Validation of orthopaedic bench models for trauma surgery

The aim of this study was to validate the use of three models of fracture fixation in the assessment of technical skills. We recruited 21 subjects (six experts, seven intermediates, and eight novices) to perform three procedures: application of a dynamic compression plate on a cadaver porcine model, insertion of an unreamed tibial intramedullary nail, and application of a forearm external fixator, both on synthetic bone models. The primary outcome measures were the Objective Structural Assessment of technical skills global rating scale on video recordings of the procedures which were scored by two independent expert observers, and the hand movements of the surgeons which were analysed using the Imperial College Surgical Assessment Device. The video scores were significantly different for the three groups in all three procedures (p < 0.05), with excellent inter-rater reliability (alpha = 0.88). The novice and intermediate groups specifically were significantly different in their performance with dynamic compression plate and intramedullary nails (p < 0.05). Movement analysis distinguished between the three groups in the dynamic compression plate model, but a ceiling effect was demonstrated in the intramedullary nail and external fixator procedures, where intermediates and experts performed to comparable standards (p > 0.6). A total of 85% (18 of 21) of the subjects found the dynamic compression model and 57% (12 of 21) found all the models acceptable tools of assessment. This study has validated a low-cost, high-fidelity porcine dynamic compression plate model using video rating scores for skills assessment and movement analysis. It has also demonstrated that Synbone models for the application of and intramedullary nail and an external fixator are less sensitive and should be improved for further assessment of surgical skills in trauma. The availability of valid objective tools of assessment of surgical skills allows further studies into improving methods of training.

Completion of hand-written surgical consent forms is frequently suboptimal and could be improved by using electronically generated, procedure-specific forms

INTRODUCTION

Completion of hand-written consent forms for surgical procedures may suffer from missing or inaccurate information, poor legibility and high variability. We audited the completion of hand-written consent forms and trialled a web-based application to generate modifiable, procedure-specific consent forms.

METHODS

The investigation comprised two phases at separate UK hospitals. In phase one, the completion of individual responses in hand-written consent forms for a variety of procedures were prospectively audited. Responses were categorised into three domains (patient details, procedure details and patient sign-off) that were considered "failed" if a contained element was not correct and legible. Phase two was confined to a breast surgical unit where hand-written consent forms were assessed as for phase one and interrogated for missing complications by two independent experts. An electronic consent platform was introduced and electronically-produced consent forms assessed.

RESULTS

In phase one, 99 hand-written consent forms were assessed and the domain failure rates were: patient details 10%; procedure details 30%; and patient sign-off 27%. Laparoscopic cholecystectomy was the most common procedure (7/99) but there was significant variability in the documentation of complications: 12 in total, a median of 6 and a range of 2-9. In phase two, 44% (27/61) of hand-written forms were missing essential complications. There were no domain failures amongst 29 electronically-produced consent forms and no variability in the documentation of potential complications.

CONCLUSION

Completion of hand-written consent forms suffers from wide variation and is frequently suboptimal. Electronically-produced, procedure-specific consent forms can improve the quality and consistency of consent documentation.

Patient-level costs in margin re-excision for breast-conserving surgery

BACKGROUND

High rates of reoperation following breast-conserving surgery (BCS) for positive margins are associated with costs to healthcare providers. The aim was to assess the quality of evidence on reported re-excision costs and compare the direct patient-level costs between patients undergoing successful BCS versus reoperations after BCS.

METHODS

The study used data from women who had BCS with or without reoperation at a single institution between April 2015 and March 2016. A systematic review of health economic analysis in BCS was conducted and scored using the Quality of Health Economic Studies (QHES) instrument. Financial data were retrieved using the Patient-Level Information and Costing Systems (PLICS) for patients. Exchange rates used were: US $1 = £0·75, £1 = €1·14 and US $1 = €0·85.

RESULTS

The median QHES score was 47 (i.q.r. 32·5-79). Only two of nine studies scored in the upper QHES quartile (score at least 75). Costs of initial lumpectomy and reoperation were in the range US $1234-11786 and $655-9136 respectively. Over a 12-month interval, 153 patients had definitive BCS and 59 patients underwent reoperation. The median cost of reoperations after BCS (59 patients) was £4511 (range 1752-18 019), representing an additional £2136 per patient compared with BCS without reoperation (P < 0·001).

CONCLUSION

The systematic review demonstrated variation in methodological approach to cost estimates and a paucity of high-quality cost estimate studies for reoperations. Extrapolating local PLICS data to a national level suggests that getting BCS right first time could result in substantial savings.

Media and agenda setting: effects on the public, interest group leaders, policy makers, and policy

Using an experimental design built around a single media event, the authors explored the impact of the media upon the general public, policy makers, interest group leaders, and public policy. The results suggested that the media influenced views about issue importance among the general public and government policy makers. The study suggests, however, that it was not this change in public opinion which led to subsequent policy changes. Instead, policy change resulted from collaboration between journalists and government staff members.

The effect of local cooling on pain perception during infiltration of local anaesthetic agents, a prospective randomised controlled trial

The effect of pre-infiltration local cooling of the site of inguinal herniorrhaphy on pain perception during infiltration of local anaesthetic was studied in a prospective randomised controlled trial. One hundred patients were randomly allocated to receive topical application of either a cooled saline bag (study group) or a saline bag at room temperature (control group) prior to injection of local anaesthetic. Pain scores were recorded using a visual analogue scale following application of the saline bags and again on completion of infiltration with local anaesthetic. There was no significant difference in pain scores following topical saline bag application. However, a highly significant difference (p = 0.0001, Mann-Whitney U) was observed between post-infiltration pain scores of the study group (median = 2) and the control group (median = 6).

Variations in consenting practice for laparoscopic cholecystectomy

INTRODUCTION

To compare the variations in consenting practice amongst trainees and consultant surgeons for laparoscopic cholecystectomy with specific reference to the documentation of significant risks of surgery.

PATIENTS AND METHODS

A proforma was devised which included significant and/or commonly recognised complications of laparoscopic cholecystectomy. This was then cross-referenced with the consent forms for the 80 patients included in the study and the documented risks explained in each case were noted.

RESULTS

The results showed that there is considerable variation between the three grades of clinicians involved in obtaining a patient's consent for laparoscopic cholecystectomy. There was a clear difference in emphasis of the significant complications depending on the seniority of the consenter. Over 80% of the consents in this study were still being obtained by junior staff.

CONCLUSIONS

More often than not, patients are not provided with consistent information to make an informed choice. We suggest that a preprinted consent form will provide a more uniform approach to consenting practice for laparoscopic cholecystectomy.

Inflammation of the residual appendix stump: a systematic review

AIM

A systematic review of the literature was undertaken to examine reported cases of stump appendicitis (SA) to determine the relationship between SA and the original operative strategy (open vs laparoscopic), and to evaluate the clinical features and diagnosis.

METHOD

A Pub-med search was conducted to identify cases of appendicitis of a residual stump following appendicectomy. Two original cases of SA following laparoscopic appendicectomy treated in our own hospitals are also included in the analysis. Sixty cases of SA reported in the English medical literature were analysed.

RESULTS

The interval from the original appendicectomy ranged from 4 days to 50 years. SA followed appendicectomy in 58% of open and 31.6% of laparoscopic procedures. SA was frequently misdiagnosed as constipation or gastroenteritis, with a significant delay to surgery. Computerized tomography diagnosed SA in 46.6% of cases. Perforation with gangrene of the stump occurred in 40%.

CONCLUSION

Stump appendicitis is rare. It may complicate open or laparoscopic appendicectomy. A high level of suspicion should be maintained in any patient with right sided abdominal pain and a history of prior appendicectomy.

A nontransfusional perioperative management regimen for patients with sickle cell disease undergoing laparoscopic cholecystectomy

BACKGROUND

Patients with sickle cell disease (SCD) are at increased risk for cholelithiasis. Laparoscopic cholecystectomy is the most frequent general surgical operation performed for this group of patients. Acute chest syndrome (ACS) is the most common cause of postoperative death among SCD patients. This study aimed to evaluate the impact of a novel perioperative management regimen involving prophylactic continuous positive airways pressure (CPAP) ventilation and avoidance of preoperative blood transfusion on postoperative SCD-related complications after laparoscopic cholecystectomy.

METHODS

A retrospective study included all SCD patients who underwent laparoscopic cholecystectomy since 1997 at our institution. Medical notes were analyzed to assess the rates of postoperative complications in relation to the severity of SCD.

RESULTS

A total of 13 patients were identified. There were no recorded episodes of acute painful crises and only one patient experienced an episode of ACS requiring protracted CPAP.

CONCLUSION

Laparoscopic cholecystectomy can be safely performed for SCD patients without prior blood transfusion. A defined perioperative regimen including the use of routine postoperative prophylactic CPAP for these patients helps to reduce SCD-related postoperative complications such as ACS and painful vaso-occlusive crises.

A multidisciplinary team approach minimises prophylactic mastectomy rates

BACKGROUND

Prophylactic mastectomy (PM) has become increasingly common but is not without complications especially if accompanied by reconstructive surgery. In patients with sporadic unilateral breast cancer, contralateral PM offers no survival advantage. Multidisciplinary team (MDT) communication and interaction may facilitate shared decision-making and curtail PM rates. The aim of this study was investigate the effect of a regional MDT meeting on PM decision-making.

METHODS

We conducted an observational study involving retrospective review of prospectively recorded MDT meeting records for a 151 patient requests for PM from 2011 to 2014. Final MDT decisions were recorded as PM 'accepted', 'declined' or 'pending'. For MDT sanctioned requests, the factors justifying PM were recorded. Where PM was declined, justification for MDT refusal was sought and recorded.

RESULTS

Approximately half of all requests for PM have been upheld (53.0%) and 1/3 of requests have been declined (32.5%). Of those declined, low risk of contralateral breast cancer versus relatively high risk of systemic relapse were commonly cited as justification for PM refusal (45.7%). A proportion of patients who initiated PM discussion subsequently changed their minds (19.6%), or failed to attend clinic appointments (6.5%). Some patients were deemed medically unfit for complex reconstructive surgery (13%), or were declined on the basis of an apparent cosmetic drive for surgery (6.5%), concerns regarding depression or anxiety (2.2%) and/or if family history could not be substantiated (6.5%).

DISCUSSION

MDT meetings facilitate cross-specialty interrogation of requests for PM, minimise unnecessary surgery and restrict PM to those likely to derive maximum benefit.

Validation of an oncoplastic breast simulator for assessment of technical skills in wide local excision

Background

Simulation enables safe practice and facilitates objective assessment of technical skills. However, simulation training in breast surgery is rare and assessment remains subjective. The primary aim was to evaluate the construct validity of technical skills assessments in wide local excision (WLE).

Methods

Surgeons of different grades performed a WLE of a 25-mm palpable tumour on an in-house synthetic breast simulator. Procedures were videotaped (blinded), reviewed retrospectively, and independently rated against a procedure-specific global rating scale by two consultant breast surgeons. Specimen radiographs were obtained and the macroscopic distance from the ‘tumour’ edge to the resection margin was recorded in four cardinal directions. Expert consensus was used to construct an Oncoplastic Deviation Score (ODS), assigning points for excessively wide (more than 10 mm) and, conversely, close (less than 5 mm) macroscopic margins.

Results

Thirty-four surgeons (12 consultant surgeons, 12 specialty trainees and 10 core trainees) participated in the study. Video-based rating scores varied hierarchically with operator expertise (P &lt; 0·050). Inter-rater reliability was excellent (α ≥ 0·80, P &lt; 0·050 for all scales), and inter-rater agreement was moderate (κ = 0·132–0·361, P &lt; 0·050 for all scales). Statistically significant differences were observed on pairwise comparisons between each grade of surgeon in scores for ‘exposure’, ‘skin flap development’, ‘glandular remodelling’, ‘skin closure’ and ‘final product review’ (P &lt; 0·050). Consultants received significantly fewer ODS points than specialty trainees (P = 0·012) and core trainees (P = 0·028). Compared with experts (median 9·0 mm), wider margins were observed amongst specialty trainees (median 12·0 mm) and narrower margins amongst core trainees (median 7·1 mm) (P = 0·001).

Conclusion

Video ratings of performance and a proposed ODS differentiate surgeons based on technical skills in WLE and may be useful for objective assessment of breast surgery trainees.

Tuberculosis control policies in major metropolitan health departments in the United States. VI. Standard of practice in 1996

Since 1980, we have surveyed at 4-yr intervals the metropolitan health departments initially reporting > 250 cases of tuberculosis to determine the perceived standard of practice for tuberculosis control and the factors affecting formulation of treatment policies. Between 1992 and 1996, use of supervised short-course (6 to 9 mo) intermittent therapy with multiple drugs including isoniazid, ethambutol, pyrazinamide, and rifampin increased from 4.3% to 46% of all new patients. Pyrazinamide use for initial treatment for children has increased substantially and now predominates (74.2% of patients in 1996 versus 48.1% of patients in 1992). Duration of treatment, which was 20 +/- 2.1 mo in 1980, is now 8.00 +/- 2.29 mo in 1996. The incidence of human immunodeficiency virus-associated tuberculosis, which was virtually unrecognized in 1984, has remained the same between 1992 and 1996 (18.0%). As in previous years, there was a wide variance among health departments in the incidence (< 5% to > 40%) of HIV-associated tuberculosis. After years of funding decreases, there has been an impressive increase in resources in the past 4 yr. In 1988, mean budget allocation for health departments decreased by 7.9% versus the prior 4 yr and, in 1992, there was no overall change in budget allocation after inflation versus 1988. In 1996, however, funds for treatment increased by 84 +/- 33%. This increase in funding has been translated into the greatly expanded use of supervised intermittent therapy and aggressive screening programs, which likely have resulted in the decreased incidence of tuberculosis since the prior survey.

Innovations for the future of breast surgery

BACKGROUND

Future innovations in science and technology with an impact on multimodal breast cancer management from a surgical perspective are discussed in this narrative review. The work was undertaken in response to the Commission on the Future of Surgery project initiated by the Royal College of Surgeons of England.

METHODS

Expert opinion was sought around themes of surgical de-escalation, reduction in treatment morbidities, and improving the accuracy of breast-conserving surgery in terms of margin status. There was emphasis on how the primacy of surgical excision in an era of oncoplastic and reconstructive surgery is increasingly being challenged, with more effective systemic therapies that target residual disease burden, and permit response-adapted approaches to both breast and axillary surgery.

RESULTS

Technologies for intraoperative margin assessment can potentially half re-excision rates after breast-conserving surgery, and sentinel lymph node biopsy will become a therapeutic procedure for many patients with node-positive disease treated either with surgery or chemotherapy as the primary modality. Genomic profiling of tumours can aid in the selection of patients for neoadjuvant and adjuvant therapies as well as prevention strategies. Molecular subtypes are predictive of response to induction therapies and reductive approaches to surgery in the breast or axilla.

CONCLUSION

Treatments are increasingly being tailored and based on improved understanding of tumour biology and relevant biomarkers to determine absolute benefit and permit delivery of cost-effective healthcare. Patient involvement is crucial for breast cancer studies to ensure relevance and outcome measures that are objective, meaningful, and patient-centred.

Best-practice care pathway for improving management of mastitis and breast abscess

BACKGROUND

Surgical subspecialization has resulted in mastitis and breast abscesses being managed with unnecessary admission to hospital, prolonged inpatient stay, variable antibiotic prescribing, incision and drainage rather than percutaneous aspiration, and loss to specialist follow-up. The objective was to evaluate a best-practice algorithm with the aim of improving management of mastitis and breast abscesses across a multisite NHS Trust. The focus was on uniformity of antibiotic prescribing, ultrasound assessment, admission rates, length of hospital stay, intervention by aspiration or incision and drainage, and specialist follow-up.

METHODS

Management was initially evaluated in a retrospective cohort (phase I) and subsequently compared with that in two prospective cohorts after introduction of a breast abscess and mastitis pathway. One prospective cohort was analysed immediately after introduction of the pathway (phase II), and the second was used to assess the sustainability of the quality improvements (phase III). The overall impact of the pathway was assessed by comparing data from phase I with combined data from phases II and III; results from phases II and III were compared to judge sustainability.

RESULTS

Fifty-three patients were included in phase I, 61 in phase II and 80 in phase III. The management pathway and referral pro forma improved compliance with antibiotic guidelines from 34 per cent to 58·2 per cent overall (phases II and III) after implementation (P = 0·003). The improvement was maintained between phases II and III (54 and 61 per cent respectively; P = 0·684). Ultrasound assessment increased from 38 to 77·3 per cent overall (P < 0·001), in a sustained manner (75 and 79 per cent in phases II and III respectively; P = 0·894). Reductions in rates of incision and drainage (from 8 to 0·7 per cent overall; P = 0·007) were maintained (0 per cent in phase II versus 1 per cent in phase III; P = 0·381). Specialist follow-up improved consistently from 43 to 95·7 per cent overall (P < 0·001), 92 per cent in phase II and 99 per cent in phase III (P = 0·120). Rates of hospital admission and median length of stay were not significantly reduced after implementation of the pathway.

CONCLUSION

A standardized approach to mastitis and breast abscess reduced undesirable practice variation, with sustained improvements in process and patient outcomes.

Assessment of the introduction of semi-digital consent into surgical practice

In this study, paper-based surgical consent is demonstrated to have significant errors of omission and legibility. These errors were improved by the introduction of a procedure-specific, patient-bespoke, semi-digital consent form application. Patient-reported experience of their involvement in shared decision-making is described for paper-based consent and the implications of future digital consent are discussed.

Neuroenhancement in surgeons: benefits, risks and ethical dilemmas

Background

Surgeons traditionally aim to reduce mistakes in healthcare through repeated training and advancement of surgical technology. Recently, performance-enhancing interventions such as neurostimulation are emerging which may offset errors in surgical practice.

Methods

Use of transcranial direct-current stimulation (tDCS), a novel neuroenhancement technique that has been applied to surgeons to improve surgical technical performance, was reviewed. Evidence supporting tDCS improvements in motor and cognitive performance outside of the field of surgery was assessed and correlated with emerging research investigating tDCS in the surgical setting and potential applications to wider aspects of healthcare. Ethical considerations and future implications of using tDCS in surgical training and perioperatively are also discussed.

Results

Outside of surgery, tDCS studies demonstrate improved motor performance with regards to reaction time, task completion, strength and fatigue, while also suggesting enhanced cognitive function through multitasking, vigilance and attention assessments. In surgery, current research has demonstrated improved performance in open knot-tying, laparoscopic and robotic skills while also offsetting subjective temporal demands. However, a number of ethical issues arise from the potential application of tDCS in surgery in the form of safety, coercion, distributive justice and fairness, all of which must be considered prior to implementation.

Conclusion

Neuroenhancement may improve motor and cognitive skills in healthcare professions with impact on patient safety. Implementation will require accurate protocols and regulations to balance benefits with the associated ethical dilemmas, and to direct safe use for clinicians and patients.

Tuberculosis control policies in major metropolitan health departments in the United States. IV. Standards in 1988

Twenty-eight metropolitan health departments reporting greater than 250 cases annually in 1978 were surveyed to determine the standard of practice in the control of pulmonary tuberculosis and the factors affecting treatment policy. The results were compared to previous surveys in 1978, 1980, and 1984 to determine the impact of policies recommended by the Centers for Disease Control, state health departments, and other agencies. A high degree of uniformity again was demonstrated in chemoprophylaxis and hospitalization policies. However, screening, drug toxicity monitoring, and post-treatment follow-up varied widely among programs. A major trend toward short-course chemotherapy (mean duration of treatment, 20.8 +/- 2.34 months in 1980 versus 7.59 +/- 1.02 months in 1988) accompanied inclusion of pyrazinamide in first-line treatment of 59.4% of all patients in 1988 versus none in 1980. The prevalence of acquired immune deficiency syndrome (AIDS) in association with tuberculosis was estimated to be 7.72% in 1988 versus 2.52% in 1984; nine programs identified AIDS + tuberculosis in greater than 5% of all new cases in 1988 versus only two programs in 1984. Health departments identified the recommendations of the Centers for Disease Control and their respective state health departments as the major source of treatment policy; recommendations of the World Health Organization, American Academy of Pediatrics, and peer-reviewed literature had little effect upon treatment policies. This survey identifies substantial departures from prior treatment policies, some of which are attributed to reduction in available funding, development of shorter-course technology, and recognition of new groups of patients at risk to develop tuberculosis in the major cities in the major cities in the United States.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract P2-12-20: Rapid evaporative ionisation mass spectrometry towards real time intraoperative oncological margin status determination in breast conserving surgery

Introduction: Positive tumour margins following attempted breast conserving surgery (BCS) is an important risk factor for local recurrence. Nationally in the United Kingdom on average approximately 25% of patients undergoing BCS require additional surgery for positive margins. Traditional techniques such as specimen xray, frozen section & imprint cytology to optimise margin clearance have significant limitations. Various research methods under investigation include optical spectroscopy, high resolution imaging and radiofrequency spectroscopy. Rapid Evaporative Ionisation Mass Spectrometry (REIMS) is a new method that uses mass spectrometric analysis of the tissue specific ionic content of the surgical diathermy smoke plume for the rapid identification of dissected breast tissues as an intelligent knife (iKnife). We investigate the ability of the "iKnife" to analyze heterogeneous breast tissue intraoperatively using mass spectrometric techniques.

Method: The study involved three stages that comprised: method development, tissue specific ex-vivo database construction and intraoperative analysis. Smoke aerosol produced as a result of electrosurgical diathermy from a variety of frozen, fresh and in-vivo breast samples were aspirated into a mass spectrometer via a modified surgical handpiece. Tissue diagnosis was confirmed by subsequent histopathological validation. The data underwent computational analysis using multivariate statistics –predominantly Principal Component Analysis (PCA) and Linear Discriminant Analysis (LDA), along with leave one patient out cross-validation. A total of 128 patients (n=40 method development, n=66 ex-vivo database, n=22 intraoperative analysis) undergoing breast surgery were enrolled in this study. Ethical approval was obtained from the Research Ethics Committee.

Results: 40 patients contributed breast samples (normal and cancerous) for method optimisation to enable analysis of high intensity spectra from heterogeneous breast tissue. Following optimisation an ex-vivo database was constructed from 89 excised fresh breast tissue samples from 66 patients using 330 spectra (246 Normal, 60 Tumour – IDC, ILC, IMC and 24 Benign - fibroadenoma). Multivariate statistical analysis of data revealed classification of tumour compared to normal tissue with sensitivities of 93.0% and specificity of 91.9%. The iKnife was used intraoperatively during the entire operation of 25 surgeries. Spectral data was obtained within 1-2 seconds. Specific margin analysis correctly identified negative margins in 10 cases.

Conclusions: The iKnife has been successfully developed for analysis of intraoperative heterogeneous breast tissue. Preliminary data suggests that this technique is suitable with high accuracy for the separation of normal, benign (fibroadenoma) and cancerous (invasive ductal and invasive lobular carcinoma) breast tissues. In comparison to the normal breast, cancerous tissues exhibit statistically different spectral profiles. Further work is aimed at the development of a real time algorithm able to match intraoperative data with the pre-existing database for the rapid interpretation and real time feedback of intraoperative data towards detecting positive margins intraoperatively.

Citation Format: St John ER, Al-Khudairi R, Balog J, Rossi M, Gildea L, Speller A, Ramakrishnan R, Shousha S, Takats Z, Leff DR, Darzi A. Rapid evaporative ionisation mass spectrometry towards real time intraoperative oncological margin status determination in breast conserving surgery. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-12-20.

Tuberculosis control policies in major metropolitan health departments in the United States. V. Standard of practice in 1992

Since 1978, we have surveyed the 28 metropolitan health departments initially reporting > 250 cases of tuberculosis/yr to determine the standard of practice in the control of pulmonary tuberculosis and the factors affecting treatment policy. In this survey, results were compared with data obtained in 1978, 1980, 1984, and 1988. As in the previous years, all departments completed the survey. The predominant treatment regimen was 6 months of chemotherapy (64 +/- 1.33% of patients) involving isoniazid (I), rifampin (R), and pyrazinamide (Z). Estimated duration of treatment, which had decreased from 20.2 +/- 2.1 months in 1980 to 7.58 +/- 1.02 months in 1988, increased to 9.34 +/- 2.32 months in 1992 (p < 0.01). This was attributed to an increase in drug-resistant cases (17 of 25 programs) and to increased incidence of HIV infection during the previous 4 yr. In 1984, HIV infection was estimated to coincide with tuberculosis in 2.54% of all patients, 7.72% in 1988, and 17.42% in 1992. Several other major departures from prior perceived practices were reported. In 1980, 32.1% of all patients were hospitalized initially for tuberculosis treatment, and this number decreased progressively to 17.8% in 1988; in 1992, 34.2 +/- 1.32% of patients with tuberculosis were hospitalized for initial treatment. In 1988, no program reported regular use of alternative therapy to isoniazid for chemoprophylaxis; in 1992, 21 programs used alternative regimens (predominantly R-containing). In 1992, nine programs reported increased funds for treatment of tuberculosis (27.2 +/- 1.97% after inflation), whereas 16 reported a mean decrease of 14% after inflation.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract P2-18-18: Improving training in breast surgical oncology: The development and preliminary validation of a simulator for wide local excision

Background

Simulation training has the potential to increase resident confidence in basic procedural tasks prior to operating room (OR) refinements, offsets a reduction in mentoring opportunities, avoids the use of patients for skills practice, and facilitates objective assessment of technical skills. Despite a multitude of benefits, adoption of simulation training and assessment in breast surgical oncology has not been forthcoming.

Aims

To develop and validate a high-fidelity surgical simulator for the practice, training and assessment of technical skills in wide local excision (WLE) of a palpable breast tumour.

Methods

Subjects (attendings and residents with an interest in breast surgery, and novice trainees) were invited to perform a WLE of 25mm palpable breast lesion located 30mm from the nipple areolar complex in the 3o clock position, on a synthetic breast simulator developed at Imperial College London as part of the London Deanery Skills Programme. Procedures were videotaped (blind) and were retrospectively reviewed and independently rated against procedure-specific ratings of performance (VAS 0-100) by two expert breast surgeons (&gt;10 years experience). Specimen radiographs were performed (BioVision, Faxitron, USA) and margin of clearance (mm) were calculated from the edge of the “tumour” to the limits of surrounding breast tissue excised in 4 cardinal directions (i.e. N, S, E W). Specimen weights were recorded (g). Subjects completed a comprehensive questionnaire to determine simulator content and face validity.

Results

21 subjects participated (5 attendings, 13 registrars, and 3 junior trainees). Data was analysed according to experience (high = &gt;100 independent wide local procedures; low = no independent wide local procedures). Statistically significant (p ≤ 0.05) differences in performance were observed between high and low experience surgeons [for each category data are VAS score medians±IQR; ‘exposure’: low = 70.0±50.0, high = 80.0±20.0; ‘skin flap development’: low = 70.0±50.0, high = 80.0±40.0; ‘resection skills’: low = 60.0±55.0, high = 80.0±45.0; ‘glandular remodelling’: low = 70.0±25.0; high = 80.0±50.0, ‘skin closure’: low = 70.0±25.0, high = 90.0±20.0]. Resection margin width and specimen weight (MWU = 52.5, p = 1.0) did not discriminate high-low experience surgeons. The majority of participants believed that training on the model simulated the same steps as a real WLE (94.7%) and was useful for real practice (84.2%).

Discussion

Preliminary data on a WLE simulator suggests that the model is face and construct valid, and may be useful to supplement early stage practice prior to skills development in the OR. Video performance ratings whilst time consuming appear to distinguish high-low experience surgeons better than do specimen weight or radiographic margin width.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-18-18.