Skills Between Laparoscopy and Arthroscopy?

OBJECTIVE The primary objective was observing transferability of minimally invasive surgical skills between virtual reality simulators for laparoscopy and arthroscopy. Secondary objectives were to assess face validity and acceptability. DESIGN Prospective single-blinded crossover randomized controlled trial. SETTING MSk Laboratory, Imperial College London. PARTICIPANTS Student doctors naïve to simulation and minimally invasive techniques. METHODS A total of 72 medical students were randomized into 4 groups (2 control groups and 2 training groups), and tested on haptic virtual reality simulators. Group 1 (control; n = 16) performed a partial laparoscopic cholecystectomy and Group 2 (control; n = 16) performed a diagnostic knee arthroscopy. Both groups then repeated the same task a week later. Group 3 (training; n = 20) completed a partial laparoscopic cholecystectomy, followed by an arthroscopic training program, and repeated the laparoscopic cholecystectomy a week later. Group 4 (training; n = 20) performed a diagnostic knee arthroscopy, followed by a laparoscopic training program, and then repeated the initial arthroscopic test a week later. The time taken, instrument path length, and speed were recorded for each participant and analyzed. RESULTS Time taken for task: All 4 cohorts were significantly quicker on their second attempt but the 2 training groups outperformed the 2 control groups, with the laparoscopy-trained group improving the most (p < 0.05). Economy of movement: All cohorts had a significant improvement in left hand path length (p < 0.01) but there was no difference for right hand path length. Left hand speed: Only the 2 training groups showed significant improvement with the laparoscopy-trained group improving the most (p < 0.05). Right hand speed: All cohorts improved significantly with the laparoscopy-trained group improving the most (p < 0.05). Face validity and acceptability were established for both simulators. CONCLUSION This study showed that minimally invasive surgical skills learnt on a laparoscopy simulator are transferable to arthroscopy and vice versa, with greater effect after training on the laparoscopy simulator.

Does Video Gaming Affect Orthopaedic Skills Acquisition? A Prospective Cohort-Study

Introduction Previous studies have suggested that there is a positive correlation between the extent of video gaming and efficiency of surgical skill acquisition on laparoscopic and endovascular surgical simulators amongst trainees. However, the link between video gaming and orthopaedic trauma simulation remains unexamined, in particular dynamic hip screw (DHS) stimulation. Objective To assess effect of prior video gaming experience on virtual-reality (VR) haptic-enabled DHS simulator performance. Methods 38 medical students, naïve to VR surgical simulation, were recruited and stratified relative to their video gaming exposure. Group 1 (n = 19, video-gamers) were defined as those who play more than one hour per day in the last calendar year. Group 2 (n = 19, non-gamers) were defined as those who play video games less than one hour per calendar year. Both cohorts performed five attempts on completing a VR DHS procedure and repeated the task after a week. Metrics assessed included time taken for task, simulated flouroscopy time and screw position. Median and Bonett-Price 95% confidence intervals were calculated for seven real-time objective performance metrics. Data was confirmed as non-parametric by the Kolmogorov-Smirnov test. Analysis was performed using the Mann-Whitney U test for independent data whilst the Wilcoxon signed ranked test was used for paired data. A result was deemed significant when a two-tailed p-value was less than 0.05. Results All 38 subjects completed the study. The groups were not significantly different at baseline. After ten attempts, there was no difference between Group 1 and Group 2 in any of the metrics tested. These included time taken for task, simulated fluoroscopy time, number of retries, tip-apex distance, percentage cut-out and global score. Conclusion Contrary to previous literature findings, there was no correlation between video gaming experience and gaining competency on a VR DHS simulator.

Should the NHS be privatized? Annual varsity medical debate - London, 22 January 2010

The Varsity Medical Debate, between Oxford and Cambridge Universities, brings together practitioners and the public, professors, pupils and members of the polis, to facilitate discussion about ethics and policy within healthcare. The motion on privatizing the National Health Service (NHS) was specifically chosen to reflect the growing sentiment in the UK where further discourse upon models of healthcare was required. Time and again, the outcome of British elections pivots upon the topic of financial sustainability of the NHS. Having recently celebrated its sixtieth anniversary, the NHS has become heavily politicized in recent months, especially in the aftermath of the devastating global recession.

Diagnosis of ruptured abdominal aortic aneurysm: a multicentre cohort study.

Objective The aim of this study was to describe the presentation of patients with ruptured abdominal aortic aneurysm (rAAA) and identify factors contributing toward misdiagnosis. Methods This was an observational study of cases with a final diagnosis of rAAA assessed at nine Emergency Departments and managed at one of two regional vascular centres in the UK. Results Eighty-five consecutive cases were included. Seventeen [20.0%, 95% confidence interval (CI) 11.5–28.5%] patients reported important symptoms up to 3 weeks before index presentation. In the Emergency Department, most patients complained of abdominal and/or back pain, seven (8.2%, 95% CI 2.4–14.0%) additionally reported atypical pain and ten (11.8%, 95% CI 4.9–18.7%) denied pain altogether. Hypotension (36.5%, 95% CI 26.3–46.7%), tachycardia (18.8%, 95% CI 10.5–27.1%) and syncope (36.5%, 95% CI 26.3–46.7%) were documented in a minority of cases. Distracting symptoms were present in 33 (38.8%, 95% CI 28.4–49.2%) patients. The median time to diagnosis was 17.5 min (range immediate–12 days), and 21 (25.6%, 95% CI 16.3–34.9%) patients were misdiagnosed during clinical assessment. Conclusion The classical signs and symptoms or rAAA are not always present and patients frequently show additional features that may confound the diagnosis. A high level of suspicion should be adopted for rAAA alongside a low threshold for immediate computed tomography. Further research is required to develop an objective clinical risk score or predictive tool for characterizing patients at risk.

Training effect of a virtual reality haptics-enabled dynamic hip screw simulator

Background and purpose — Virtual reality (VR) simulation offers a safe, controlled, and effective environment to complement training but requires extensive validation before it can be implemented within the curriculum. The main objective was to assess whether VR dynamic hip screw (DHS) simulation has a training effect to improve objective performance metrics. Patients and methods — 52 surgical trainees who were naïve to DHS procedures were randomized to 2 groups: the training group, which had 5 attempts, and the control group, which had only one attempt. After 1 week, both cohorts repeated the same number of attempts. Objective performance metrics included total procedural time (sec), fluoroscopy time (sec), number of radiographs (n), tip-apex distance (TAD; mm), attempts at guide-wire insertion (n), and probability of cut-out (%). Mean scores (with SD) and learning curves were calculated. Significance was set as p < 0.05. Results — The training group was 68% quicker than the control group, used 75% less fluoroscopy, took 66% fewer radiographs, had 82% less retries at guide-wire insertion, achieved a reduced TAD (by 41%), had lower probability of cut-out (by 85%), and obtained an increased global score (by 63%). All these results were statistically significant (p < 0.001). The participants agreed that the simulator provided a realistic learning environment, they stated that they had enjoyed using the simulator, and they recognized the need for the simulator in formal training. Interpretation — We found a significant training effect on the VR DHS simulator in improving objective performance metrics of naïve surgical trainees. Patient safety, an important priority, was not compromised.