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OBJECTIVE: Extreme variation exists in teaching and clinical exposure for medical students, both from specialty-to-specialty but also between universities. There is mounting literature highlighting the need to reform and standardize surgical education to allow for unified graduate competency. In line with the recommendations from the GMC and the Royal College of Surgeons England (RCSEng), Queens University Belfast (QUB) significantly revised their undergraduate medical programme. Within this new curriculum is the introduction of Specialty Focus week in Surgery. This report reviews the processes used in the introduction of this week. DESIGN: The initial week was formulated with a weekly timetable consisting of tutorials, bedside teaching and students following a peri-operative case. Run charts were populated with an alert when feedback dropped below a certain standard, which then triggered an intervention. PARTICIPANTS: Feedback was collected via a QR code from the first 200 surgical student. SETTINGS: Belfast City Hospital in association with QUB undergraduate curriculum. RESULTS: Run charts resulted in an alert when feedback dropped below 8/10. Following this we implemented smaller group bedside teaching. There was a significant improvement in feedback post intervention (pâ¯=â¯0.04) with no further alerts. Overall feedback had a nonsignificant feedback improvement post intervention (pâ¯=â¯0.07) with once again, no further alerts. CONCLUSION: This review has shown how we have provided some standardization of local surgical teaching, as well as having a process centered model of monitoring. This approach is easy to implement and could be reproduced elsewhere.
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BACKGROUND: Only rigorous evaluation of competence will result in the production of safe surgeons that are able to provide the best care for patients. The development of competency-based assessment should ultimately be evidence driven. OBJECTIVES: Explore the volume of existing evidence pertaining to the different objective assessment methods reported in the literature. ELIGIBILITY CRITERIA: Studies describing objective assessment of postgraduate general surgical trainees within the last 20 years. SOURCES OF EVIDENCE: PubMed, Ovid Medline and Web of Sciences. CHARTING METHODS: A data chart proforma was designed and data were extracted into tables. Basic numerical analysis of extracted data and narrative synthesis of charted data. RESULTS: A total of 343 papers were reviewed. 26 were eligible for inclusion. 92% of articles were published from 2008 onwards. 50% have been published in the last five years. The articles originated from 6 different countries, predominantly the United Kingdom (42%), followed by the United States of America (38%). In addition, a small number were published from Canada (8%), Japan (4%), Germany (4%) and Australia (4%). UK publications were predominantly between 2008 and 2014 while the USA had a later predominance between 2015 and 2018. 42% were based on quantitative methodology, 27% had a qualitative approach while 31% had mixed analysis. There were sixteen assessment methods presented. The most common type of assessment was Objective Structured Assessments (27%), which included Objective Structured Assessment of Technical Skill (OSATS) (23%) and Objective Structured Assessment of Non-Technical Skill (4%). Procedure Based Assessment (PBA) (23%) and Entrustability Scales (23%) were also prevalent. CONCLUSIONS: This scoping review has identified a range of different assessment methods. The assessment methods with a higher volume and level of supporting evidence were OSATS, PBAs and Entrustability Scales. There was a lower volume and level of supporting evidence found within this review for the remaining assessment methods.
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Internado y Residencia , Cirujanos , Humanos , Estados Unidos , Competencia Clínica , Reino Unido , CanadáRESUMEN
OBJECTIVES: To characterize the morphology and imaging findings of femoral head subchondral insufficiency fractures (SIF), and to investigate clinical outcomes in relation to imaging findings. METHODS: Fifty-one patients with hip/pelvis magnetic resonance (MR) images and typical SIF characteristics were identified and reviewed by two radiologists. Thirty-five patients had follow-up documentation allowing assessment of clinical outcome. Subgroup comparisons were performed using regression models adjusted for age and body mass index. RESULTS: SIF were frequently associated with cartilage loss (35/47, 74.5 %), effusion (33/42, 78.6 %), synovitis (29/44, 66 %), and bone marrow oedema pattern (BMEP) (average cross-sectional area 885.7 ± 730.2 mm(2)). Total hip arthroplasty (THA) was required in 16/35 patients, at an average of 6 months post-MRI. Compared to the THA cohort, the non-THA group had significantly (p < 0.05) smaller overlying cartilage defect size (10 mm vs. 29 mm), smaller band length ratio and fracture diameters, and greater incidence of parallel fracture morphology (p < 0.05). Male gender and increased age were significantly associated with progression, p < 0.05. CONCLUSIONS: SIF were associated with synovitis, cartilage loss, effusion, and BMEP. Male gender and increased age had a significant association with progression to THA, as did band length ratio, fracture diameter, cartilage defect size, and fracture deformity/morphology. KEY POINTS: ⢠Femoral head subchondral insufficiency fractures (SIF) frequently require total hip arthroplasty (THA). ⢠SIF frequently coexist with synovitis, cartilage loss, and bone marrow oedema pattern. ⢠SIF cartilage defect size, band length ratio, and fracture diameter/morphology can predict progression risk.
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Fracturas del Fémur/diagnóstico , Cabeza Femoral/lesiones , Fracturas por Estrés/diagnóstico , Imagen por Resonancia Magnética/métodos , Anciano , Progresión de la Enfermedad , Femenino , Cabeza Femoral/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios RetrospectivosRESUMEN
OBJECTIVE: To determine the characteristics of femoral condyle insufficiency fracture (FCIF) lesions and their relative associations with the risk of clinical progression. MATERIALS AND METHODS: This HIPAA-compliant retrospective study was approved by our Institutional Review Board. Seventy-three patients (age range, 19-95) were included after excluding patients with post-traumatic fractures, bone marrow infarct, osteochondritis dissecans, or underlying tumor. Two board-certified musculoskeletal radiologists classified morphologic findings including lesion diameter, associated bone marrow edema pattern, and associated cartilage/meniscus damage. Electronic medical charts were evaluated for symptoms, risk factors, and longitudinal outcomes, including total knee arthroplasty (TKA). Imaging characteristics were correlated with clinical findings, and comparison of outcome groups was performed using a regression model adjusted for age. RESULTS: The majority of patients with FCIF were women (64.4%, 47/73), on average 10 years older than men (66.28 ± 15.86 years vs. 56.54 ± 10.39 years, p = 0.005). The most common location for FCIF was the central weight-bearing surface of the medial femoral condyle; overlying full thickness cartilage loss (75.7%, 53/70) and ipsilateral meniscal injury (94.1%, 64/68) were frequently associated. Clinical outcomes were variable, with 23.9% (11/46) requiring TKA. Cartilage WORMS score, adjacent cartilage loss, and contralateral meniscal injury, in addition to decreased knee range of motion at presentation, were significantly associated with progression to TKA (p < 0.05). CONCLUSIONS: FCIF are frequently associated with overlying cartilage loss and ipsilateral meniscal injury. The extent of cartilage loss and meniscal damage, in addition to loss of knee range of motion at the time of presentation, are significantly associated with clinical progression.
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Enfermedades de los Cartílagos/epidemiología , Fracturas del Fémur/epidemiología , Fracturas del Fémur/cirugía , Fracturas por Estrés/epidemiología , Fracturas por Estrés/cirugía , Osteonecrosis/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Enfermedades de los Cartílagos/patología , Causalidad , Comorbilidad , Femenino , Fracturas del Fémur/patología , Fracturas por Estrés/patología , Humanos , Masculino , Persona de Mediana Edad , Osteonecrosis/patología , Prevalencia , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , San Francisco/epidemiología , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: Several trials have reported early superior patency of stenting over isolated angioplasty (plain old balloon angioplasty [POBA]) for infra-inguinal occlusive disease, yet long-term data are sparse. The purpose of this study was to contrast long-term clinical outcomes and costs of angioplasty alone vs angioplasty with selective stenting in the treatment of femoropopliteal occlusive disease. METHODS: Patients undergoing primary endovascular treatments of the native femoropopliteal arteries from 2002 to 2009 were divided into two groups, POBA alone or stenting based on final treatment received at their index procedure. Study end points included actuarial 5-year primary patency (using strict criteria of any hemodynamic deterioration or return of symptoms), 5-year limb salvage, and 5-year survival and hospital costs. RESULTS: Eight hundred twenty-four primary procedures were performed during the study interval; 517 (63%) were POBA and 307 (37%) were stenting. The mean follow-up duration was 33 months (range, 0-98 months). The indication for intervention in the stenting group was claudication in 71% of the patients, whereas the remaining 29% had critical limb ischemia (CLI). In the POBA cohort, the indication for treatment was claudication in 59% of the patients and CLI in the remaining 41%. A higher percentage of POBA lesions were TransAtlantic Inter-Society Consensus (TASC) II A & B when compared to stenting (91% POBA vs 73% stenting; P < .001). There was no difference in overall 5-year primary patency (POBA 36% ± 3%; stenting 41% ± 4%; P = .31), nor was there a difference in patients with claudication (POBA 42% ± 4%; stenting 45% ± 4%; P = .8). In patients with CLI, the 4-year primary patency was 27% ± 5% (POBA) vs 36% ± 8% (stenting), P = .22; the 4-year limb salvage was 80% ± 4% (POBA) vs 90% ± 5% (stenting), P = .18. There was no difference in survival between the two groups (claudication: 83% ± 3% POBA vs 84% ± 4% stenting at 5 years (P = .65), CLI: 44% ± 4% POBA vs 49% ± 6% stenting at 4 years (P = .40). Subgroup analysis by lesion anatomy showed similar primary patency between POBA and stenting for TASC II A & B lesions, while the primary patency was significantly higher at 5 years after stenting of TASC II C & D lesions (34% ± 6% vs 12% ± 9%; P < .05). Stenting increased the procedural cost by 57% when compared to POBA (P < .001) regardless of treatment indication. In addition, stenting added 45% (P < .001) to the overall hospital cost of patients treated for claudication. CONCLUSION: Stenting resulted in equivalent long-term outcomes compared to POBA when stratified by indications. However, stenting yielded statistically better primary patency in patients with TASC II C & D lesions. The lack of improved clinical outcomes and significantly higher cost of stenting supports a posture of selective use of stents (especially in TASC II A & B) in the endovascular treatment of femoropopliteal occlusive disease.
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Angioplastia de Balón/métodos , Arteriopatías Oclusivas/terapia , Arteria Femoral , Arteria Poplítea , Stents , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/economía , Angioplastia de Balón/mortalidad , Arteriopatías Oclusivas/diagnóstico , Arteriopatías Oclusivas/economía , Arteriopatías Oclusivas/mortalidad , Arteriopatías Oclusivas/fisiopatología , Boston , Distribución de Chi-Cuadrado , Constricción Patológica , Femenino , Arteria Femoral/fisiopatología , Costos de Hospital , Hospitales Generales , Humanos , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Arteria Poplítea/fisiopatología , Modelos de Riesgos Proporcionales , Diseño de Prótesis , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents/economía , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
Scaphoid fractures are among the most common hand fractures in adults. The geometry of the scaphoid as it relates to its retrograde blood supply renders it particularly prone to avascular necrosis and other fracture complications. Though there has been long-standing debate over the optimal method of diagnosing scaphoid fractures, the best and most cost-effective methods combine clinical exam with other imaging modalities such as navicular view plain films, CT, and MRI for particularly questionable presentations. Once a scaphoid fracture is diagnosed, it should be followed by an orthopaedic surgeon and treated with cast immobilization or operative management in the case of displaced fractures. Fractures should be followed to monitor healing progress in order to ensure the eventual development of bridging bone across the fracture line, usually best appreciated on CT. Proper treatment of scaphoid fractures and assessment of fracture healing can minimize the occurrence of non-unions and associated arthritic changes.
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OBJECTIVES: Recent reports have shown promising early results after endovascular revascularization (percutaneous transluminal angioplasty [PTA]/stent) of patients with peroneal artery-only runoff (PAOR), although the long-term durability is unclear. This study evaluated long-term primary patency and limb salvage of PTA/stent in patients with single-vessel runoff and critical limb ischemia to determine if the peroneal artery yields inferior results. METHODS: From January 2002 to December 2007, 1075 infrainguinal PTA/stent procedures were performed in 920 patients. The study cohort comprised 201 limbs in 187 patients with single-vessel runoff and critical limb ischemia. End points included primary patency, assisted patency, limb salvage, and survival. Long-term outcomes were determined by Kaplan-Meier life-table and multivariate Cox regression analyses. RESULTS: There were 104 PAOR and 97 limbs with single-vessel posterior or anterior tibial artery runoff (non-PAOR). Median follow-up was 25 months (range, 0-75 months). PAOR patients tended to be older (77.36 ± 0.92 vs 72.65 ± 1.18 years, P = .002) and were more likely to be taking clopidogrel at presentation (88% vs 76%; P = .04). There were no statistically significant differences in 5-year primary patency (26% ± 6.8% vs 30% ± 7.6%; P = .79), assisted patency (75% ± 8.8% vs 81% ± 7.0%; P = .77), limb salvage (74% ± 8.0% vs 75% ± 7.1%; P = .47), and survival (38% ± 7.7% vs 47% ± 6.6%; P = .99) between the PAOR and the non-PAOR groups, respectively. On Cox regression multivariate analysis, total occlusions predicted decreased assisted patency (hazard ratio, 2.99; 95% confidence interval, 1.21-7.41; P = .02), whereas younger age predicted poor limb salvage (hazard ratio, 0.97; 95% confidence interval, 0.94-0.99; P = .04). PAOR was not an independent predictor of any outcome on multivariate analysis. CONCLUSIONS: Patients with PAOR have similar long-term outcomes to patients with non-PAOR. Thus, infrainguinal endovascular revascularization can be considered a first-line therapy for patients with PAOR and critical limb ischemia.
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Angioplastia de Balón , Isquemia/terapia , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/terapia , Anciano , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Índice Tobillo Braquial , Boston , Enfermedad Crítica , Femenino , Humanos , Isquemia/diagnóstico , Isquemia/etiología , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Selección de Paciente , Enfermedad Arterial Periférica/complicaciones , Enfermedad Arterial Periférica/diagnóstico , Enfermedad Arterial Periférica/mortalidad , Enfermedad Arterial Periférica/fisiopatología , Modelos de Riesgos Proporcionales , Flujo Sanguíneo Regional , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: Although percutaneous intervention (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in critical limb ischemia (CLI), wherein anatomic disease is more extensive, remains unclear. In the present study, late (5-year) clinical and patency data for PTA in CLI are defined. METHODS: From January 2002 to December 2007, 409 patients underwent infrainguinal PTA ± stent for CLI (Rutherford IV-VI) of 447 limbs. Primary patency, assisted patency, limb salvage, and survival were assessed using Kaplan-Meier. Predictors of patency, limb salvage, and death were determined using multivariate models. RESULTS: Demographics included age (70 ± 12 years old), diabetes (65.8%), and dialysis dependence (13%). The superficial femoral artery was treated in 58% of the patients, 16% were limited to the crural vessels, 38% had multilevel treatment, and stents were placed in 26%. Eighty percent of patients received postprocedure clopidogrel. Mean follow-up was 28 months (0-83). Five-year primary and assisted patency were 31% ± 0.04 and 75% ± 0.04, respectively. Limb salvage at 5 years was 74% ± 0.038. Sixty-three patients had major amputations. Survival at 5 years was 39% ± 0.03. Multivariate analysis identified dialysis dependence (P = .0005; 2.7 [1.6-4.8]), ≤1 vessel runoff (P = .02; 1.5 [1.1-2.0]), and warfarin use (P = .001; 1.7 [1.25-2.3]) as negative predictors of primary patency, but none of these were negative predictors of assisted patency. Dialysis dependence (P = .006; 2.5 [1.3-4.8]), female gender (P = .02; 2.0 [1.1-3.7]), and ≤1 vessel run-off (P = .04; 1.8 [1.0-3.2]) predicted limb loss. Dialysis dependence (P = .0003; 2.3 [1.5-3.5]), diabetes (P = .04; 1.5 [0.5-2.1]), and poor run-off (P = .04; 1.6 [1.2-2.1]) were predictors of mortality. CONCLUSION: Although primary patency is low, excellent limb salvage rates can be achieved in patients with CLI through close follow-up and secondary interventions. These data, and the 12% annual death rate, validate PTA as first-line therapy in patients with CLI.
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Angioplastia de Balón , Isquemia/terapia , Extremidad Inferior/irrigación sanguínea , Anciano , Anciano de 80 o más Años , Amputación Quirúrgica , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Angioplastia de Balón/mortalidad , Boston , Clopidogrel , Enfermedad Crítica , Femenino , Humanos , Isquemia/mortalidad , Isquemia/fisiopatología , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Persona de Mediana Edad , Selección de Paciente , Inhibidores de Agregación Plaquetaria/uso terapéutico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéutico , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
OBJECTIVE: Diabetes mellitus (DM) has traditionally predicted poor outcomes after lower extremity revascularization for peripheral vascular disease (PVD). This study assessed the influence of DM on long-term outcomes of percutaneous transluminal angioplasty, with or without stenting (PTA/stent), in patients with PVD. METHODS: From January 2002 to December 2007, 920 patients underwent 1075 PTA/stent procedures. Patients were stratified into DM and non-DM cohorts. Study end points included primary patency (PP), assisted patency (AP), limb salvage, and survival and were evaluated using Kaplan-Meier and Cox regression analyses. RESULTS: There were 533 DM and 542 non-DM limbs. Median follow-up was 34 months. Overall, the 5-year actuarial PP was 42% +/- 2.4%, AP was 81% +/- 2.0%, limb salvage was 89% +/- 1.6%, and survival was 60% +/- 2.4%. On univariate analysis, DM vs non-DM was associated with inferior 5-year PP (37% +/- 3.4% vs 46% +/- 3.3%; P = .009), limb salvage (84% +/- 2.6% vs 93% +/- 1.8%, P < .0001), and survival (52% +/- 3.5% vs 68% +/- 3.1%, P = .0001). AP did not differ between DM and non-DM patients (P = .18). In the entire cohort, DM (hazard ratio [HR], 1.25; 95% confidence interval [CI], 1.01-1.54; P = .04), single-vessel peroneal runoff (HR, 1.54; 95% CI, 1.16-2.08; P = .003), and dialysis (HR, 1.59; 95% CI, 1.10-2.33; P = .02) were associated with decreased PP on multivariate analysis. The only variables on multivariate analysis to predict limb loss and death were critical limb ischemia (HR, 9.09; 95% CI, 4.17-20.00; P < . 0001; HR, 2.99; 95% CI, 2.01-4.44; P < .0001, respectively) and dialysis (HR, 2.94; 95% CI, 1.39-5.00; P = .003; HR, 4.24; 95% CI 2.80-6.45; P < .0001, respectively). CONCLUSIONS: DM is an independent predictor of decreased long-term primary patency after PTA/stent. Although acceptable assisted patency rates can be achieved with close surveillance and reintervention, long-term limb salvage remains inferior in diabetic patients compared with non-diabetic patients due to a more severe clinical presentation and poor runoff.
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Angioplastia de Balón , Arteriopatías Oclusivas/terapia , Complicaciones de la Diabetes/terapia , Anciano , Amputación Quirúrgica , Angioplastia de Balón/efectos adversos , Angioplastia de Balón/instrumentación , Índice Tobillo Braquial , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/mortalidad , Arteriopatías Oclusivas/fisiopatología , Boston , Distribución de Chi-Cuadrado , Complicaciones de la Diabetes/mortalidad , Complicaciones de la Diabetes/fisiopatología , Femenino , Humanos , Estimación de Kaplan-Meier , Recuperación del Miembro , Masculino , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Stents , Factores de Tiempo , Resultado del Tratamiento , Grado de Desobstrucción Vascular , Procedimientos Quirúrgicos VascularesRESUMEN
C-C chemokine receptor 5 (CCR5), a member of G-protein-coupled receptors, serves as a coreceptor for human immunodeficiency virus type 1 (HIV-1). In the present study, we examined the interactions between CCR5 and novel CCR5 inhibitors containing the spirodiketopiperazine scaffolds AK530 and AK317, both of which were lodged in the hydrophobic cavity located between the upper transmembrane domain and the second extracellular loop (ECL2) of CCR5. Although substantial differences existed between the two inhibitors--AK530 had 10-fold-greater CCR5-binding affinity (K(d)=1.4 nM) than AK317 (16.7 nM)-their antiviral potencies were virtually identical (IC(50)=2.1 nM and 1.5 nM, respectively). Molecular dynamics simulations for unbound CCR5 showed hydrogen bond interactions among transmembrane residues Y108, E283, and Y251, which were crucial for HIV-1-gp120/sCD4 complex binding and HIV-1 fusion. Indeed, AK530 and AK317, when bound to CCR5, disrupted these interhelix hydrogen bond interactions, a salient molecular mechanism enabling allosteric inhibition. Mutagenesis and structural analysis showed that ECL2 consists of a part of the hydrophobic cavity for both inhibitors, although AK317 is more tightly engaged with ECL2 than AK530, explaining their similar anti-HIV-1 potencies despite the difference in K(d) values. We also found that amino acid residues in the beta-hairpin structural motif of ECL2 are critical for HIV-1-elicited fusion and binding of the spirodiketopiperazine-based inhibitors to CCR5. The direct ECL2-engaging property of the inhibitors likely produces an ECL2 conformation, which HIV-1 gp120 cannot bind to, but also prohibits HIV-1 from utilizing the "inhibitor-bound" CCR5 for cellular entry--a mechanism of HIV-1's resistance to CCR5 inhibitors. The data should not only help delineate the dynamics of CCR5 following inhibitor binding but also aid in designing CCR5 inhibitors that are more potent against HIV-1 and prevent or delay the emergence of resistant HIV-1 variants.