Teaching Basic Surgical Skills Using a More Frugal, Near-Peer, and Environmentally Sustainable Way: Mixed Methods Study

BACKGROUND

The Royal College of Surgeons Basic Surgical Skills (BSS) course is ubiquitous among UK surgical trainees but is geographically limited and costly. The COVID-19 pandemic has reduced training quality. Surveys illustrate reduced logbook completion and increased trainee attrition. Local, peer-led teaching has been shown to be effective at increasing confidence in surgical skills in a cost-effective manner. Qualitative data on trainee well-being, recruitment, and retention are lacking.

OBJECTIVE

This study aims to evaluate the impact of a novel program of weekly, lunchtime BSS sessions on both quantitative and qualitative factors.

METHODS

A weekly, lunchtime BSS course was designed to achieve the outcomes of the Royal College of Surgeons BSS course over a 16-week period overlapping with 1 foundation doctor rotation. All health care workers at the study center were eligible to participate. The study was advertised via the weekly, trust-wide information email. Course sessions included knot tying, suturing, abscess incision and drainage, fracture fixation with application of plaster of Paris, joint aspirations and reductions, abdominal wall closure, and basic laparoscopic skills. The hospital canteen sourced unwanted pig skin from the local butcher for suturing sessions and pork belly for abscess and abdominal wall closure sessions. Out-of-date surgical equipment was used. This concurrent, nested, mixed methods study involved descriptive analysis of perceived improvement scores in each surgical skill before and after each session, over 4 iterations of the course (May 2021 to August 2022). After the sessions, students completed a voluntary web-based feedback form scoring presession and postsession confidence levels on a 5-point Likert scale. Qualitative thematic analysis of voluntary semistructured student interview transcripts was also performed to understand the impact of a free-to-attend, local, weekly, near-peer teaching course on perceived well-being, quality of training, and interest in a surgical career. Students consented to the use of feedback and interview data for this study. Ethics approval was requested but deemed not necessary by the study center's ethics committee.

RESULTS

There were 64 responses. Confidence was significantly improved from 47% to 73% (95% CI 15%-27%; P<.001; t13=5.3117) across all surgical skills over 4 iterations. Among the 7 semistructured interviews, 100% (7/7) of the participants reported improved perceived well-being, value added to training, and positivity toward near-peer teaching and 71% (5/7) preferred local weekly teaching. Interest in a surgical career was unchanged.

CONCLUSIONS

This course was feasible around clinical workloads, resourced locally at next to no cost, environmentally sustainable, and free to attend. The course offered junior doctors not only a weekly opportunity to learn but also to teach. Peer-led, decentralized surgical education increases confidence and has a positive effect on perceptions about well-being and training. We hope to disseminate this course, leading to reproduction in other centers, refinement, and wide implementation.

Epidemiology of traumatically injured Yemeni civilians treated at the Omani National Trauma Centre over a 2-year period: a retrospective cohort study

INTRODUCTION

Armed conflict is a growing global cause of death, posing a significant threat to the resilience of global health systems. However, the burden of disease resulting from the Yemeni Civil War remains poorly understood. Approximately half of healthcare facilities in Yemen are non-operational, and around 15% of the population has been displaced. Consequently, neighbouring countries' trauma systems have been providing care to the injured. The objective of this study was to investigate the epidemiology and management of Yemeni civilian victims injured during the war who were subsequently extracted and treated at the study centre in Oman.

METHODS

We conducted a retrospective cohort study, including all Yemeni civilians treated for traumatic injuries at the study centre from January 2015 to June 2017. We extracted data on age, sex, date of attendance, mechanism of injury, injuries sustained and treatment.

RESULTS

A total of 254 injured patients were identified. Their median age was 25 (range 3-65) years and 244 (96.1%) were male. Explosions (160 patients, 63.0%) were the most common mechanism of injury, and fractures (n=232 fractures, 42.3% of all injuries; in 149 patients, 58.7% of all patients) the most common injury. Eighty-four of the 150 patients (56%) who received operative management at the study centre were receiving a second procedure after an index procedure outside of Oman.One hundred and twenty-eight (50.4%) patients experienced permanent loss of function in at least one body part and/or limb loss.

CONCLUSIONS

This study demonstrates the downstream needs of Yemeni civilians who were evacuated to the study centre, revealing a considerable burden of morbidity associated with this population. The findings emphasise key areas that receiving hospitals should prioritise in resource allocation when managing conflict-wounded evacuees. Additionally, the study underscores the need for holistic rehabilitation for civilian casualties displaced by conflict.

FFP3 Feelings and Clinical Experience (FaCE). Facial pressure injuries in healthcare workers from FFP3 masks during the COVID-19 pandemic

AIMS

Prolonged wear of filtering facepiece 3 (FFP3) masks during the COVID-19 pandemic has led to dermatoses, including pressure sores. This study aimed to better understand the local scale and nature of the problem, coping strategies, and impact on those affected.

METHODS

A survey was designed by plastic surgeons, tissue viability nurses, and critical care doctors. Key elements were demographics, mask-wearing behaviours, facial injuries, coping mechanisms, and impacts, such as time off work or redeployment. Question types were multiple-choice questions, visual analogue scales, and blank space. It was distributed for voluntary completion at a London NHS Trust via staff update emails and posters.

RESULTS

Between 24th April-15th May 2020, 178 surveys were completed in full. Participants were 84% female, 55% worked in ITU, and 48% were nurses. Grade 1 facial pressure injuries were reported by 79% of respondents (n=124). Other significant occupational dermatoses included pain (70%), dry skin (50%), and acne (41%). The cheeks and bridge of nose were most affected. Staff used barrier creams (17%), dressings (17%), and analgesia (10%) to manage facial injuries. Half of those who modified their mask were not re-fit tested. A total of 33% required redeployment to a non-FFP3 area or time off.

CONCLUSIONS

FFP3 masks worn beyond the recommended 1 h are associated with facial injuries. When advanced PPE (i.e., powered airflow masks) is unavailable, we must provide targeted skincare support (prevent and manage), modify shift patterns to reduce mask wear intensity, and amend fit test protocols to optimise protection against COVID-19.

Triaging of respiratory protective equipment on the assumed risk of SARS-CoV-2 aerosol exposure in patient-facing healthcare workers delivering secondary care: a rapid review

OBJECTIVES

In patient-facing healthcare workers delivering secondary care, what is the evidence behind UK Government personal protective equipment (PPE) guidance on surgical masks versus respirators for SARS-CoV-2 protection?

DESIGN

Two independent reviewers performed a rapid review. Appraisal was performed using Critical Appraisal Skills Programme checklists and Grading of Recommendations, Assessment, Development and Evaluations methodology. Results were synthesised by comparison of findings and appraisals.

DATA SOURCES

MEDLINE, Google Scholar, UK Government COVID-19 website and grey literature.

ELIGIBILITY CRITERIA

Studies published on any date containing primary data comparing surgical facemasks and respirators specific to SARS-CoV-2, and studies underpinning UK Government PPE guidance, were included.

RESULTS

Of 30 identified, only 3 laboratory studies of 14 different respirators and 12 surgical facemasks were found. In all three, respirators were significantly more effective than facemasks when comparing protection factors, reduction factors, filter penetrations, total inspiratory leakages at differing particle sizes, mean inspiratory flows and breathing rates. Tests included live viruses and inert particles on dummies and humans. In the six clinical studies (6502 participants) included the only statistically significant result found continuous use of respirators more effective in clinical respiratory illness compared with targeted use or surgical facemasks. There was no consistent definition of 'exposure' to determine the efficacy of respiratory protective equipment (RPE). It is difficult to define 'safe'.

CONCLUSIONS

There is a paucity of evidence on the comparison of facemasks and respirators specific to SARS-CoV-2, and poor-quality evidence in other contexts. The use of surrogates results in extrapolation of non-SARS-CoV-2 specific data to guide UK Government PPE guidance. The appropriateness of this is unknown given the uncertainty over the transmission of SARS-CoV-2.This means that the evidence base for UK Government PPE guidelines is not based on SARS-CoV-2 and requires generalisation from low-quality evidence of other pathogens/particles. There is a paucity of high-quality evidence regarding the efficacy of RPE specific to SARS-CoV-2. UK Government PPE guidelines are underpinned by the assumption of droplet transmission of SARS-CoV-2.These factors suggest that the triaging of filtering face piece class 3 respirators might increase the risk of COVID-19 faced by some.

Genetic diversity based on 28S rDNA sequences among populations of Culex quinquefasciatus collected at different locations in Tamil Nadu, India

The basis of the present study was to distinguish the existence of any genetic variability among populations of Culex quinquefasciatus which would be a valuable tool in the management of mosquito control programmes. In the present study, population of Cx. quinquefasciatus collected at different locations in Tamil Nadu were analyzed for their genetic variation based on 28S rDNA D2 region nucleotide sequences. A high degree of genetic polymorphism was detected in the sequences of D2 region of 28S rDNA on the predicted secondary structures in spite of high nucleotide sequence similarity. The findings based on secondary structure using rDNA sequences suggested the existence of a complex genotypic diversity of Cx. quinquefasciatus population collected at different locations of Tamil Nadu, India. This complexity in genetic diversity in a single mosquito population collected at different locations is considered an important issue towards their influence and nature of vector potential of these mosquitoes.

Studies on LH modulated 8kDa peptide involved regulation of testosterone production in rat Leydig cells

AIM

To demonstrate the role of the 8 kDa peptide in regulation of testosterone production by rat Leydig cells.

METHODS

A peptide similar to 8 kDa peptide purified from immature rat Leydig cells was isolated and purified from rat lung cytosol. Immunological and structural similarity between the peptides purified from lung and Leydig cells was established by Western blot and tryptic map comparison respectively.

RESULTS

Addition of the 8 kDa peptide 10, 50, 100, and 150 microg decreased the production of testosterone in Leydig cells dose-dependently. But the addition of the peptide 150 microg along with hCG had no effect on hCG-stimulated increase in testosterone production.

CONCLUSION

In vitro addition of the peptide purified from lung cytosol to adult rat Leydig cells resulted in a concentration-dependent decrease in basal testosterone production although it had no effect on hCG-stimulated testosterone production.

Regulation of an 8-kDa peptide involved in testosterone production by luteinizing hormone in rat Leydig cells

Results of Western blot analysis carried out with an interstitial cell extract from male guinea pig and ovarian extract from immature female rats administered equine chorionic gonadotropin (eCG) provide supportive evidence to our earlier suggestion that an 8-kDa peptide is involved in acquisition of steroidogenic capacity by the rat Leydig cells. It was found that though the signal was observed in other tissues such as liver, kidney and lung which do not produce gonadal hormones, the peptide was modulated only by lutenizing hormone (LH) in the rat Leydig cells.

Selective restoration of male fertility in mice lacking angiotensin-converting enzymes by sperm-specific expression of the testicular isozyme

Although angiotensin-converting enzyme (ACE) has been studied primarily in the context of its role in blood pressure regulation, this widely distributed enzyme has many other physiological functions. The ACE gene encodes two isozymes. The somatic isozyme is expressed in many tissues, including vascular endothelial cells, renal epithelial cells, and testicular Leydig cells, whereas the testicular or germinal angiotensin-converting enzyme is expressed only in sperm. The ACE gene knockout mice lack both isozymes and they exhibit low blood pressure, kidney dysfunctions, and male infertility. Here, we report the use of a sperm-specific promoter and interbreeding of transgenic and gene knockout mice for generating a mouse strain that expressed ACE only in sperm. The experimental mice maintained the kidney defects of ACE-/- mice, but unlike the knockout strain, the males were fertile. Thus, we established that the role of ACE in male fertility is completely dependent on its exclusive expression in sperm. Our study clearly demonstrated how transgenic and knockout techniques can be combined for ascribing a specific physiological function to the expression of a multifunctional protein in a given tissue.

Effects of mutating specific residues present near the amino terminus of 2'-5'-oligoadenylate synthetase

In this study, we investigated the role of specific amino acid residues present near the amino terminus of the 9-2 isozyme of 2'-5'-oligoadenylate synthetase. In vitro expression of deletion mutants showed that residues 1-9 are required for enzyme activity. Within this region, residues 3, 7, and 8 were found to be conserved among all known isozymes of 2'-5'-oligoadenylate synthetase. Mutation of these residues singly or in combination resulted in partial or total loss of enzyme activity. Substitution of the proline residue at position 7 by different residues caused a partial or complete loss of activity. The properties of the inactive P7Q mutant were further explored by expressing the protein in bacteria. The bacterially expressed protein was also enzymatically inactive. The mutant protein could bind the substrate ATP and the activator double-stranded RNA normally. Oligomerization properties of the protein were examined by an affinity-based interaction assay and by glycerol gradient centrifugation; there was no detectable difference between the wild type and the P7Q mutant. These results demonstrated the importance of the proline residue at position 7 in conferring enzyme activity to the protein without affecting its other properties.

A possible role for a low molecular weight peptide in regulation of testosterone production by rat Leydig cells

Sodium dodecyl sulphate-polyacrylamide gel electrophoresis of Percoll purified Leydig cell proteins from 20- and 120-day-old rats revealed a significant decrease in a low molecular weight peptide in the adult rats. Administration of human chorionic gonadotropin to immature rats resulted in a decrease in the low molecular weight peptide along with increase in testosterone production. Modulation of the peptide by human chorionic gonadotropin could be confirmed by Western blotting. The presence of a similar peptide could be detected by Western blotting in testes of immature mouse, hamster, guinea pig but not in adrenal, placenta and corpus luteum. Administration of testosterone propionate which is known to inhibit the pituitary luteinizing hormone levels in adult rats resulted in an increase in the low molecular weight peptide, as checked by Western blotting. It is suggested that this peptide may have a role in regulation of acquisition of responsiveness to luteinizing hormone by immature rat Leydig cells.